Comparison of intraosseous access and central venous catheterization in Chinese adult emergency patients: A prospective, multicenter, and randomized study.

BACKGROUND: It is challenging to establish peripheral intravenous access in adult critically patients. This study aims to compare the success rate of the first attempt, procedure time, operator satisfaction with the used devices, pain score, and complications between intraosseous (IO) access and central venous catheterization (CVC) in critically ill Chinese patients. METHODS: In this prospective clustered randomized controlled trial, eight hospitals were randomly divided into either the IO group or the CVC group. Patients who needed emergency vascular access were included. From April 1, 2017 to December 31, 2018, each center included 12 patients. We recorded the data mentioned above. RESULTS: A total of 96 patients were enrolled in the study. There were no statistically significant differences between the two groups regarding sex, age, body mass index, or operator satisfaction with the used devices. The success rates of the first attempt and the procedure time were statistically significant between the IO group and the CVC group (91.7% vs. 50.0%, P<0.001; 52.0 seconds vs. 900.0 seconds, P<0.001). During the study, 32 patients were conscious. There was no statistically significant difference between the two groups regarding the pain score associated with insertion. There were statistically significant differences between the two groups regarding the pain score associated with IO or CVC infusion (1.5 vs. 0.0, P=0.044). Complications were not observed in the two groups. CONCLUSIONS: IO access is a safe, rapid, and effective technique for gaining vascular access in critically ill adults with inaccessible peripheral veins in the emergency departments.

An analysis of patients receiving emergency CAG without PCI and the value of GRACE score in predicting PCI possibilities in NSTE-ACS patients.

BACKGROUND: There are patients who underwent emergency coronary angiography (CAG) but did not receive percutaneous coronary intervention (PCI). The aim of this study was to analyze these reasons. METHODS: This is a single-center retrospective study. We recruited 201 consecutive patients who received emergency CAG but did not receive PCI. To investigate the value of the Global Registry of Acute Coronary Events (GRACE) score in predicting PCI possibilities in non-ST segment elevation acute coronary syndrome (NSTE-ACS) patients, we recruited 80 consecutive patients who presented with NSTE-ACS and received emergency CAG as well as emergency PCI. RESULTS: Among the 201 patients who received emergency CAG but did not receive PCI, 26% patients had final diagnosis other than coronary heart disease. In the patients with significant coronary artery stenosis, 23 patients (11.5%) were recommended to coronary artery bypass grafting (CABG), one patient (0.5%) refused PCI; 13 patients (6.5%) with significant thrombus burden were treated with glycoprotein IIb/IIIa receptor antagonist; 74 patients (36.8%) were treated with drug therapy because no severe stenosis (> 70%) was present in the crime vessel. Moreover, 80 of the 201 patients were presented with NSTE-ACS (excluding those patients with final diagnosis other than coronary heart disease, excluding those patients planned for CABG treatment), referred as non PCI NSTE-ACS. When comparing their GRACE scores with 80 consecutive patients presented with NSTE-ACS who received emergency CAG as well as emergency PCI (referred as PCI NSTE-ACS), we found that PCI NSTE-ACS patients had significantly higher GRACE scores compared with non PCI NSTE-ACS patients. We then used Receiver Operator Characteristic Curve (ROC) to test whether the GRACE score is good at evaluating the possibilities of PCI in NSTE-ACS patients. The area under the curve was 0.854 ± 0.030 (P < 0.001), indicating good predictive value. Furthermore, we analyzed results derived from ROC statistics, and found that a GRACE score of 125.5, as a cut-off, has high sensitivity and specificity in evaluating PCI possibilities in NSTE-ACS patients. CONCLUSIONS: Our findings indicate that the GRACE score has predictive value in determining whether NSTE-ACS patients would receive PCI.

Vasospastic angina with J waves formation in patients with sudden loss of consciousness.

Vasospastic angina is caused by sudden occlusive vasoconstriction of a segment of an epicardial artery, which can present with a wide spectrum of clinical scenario. We report the cases of two patients diagnosed with vasospastic angina, with one of which presenting with sudden cardiac arrest, while the other presenting with a relatively benign syncope. But both of them have J waves formation on ECG during active ischemia. The diagnosis and management of vasospastic angina, as well as the proposed clinical significance of J waves during coronary spasm are discussed.

Platelet-derived microparticles are implicated in remote ischemia conditioning in a rat model of cerebral infarction.

AIM: Remote ischemic preconditioning protects against ischemic organ damage by giving short periods of subcritical ischemia to a remote organ. We tested the hypothesis that remote ischemic conditioning can attenuate cerebral stroke in a rat middle cerebral artery occlusion (MCAO) model by microparticles (MPs). METHODS AND RESULTS: MPs were extracted from healthy rats that underwent hindlimb ischemia-reperfusion preconditioning (RIPC), and were transfused into rats that had undergone MCAO without RIPC. The transfusion resulted in an increase in platelet-derived MPs in blood and reduction in infarction area, confirmed by both 2-3-5-triphenyltetrazolium chloride staining and magnetic resonance imaging, albeit to a lesser degree than RIPC itself. Behavioral tests (modified Neurological Severity Score [mNSS]) were calculated to judge the behavioral change. However, no significant difference was observed after MP transfusion in 24 h or the following consecutive 9 days. CONCLUSIONS: RIPC induces an increase in MPs, and platelet-derived MPs may confer at least part of the remote protective effect against cerebral ischemic-reperfusion injury.

[Adhesion between monocytes and vascular smooth muscle cells induced by integrin beta1-mediated platelet-derived growth factor].

