Effects of communication team training on clinical competence in Korean Advanced Life Support: A randomized controlled trial.

We conducted a randomized controlled trial to study the effects of interprofessional communication team training on clinical competence in the Korean Advanced Life Support provider course using a team communication framework. Our study involved 73 residents and 42 nurses from a tertiary hospital in Seoul. The participants were randomly assigned to the intervention or control group, forming 10 teams per group. The intervention group underwent interprofessional communication team training with a cardiac arrest simulation and standardized communication tools. The control group completed the Korean Advanced Life Support provider course. All participants completed a communication clarity self-reporting questionnaire. Clinical competence was assessed using a clinical competency scale comprising technical and nontechnical tools. Blinding was not possible due to the educational intervention. Data were analyzed using a Mann-Whitney U test and a multivariate Kruskal-Wallis H test. While no significant differences were observed in communication clarity between the two groups, there were significant differences in clinical competence. Therefore, the study confirmed that the intervention can enhance the clinical competence of patient care teams in cardiopulmonary resuscitation.

The effect of audiovisual feedback of monitor/defibrillators on percentage of appropriate compression depth and rate during cardiopulmonary resuscitation.

BACKGROUND: High quality cardiopulmonary resuscitation (CPR) is one of the key elements of the survival chain in cardiac arrest. Audiovisual feedback of chest compressions have been suggested to be beneficial by increasing the quality of CPR in the simulated cardiac arrests. METHODS: A prospective before and after study was performed to investigate the effect of a real-time audiovisual feedback system on CPR quality during in-hospital cardiac arrest in intensive care units from November 2018 to February 2022. In the feedback period, CPR was performed with the aid of the real-time audiovisual feedback system. The primary outcome was the percentage of compressions with both adequate depth (5.0-6.0 cm) and rate (100-120/minute). RESULTS: A total of 27,295 compressions in 30 cardiac arrests in the no-feedback period and 27,965 compressions in 30 arrests in the feedback period were analyzed. The percentage of compressions with both adequate depth and rate was 11.8% in the feedback period and 16.8% in the no-feedback period (P < 0.01). The percentage of compressions with adequate rate in the feedback period was lower than that in the no-feedback period (67.3% vs. 75.5%, P < 0.01). The percentage of beyond-target depth with the feedback was significantly higher than that without feedback (64.2% vs. 51.4%, P < 0.01). CONCLUSION: Real-time audiovisual feedback system did not increase CPR quality and was associated with a higher percentage of compression depth deeper than the recommended 5.0-6.0 cm. It is essential to explore more effective ways of implementing feedback in real clinical settings to improve of the quality of CPR. TRIAL REGISTRATION: NCT03902873 (study start: Nov. 2018, initial release April 2019, retrospectively registered).

Does Coronary Vasospasm Show a Better Prognosis in Out of Hospital Cardiac Arrest: Data from the Korean Cardiac Arrest Research Consortium (KoCARC) Registry.

BACKGROUND: Previous cohort studies focused on relative risk stratification among patients diagnosed with vasospastic angina, and it is unknown how much vasospasm accounts for the cause of out-of-hospital cardiac arrest, and whether prognosis differs. METHODS: From a registry data collected from 65 hospitals in Korea, 863 subjects who survived hospital cardiac arrest were evaluated. The patients with insignificant coro- nary lesion, vasospasm, and obstructive lesion were each grouped as group I, group II, and group III, respectively. The primary and secondary outcomes were survival to hospital discharge and good neurological function at discharge defined as cerebral performance index 1. RESULTS: At hospital discharge, 529 subjects (61.3%) survived. There was no significant dif- ference in survival according to coronary angiographic findings (P = .133 and P = .357, group II and group III compared to group I), but the neurological outcome was significantly bet- ter in groups II and III (P = .046 and P = .022, groups II and III compared to group I). Two mul- tivariate models were evaluated to adjust traditional risk factors and cardiac biomarkers. The presence of coronary artery vasospasm did not affect survival to hospital discharge (P = 0.060 and P = .162 for both models), but neurological function was significantly better (OR: 1.965, 95% CI: 1.048-3.684, P = .035, and OR: 1.706, 95% CI: 1.012-2.878, P = .045 for vasospasm, models I and II, respectively). CONCLUSIONS: Coronary vasospasm does not show better survival to hospital discharge, but shows better neurological outcomes. Aggressive coronary angiography and intensive medical treatment for adequate control of vasospasm should be emphasized to prevent and manage fatal events.

