Video characteristics for remote recognition of agonal respiration: A pilot study.

Aim: The mobile network quality in ambulances can be variable and limited. This pilot study aimed to identify a suitable network setting for recognizing agonal respiration under limited network conditions. Methods: We recruited five emergency medical technicians, and each participant viewed 30 real-life videos with different resolutions, frame rates, and network scenarios. Thereafter, they reported the respiration pattern of the patient and identified agonal respiration cases. The time at which agonal respiration was identified was also recorded. The answers provided by the five participants were compared with those of two emergency physicians to compare the accuracy and time delay in breathing pattern recognition. Results: The overall accuracy for initial respiratory pattern recognition was 80.7% (121/150). The accuracy for normal breathing was 93.3% (28/30), for not breathing was 96% (48/50), and for agonal breathing was 64.3% (45/70). There was no significant difference in successful recognition between video resolutions. However, the rate of time delay in recognizing agonal respiration less than 10 seconds between 15-fps group and 30-fps group had statistical significance (21% vs 52%, p = 0.041). Conclusion: The frame rate emerges as one of critical factors in agonal respiration recognition through telemedicine, outweighing the significance of video resolution.

Effect of using G-FAST to recognize emergent large vessel occlusion: A city-wide community experience.

BACKGROUND/PURPOSE: A prehospital bypass strategy was suggested for large vessel occlusion. This study aimed to evaluate the effect of a bypass strategy using the gaze-face-arm-speech-time test (G-FAST) implemented in a metropolitan community. METHODS: Pre-notified patients with positive Cincinnati Prehospital Stroke Scale and symptom onset <3 h from July 2016 to December 2017 (pre-intervention period) and those with positive G-FAST and symptom onset <6 h from July 2019 to December 2020 (intervention period) were included. Patients aged <20 years and those with missing in-hospital data were excluded. The primary outcomes were the rates of receiving endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT). The secondary outcomes were total prehospital time, door-to-computed tomography (CT) time, door-to-needle (DTN) time, and door-to-puncture (DTP) time. RESULTS: We included 802 and 695 pre-notified patients from the pre-intervention and intervention periods, respectively. The characteristics of the patients in the two periods were similar. In the primary outcomes, pre-notified patients during the intervention period showed higher rates of receiving EVT (4.49% vs. 15.25%, p < 0.001) and IVT (15.34% vs. 21.58%, p = 0.002). In the secondary outcomes, pre-notified patients during intervention period had longer total prehospital time (mean 23.38 vs 25.23 min, p < 0.001), longer door-to-CT time (median 10 vs 11 min, p < 0.001), longer DTN time (median 53 vs 54.5 min, p < 0.001) but shorter DTP time (median 141 vs 139.5 min, p < 0.001). CONCLUSION: The prehospital bypass strategy with G-FAST showed benefits for stroke patients.

Outcomes of out-of-hospital cardiac arrests after a decade of system-wide initiatives optimising community chain of survival in Taipei city.

OBJECTIVE: A strengthened chain of survival benefits patient outcomes after out-of-hospital cardiac arrest (OHCA).2 Over the past decade, the Taipei Fire Department (TFD) has continuously implemented system-wide initiatives on this issue.We hypothesised that for adult, non-trauma OHCA patients, the bundle of these system-wide initiatives are associated with better outcomes. METHODS: We conducted a registry-based, retrospective study to examine the association between consecutive system-level initiatives and OHCA survival on a two-yearly basis using trend analysis and multivariable logistic regression. The primary outcome was survival to hospital discharge (STHD) and favourable neurological status. RESULTS: We analysed 18,076 cases from 2008 to 2017. The numbers of two-yearly cases of OHCA with resuscitation attempts from 2008 to 2017 were 3,576, 3,456, 3,822, 3,811, and 3,411. There was a significant trend of improved STHD (Two-fold) and favourable neurological outcome (Six-fold) over the past decade. Similar trends were observed in the shockable and non-shockable groups. Considering the first 2 years as baseline, the odds of STHD and favourable neurological status in the end of the initiatives increased significantly after adjusting for universally recognised predictors for OHCA survival. CONCLUSION: For non-trauma adult OHCA in Taipei, continuous, multifaceted system-wide initiatives on the community chain of survival were associated with improved odds of STHD and favourable neurologic outcomes.

(-)-Epigallocatechin Gallate Promotes MicroRNA 145 Expression against Myocardial Hypoxic Injury through Dab2/Wnt3a/ß-catenin.

