Diuretic or Beta-Blocker for Hypertensive Patients Already Receiving ACEI/ARB and Calcium Channel Blocker.

BACKGROUND: In patients already receiving combination of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB) and calcium channel blocker (CCB), whether the choice of additional diuretic or beta-blocker affects the cardiovascular and cerebrovascular outcomes remains unclear. METHODS: A total of 13,551 patients who were concurrently receiving three anti-hypertensive agents of different classes through outpatient clinics during 2004-2006 were identified from the National Health Insurance Research Database of Taiwan. Patients were further classified into two treatment groups according to the medication possession ratio of drug combinations; the A + B + C group as those who received concurrent therapy of ACEI/ARB, beta-blocker and CCB. The A + C + D group as patients who received ACEI/ARB, CCB, and diuretics. The event-free survival of stroke, acute myocardial infarction (AMI), mortality, and major adverse cardiovascular events (MACE) between the two treatment groups was investigated. RESULTS: After propensity score matching, there were 5120 patients in each group. There were no differences in the incidence of cardiovascular events between the two groups. In patients with prior history of cerebrovascular accident (CVA), the A + C + D group had a significantly higher AMI-free survival (adjusted HR = 1.56; 95% CI 1.051-2.307; p < 0.05) as compared with the A + B + C group. CONCLUSION: Adding a diuretic may be better than adding a beta-blocker for treating hypertensive patients with prior CVA history who have already received ACEIs/ARBs and CCBs.

Factors associated with use of emergency medical services in patients with acute stroke.

PURPOSES: The aim of this study was to investigate the factors associated with use of emergency medical services (EMS) in patients with acute stroke. METHODS: Prospective data on consecutive patients with acute stroke who presented to the emergency department of a university medical center from January 1, 2010, to July 31, 2011, were analyzed. Patients were excluded if they had an unknown residence, had onset of stroke at a nursing home or hospital, or were transferred from another hospital. Variables for all patients with stroke and ischemic stroke who did and did not use EMS were compared. RESULTS: In total, 1344 patients (60% male; mean age, 68.7 years) were included. Use of EMS (n = 409; 30.4%) was significantly associated with a higher level of education (≧6 years vs <6 years; odds ratio [OR], 1.69; 95% confidence interval [CI], 1.25-2.29), a higher National Institutes of Health Stroke Scale score (OR, 1.08; 95% CI, 1.05-1.11), altered consciousness (OR, 1.88; 95% CI, 1.25-2.84), and atrial fibrillation (OR, 2.43; 95% CI, 1.71-3.44) after adjustment. For patients with ischemic stroke, use of EMS was significantly higher in cases of cardioembolism (OR, 3.04; 95% CI, 1.40-6.60) and large artery atherothrombosis (OR, 2.10; 95% CI, 1.22-3.62) than lacunar infarction. CONCLUSION: Patients with stroke who have altered consciousness, a higher level of education, a higher National Institutes of Health Stroke Scale score, atrial fibrillation, and cardioembolic stroke were more likely to use EMS.

Exercise related spinal cord infarction: a case report.

PURPOSE: A sudden elevation of the intervertebral disc pressure could result in injection of cartilaginous material into spinal small caliber vessels causing embolism of the underlying vessels is well documented but rarely occurs. CASE REPORT: Here we present a patient with sudden onset of weakness over left upper extremity several minutes after neck rotation exercise. The symptoms were progressive with quadra-paresis and urine incontinence without cranial nerve or sensory function deficit. The cervical spine MRI showed cervical spondylosis with degenerative osteophytes of lower cervical-spine with mild indentation of the thecal sac. There was also focal T2-high intensity edema of "H" gray matters of C3 spinal cord. According to the preliminary examination and clinical course, the symptoms of the patient can be explained by the ischemia of spinal cord secondary to fibrocartilaginous embolism(FCE) derived from intervertebral discs. After aspirin and IV dexamethasone treatment, the clinical condition of the patient improved significantly. CONCLUSION: Neck rotation exercise is common among all kinds of relaxation or physical rehabilitation activities. However, the potential unwanted effects of this exercise suggest that one should be aware of the potential adverse neurologic outcomes especially inappropriate non- professional method.

Association between hemoglobin levels and clinical outcomes in adult patients after in-hospital cardiac arrest: a retrospective cohort study.

