Abstract 9114: Impact of the Number of Prehospital Defibrillation Attempts on Neurologically Intact Survival in Patients With Out-of-Hospital Cardiac Arrest and Shockable Rhythm

Background: Early return of spontaneous circulation (ROSC) leads to survival with a favorable neurologic outcome in patients with out-of-hospital cardiac arrest (OHCA). For the early ROSC, defibrillation plays a crucial role for OHCA with shockable rhythm. However, little is known about the relation between the number of prehospital defibrillation attempts or etiology of OHCA and neurologically intact survival. Methods: Using a nationwide OHCA registry database from 2005 to 2017 in Japan, a cohort of 1,527,447 patients with OHCA were retrospectively analyzed. We included the patients of witnessed OHCAs with initial shockable rhythm. The relation between early ROSC, defined as prehospital ROSC achieved with defibrillation ≤3 times without adrenaline, and a neurologically intact survival rate (cerebral performance category score of 1 or 2 at 1 month) was evaluated. We also analyzed factors related to the successful early ROSC, including etiology of OHCA. Results: A total of 75,342 patients were included. Among patients with OHCA and prehospital ROSC, neurologically intact survival rates were better in patients who achieved early ROSC than their counterpart (62% vs. 36%, p<0.001). Success in early ROSC was an independent predictor of neurologically intact survival after adjustment of multiple cofounders (Table). Multivariate analysis showed cerebral vascular disease as an etiology of OHCA was a predictor of early ROSC (odds ratio 1.15, 95% confidence interval 1.03-1.29, p=0.02), but was significantly associated with a poor neurologic outcome at 1 month (Table). Conclusions: Success in early ROSC was associated with neurologically intact survival in patients with OHCA and initial shockable rhythm. Patients with OHCA due to cerebral vascular disease were likely to be resuscitated from cardiac arrest by defibrillations but had a poor neurologic outcome.

Impact of Comorbidities on Beneficial Effect of Lactated Ringers Versus Saline in Sepsis Patients

Background: Lactated Ringers reduced mortality more than saline in sepsis patients but increased mortality more than saline in traumatic brain injury patients. Method: This prospective cohort study included sepsis patients and identified heart, lung, liver, kidney, and endocrine comorbidities by detailed history taking and routine admission survey such as HbA1C, and liver functions. We evaluate resuscitation response with central venous pressure, central venous oxygen saturation, and serum lactate level simultaneously. Propensity-score matching and Cox regression were used to estimate 60-day mortality. The competing risk model compared the lengths of hospital and ICU stays with the subdistribution hazard ratio (SHR). Mixed-effect linear models were used to fit clinical variables and electrolyte trends.Results: Overall, 874 patients were included in the analysis; 636 patients were in the saline group, and 302 patients were in the lactated Ringers group. The lactated Ringers group had a lower mortality rate (adjusted hazard ratio, 0.59; 95% CI 0.43-0.81) and shorter lengths of hospital (SHR, 1.39; 95% C.I. 1.15-1.67) and ICU stays (SHR, 1.41; 95% CI 1.17, 1.71) than the saline group; the differences were greater in patients with chronic pulmonary disease and small and nonsignificant in those with chronic kidney disease, moderate to severe liver disease and cerebral vascular disease. The resuscitation efficacy was the same between fluid types, but serum lactate levels were significantly higher in the lactated Ringers group than in the saline group (0.12 mg/dL/hour; 95% C.I.: 0.03, 0.21), especially in chronic liver disease patients receiving lactated Ringers. The serum potassium level increased within the first few hours and recovered more slowly in patients with chronic kidney disease regardless of fluid type. Compared to the saline group, the lactated Ringers group achieved target glucose level earlier in both diabetes and non-diabetes patients.Conclusion: Patients receiving lactated Ringers had lower mortality and shorter lengths of hospital and ICU stays than those receiving saline, especially patients with chronic pulmonary disease, but there were no differences in those with chronic kidney disease, chronic liver disease and cerebral vascular disease. Comorbidities are important for clinicians to consider before choosing a fluid type.

Dysfunction of the Neurovascular Unit in Ischemic Stroke: Highlights on microRNAs and Exosomes as Potential Biomarkers and Therapy

Ischemic stroke is a damaging cerebral vascular disease associated with high disability and mortality rates worldwide. In spite of the continuous development of new diagnostic and prognostic methods, early detection and outcome prediction are often very difficult. The neurovascular unit (NVU) is a complex multicellular entity linking the interactions between neurons, glial cells, and brain vessels. Novel research has revealed that exosome-mediated transfer of microRNAs plays an important role in cell-to-cell communication and, thus, is integral in the multicellular crosstalk within the NVU. After a stroke, NVU homeostasis is altered, which induces the release of several potential biomarkers into the blood vessels. The addition of biological data representing all constituents of the NVU to clinical and neuroradiological findings can significantly advance stroke evaluation and prognosis. In this review, we present the current literature regarding the possible beneficial roles of exosomes derived from the components of the NVU and multipotent mesenchymal stem cells in preclinical studies of ischemic stroke. We also discuss the most relevant clinical trials on the diagnostic and prognostic roles of exosomes in stroke patients.

