Summary Background The American Heart Association recommends cardiopulmonary resuscitation (CPR) by bystanders with chest compression only for adults who have cardiac arrests, but not for children. ...We assessed the effect of CPR (conventional with rescue breathing or chest compression only) by bystanders on outcomes after out-of-hospital cardiac arrests in children. Methods In a nationwide, prospective, population-based, observational study, we enrolled 5170 children aged 17 years and younger who had an out-of-hospital cardiac arrest from Jan 1, 2005, to Dec 31, 2007. Data collected included age, cause, and presence and type of CPR by bystander. The primary endpoint was favourable neurological outcome 1 month after an out-of-hospital cardiac arrest, defined as Glasgow-Pittsburgh cerebral performance category 1 or 2. Findings 3675 (71%) children had arrests of non-cardiac causes and 1495 (29%) cardiac causes. 1551 (30%) received conventional CPR and 888 (17%) compression-only CPR. Data for type of CPR by bystander were not available for 12 children. Children who were given CPR by a bystander had a significantly higher rate of favourable neurological outcome than did those not given CPR (4·5% 110/2439 vs 1·9% 53/2719; adjusted odds ratio OR 2·59, 95% CI 1·81–3·71). In children aged 1–17 years who had arrests of non-cardiac causes, favourable neurological outcome was more common after bystander CPR than no CPR (5·1% 51/1004 vs 1·5% 20/1293; OR 4·17, 2·37–7·32). However, conventional CPR produced more favourable neurological outcome than did compression-only CPR (7·2% 45/624 vs 1·6% six of 380; OR 5·54, 2·52–16·99). In children aged 1–17 years who had arrests of cardiac causes, favourable neurological outcome was more common after bystander CPR than no CPR (9·5% 42/440 vs 4·1% 14/339; OR 2·21, 1·08–4·54), and did not differ between conventional and compression-only CPR (9·9% 28/282 vs 8·9% 14/158; OR 1·20, 0·55–2·66). In infants (aged <1 year), outcomes were uniformly poor (1·7% 36/2082 with favourable neurological outcome). Interpretation For children who have out-of-hospital cardiac arrests from non-cardiac causes, conventional CPR (with rescue breathing) by bystander is the preferable approach to resuscitation. For arrests of cardiac causes, either conventional or compression-only CPR is similarly effective. Funding Fire and Disaster Management Agency and the Ministry of Education, Culture, Sports, Science and Technology (Japan).
Background The stratum corneum and tight junctions (TJs) form physical barriers in the epidermis. Dendrites of activated Langerhans cells (LCs) extend beyond the TJs to capture external antigens in ...mice. LCs and inflammatory dendritic epidermal cells (IDECs) are observed in the skin of patients with atopic dermatitis (AD). Objective We sought to investigate the characteristics of LCs and IDECs and the distribution of their antigen capture receptors in relation to TJs in normal and AD skin. Methods We characterized the interactions of LCs and IDECs with TJs and the expression patterns of langerin and FcεRI by using whole-mount epidermal sheets from healthy subjects and patients with AD, ichthyosis vulgaris, and psoriasis vulgaris. Results As in mouse skin, activated LCs penetrate TJs in human skin. The number of LCs with TJ penetration increased approximately 5-fold in erythematous lesional skin of patients with AD but not in nonlesional skin of patients with AD or lesions of patients with ichthyosis vulgaris or psoriasis. In contrast, IDECs localized in the lower part of the epidermis, and their dendrites extended horizontally without penetration through TJs. Although langerin accumulated on the tips of dendrites of activated LCs, FcεRI was expressed diffusely on the cell surfaces on LCs and IDECs in lesional skin from patients with AD. Conclusions These findings highlight interesting differences between LCs and IDECs in epidermis of patients with AD, where LCs, but not IDECs, extend dendrites through the TJs, likely to capture antigens from outside the TJ barrier with a polarized distribution of langerin but not FcεRI. These behavioral differences between skin dendritic cells might reflect an important pathophysiology of AD.
