Comparison of tumor markers and inflammatory biomarkers in chronic obstructive pulmonary disease (COPD) exacerbations.

OBJECTIVE: The aim of the present study was: (a) to measure levels of the tumor markers, Carcinoembryonic antigen (CEA), Cancer antigen 19-9 (CA19-9), Cancer antigen 125 (CA125), Neuron specific enolase (NSE) and Cytokeratin fragments 19 (CYFRA21-1); (b) to investigate any correlation between them and the inflammatory biomarkers C-reactive protein (CRP), Erythrocyte sedimentation rate (ESR) and white blood cells count (WBC), in patients with chronic obstructive pulmonary disease (COPD) exacerbation, who belong in groups of severity C and D, as classified by the Global Initiative for Chronic Obstructive Lung Disease (GOLD); (c) and finally, to compare these results in these two groups. MATERIAL AND METHODS: Fifty-two patients with COPD exacerbation [35 male/17 female, mean age (± SD) 68.3 ± 6.4 years] were the study subjects, and were classified in severity groups C (n = 27) and D (n = 25), based on the spirometric classification, the number of exacerbations in the preceding year and the assessment of their symptoms by GOLD. Results. CEA and CA125 were increased in group D. In group C, there was a significant correlation between CRP and CA125 (p = 0.05). In group D, there was a significant correlation between WBC and NSE (p = 0.02), between CRP and CA19-9 (p = 0.02) and NSE (p < 0.001), and between the ESR and NSE (p = 0.03). CA125 (p = 0.01) and CA19-9 (p = 0.01) were significantly higher in group D compared to group C. In contrast, there was no significant difference in two groups for NSE, CEA and CYFRA21-1. CONCLUSION: Certain tumor markers were increased and were associated with increased levels of inflammatory biomarkers and with the disease severity. Inflammation might have a key pathogenetic role linking the above tumor markers with the severity of COPD.

Supreme Laryngeal Mask Airway achieves faster insertion times than Classic LMA during chest compressions in manikins.

BACKGROUND: According to the 2010 European Resuscitation Council guidelines on cardiopulmonary resuscitation (CPR), one can appreciate that the classic laryngeal mask airway (CLMA) is acceptable as an alternative airway device to endotracheal intubation for airway management in cardiac arrest victims. OBJECTIVE: To compare a relatively new supraglottic airway device, the Supreme Laryngeal Mask Airway (SLMA), with the CLMA in a cardiac arrest scenario. METHODS: Fifty healthcare professionals inexperienced in advanced airway management attempted to insert both airway devices in a manikin in 2 scenarios: in the first, chest compressions were not performed (non-CPR scenario), and in the second, uninterrupted chest compressions were performed (CPR scenario). The primary end points were insertion time and success rate at first attempt. The level of self-confidence of each participant was recorded. RESULTS: SLMA achieves faster insertion times both in the non-CPR (SLMA: 10.4 ± 2.7 seconds vs CLMA: 13.4 ± 3.2 seconds, P < .05) and in the CPR scenario (SLMA: 9.9 ± 2.0 seconds Vs CLMA: 11.9 ± 2.3 seconds, P < .05). The difference between first attempt success rates was not statistically significant both in the non-CPR (SLMA: 96% vs CLMA: 90%, P = .18) and in the CPR scenario (SLMA: 98% vs CLMA: 94%, P = .32). The participants are more self-confident using SLMA instead of CLMA (P < .001) and 94% of them would prefer SLMA for future use. CONCLUSION: SLMA could be a useful alternative to CLMA during CPR in the hands of healthcare professionals with minimal experience in airway management.

The role of opioid receptor agonists in ischemic preconditioning.

Opioids and their receptor agonists have been widely used because of their beneficial effects on pain management and control. Over the past decade, there has been an increasing interest on the experimental use of opioid agonists in the laboratory setting of ischemia and reperfusion; existing data suggest that there is a potential association between opioid agonism and the reduction of infarct size in several animal models of regional ischemia similar to that following ischemic preconditioning. Most of these studies seem to attribute these beneficial and cardioprotective effects to the stimulation of a specific opioid receptor type, the delta (δ) opioid receptor. This review focuses on the role of the delta opioid receptor agonism in several models of ischemia and reperfusion, as well as on hemorrhagic shock models, on the potential mechanisms of action following delta opioid receptor activation and on the time window for opioid administration in various animal studies.