MicroRNA 145 (miR-145) is a critical modulator of cardiovascular diseases. The downregulation of myocardial miR-145 is followed by an increase in disabled-2 (Dab2) expression in cardiomyocytes. (-)-epigallocatechin gallate (EGCG) is a flavonoid that has been evaluated extensively due to its diverse pharmacological properties including anti-inflammatory effects. The aim of this study was to investigate the cardioprotective effects of EGCG under hypoxia-induced stress in vitro and in vivo. The hypoxic insult led to the suppression of miR-145 expression in cultured rat cardiomyocytes in a concentration-dependent manner. Western blotting and real-time PCR were performed. In rat myocardial infarction study, in situ hybridization, and immunofluorescent analyses were adopted. The western blot and real-time PCR data revealed that hypoxic stress with 2.5% O2 suppressed the expression of miR-145 and Wnt3a/ß-catenin in cultured rat cardiomyocytes but augmented Dab2. Treatment with EGCG attenuated Dab2 expression, but increased Wnt3a and ß-catenin in hypoxic cultured cardiomyocytes. Following in vivo myocardial infarction (MI) study, the data revealed the myocardial infarct area reduced by 48.5%, 44.6%, and 48.5% in EGCG (50mg/kg) or miR-145 dominant or Dab2 siRNA groups after myocardial infarction for 28 days, respectively. This study demonstrated that EGCG increased miR-145, Wnt3a, and ß-catenin expression but attenuated Dab2 expression. Moreover, EGCG ameliorated myocardial ischemia in vivo. The novel suppressive effect was mediated through the miR-145 and Dab2/Wnt3a/ß-catenin pathways.

Catalpol Ameliorates Neointimal Hyperplasia in Diabetic Rats.

Catalpol, an iridoid glycoside, is an isolated natural product of Rehmannia glutinosa, which has been reported to have antidiabetic properties. This study investigated the vascular protective effects of catalpol in hyperglycemic rats with balloon-injured carotid arteries. Balloon injury stress led to the upregulation of monocyte chemoattractant protein-1 expression in rats with streptozotocin-induced diabetes. Western blotting and real-time PCR were performed. In situ hybridization, immunohistochemistry, and confocal analyses were employed. Monocyte chemoattractant protein-1 levels were increased through streptozotocin induction or balloon injury. After treatment with catalpol, the neointimal hyperplasia area was reduced 2 weeks after balloon injury in hyperglycemic rats. Real-time PCR and immunohistochemical analysis demonstrated reduced levels of monocyte chemoattractant protein-1 2 weeks after the balloon injury. Monocyte chemoattractant protein-1 expression was significantly increased in balloon-injured rats compared with the control groups. Thus, treatment with catalpol affected monocyte chemoattractant protein-1 expression. This study demonstrated that catalpol downregulated monocyte chemoattractant protein-1 expression in carotid arteries and ameliorated neointimal hyperplasia in hyperglycemic rats. The suppressive effect of monocyte chemoattractant protein-1 suggests that it plays a key role in neointimal hyperplasia. The results imply that catalpol is potentially effective for preventing hyperglycemia-related ischemic cardiac diseases.

Comparison of the validity of checklist assessment in cardiac arrest simulations with an app in an academic hospital in Taiwan: a retrospective observational study.

INTRODUCTION: Robust assessment is a crucial component in Advanced Cardiac Life Support (ACLS) training to determine whether participants have achieved learning objectives with little or no variation in their overall outcomes. This study aimed to evaluate resuscitation performance by real-time logs. We hypothesised that instructors may not be able to evaluate time-sensitive parameters, namely, chest compression fraction, time to initiating chest compression and time to initiating defibrillation accurately in a subjective manner. METHODS: Video records and formal checklist-based test results of Megacode scenarios for the ACLS certification examination at several hospitals in Taipei were examined. For the study interest, three time-sensitive parameters were measured via video review assisted by a mobile phone application, and were used for evaluation. We evaluated if the pass/fail results made by instructors via checklists were correlated with these parameters. RESULTS: A total of 185 Megacode scenarios were eligible for the final analysis. Among the three parameters, good chest compression fraction was statistically significant with a higher OR of passing (OR=3.65; 95% CI 1.36 to 9.91; p=0.01). In 112 participants with one parameter that did not meet the criteria, 25 were graded as fail, making the specificity 22.3% (95% CI 15.0% to 31.2%). CONCLUSIONS: Visual observation of cardiopulmonary resuscitation performance is not accurate when evaluating time-sensitive parameters. Objective results should be offered for training outcome evaluation, and also for feedback to participants.