In addition to cardiac output, oxygen delivery is determined by the amount of oxygen carried by hemoglobin, which is estimated by the product of hemoglobin level and peripheral hemoglobin oxygen saturation (SpO2). Optimal hemoglobin concentration for post-cardiac arrest syndrome (PCAS) has not yet been investigated thoroughly. We conducted a retrospective observational study in a single medical center. We included adult patients between 2006 and 2012 who experienced in-hospital cardiac arrest, and achieved sustained return of spontaneous circulation (ROSC). We used multivariable logistic regression analysis to identify factors associated with favorable neurological status at hospital discharge, defined as a score of 1 or 2 on the Cerebral Performance Category scale. Minimum hemoglobin concentration and SpO2 during the initial 24 h after ROSC were used for analysis. Anemia was defined by the World Health Organization criteria as a hemoglobin concentration <12 g/dL in women and <13 g/dL in men. Of the 426 patients included in our analysis, 387 patients (90.8 %) met the criteria for anemia. The mean minimum hemoglobin concentration among all the patients was 9.2 g/dL. The product of hemoglobin × SpO2 was correlated with a favorable neurological outcome (odds ratio 1.003, 95 % confidence interval 1.002-1.004). According to recommended SpO2 by resuscitation guidelines (94-98 %), we calculated the corresponding range of minimum required hemoglobin concentration to be 8.6-9.0 g/dL for a favorable neurological outcome. Anemia common among PCAS patients. Neurological outcome in PCAS might be correlated with hemoglobin concentration following resuscitation.

Therapeutic Hypothermia and the Risk of Hemorrhage: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Current guidelines recommend a period of moderate therapeutic hypothermia (TH) for comatose patients after cardiac arrest to improve clinical outcomes. However, in-vitro studies have reported platelet dysfunction, thrombocytopenia, and coagulopathy, results that might discourage clinicians from applying TH in clinical practice. We aimed to quantify the risks of hemorrhage observed in clinical studies.Medline and Embase were searched from inception to October 2015.Randomized controlled trials (RCTs) comparing patients undergoing TH with controls were selected, irrespective of the indications for TH. There were no restrictions for language, population, or publication year.Data on study characteristics, which included patients, details of intervention, and outcome measures, were extracted.Forty-three trials that included 7528 patients were identified from 2692 potentially relevant references. Any hemorrhage was designated as the primary outcome and was reported in 28 studies. The pooled results showed no significant increase in hemorrhage risk associated with TH (risk difference [RD] 0.005; 95% confidence interval [CI] -0.001-0.011; I, 0%). Among secondary outcomes, patients undergoing TH were found to have increased risk of thrombocytopenia (RD 0.109; 95% CI 0.038-0.179; I 57.3%) and transfusion requirements (RD 0.021; 95% CI 0.003-0.040; I 0%). The meta-regression analysis indicated that prolonged duration of cooling may be associated with increased risk of hemorrhage.TH was not associated with increased risk of hemorrhage despite the increased risk of thrombocytopenia and transfusion requirements. Clinicians should cautiously assess each patient's risk-benefit profile before applying TH.

Optimal blood pressure for favorable neurological outcome in adult patients following in-hospital cardiac arrest.

BACKGROUND: Adequate cerebral blood flow maintained by optimal blood pressure is important in neurological recovery for patients sustaining transient brain ischemia. Few clinical studies have investigated the relationship between blood pressure and neurological outcomes of patients resuscitated following cardiac arrest. METHODS: This was a retrospective observational study, from a single medical center, of adult patients between 2006 and 2012 who had in-hospital cardiac arrest and achieved sustained return of spontaneous circulation (ROSC). Multivariable logistic regression analysis was used to identify factors associated with a favorable neurological outcome at hospital discharge. Maximal mean arterial pressure (MAP) during the initial 24h after sustained ROSC was used for analysis. RESULTS: Of the 319 study patients, 56 (17.6%) achieved a favorable neurologic outcome. The mean MAP was 95 mmHg. MAP above 85 mmHg was found to correlate with a favorable neurological outcome (odds ratio [OR] 4.12, 95% confidence interval [CI] 1.47-14.39, p = 0.01). For patients without arterial hypertension, the optimal MAP was between 85 and 115 mmHg (OR 8.80, 95% CI 3.13-28.55, p < 0.001); for patients with arterial hypertension, the threshold MAP for achieving a favorable neurological outcome was above 88 mmHg (OR 4.04, 95% CI 1.41-13.03, p = 0.01). CONCLUSIONS: The blood pressure over the first 24h following resuscitation was correlated with neurological outcome. There may be a threshold blood pressure required to affect a favorable neurological outcome. The optimal blood pressure may be dependent on the presence or absence of arterial hypertension.