An intraoperative case of spontaneous restoration of circulation from asystole: a case of lazarus phenomenon.

This case report refers to a victim of intraoperative cardiac arrest, who restored spontaneous circulation despite of cessation of cardiopulmonary resuscitation (CPR). The victim, a 53-year-old man, was undergoing a surgical investigation and rehabilitation of a thigh hematoma. Two minutes after discontinuation of a 46 min CPR, a normotensive sinus node rhythm appeared at monitor. Despite of lack of an adequate explanation, the authors believe that the combination of the high total dose of adrenaline with the cessation of mechanical ventilation might augment venous return and lead to restoration of spontaneous circulation.

A comparison of the i-gel and classic LMA insertion in manikins by experienced and novice physicians.

OBJECTIVE: Airway management is of utmost importance in critical patients, for whom endotracheal intubation remains the gold standard. However, it is a difficult skill to acquire and success rates in novices are unacceptably low. Supraglottic devices constitute promising alternatives. The aim of this study was to assess the use of laryngeal mask airway (LMA) classic LMA (cLMA) and a relatively new supraglottic device, the i-gel, in experienced and novice doctors in a manikin setting. METHODS: The study population comprised 116 doctors. After a brief educational session and presentation of cLMA and i-gel, participants were randomly allocated to insert both devices in an adult manikin. Insertions were performed using a size-4 cLMA and a size-4 i-gel. The primary endpoints were the success rate for each device and the duration of the insertion attempt. Secondary endpoint was the perception of ease of use with each device. RESULTS: First attempt success rate was 90.5% for i-gel and 63.8% for cLMA (P<0.001). I-gel use reduced insertion times (13.32±4.99 s vs. 17.99±6.87 s, P<0.001) and was related with significantly higher first attempt success rates than cLMA in novices (90 vs. 48.3%, P<0.001). In addition, i-gel use provided almost equal success rates for experienced and novice doctors (91 vs. 90%, P=not significant), whereas cLMA use resulted in significantly lower success rates for novices (48.3 vs. 80.4%, P<0.001). CONCLUSION: In this manikin setting i-gel significantly improved success rates and insertion time compared with cLMA. Most importantly, i-gel use resulted in high first pass success rates for novice doctors, equal to those achieved by experienced doctors.

Inexperienced nurses and doctors are equally efficient in managing the airway in a manikin model.

OBJECTIVE: The aim of the present study was to investigate whether minimally trained medical and nursing school graduates would be equally efficient in placing a laryngeal mask airway (LMA) and in intubating the trachea with the Macintosh blade or a videolaryngoscope in a manikin model. Airway management is an essential skill for both physicians and nurses who may be confronted with a critically ill patient, because in the emergency department the airway is not exclusively managed by medical personnel. Several studies have shown that other healthcare professionals are not any less efficient in securing the airway. METHODS: Ninety-six graduates from medical and nursing faculties comprised our study population. After a brief educational session, participants were randomly allocated into 3 groups to secure the airway in manikins with 3 techniques: LMA (The Laryngeal Mask Company Limited, Buckinghamshire, UK) insertion and intubation with the Macintosh blade and with a videolaryngoscope (GlideScope, Verathon Inc, Bothell, WA). The number of attempts until the first successful intubation, time required for the first successful attempt, and severity of dental trauma were assessed. RESULTS: No statistically significant difference was observed between physicians and nurses in the number of attempts and in the time required for the first successful attempt with any of the 3 techniques studied. From the 3 techniques studied, LMA placement was the fastest (P < .001). No significant difference was observed between physicians and nurses in the severity of dental trauma. CONCLUSION: Nurses are as efficient as physicians in managing the airway safely and adequately with the 3 different techniques in manikins.