Ultrasound diagnosis of cardiac rupture caused by mechanical chest compression.

A 74-year-old male with chronic kidney disease presented to the emergency department with asystole. Mechanical chest compression was started immediately using a piston-type thumper device. The initial potassium level was 7.7 mEq/L and bedside point-of-care ultrasound (POCUS) revealed no pericardial fluid. With standard resuscitation and anti-hyperkalemia treatment, return of spontaneous circulation (ROSC) was achieved within 10 minutes of compressions. At 15 minutes post-ROSC, the patient went into pulseless electrical activity. A repeated POCUS discovered massive pericardial fluid suggesting the presence of cardiac tamponade. Bedside pericardiotomy was performed followed by open thoracotomy. Laceration of the right ventricular wall adjacent to the fracture site of sternum was found, implicating that it was the complication of mechanical chest compression. After surgical repair and intensive post-operative care, the patient survived with full conscious recovery at day 6 of admission. Our case emphasizes the importance of POCUS in resuscitation, especially when the patient's condition deteriorates unexpectedly.

Effects of flavonoids on MicroRNA 145 regulation through Klf4 and myocardin in neointimal formation in vitro and in vivo.

MicroRNA 145 (miR-145) is a critical modulator of vascular smooth muscle cell (VSMC) phenotyping and proliferation. Flavonoids have been studied extensively due to their diverse pharmacological properties, including anti-inflammatory effects. The aims of this study is designed to evaluate the atheroprotective effects on angiotensin II (Ang II)-induced miR-145 and Klf4/myocardin expression in vitro and in vivo of flavonoids, including (-)-epigallocatechin gallate (EGCG), chrysin, wogonin, silibinin, and ferulic acid. Ang II significantly reduced the miR-145 compared with the control VSMC groups; all the tested flavonoids increased miR-145 in the 100 nM concentration. Among the test compounds, EGCG showed the strongest augmenting effect on miR-145 and myocardin, however, it also abolished Ang II-induced Klf4. A [3H]-thymidine incorporation proliferation assay demonstrated that EGCG inhibited Ang II-induced VSMC proliferation, and Klf4 siRNA presented with the similar results. Immunohistochemical analysis and confocal microscopy demonstrated increased Klf4 expression and the arterial lumen was narrowed after balloon injury 14 days. With the addition of EGCG (50 mg/kg) and Klf4 siRNA, neointimal formation was reduced by 40.7% and 50.5% compared with balloon injury 14 days; Klf4 expression also was attenuated. This study demonstrated EGCG increased miR-145 and attenuated Klf4, and ameliorated neointimal formation in vitro and in vivo. The novel suppressive effect was mediated through the miR-145 and Klf4/myocardin pathways.

End-tidal carbon dioxide monitoring may be associated with a higher possibility of return of spontaneous circulation during out-of-hospital cardiac arrest: a population-based study.

BACKGROUND: During cardiac arrest, end-tidal carbon dioxide (ETCO2) monitoring is recommended as a chest compression performance indicator. However, its frequency of use during out-of-hospital cardiac arrest (OHCA) and its benefits have never been evaluated in real clinical situations. OBJECTIVE: We investigated OHCA patients in Taiwan to evaluate the frequency of ETCO2 monitoring and its effects on sustained return of spontaneous circulation (ROSC). METHODS: We sampled the Taiwan National Health Insurance claims database, which contains 1 million beneficiaries. All adult beneficiaries older than 18 years who presented with OHCA and received chest compression between 1 January 2005 and 31 December 2012 were enrolled. We further identified patients with ETCO2 monitoring and matched each 1 with 20 patients who did not receive ETCO2 monitoring based on their propensity scores. A simple conditional logistic regression model was applied to compare the odds ratio (OR) for sustained ROSC in the matched cohorts. RESULTS: A total of 5041 OHCA patients were enrolled. The frequency of ETCO2 monitoring has increased since 2010 but still is low. After matching, 53 patients with ETCO2 monitoring and 1060 without ETCO2 monitoring were selected. The OR of sustained ROSC in the ETCO2 group was significantly increased (2.38, 95 % CI 1.28-4.42). CONCLUSION: Patients who received ETCO2 monitoring during OHCA had a higher possibility of sustained ROSC, but the overall use of ETCO2 monitoring is still low despite strong recommendations for its use.