Implications of the heterogeneity between guideline recommendations for the use of low dose aspirin in primary prevention of cardiovascular disease.

The most recent primary cardiovascular disease (CVD) prevention clinical guidelines used in Europe, Italy, the USA, China, and South Korea differ in aspects of their approach to CVD risk assessment and reduction. Low dose aspirin use is recommended in certain high-risk patients by most but not all the countries. Assessment of traditional risk factors and which prediction models are commonly used differ between countries. The assessments and tools may not, however, identify all patients at high risk but without manifest CVD. The use of coronary artery calcium (CAC) score to guide decisions regarding primary prevention aspirin therapy is recommended only by the US primary prevention guidelines and the 2021 European Society of Cardiology guidelines. A more consistent and comprehensive global approach to CVD risk estimation in individual patients could help to personalize primary CVD prevention. Wider detection of subclinical atherosclerosis, together with structured assessment and effective mitigation of bleeding risk, may appropriately target patients likely to gain net benefit from low dose aspirin therapy.

Use of direct oral anticoagulants does not significantly increase delayed bleeding after endoscopic submucosal dissection for early gastric neoplasms.

Direct oral anticoagulants (DOACs) are widely prescribed for the prevention of stroke in elderly patients with atrial fibrillation and approved indication for DOAC has been expanded. We aimed to evaluate the risk of delayed bleeding in patients who had taken DOAC and underwent endoscopic submucosal dissection (ESD) for gastric neoplasms. We included consecutive patients who underwent ESD between January 2016 and July 2019 in Seoul National University Hospital. Patients were divided into four groups (no med; no medication, DOAC, WFR; warfarin, anti-PLT; anti-platelet agent) according to the medications they had been taken before the procedure. We defined delayed bleeding as obvious post-procedural gastrointestinal bleeding sign including hematemesis or melena combined with hemoglobin drop ≥ 2 g/dL. Among 1634 patients enrolled in this study, 23 (1.4%) patients had taken DOAC and they usually stopped the medication for 2 days before the ESD and resumed within 1 or 2 days. We compared rates of delayed bleeding between groups. Delayed bleeding rates of the groups of no med, DOAC, WFR, and anti-PLT were 2.1% (32/1499) 8.7% (2/23), 14.3% (2/14), 11.2% (11/98), respectively (P < 0.001). However, there was no difference of delayed bleeding rate between no med and DOAC group after propensity score matching (no med vs DOAC, 1.7% vs 10.0%, P = 0.160). Taking DOAC was not associated statistically with post-ESD bleeding when adjusted by age, sex, comorbidities and characteristics of target lesion (Adjusted Odds Ratio: 2.4, 95% Confidence intervals: 0.41-13.73, P = 0.335). Crude rate of bleeding in DOAC users seemed to be higher than no medication group after performing ESD with 2 days of medication cessation. When adjusted by age, sex, and comorbidity, however, this difference seems to be small, which suggests that gastric post-ESD bleeding may be influenced by patients' underlying condition in addition to medication use.

Effect of pregabalin on nociceptive thresholds and immune responses in a mouse model of incisional pain.