Glidescope(®) videolaryngoscope improves intubation success rate in cardiac arrest scenarios without chest compressions interruption: a randomized cross-over manikin study.

AIM: The aim of this study was to assess the performance of the Glidescope(®) in a manikin cardiopulmonary resuscitation (CPR) scenario. METHODS: Following a brief didactic session, 45 volunteer doctors inexperienced with airway management, attempted to intubate a manikin using a Macintosh laryngoscope and Glidescope(®) with uninterrupted and without chest compressions. Primary endpoints were intubation times and success rate with each device. Dental compression and level of self-confidence in using each device were also assessed. RESULTS: In the scenario without chest compressions the cumulative success rate related to time to intubation was significantly higher with the Macintosh blade than with the Glidescope(®) (p<0.001). On the contrary, in the scenario with continuous chest compressions, the cumulative rate related to time to intubation was significantly higher with the Glidescope(®) (p=0.035). Significantly fewer attempts were required for the first successful intubation with the Macintosh blade in the non-CPR scenario versus the CPR scenario (p=0.007). Moreover, the number of attempts for the first successful intubation was significantly lower for the Glidescope(®) in the non-CPR (p=0.001) and the CPR scenario (p<0.001). Dental compression was significantly lower with the Glidescope(®) in both scenarios (p<0.001). CONCLUSIONS: Using the GlideScope(®) in a manikin CPR scenario provides extremely high intubation success rates in short times with the first attempt, in medical practitioners inexperienced in intubation.

Abdominal compressions do not achieve similar survival rates compared with chest compressions: an experimental study.

AIM: The aim of this study is to investigate whether abdominal compression cardiopulmonary resuscitation (CPR) would result in similar survival rates and neurologic outcome than chest compression CPR in a swine model of cardiac arrest. MATERIALS AND METHODS: Forty Landrace/Large White piglets were randomized into 2 groups: group A (n = 20) was resuscitated using chest compression CPR, and group B (n = 20) was resuscitated with abdominal compression CPR. Ventricular fibrillation was induced with a pacemaker catheter, and animals were left untreated for 8 minutes. Abdominal and chest compressions were applied with a mechanical compressor. Defibrillation was then attempted. RESULTS: Neuron-specific enolase and S-100 levels were significantly higher in group B. Ten animals survived for 24 hours in group A in contrast to only 3 animals in group B (P < .05). Neurologic alertness score was worse in group B compared with group A. CONCLUSION: Abdominal compression CPR does not improve survival and neurologic outcome in this swine model of cardiac arrest and CPR.

Conventional direct laryngoscopy versus videolaryngoscopy with the GlideScope®: a neonatal manikin study with inexperienced intubators.

We hypothesized that because the view of the glottis is better with videolaryngoscopes, successful intubation in neonates would be accomplished in a shorter time with the GlideScope (®) (Verathon, Inc., Bothell, WA) videolaryngoscope (GVL). Forty-five students of the University of Athens, inexperienced in both techniques, participated in the study (21 medical students and 24 nursing students, crossover randomized study). Following a brief educational session, each participant practiced and attempted intubation on a neonatal manikin using conventional laryngoscope and GVL, as many times as required to secure the airway. The time required to successful intubation and the number of attempts with each device were recorded. No significant difference was observed between the number of attempts required for successful intubation with either laryngoscope. The time required for the first successful intubation with the conventional laryngoscope was significantly shorter compared with that required with the GVL ( P = 0.0013). There was no difference regarding the time required for the successful intubation between medical and nursing students, using the conventional laryngoscope or the GVL. The number of attempts to successful intubation with either device did not differ. The time required for intubation with the GVL was longer, and this is probably due to a design flaw.

Ischaemia-modified albumin predicts the outcome of cardiopulmonary resuscitation: An experimental study.