Molecular mechanism of (-)-epigallocatechin-3-gallate on balloon injury-induced neointimal formation and leptin expression.

Leptin contributes to the pathogenesis of vascular repair and cardiovascular events. This study evaluated the molecular mechanism of EGCG in balloon injury-induced leptin expression. According to immunohistochemical and confocal analyses, leptin expression was increased and the aortic lumen exhibited narrowing after balloon injury. EGCG treatment attenuated leptin expression and diminished neointimal formation. The in vitro study showed that angiotensin II (Ang II) induced the migration and proliferation of cultured vascular smooth muscle cells (VSMCs), whereas treatment with EGCG, leptin siRNA, and c-Jun siRNA inhibited the migration and proliferation of VSMCs significantly. The EMSA shows that balloon injury increased AP-1-binding activity, and EGCG and c-Jun siRNA inhibited the AP-1-binding activity. Western blot and real-time RT-PCR analyses revealed similar results in intimal tissue samples. In summary, balloon injury induces leptin expression in the carotid artery of rats, and EGCG inhibits leptin expression through the JNK/AP-1 pathway and also attenuates neointimal formation.

Increased risk of acute pancreatitis in patients with chronic hemodialysis: a 4-year follow-up study.

BACKGROUND: The risk of acute pancreatitis in patients on long-term peritoneal dialysis is higher as compared to the general population. However, the relationship between long-term hemodialysis and acute pancreatitis has never been established. OBJECTIVES: We investigated the incidence of acute pancreatitis among patients on long-term hemodialysis in Taiwan to evaluate if there is a higher risk of acute pancreatitis in comparison to the general population. METHODS: We utilized a National Health Insurance (NHI) claims data sample containing one million beneficiaries. We followed all adult beneficiaries from January 1, 2007 until December 31, 2010 to see if they had been hospitalized for acute pancreatitis during this period. We further identified patients on chronic hemodialysis and compared their risk of acute pancreatitis with the general population. RESULTS: This study included 2603 patients with long-term hemodialysis and 773,140 patients without hemodialysis. After controlling for age, gender, Charlson Comorbidity Index Score, geographic region, socioeconomic status and urbanization level, the adjusted hazard ratio was 3.44 (95% Confidence interval, 2.5-4.7). CONCLUSIONS: The risk of acute pancreatitis in patients on long-term hemodialysis is significantly higher in comparison to the general population.

Increased risk of dementia in patients with mild traumatic brain injury: a nationwide cohort study.

BACKGROUND: It is known that the risk of dementia in patients with moderate to severe traumatic brain injury (TBI) is higher. However, the relationship between mild traumatic brain injury (mTBI) and dementia has never been established. OBJECTIVES: We investigated the incidences of dementia among patients with mTBI in Taiwan to evaluate if there is higher risk compared with general population. METHODS: We utilized a sampled National Health Insurance (NHI) claims data containing one million beneficiaries. We followed all adult beneficiaries from January 1, 2005 till December 31, 2009 to see if they had been diagnosed with dementia. We further identify patients with mTBI and compared their risk of dementia with the general population. RESULTS: We identified 28551 patients with mTBI and 692382 without. After controlled for age, gender, urbanization level, socioeconomic status, diabetes, hypertension, coronary artery disease, hyperlipidemia, history of alcohol intoxication, history of ischemic stroke, history of intracranial hemorrhage and Charlson Comorbidity Index Score, the adjusted hazard ratio is 3.26 (95% Confidence interval, 2.69-3.94). CONCLUSIONS: TBI is an independent significant risk factor of developing dementia even in the mild type.

Sonographic diagnosis of spontaneous intramural small bowel hematoma in a case of warfarin overdose.

A 38-year-old man who had been treated with warfarin since mitral valve replacement 10 years earlier presented with acute onset of epigastralgia and melena. Coagulation tests were abnormal with a prolonged prothrombin time of >60 seconds and a prolonged activated partial thromboplastin time of >120 seconds. Abdominal sonographic examination revealed duodenal intramural hematoma that was confirmed on CT. Warfarin therapy was stopped and the patient was treated conservatively with vitamin K and fresh frozen plasma. Recovery was uneventful, and the patient was re-warfarinized 2 weeks later. Duodenal hematoma can be readily diagnosed with bedside sonography.