Abstract Background Takotsubo cardiomyopathy (TC) is an acute cardiac syndrome characterized by transient left ventricular dysfunction and relatively good prognosis after discharge. However, cardiac ...complications during hospitalization remain to be fully determined. We attempted to determine features characterizing patients with adverse clinical outcome by comparing those with cardiac complication and without cardiac complication during hospitalization. Methods and results We investigated 107 patients with TC from the Tokyo CCU Network database, comprising 67 cardiovascular centers in the metropolitan area during January 1 to December 31, 2010. Cardiac complications were defined as cardiac death, pump failure (Killip grade ≥ II), sustained ventricular tachycardia or fibrillation (SVT/VF), and advanced atrioventricular block (AVB). Cardiac complications were observed in 41 patients (37 pump failure complicated by 3 cardiac deaths and 2 SVT/VF and 2 AVB without pump failure), and there was no cardiac complication in the remaining 66 patients. There was no difference in age, peak creatinine kinase level, C-reactive protein level and ST elevation on electrocardiogram. Multiple logistic regression analysis showed that white blood cell count ( p = 0.039) and brain natriuretic peptide ( p = 0.001) were independent predictors of in-hospital adverse cardiac complications. Conclusions Cardiac complications are relatively high in patients with TC during hospitalization. High white blood cell count and brain natriuretic peptide level are associated with poor clinical outcome in patients with TC.
Abstract Background Little is known about physiological anticoagulation effects via antithrombin III (AT III) and protein C/S (PC/PS) in patients using new oral anticoagulants (NOACs). Methods We ...evaluated 120 consecutive patients with non-valvular atrial fibrillation (AF) receiving NOACs. Patients were randomly divided into three groups: a dabigatran group (DG, N =40), a rivaroxaban group (RG, N =40) or an apixaban group (AG, N =40). A warfarin group (WG, N =40) was matched with NOAC groups for age, sex and type of AF during the same time period. Blood samples were obtained in pretreatment, trough and peak phases to measure the activity of physiological coagulation inhibitors, including AT III and PC/PS or thrombus formation markers such as D-dimer and thrombin–antithrombin complex (TAT). Results D-dimer, TAT and AT III values for the NOAC groups were equivalent in the peak and trough phases. PC/PS activity in both phases was equally maintained in the pretreatment phase in the NOAC groups, while the activity in the WG was significantly suppressed in steady state. Moreover, no differences in trends for PC/PS activity were observed among NOAC groups. Conclusions PC/PS activity was constant in both peak and trough phases in the patients on NOACs compared with activity of those on warfarin. In addition, there was no difference in the findings among NOACs.
This study aimed to assess the balance of serum n-3 to n-6 polyunsaturated fatty acids (PUFAs) in patients with acute coronary syndrome (ACS). We enrolled 1,119 patients who were treated and in whom ...serum PUFA level was evaluated in 5 divisions of cardiology in a metropolitan area in Japan. Serum levels of PUFAs, including eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and arachidonic acid (AA), were compared between patients with and without ACS. We also evaluated the balance of serum n-3 to n-6 PUFAs, including EPA/AA and DHA/AA ratios. EPA/AA values were 0.46 ± 0.32 and 0.50 ± 0.32 in the ACS and non-ACS groups, respectively. DHA/AA values were 0.95 ± 0.37 and 0.96 ± 0.41 in the ACS and non-ACS groups, respectively. Next, we divided the patients into 3 groups based on the tertiles of EPA/AA or tertiles of DHA/AA to determine the independent risk factors for ACS. According to multivariate logistic regression analysis, the group with the lowest EPA/AA (≤0.33) had a greater probability of ACS (odds ratio 3.14, 95% confidence interval 1.16 to 8.49), but this was not true for DHA/AA. In conclusion, an imbalance in the ratio of serum EPA to AA, but not in the ratio of DHA to AA, was significantly associated with ACS.