INTRODUCTION: Ischaemia-modified albumin (IMA) has recently been shown to be an early and sensitive marker of ischaemia. It is generally accepted that cardiac arrest causes the most severe form of global ischaemia. The aim of the present study was to identify whether IMA is an independent predictor of return of spontaneous circulation (ROSC) in a swine model of cardiac arrest. METHODS: Ventricular fibrillation (VF) was induced in 30 piglets, which were left untreated for 8 min before attempting resuscitation with precordial compression, mechanical ventilation and electrical defibrillation. Electrical defibrillation was attempted after 10 min of VF. Blood samples for IMA determination were drawn at baseline, after 8 min of VF and before delivery of each shock. A binary logistic regression model was implemented for the prediction of animals achieving ROSC from data available before the first defibrillation attempt. Backward stepwise selection was used to extract the final model. Inclusion and exclusion significance levels were 0.1 and 0.05, respectively. Receiver operating characteristic curves were used to determine the diagnostic accuracy, sensitivity and specificity of the parameters and to obtain the appropriate cut-off points. RESULTS: IMA exhibited 100% sensitivity and 93.8% specificity in defining the subgroup of animals that will achieve ROSC. This high-accuracy prediction had a very early onset (from eighth VF minute) and remained at the same level until the end of the experiment. When combining IMA and coronary perfusion pressure (CPP) measurements from the first CPR cycle in the form of the simple ratio IMA/CPP, a cut-off point of 7 could provide 100% sensitivity and specificity in distinguishing the animals that will achieve ROSC in the upcoming defibrillation attempts. CONCLUSIONS: Until today, CPP has been found to be the only key determinant of successful resuscitation. Our study suggests that IMA can be a predictive index of ROSC even before the initiation of CPR.

Distribution of pre-course BLS/AED manuals does not influence skill acquisition and retention in lay rescuers: a randomised study.

AIM: The present study aims to investigate whether the distribution of the Basic Life Support and Automated External Defibrillation (BLS/AED) manual, 4 weeks prior to the course, has an effect on skill acquisition, theoretical knowledge and skill retention, compared with courses where manuals were not distributed. METHODS: A total of 303 laypeople were included in the present study. The courses were randomised with sealed envelopes in 12 courses, where manuals were distributed to participants (group A) and in 12 courses, where manuals were not distributed to participants (group B). The participants were formally evaluated at the end of the course, and at 1, 3 and 6 months after each course. The evaluation procedure was the same at all time intervals and consisted of two distinct parts: a written test and a simulated cardiac arrest scenario. RESULTS: No significant difference was observed between the two groups in skill acquisition at the time of initial training. Furthermore, there was no significant difference between the groups in performing BLS/AED skills at 1, 3 and 6 months after initial training. Theoretical knowledge in either group at the specified time intervals did not exhibit any significant difference. Significant deterioration of skills was observed in both groups between initial training and at 1 month after the course, as well as between the first and third month after the course. CONCLUSION: The present study shows that distribution of BLS/AED manuals 1 month prior to the course has no effect on theoretical knowledge, skill acquisition and skill retention in laypeople.

Combination pharmacotherapy in the treatment of experimental cardiac arrest.

STUDY OBJECTIVES: Full recovery after cardiopulmonary resuscitation (CPR) is poor. We hypothesized that the coadministration of epinephrine, a beta-blocker such as atenolol, and a calcium sensitizer such as levosimendan during CPR would improve survival and postresuscitation myocardial function. METHODS: Ventricular fibrillation was induced in 60 piglets, which were left untreated for 8 minutes before attempted resuscitation. Animals were randomized into 4 groups (n = 15), to receive epinephrine (group E), epinephrine + atenolol (group E + A), epinephrine + levosimendan (group E + L) and epinephrine + atenolol + levosimendan (group E + A + L) during CPR. Electrical defibrillation was attempted 2 minutes after drug administration. RESULTS: Five animals in group E survived for 48 hours in comparison to 8 animals in groups E + A and E + L and 12 animals in group E + A + L. Postresuscitation cardiac output was significantly better in the animals of group E + A + L. Troponin I remained significantly lower in groups E + A and E + A + L. Serum astroglial protein (S-100) and neuron-specific enolase values in group E + L and E + A + L were statistically lower than those measured in groups E and E + A during the entire observation period. The neurologic alertness score was higher in group E + A + L compared to groups E and E + A. CONCLUSIONS: The administration of a drug combination of epinephrine + atenolol + levosimendan, when given during CPR, in a pig model of cardiac arrest, results in improved 48-hour survival and improves postresuscitation cardiac function.