Association between early arterial blood gas tensions and neurological outcome in adult patients following in-hospital cardiac arrest.

OBJECTIVE: The early partial pressures of arterial O2 (PaO2) and CO2 (PaCO2) have been found in animal studies to be correlated with neurological outcome after brain injury. However, the relationship of early PaO2 and PaCO2 to the neurological outcomes of resuscitated patients after cardiac arrest was still not clear. METHODS: This was a retrospective observational cohort study in a single medical center. Adult patients who had in-hospital cardiac arrest between 2006 and 2012 and achieved sustained return of spontaneous circulation (ROSC) (ROSC>20min without resumption of chest compression) were included. Multivariable logistic regression analysis was used to identify factors associated with favorable neurological outcome at hospital discharge. The first PaO2 and PaCO2 values measured after first sustained ROSC were used for analysis. RESULTS: Of the 550 included patients, 154 (28%) survived to hospital discharge and 74 (13.5%) achieved favorable neurological outcome. The mean time from sustained ROSC to the measurement of PaO2 and PaCO2 was 136.8min. The mean PaO2 and PaCO2 were 167.4mmHg and 40.3mmHg, respectively. PaO2 between 70 and 240mmHg (odds ratio [OR] 1.96, 95% confidence interval [CI] 1.08-3.64) and PaCO2 levels (OR 0.98, 95% CI 0.95-0.99) were positively and inversely associated with favorable neurological outcome, respectively. CONCLUSIONS: The early PaO2 and PaCO2 levels obtained after ROSC might be correlated with neurological outcome of patients with in-hospital cardiac arrest. However, because of the inherent limitations of the retrospective design, these results should be further validated in future studies.

The effect of hyperoxia on survival following adult cardiac arrest: a systematic review and meta-analysis of observational studies.

OBJECTIVE: Studies have shown the detrimental effect of hyperoxia in animals with return of spontaneous circulation (ROSC) after cardiac arrest. To maximize the value of existing clinical studies, we performed the systemic review and meta-analysis of human observational studies to examine the effect of hyperoxia on outcomes of post-ROSC patients. METHODS: We searched PubMed and Embase from the inception to October 2013. We selected adult observational studies that compared different levels of partial pressure of arterial oxygen (PaO2) in post-ROSC patients with mortality or neurological status at hospital discharge as outcome. Studies comparing hypoxia with normoxia only were excluded. RESULTS: Fourteen studies were identified from 2982 references. Odds ratio (OR) was used as effect estimate. OR was reconstructed if not provided in original articles. Hyperoxia was defined as a PaO2>300 mmHg. Meta-analysis indicated that hyperoxia appeared to be correlated with increased in-hospital mortality (OR, 1.40; 95% CI, 1.02-1.93; I2, 69.27%; 8 studies) but not worsened neurological outcome (OR, 1.62; 95% CI, 0.87-3.02; I2, 55.61%; 2 studies). However, the results were inconsistent in subgroup and sensitivity analyses. CONCLUSIONS: Hyperoxia appears to be correlated with increased in-hospital mortality of post-ROSC patients. This result should be interpreted cautiously because of the significant heterogeneity and limited number of studies analyzed. However, because exposure to hyperoxia had no obvious benefits, clinicians should monitor PaO2 closely and titrate oxygen administration cautiously.

Color-tunable mixed photoluminescence emission from Alq3 organic layer in metal-Alq3-metal surface plasmon structure.

This work reports the color-tunable mixed photoluminescence (PL) emission from an Alq3 organic layer in an Au-Alq3-Au plasmonic structure through the combination of organic fluorescence emission and another form of emission that is enabled by the surface plasmons in the plasmonic structure. The emission wavelength of the latter depends on the Alq3 thickness and can be tuned within the Alq3 fluorescent spectra. Therefore, a two-color broadband, color-tunable mixed PL structure was obtained. Obvious changes in the Commission Internationale d'Eclairage (CIE) coordinates and the corresponding emission colors of Au-Alq3-Au samples clearly varied with the Alq3 thickness (90, 130, and 156 nm).