Dipeptidyl peptidase-4 (DPP-4) inhibitors may affect the serum levels of plasminogen activator inhibitor-1 (PAI-1) associated with triglyceride (TG) metabolism, which is a prognostic factor for ...cardiovascular disease, in diabetic patients. We conducted an 8-week, prospective, randomized study in which we assigned type 2 diabetic patients who were inadequately controlled with antidiabetic therapy to the vildagliptin group (50 mg bid, n = 49) or the control group (n = 49). The primary efficacy parameter was the change in the serum level of PAI-1, and the secondary end point was the change in the serum levels of TG-rich lipoproteins. In the vildagliptin group, significant decrease of the serum PAI-1 level by 16.3% (p <0.0001) and significant decreases of the serum TG, remnant-like particle cholesterol, and apolipoprotein B levels by 12.1% (p = 0.002), 13.9% (p = 0.003), and 9.5% (p <0.0001), respectively, were observed. No such changes were observed in the control group. Multivariate regression analyses identified the absolute change from the baseline (Δ) of the PAI-1, but not that of the fasting blood glucose or hemoglobin A1c, as independent predictors of the ΔTG, Δ remnant-like particle cholesterol, and Δ apolipoprotein B. In conclusion, treatment of type 2 diabetes with vildagliptin might prevent the progression of atherosclerotic cardiovascular disease in diabetic patients by decreasing the serum PAI-1 levels and improving TG metabolism.
Abstract Background Several studies from Western countries have reported associations between cardiac troponin and B-type natriuretic peptide (BNP) levels and acute pulmonary embolism prognosis; ...however, the number of such reports from Asian countries, including Japan, is limited. Thus, we evaluated the relationship between blood biochemical findings and acute-phase pulmonary embolism prognosis in Japanese patients. Methods The subjects included 441 patients with acute pulmonary embolism (191 men, 250 women; average age, 65.8 ± 16.0 years) treated at Tokyo CCU Network Institutions from 2009 to 2011 and registered via survey forms. The association between blood biochemical findings at admission and 30-day mortality was investigated. Results The median BNP value was 186.5 pg/mL (25th to 75th interquartile range: 49.8–500 pg/mL) of 210 cases. No deaths were recorded among those with BNP levels <90 pg/mL ( n = 70), whereas significantly higher mortality (10 deaths/140 cases, 7.1%; p = 0.033) was observed among those with BNP levels ≥90 pg/mL. A qualitative cardiac troponin test was positive in 58 of the 204 cases (28.4%), with a significantly higher mortality incidence ( p = 0.017) among the troponin-positive cases 6 (10.3%) versus 3 (2.1%) deaths among the 146 troponin-negative cases. The overall mean blood glucose level at admission of 331 cases was 152.0 ± 74.0 mg/dL, and 30-day mortality significantly increased with blood glucose values ( p = 0.048). Conclusions Troponin, BNP, and blood glucose levels are useful prognostic biomarkers for acute pulmonary embolism in Japanese patients.
Abstract Background Acute heart failure (AHF) is one of the most frequently encountered cardiovascular conditions that can seriously affect the patient’s prognosis. However, the importance of early ...triage and treatment initiation in the setting of AHF has not been recognized. Methods and Results The Tokyo Cardiac Care Unit Network Database prospectively collected information of emergency admissions to acute cardiac care facilities in 2005–2007 from 67 participating hospitals in the Tokyo metropolitan area. We analyzed records of 1,218 AHF patients transported to medical centers via emergency medical services (EMS). AHF was defined as rapid onset or change in the signs and symptoms of heart failure, resulting in the need for urgent therapy. Patients with acute coronary syndrome were excluded from this analysis. Logistic regression analysis was performed to calculate the risk-adjusted in-hospital mortality. A majority of the patients were elderly (76.1 ± 11.5 years old) and male (54.1%). The overall in-hospital mortality rate was 6.0%. The median time interval between symptom onset and EMS arrival (response time) was 64 minutes (interquartile range IQR 26–205 minutes), and that between EMS arrival and ER arrival (transportation time) was 27 minutes (IQR 9–78 minutes). The risk-adjusted mortality increased with transportation time, but did not correlate with the response time. Those who took >45 minutes to arrive at the medical centers were at a higher risk for in-hospital mortality (odds ratio 2.24, 95% confidence interval 1.17–4.31; P = .015). Conclusions Transportation time correlated with risk-adjusted mortality, and steps should be taken to reduce the EMS transfer time to improve the outcome in AHF patients.