BACKGROUND: It is known that some analgesics as well as pain can affect the immune system. The aim of this study was to investigate the analgesic effect and immunomodulation of pregabalin (PGB) in a mouse incisional pain model. METHODS: A postoperative pain model was induced by hind paw plantar incision in male BALB/c mice. Mice were randomly divided into four groups (n = 8): a saline-treated incision (incision), PGB-treated incision (PGB-incision), sham controls without incision or drug treatment (control), and a PGB-treated control (PGB-control). In the PGB treated groups, PGB was administered intraperitoneally (IP) 30 minutes before and 1 hour after the plantar incision. Changes of the mechanical nociceptive thresholds following incision were investigated. Mice were euthanized for spleen harvesting 12 hours after the plantar incision, and natural killer (NK) cytotoxicity to YAC 1 cells and lymphocyte proliferation responses to phytohemagglutinin were compared among these four groups. RESULTS: Mechanical nociceptive thresholds were decreased after plantar incision and IP PGB administration recovered these decreased mechanical nociceptive thresholds (P < 0.001). NK activity was increased by foot incision, but NK activity in the PGB-incision group was significantly lower than that in the Incision group (P < 0.001). Incisional pain increased splenic lymphocyte proliferation, but PGB did not alter this response. CONCLUSIONS: Incisional pain alters cell immunity of the spleen in BALB/c mice. PGB showed antinocieptive effect on mouse incisional pain and attenuates the activation of NK cells in this painful condition. These results suggest that PGB treatment prevents increases in pain induced NK cell activity.

Effect of botulinum toxin in stellate ganglion for craniofacial hyperhidrosis: a case report.

Craniofacial hyperhidrosis causes sweating of the face and scalp due to excessive action of the sweat glands and manifests when patients become tense/nervous or develop an elevated body temperature. If noninvasive treatments are ineffective, invasive treatments such as a sympathetic block and resection are considered. A 32-year-old woman with no specific medical history was referred for uncontrolled craniofacial hyperhidrosis that included excessive sweating and hot flushing. Physical examination showed profuse sweating, and infrared thermography showed higher temperature in the neck and face than in the trunk. The patient underwent several stellate ganglion blocks, and her symptoms improved; however, the treatment effect was temporary. Botulinum toxin was then injected into the stellate ganglion. At the time of this writing, her sweating had been reduced for about 6 months and she was continuing to undergo follow-up. Craniofacial hyperhidrosis is a clinical condition in which patients experience excessive sweating of their faces and heads. It is less common than palmar and plantar hyperhidrosis. Botulinum toxin injection into the stellate ganglion is simple and safe and produces longer-lasting effects than other treatments, such as endoscopic sympathectomy and a single nerve block.

End-tidal CO2-guided automated robot CPR system in the pig. Preliminary communication.

BACKGROUND: Our aim was to compare the efficacy of the end-tidal CO2-guided automated robot CPR (robot CPR) system with manual CPR and mechanical device CPR. METHODS: We developed the algorithm of the robot CPR system which automatically finds the optimal compression position under the guidance of end-tidal CO2 feedback in swine models of cardiac arrest. Then, 18 pigs after 11 min of cardiac arrest were randomly assigned to one of three groups, robot CPR, LUCAS CPR, and manual CPR groups (n = 6 each group). Return of spontaneous circulation (ROSC) and Neurological Deficit Score 48 h after ROSC were compared. RESULTS: A ROSC was achieved in 5 pigs, 4 pigs, and 3 pigs in the robot CPR, LUCAS CPR, and manual CPR groups, respectively (p = 0.47). Robot CPR showed a significant difference in Neurological Deficit Score 48 h after ROSC compared to manual CPR, whereas LUCAS CPR showed no significant difference over manual CPR. (p = 0.01; Robot versus Manual adjusted p = 0.04, Robot versus LUCAS adjusted p = 0.07, Manual versus LUCAS adjusted p = 1.00). CONCLUSIONS: The end-tidal CO2-guided automated robot CPR system did not significantly improve ROSC rate in a swine model of cardiac arrest. However, robot CPR showed significant improvement of Neurological Deficit Score 48 h after ROSC compared to Manual CPR while LUCAS CPR showed no significant improvement compared to Manual CPR.

A Fortified Method to Screen and Detect Left Ventricular Hypertrophy in Asymptomatic Hypertensive Adults: A Korean Retrospective, Cross-Sectional Study.