The potential beneficial effects of beta adrenergic blockade in the treatment of ventricular fibrillation.

Cardiac arrest remains a major medical emergency in Western societies, with ventricular fibrillation being the initial rhythm in a significant proportion of cases. Adrenaline is generally accepted to improve the resuscitation outcome, since it improves coronary and cerebral blood flow during cardiopulmonary resuscitation, but several detrimental effects have been associated with its use, most of which are thought to be mediated by its beta adrenergic properties. Several animal studies suggest that beta adrenergic blockade during resuscitation, is associated with increased rates of resuscitation and improved post-resuscitation myocardial function. This article reviews the presence and function of beta-adrenoceptor subtypes in the intact and diseased human myocardium, as well as the differences observed in beta(1)- and beta(2) adrenoceptor subtypes in different species.

Using the 30:2 compression-ventilation ratio: five cycles is easier to follow than 2 min of cardiopulmonary resuscitation.

This study assessed the time it takes for newly trained basic life-support/automated external defibrillator (BLS/AED) providers to complete five cycles of cardiopulmonary resuscitation (CPR) and whether it is easier to follow a 2-min time frame or to count five cycles of CPR. Then, it assesses how many chest compressions are delivered with each of the two methods and the time needed to deliver the first two rescue breaths. Eighty BLS/AED providers were asked to provide 2 min of CPR with a compression-ventilation ratio of 30:2 and at a compression rate of 100/min without looking at any timing device and then to provide five cycles of CPR with the same compression-ventilation ratio. The number of chest compressions delivered, the time needed to complete five cycles of CPR, and the time needed to perform the first two rescue breaths were recorded. Finally, a scripted set of questions was asked to each participant. The time required to perform five cycles of CPR was 115+/-5 s and to perform the 2 min of CPR was 102+/-19 s (P = NS). Chest compressions delivered in the presumed 2-min CPR were 123+/-12 and 149+/-2 in the five cycles CPR (P<0.05). Sixty-two participants (77.5%) found it easier to count five cycles of CPR. The time needed to deliver the first two rescue breaths was between 12 and 15 s. The average time to complete five cycles of CPR is approximately 2 min for newly trained BLS/AED providers and the majority of the participants found it easier to perform five cycles.

Nurses are more efficient than doctors in teaching basic life support and automated external defibrillator in nurses.

BACKGROUND: Cardiac arrest (CA) is a leading cause of death worldwide. The European Resuscitation Council (ERC) has developed basic life support/automated external defibrillation (BLS/AED) courses for uniform training in out-of-hospital CA. OBJECTIVE: The present study compares the resuscitation skills of two groups of nursing staff, one taught by newly trained ERC nurse-instructors and the other by newly trained doctor-instructors. METHOD: Eighteen doctors and 18 nurses were asked to teach a total of 108 nurses in a (BLS/AED) course. One month after its completion, all 108 nurses were asked to be re-evaluated, with the use of the objective structured clinical examination. CONCLUSIONS: No statistical significant difference between the two groups was noted in the written test, in contrast with data collected from the practice skills check-list. Nurses in group A could easily identify the patient in cardiac arrest but had difficulties concerning chest compressions and handling the AED. Nurses in group B were more focused during the performances, used AED more accurately and continued cardiopulmonary resuscitation with no delays. Nurses prove to be more efficient in training nurses.

Atenolol in combination with epinephrine improves the initial outcome of cardiopulmonary resuscitation in a swine model of ventricular fibrillation.