Abstract Background It is unclear whether the number of paramedics in an ambulance improves the outcome of patients with out-of-hospital cardiac arrest (OHCA) or not. Methods and Results This study ...was a prospective, observational study conducted on patients with OHCA. Patients were divided into the One-paramedic group (Group O) and the Two-or-more-paramedic group (Group T) and we analyzed the differences. Patients who were treated with only basic life support during transportation, and whose cause of cardiac arrest were extrinsic cause such as trauma and poisoning were excluded. Good neurological outcome was defined as cerebral performance category (CPC) 1 or 2. In Group O, there were 1516 patients (male/female, 922/594). In Group T, there were 2932 patients (male/female, 1798/1134). Return of spontaneous circulation (ROSC) was obtained in 528 patients (34.8%) in Group O and 1058 patients (36.1%) in Group T (p = 0.589). 320 patients (21.1%) in Group O and 656 patients (22.4%) in Group T were admitted to hospital after ROSC (p = 0.461). At 90 days, there were 57 survivors (3.8%) in Group O and 114 survivors (3.9%) in Group T (p = 0.873). At 90 days, 14 patients (0.9%) in Group T had a CPC of 1 or 2, while 30 patients (1.0%) in Group T did so (p = 0.87). From the results of logistic regression analysis, age odds ratio (OR): 0.983, 95% confidence interval (CI): 0.952
–
0.993, witnessed OHCA (OR: 4.583, 95% CI: 1.587
–
13.234), and shockable rhythm as first documented (OR: 19.67, 95% CI: 9.181
–
42.13) were associated with good outcome. Conclusion The number of paramedics in an ambulance did not affect the outcome in OHCA patients.
Optimal coronary reflow is the critical key issue to ameliorate clinical outcomes in patients with cardiogenic shock complicating ST-segment elevation myocardial infarction (Shock-STEMI). We ...investigated our hypothesis that pre-percutaneous coronary intervention (PCI) procedural coronary thrombectomy may provide clinical advantages to attempt optimal coronary reflow in patients with Shock-STEMI. Of 7,650 patients with acute myocardial infarction registered in the Tokyo CCU Network Scientific Council from January 2009 to December 2011, a total of 180 consecutive patients (144 men, 68 ± 13 years) with Shock-STEMI who showed pre-PCI procedural Thrombolysis in Myocardial Infarction flow grade 0 (absent initial coronary flow) were recruited. Achievements of post-PCI procedural Thrombolysis in Myocardial Infarction flow grade 3 (optimal coronary reflow) and also in-hospital mortality were evaluated in those in accordance with and without coronary thrombectomy. Coronary thrombectomy was performed in 128 patients with Shock-STEMI (71% of all). Overall in-hospital mortality was 41% and that in anterior Shock-STEMI with a necessity of mechanical circulatory support increased by 59% (i.e., profound shock). Coronary thrombectomy did not affect any improvements in the achievement of optimal coronary reflow (65% vs 58%, p = 0.368) and in-hospital mortality (42% vs 37%, p = 0.484) in these patients. Even when focused on 76 patients with profound shock, neither an achievement of optimal coronary reflow (56% vs 47%, p = 0.518) nor in-hospital mortality (58% vs 65%, p = 0.601) were different between with and without coronary thrombectomy. Multivariate logistic analysis did not demonstrate any association of coronary thrombectomy (p = 0.798), left main Shock-STEMI (p = 0.258), and use of mechanical circulatory support (p = 0.119) except a concentration of hemoglobin (for each 1 g/dl increase, odds ratio 1.247, 95% confidence interval 1.035 to 1.531, p = 0.019) with optimal coronary reflow. In conclusion, pre-PCI procedural coronary thrombectomy may have serious limitations on attempting optimal coronary reflow that indicates a necessity of promising strategies for this critical illness.
PDF