PURPOSE: Left ventricular (LV) mass is determined by the wall thickness and diameter. LV hypertrophy (LVH), the increase in LV mass, is usually screened with electrocardiography but is often insensitive. We tried to fortify the rule to detect LVH using cardiothoracic ratio (CTR) in chest X-ray and well-known risk factors besides electrocardiography. MATERIALS AND METHODS: This retrospective cross-sectional study included asymptomatic hypertensive individuals aged ≥40 y who underwent voluntary checkups including echocardiography. Independent variables to explain LVH (LV mass index>115 g/m2 for men and >95 g/m2 for women calculated on echocardiography) were chosen among Sokolow-Lyon voltage amplitude (SLVA), CTR and cardiovascular risk factors by multiple logistic regression analysis. The diagnostic rule to detect LVH was made by summing up the rounded-off odds ratio of each independent variable and was validated using bootstrapping method. RESULTS: Among the 789 cases enrolled (202 females (25.6%), mean age 59.6±8.8 y), 168 (21.3%) had LVH. The diagnostic rule summed female, age≥65 y, BMI≥25 kg/m2, SLVA≥35 mm, and CTR≥0.50 (scoring 1 per each). Its c-statistics was 0.700 (95% CI: 0.653, 0.747), significantly higher (p<0.001) than that of SLVA≥35 mm, 0.522 (95% CI: 0.472, 0.572). The sensitivity and specificity of the model were 61.9% and 72.1% for score≥2 and 30.4% and 92.9% for score≥3. The SLVA≥35 mm criteria showed sensitivity of 12.5% and specificity of 91.9%. CONCLUSIONS: The rule to sum up the number of the risk factors of female, age≥65 y, BMI≥25 kg/m2, SLVA≥35 mm, and CTR≥0.50 may be a better diagnostic tool for screening LVH, than the electrocardiography-only criteria, at the score≥2.

Role of Quantitative Wall Motion Analysis in Patients with Acute Chest Pain at Emergency Department.

BACKGROUND: Evaluation of acute chest pain in emergency department (ED), using limited resource and time, is still very difficult despite recent development of many diagnostic tools. In this study, we tried to determine the applicability of new semi-automated cardiac function analysis tool, velocity vector imaging (VVI), in the evaluation of the patients with acute chest pain in ED. METHODS: We prospectively enrolled 48 patients, who visited ED with acute chest pain, and store images to analyze VVI from July 2005 to July 2007. RESULTS: In 677 of 768 segments (88%), the analysis by VVI was feasible among 48 patients. Peak systolic radial velocity (Vpeak) and strain significantly decreased according to visual regional wall motion abnormality (Vpeak, 3.50 ± 1.34 cm/s for normal vs. 3.46 ± 1.52 cm/s for hypokinesia, 2.51 ± 1.26 for akinesia, p < 0.01; peak systolic radial strain -31.74 ± 9.15% fornormal, -24.33 ± 6.28% for hypokinesia, -20.30 ± 7.78% for akinesia, p < 0.01). However, the velocity vectors at the time of mitral valve opening (MVO) were directed outward in the visually normal myocardium, inward velocity vectors were revealed in the visually akinetic area (VMVO, -0.85 ± 1.65 cm/s for normal vs. 0.10 ± 1.46 cm/s for akinesia, p < 0.001). At coronary angiography, VMVO clearly increased in the ischemic area (VMVO, -0.88+1.56 cm/s for normal vs. 0.70 + 2.04 cm/s for ischemic area, p < 0.01). CONCLUSION: Regional wall motion assessment using VVI showed could be used to detect significant ischemia in the patient with acute chest pain at ED.

Diagnostic Performance of Resting and Hyperemic Invasive Physiological Indices to Define Myocardial Ischemia: Validation With 13N-Ammonia Positron Emission Tomography.