STUDY OBJECTIVES: The aim of the present study was to assess whether a beta-adrenergic blocking agent such as atenolol, administered during cardiopulmonary resuscitation, would improve initial resuscitation success. METHODS: Ventricular fibrillation was induced in 20 Landrace/Large White piglets, which were left untreated for 8 minutes before attempted resuscitation with precordial compression, mechanical ventilation, and electrical defibrillation. Animals were randomized into 2 groups (10 animals each) to receive saline as placebo (20 mL dilution, bolus) + epinephrine (0.02 mg/kg) (group A) or atenolol (0.05 mg/kg per 20 mL dilution, bolus) + epinephrine (0.02 mg/kg) (group B) during cardiopulmonary resuscitation. Electrical defibrillation was attempted after 10 minutes of ventricular fibrillation. RESULTS: Nine animals in group B restored spontaneous circulation in comparison to only 4 in group A. Aortic systolic and diastolic pressures as well as coronary perfusion pressure were significantly increased during cardiopulmonary resuscitation in group B. Furthermore, postresuscitation heart rate of the atenolol-treated group was significantly decreased. CONCLUSIONS: A beta-adrenergic blocking agent, when administered during cardiopulmonary resuscitation, significantly improves initial resuscitation success and increases blood and coronary perfusion pressures during cardiopulmonary resuscitation.

Cardiac implications of Lyme disease, diagnosis and therapeutic approach.

Lyme is a tick-borne disease. The genetic diversity of Borreliae its distribution worldwide and its epidemiology have been related to different clinical manifestations. Carditis is a rare manifestation of Lyme disease. The commonest abnormality is atrioventricular block of various degrees, though other rhythm abnormalities have been reported. Pericarditis, myocarditis, cardiomyopathy and degenerative valvular disease have been associated with B. burgdorferi. Temporary pacing might be required in unstable patients. The majority of the conduction disturbances have a benign prognosis, if the infectious agent is identified and treated appropriately.

Baseline hemodynamics in anesthetized landrace-large white swine: reference values for research in cardiac arrest and cardiopulmonary resuscitation models.

The use of swine in cardiopulmonary resuscitation (CPR) research has increased in the last decades. Landrace-Large White (LLW) swine are a farm breed of pigs. The aims of the present study were to describe the baseline hemodynamics of this breed and to demonstrate that it is suitable for CPR research. The systolic and diastolic pressures of the descending aorta (mean +/- 1 standard deviation; n = 29) were 111.72 +/- 13.61 and 79.03 +/- 12.08 mm Hg, respectively, whereas the mean systolic and diastolic pressures of the left ventricle were 108.97 +/- 12.06 and 8.88 +/- 1.81 mm Hg, respectively. The mean pressures of the right atrium were 10.93 +/- 1.36 mm Hg (systolic) and 4.10 +/- 1.01 mm Hg (diastolic), whereas the value obtained by using near-infrared spectroscopy to determine brain regional oxygen saturation was 64.55% +/- 3.88%. LLW can be considered a suitable breed for CPR research because of the close similarity of its hemodynamic values to those of humans.

Intravenous and oral administration of amiodarone for the treatment of recent onset atrial fibrillation after digoxin administration.

BACKGROUND: Atrial fibrillation (AF) remains a significant contributor to cardiovascular morbidity. Amiodarone is a potent antiarrhythmic drug. The safety and efficacy of oral versus intravenous (i.v.) Amiodarone in the treatment of AF of recent onset (duration <48 h) was investigated. METHODS: The study population consisted of 223 patients with symptomatic AF, of whom 110 received 600 mg oral Amiodarone (Group A) in three divided doses and 113 received i.v. Amiodarone (5 mg/kg over 30 min followed by 1000 mg over the next 24 h) (Group B). Digoxin was administered to all patients, who had not previously received it. All patients were monitored for 24 h. RESULTS: Conversion to sinus rhythm occurred in 85.45% of group A and 82.30% in group B (p=NS). Mean time of cardioversion in group A was 20+/-4.5 h and in group B was 12+/-8 h (p<0,001). However, blood pressure (BP) in group A remained stable for the observation period, whereas it fell significantly in group B. Treatment was not discontinued in any of the patients in either group, however 13 patients in group B developed superficial phlebitis. CONCLUSIONS: Both forms of the drug are extremely efficient in restoring sinus rhythm in AF of recent onset, although the i.v. form acts quicker. The oral form of the drug does not alter significantly the patients' BP.