Real-time tracheal ultrasonography for confirmation of endotracheal tube placement during cardiopulmonary resuscitation.

OBJECTIVE: This study aimed to evaluate the accuracy of tracheal ultrasonography for assessing endotracheal tube position during cardiopulmonary resuscitation (CPR). METHODS: We performed a prospective observational study of patients undergoing emergency intubation during CPR. Real-time tracheal ultrasonography was performed during the intubation with the transducer placed transversely just above the suprasternal notch, to assess for endotracheal tube positioning and exclude esophageal intubation. The position of trachea was identified by a hyperechoic air-mucosa (A-M) interface with posterior reverberation artifact (comet-tail artifact). The endotracheal tube position was defined as endotracheal if single A-M interface with comet-tail artifact was observed. Endotracheal tube position was defined as intraesophageal if a second A-M interface appeared, suggesting a false second airway (double tract sign). The gold standard of correct endotracheal intubation was the combination of clinical auscultation and quantitative waveform capnography. The main outcome was the accuracy of tracheal ultrasonography in assessing endotracheal tube position during CPR. RESULTS: Among the 89 patients enrolled, 7 (7.8%) had esophageal intubations. The sensitivity, specificity, positive predictive value, and negative predictive value of tracheal ultrasonography were 100% (95% confidence interval [CI]: 94.4-100%), 85.7% (95% CI: 42.0-99.2%), 98.8% (95% CI: 92.5-99.0%) and 100% (95% CI: 54.7-100%), respectively. Positive and negative likelihood ratios were 7.0 (95% CI: 1.1-43.0) and 0.0, respectively. CONCLUSIONS: Real-time tracheal ultrasonography is an accurate method for identifying endotracheal tube position during CPR without the need for interruption of chest compression. Tracheal ultrasonography in resuscitation management may serve as a powerful adjunct in trained hands.

Cranberry-containing products for prevention of urinary tract infections in susceptible populations: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Urinary tract infection (UTI) is one of the most commonly acquired bacterial infections. Cranberry-containing products have long been used as a folk remedy to prevent UTIs. The aims of this study were to evaluate cranberry-containing products for the prevention of UTI and to examine the factors influencing their effectiveness. METHODS: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were systemically searched from inception to November 2011 for randomized controlled trials that compared prevention of UTIs in users of cranberry-containing products vs placebo or nonplacebo controls. There were no restrictions for language, population, or publication year. RESULTS: Thirteen trials, including 1616 subjects, were identified for qualitative synthesis from 414 potentially relevant references; 10 of these trials, including a total of 1494 subjects, were further analyzed in quantitative synthesis. The random-effects pooled risk ratio (RR) for cranberry users vs nonusers was 0.62 (95% CI, 0.49-0.80), with a moderate degree of heterogeneity (I(2) = 43%) after the exclusion of 1 outlier study. On subgroup analysis, cranberry-containing products seemed to be more effective in several subgroups, including women with recurrent UTIs (RR, 0.53; 95% CI, 0.33-0.83) (I(2) = 0%), female populations (RR, 0.49; 95% CI, 0.34-0.73) (I(2) = 34%), children (RR, 0.33; 95% CI, 0.16-0.69) (I(2) = 0%), cranberry juice drinkers (RR, 0.47; 95% CI, 0.30-0.72) (I(2) = 2%), and subjects using cranberry-containing products more than twice daily (RR, 0.58; 95% CI, 0.40-0.84) (I(2) = 18%). CONCLUSIONS: Our findings indicate that cranberry-containing products are associated with protective effect against UTIs. However, this result should be interpreted in the context of substantial heterogeneity across trials.

GaN-based stacked micro-optics system.

A prototype of a GaN-based stacked micro-optics system is demonstrated. The system consists of a GaN microlens, GaN membrane gratings, six spacers, a spatial filter, and a 980 nm VCSEL. The laser beam is collimated by the GaN microlens and diffracted by the GaN membrane grating. The systems can be used in blue-violet-UV micro-optics systems.