OBJECTIVES: The authors sought to compare the diagnostic performance of fractional flow reserve (FFR), instantaneous wave-free ratio (iFR), and resting distal coronary artery pressure/aortic pressure (Pd/Pa) using 13N-ammonia positron emission tomography (PET). BACKGROUND: The diagnostic performance of invasive physiological indices was reported to be different according to the reference to define the presence of myocardial ischemia. METHODS: A total of 115 consecutive patients with left anterior descending artery stenosis who underwent both 13N-ammonia PET and invasive physiological measurement were included. Optimal cutoff values and diagnostic performance of FFR, iFR, and resting Pd/Pa were assessed using PET-derived coronary flow reserve (CFR) and relative flow reserve (RFR) as references. To compare discrimination and reclassification ability, each index was compared with integrated discrimination improvement (IDI) and category-free net reclassification index (NRI). RESULTS: All invasive physiological indices correlated with CFR and RFR (all p values <0.001). The overall diagnostic accuracies of FFR, iFR, and resting Pd/Pa were not different for CFR <2.0 (FFR 69.6%, iFR 73.9%, and resting Pd/Pa 70.4%) and RFR <0.75 (FFR 73.9%, iFR 71.3%, and resting Pd/Pa 74.8%). Discrimination and reclassification abilities of invasive physiological indices were comparable for CFR. For RFR, FFR showed better discrimination and reclassification ability than resting indices (IDI = 0.170 and category-free NRI = 0.971 for iFR; IDI = 0.183 and category-free NRI = 1.058 for resting Pd/Pa; all p values <0.001). CONCLUSIONS: The diagnostic performance of invasive physiological indices showed no differences in the prediction of myocardial ischemia defined by CFR. Using RFR as a reference, FFR showed a better discrimination and reclassification ability than resting indices.

Impact of Longitudinal Lesion Geometry on Location of Plaque Rupture and Clinical Presentations.

OBJECTIVES: This study sought to investigate the impact of longitudinal lesion geometry on the location of plaque rupture and clinical presentation and its mechanism. BACKGROUND: The relationships among lesion geometry, external hemodynamic forces acting on the plaque, location of plaque rupture, and clinical presentation have not been comprehensively investigated. METHODS: This study enrolled 125 patients with plaque rupture documented by intravascular ultrasound. Longitudinal locations of plaque rupture were identified and categorized by intravascular ultrasound. Patients' clinical presentations and TIMI (Thrombolysis In Myocardial Infarction) flow grade in an initial angiogram were compared according to the location of plaque rupture. Longitudinal lesion asymmetry was quantitatively assessed by the luminal radius change over the segment length (radius gradient [RG]). Lesions with a steeper radius change in the upstream segment compared with the downstream segment (RGupstream > RGdownstream) were defined as upstream-dominant lesions. RESULTS: On the basis of the site of maximum rupture aperture, 56.0%, 16.0%, and 28.0% of the patients had upstream, minimal lumen area, and downstream rupture, respectively. Patients with upstream rupture more frequently presented with ST-segment elevation myocardial infarction (45.7%, 40.0%, 22.9%; p = 0.030) and with TIMI flow grade <3 (32.9%, 20.0%, 17.1%; p = 0.042). According to the ratio of upstream and downstream RG, 69.5% of lesions were classified as upstream-dominant lesions, and 30.5% were classified as downstream-dominant lesions. Among the 66 upstream-dominant lesions, 65 cases (98.5%) had upstream rupture, and the RG ratio (RGupstream/RGdownstream) was an independent predictor of upstream rupture (odds ratio: 1.481; 95% confidence interval: 1.035 to 2.120; p = 0.032). Upstream-dominant lesions more frequently manifested with ST-segment elevation myocardial infarction than did downstream-dominant lesions (48.5% vs. 24.1%; p = 0.026). CONCLUSIONS: Both clinical presentation and degree of flow limitation were associated with the location of plaque rupture. Longitudinal lesion asymmetry assessed by RG, which can affect regional distribution of hemodynamic stress, was associated with the location of rupture and with clinical presentation.