Effects of Antithrombotic Treatment on Bleeding Complications of EBUS-TBNA

Background and Objectives: The application of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been markedly increased over the past decade. EBUS-TBNA is known to be a very safe and accurate procedure; however, the incidence of bleeding complications in patients who are taking antithrombotic agents (ATAs) is not well established. Materials and Methods: We conducted a retrospective analysis of a prospectively registered EBUS-TBNA cohort in a single tertiary hospital from May 2009 to December 2016. The patients were divided into two groups: an insufficient discontinuation group, defined as having a prescription for ATAs on the procedure day or only interrupting them for a short period of time, and a sufficient discontinuation group, defined as having prescription for ATAs during 30 days prior to the procedure and interrupting them for a sufficient period of time. Results: During the study period, a total of 4271 patients, after excluding 3773 patients who did not take ATAs at all, 498 patients were classified into the insufficient discontinuation group (n = 102) and the sufficient discontinuation group (n = 396). The baseline characteristics of patients and examined lesions between two groups were not significantly different, except insufficient discontinuation group had longer prothrombin times than the sufficient discontinuation group. In the insufficient discontinuation group, the most common reasons for prescriptions of ATAs were ischemic heart disease (48.0%) and cerebral vascular disease (28.4%), and half of the patients were taking two or more ATAs. Eventually, only one bleeding complication in the insufficient discontinuation group (1/102, 1.0%) and one event in the sufficient discontinuation group (1/396, 0.3%) occurred (p = 0.368). Conclusions: EBUS-TBNA is considered a safe procedure in terms of bleeding complications, even in patients with insufficient stopping of ATAs.

Association of exhaled carbon monoxide with risk of cardio-cerebral-vascular disease in the China Kadoorie Biobank cohort study

Exhaled carbon monoxide (COex) level has been proposed as a noninvasive and easily-obtainable cardiovascular risk marker, however, with limited prospective evidence, and its association with stroke risk has been rarely explored. Measurements of COex were performed during 2004–2008 baseline examinations in the China Kadoorie Biobank study among 512,891 adults aged 30–79 years from 10 diverse study areas. After excluding participants with baseline cardiopulmonary diseases, stroke and cancer, 178,485 men and 267,202 women remained. Cox regression yielded hazard ratios (HRs) and 95% confidence intervals (CIs) for risk of cardio-cerebral-vascular disease (CCVD) associated with COex levels, with sequential addition of adjustment for proxy variables for CO exposure, including study area indexing ambient CO variations at large, and smoking and solid fuel use, apart from adjusting for traditional cardiovascular risk factors. During 7-year follow-up, we documented 1744 and 1430 major coronary events (myocardial infarction plus fatal ischemic heart disease), 8849 and 10,922 ischemic strokes, and 2492 and 2363 hemorrhagic strokes among men and women, respectively. The HRs with 95% CIs comparing the highest with lowest COex quintile were 2.15 [1.72, 2.69] for major coronary events, 1.65 [1.50, 1.80] for ischemic stroke, and 1.35 [1.13, 1.61] for hemorrhagic stroke among men, while among women higher associated risk was only observed for major coronary events (1.64 [1.35, 2.00]) and ischemic stroke (1.87 [1.73, 2.01]). The elevated risks were consistent when COex level was over 3 ppm. However, these associations were all attenuated until null by sequential addition of stratification by study areas, and adjustments of smoking and solid fuel use. Nevertheless, the association with ischemic stroke was maintained among the subgroup of male smokers even with adjustment for the depth and amount of cigarette smoking (HR [95% CI]: 1.37 [1.06, 1.77]), while a negative association with hemorrhagic stroke also appeared within this subgroup. Higher COex level (over 3 ppm) was associated with elevated risk of ischemic CCVD, but not independently of CO exposure. Our finding suggests that, though not an independent risk factor, COex could potentially provide a cost-effective biomarker for ischemic cardio-cerebral-vascular risk, given that CO exposure is ubiquitous.