OBJECTIVE: To investigate the effects of platelet-derived growth factor (PDGF)-BB on the vascular smooth muscle cell (VSMC)-monocyte interaction and the mechanism thereof. METHODS: Rat aortic VSMC were pretreated with PDGF-BB of the concentrations of 0, 2.5, 5, 10, and 20 ng/ml for 8 hours and then co-incubated with human monocytes of the line THP-1 labeled with PKH26, a cellular membrane fluorescent marker, i.e., to be subjected to binding assay to observe the dose-effect relationship. Other VSMC were co-cultured with PDGF of the concentration of 10 ng/ml for 1, 2, 4, 12, and 24 hours respectively and then interacted with PKH26-abeled THP-1 cells so as to observe the time-response relationship. Monoclonal antibody against integrin beta1 was co-cultured with VSMC for 30 min, and then PKH26-labeled THP-1 cells were added to block the effect of PDGF. After the incubation of THP-1 cells and VSMC, the amount of bound cells was counted using fluorescent phase-contrast microscopy. The effect of PDGF on the expression of integrin beta1 was detected by Western blotting. RESULTS: The amounts of THP-1 cells bound to VSMC pretreated with PDGF of the concentrations of 2.5, 5, 10, and 20 ng/ml respectively were 1.1, 2.1, 3.1, and 4.4 times that of the untreated cells. Incubated with 10 ng/ml PDGF for 0-18 h, the adhesion rate between the VSMC and THP-1 cells increased time-1dependently. After the blocking by the antibody against integrin beta1, the adhesion rate between the VSMC and THP-1 cells decreased from (25.4+/-11.4)% to (9.2+/-4.1)% (P<0.01). Western blotting showed that the level of integrin beta1 of the VSMC treated by 10 ng/ml PDGF increased since 4 h after the treatment, peaked 8 h later, and then decreased gradually. CONCLUSION: PDGF-BB can induce the binding of monocytes to VSMC via the integrin-beta1 signaling pathway. The effect may therefore facilitate the progression of atherosclerosis by augmenting the VSMC-monocyte adhesive interaction.

[Effects of tissue inhibitor of matrix metalloproteinases-4 on the activities of matrix metalloproteinases and collagen of artery: experiment with rats].

OBJECTIVE: To investigate the effects of tissue inhibitor of matrix metalloproteinases-4 (TIMP-4) on the activities of matrix metalloproteinases (MMPs) and the collagen deposition. METHODS: Vascular smooth muscle cells (VSMCs) of rat thoracic aorta were cultured and divided into 3 groups: 2 groups to be transfected with adenovirus vector containing green fluorescence protein (AdGFP) or adenovirus vector containing TIMP-4 (AdTIMP-4), and one group un-transfected. Zymography and reverse zymography were used to detect the activities of MMP-2, MMP-9 and TIMP-4 in the supernatants. Male Wistar rats underwent balloon injury of common carotid artery and then divided into 3 groups: pure injury group, AdGFP transfection group, and AdTIMP-4. transfection group. Four and 28 days later 3 and 6 rats were killed in each group respectively to undergo microscopy and examination of the activities of MMP-2, MMP-9, and TIMP-4, and collagen quantity. RESULTS: The MMP-2 activity in the VSMC culture fluid supernatant of the AdTIMP-4 group was decreased dose-dependently, however, the activity of MMP-9 did not changed significantly among the 3 groups. Bands of activated MMP-2 and MMP-9 could not be examined in the normal vessel tissues. Four hours after the injury, the activity of MMP-2 was significantly increased in the pure injury group and AdGFP group, however, was significantly decreased in the AdTIMP-4 group. Four days later no MMP activity could be detected in either group. The neoformation of tunica intima was inhibited by 66% in the AdTIMP-4 group, The collagen quantity per vessel cell was 12.1 +/- 1.0 in the AdGFP group, not significantly different from that of in the AdTIMP-4 group (11.9 +/- 1, P > 0.05), and the collagen quantity per tunica adventitia cell in the AdTIMP-4 group was 118 +/- 13, not significantly different from that of the pure injury group (135 +/- 11, P > 0.05). CONCLUSION: The regulation of MMP/TIMP balance by TIMP-4 may control the metabolism of collagen and play an important role in the vascular repair process.

[Combined gene therapy enhances collateral vascularization in coronary artery occlusion swine model].

OBJECTIVE: To investigate the efficacy of combined gene transfer of vascular endothelial growth factor (VEGF) and angiotensin-1 (Ang-1) in swine coronary artery occlusion. METHODS: Swine underwent left thoracotomy followed by ligation of left anterior descending coronary artery. Constructed PCD(2)/VEGF and/or PCD(2)/Ang-1 eukaryotic expression plasmid was directly injected into the swine myocardium. RT-PCR, immunohistochemistry, capillary density and arteriole density were used to detect gene expression and biological effect. Coronary angiography was done to evaluate collateral circulation of the occluded artery. RESULTS: High levels of VEGF and Ang-1 mRNA and protein expression were detected. There was a significant increase in the number of capillaries and arterioles as compared with a control group (P < 0.05). Capillary density and arteriole density of the combination therapy group were higher than those of the swing receiving either therapy alone. Coronary angiography showed better collateral circulation in the combination therapy group. CONCLUSIONS: Direct injection of PCD(2)/VEGF and PCD(2)/Ang-1 can transfect the myocardium and express VEGF and Ang-1 protein. Combined gene transfer of VEGF and Ang-1 can increase capillary and arteriole number and enhance collateral circulation of the occluded coronary artery more effectively.