Dysregulation of Endothelin-1: Implications for Health Disparities in Alzheimer’s Disease

Alzheimer’s disease (AD) and related dementias disproportionately impact racial and ethnic minorities. The racial and ethnic disparities in AD could be explained by differences in cerebral vascular disease pathology. Endothelin-1 (ET-1) is a potent vasoconstrictive peptide that regulates smooth muscle, endothelial cell, and pericyte contractions that may result in cerebral vascular constriction, leading to cerebral hypoperfusion; over time, ET-1 may result in neuronal injury contributing to the pathology of AD. Upregulation of the ET-1 system has been observed in African Americans when compared with non-Hispanic Whites. The role of the ET-1 system as a driver of ethnic disparities in AD requires further investigation. Targeting of the ET-1 system as a therapeutic intervention that could impact AD progression also needs further study. Dysregulation of ET-1 in Hispanic/Latino populations largely have been unexplored. Genetics linking ET-1 dysregulation and racial disparities in AD also needs further investigation. In this review, I examine how AD effects underserved minority populations and how dysregulation of the ET-1 system specifically predisposes ethnic minorities to AD. In addition, I examine the molecular interactions of the ET-1 system and amyloid beta, the role the ET-1 system in neurodegeneration, potential therapeutics for ET-1 dysregulation, and the impact on AD progression.

PELATIHAN DETEKSI DINI MENCEGAH TERJADINYA STROKE PADA LANSIA PIMPINAN RANTING ‘AISYIYAH ALUN-ALUN UTARA KOTAGEDE YOGYAKARTA

ABSTRAK Latar belakang :Stroke adalah gejala-gejala defisitfungsi saraf yang diakibatkan oleh penyakit pembuluh darah otak, bukan oleh sebab yang lain (WHO). Gangguan fungsi syaraf pada stroke disebabkan oleh gangguan peredaran darah otak non traumatik. Gangguan syaraf tersebut menimbulkan gejala antara lain: kelumpuhan wajah atau anggota badan, bicara tidak lancar, bicara tidak jelas (pelo), perubahan kesadaran, gangguan penglihatan, dan lain-lain. Stroke merupakan penyebab disabilitas nomor satu dan penyebab kematian nomor dua di dunia setelah penyakit jantung iskemik baik di negara maju maupun berkembang. Metode : pelatihan ini dilakukan dengan metode ceramah dan apllikasi kepada kader dan lansia di PRA Alun-alun Utara kotagede Tujuan: Bertambahnya pengetahuan kader posyandu dan ibu ‘Aisyiyah Alun-Alun Utara tentang gangguan pembuluh darah otak, tentang deteksi dini terjadinya stroke serta pelatihan dalam mencegah terjadinya stroke. Hasil para Kader lansia mampu melakukan cara bagaimana deteksi dini stroke dengan melakukan pengukuran tensi darah serta mampu mengetahui batas normal dari nilai kadar kolesterol dan gula darah, Rekomendasi kegiatan ini bisa dilakukan secara rutin dengan diadakannya posyandu lansia Kata Kunci: Stroke, Deteksi Dini stroke, pencegahan stroke ABSTRACT Background: Stroke is a symptom of nerve deficit function caused by cerebral vascular disease, not by other causes (WHO). Nerve function disorders in stroke are caused by non-traumatic brain circulatory disorders. This nerve disorder causes symptoms, including: paralysis of the face or limbs, speech is not fluent, speech is not clear (pelo), Stroke is the number one cause of disability and the number two cause of death in the world after ischemic heart disease in both developed and developing countries. Methods: This training was conducted by lecturing and applying to cadres and the elderly at PRA Alun-alun Utara, Kotagede. Objectives: Increasing the knowledge of posyandu cadres and 'Aisyiyah Alun-Alun Utara' about brain blood vessel disorders, early detection of stroke and training in preventing the occurrence of a stroke. The results of the elderly cadres are able to do how to detect stroke early by measuring blood pressure and being able to know the normal limit of the value of cholesterol and blood sugar levels. Recommendations for this activity can be done regularly by holding posyandu for the elderly Keywords: Stroke, Stroke Early Detection, Stroke Prevention

Diagnosis and treatment of adults with congenital heart disease

Approximately 50 million adults worldwide have known congenital heart disease (CHD). Among the most common types of CHD defects in adults are atrial septal defects and ventricular septal defects followed by complex congenital heart lesions such as tetralogy of Fallot. Adults with CHDs are more likely to have hypertension, cerebral vascular disease, diabetes and chronic kidney disease than age-matched controls without CHD. Moreover, by the age of 50, adults with CHD are at a greater than 10% risk of experiencing cardiac dysrhythmias and approximately 4% experience sudden death. Consequently, adults with CHD require healthcare that is two- to four-times greater than adults without CHD. This paper discusses the diagnosis and treatment of adults with atrial septal defects, ventricular septal defects and tetralogy of Fallot.