Managing cardiac arrest with refractory ventricular fibrillation in the emergency department: Conventional cardiopulmonary resuscitation versus extracorporeal cardiopulmonary resuscitation

AbstractAimRefractory ventricular fibrillation, resistant to conventional cardiopulmonary resuscitation (CPR), is a life threatening rhythm encountered in the emergency department. Although previous reports suggest the use of extracorporeal CPR can improve the clinical outcomes in patients with prolonged cardiac arrest, the effectiveness of this novel strategy for refractory ventricular fibrillation is not known. We aimed to compare the clinical outcomes of patients with refractory ventricular fibrillation managed with conventional CPR or extracorporeal CPR in our institution.MethodThis is a retrospective chart review study from an emergency department in a tertiary referral medical center. We identified 209 patients presenting with cardiac arrest due to ventricular fibrillation between September 2011 and September 2013. Of these, 60 patients were enrolled with ventricular fibrillation refractory to resuscitation for more than 10min. The clinical outcome of patients with ventricular fibrillation received either conventional CPR, including defibrillation, chest compression, and resuscitative medication (C-CPR, n=40) or CPR plus extracorporeal CPR (E-CPR, n=20) were compared.ResultsThe overall survival rate was 35%, and 18.3% of patients were discharged with good neurological function. The mean duration of CPR was longer in the E-CPR group than in the C-CPR group (69.90±49.6min vs 34.3±17.7min, p=0.0001). Patients receiving E-CPR had significantly higher rates of sustained return of spontaneous circulation (95.0% vs 47.5%, p=0.0009), and good neurological function at discharge (40.0% vs 7.5%, p=0.0067). The survival rate in the E-CPR group was higher (50% vs 27.5%, p=0.1512) at discharge and (50% vs 20%, p=0. 0998) at 1 year after discharge.ConclusionsThe management of refractory ventricular fibrillation in the emergency department remains challenging, as evidenced by an overall survival rate of 35% in this study. Patients with refractory ventricular fibrillation receiving E-CPR had a trend toward higher survival rates and significantly improved neurological outcomes than those receiving C-CPR

Canagliflozin and renal outcomes in type 2 diabetes and nephropathy

BACKGROUND Type 2 diabetes mellitus is the leading cause of kidney failure worldwide, but few effective long-term treatments are available. In cardiovascular trials of inhibitors of sodium–glucose cotransporter 2 (SGLT2), exploratory results have suggested that such drugs may improve renal outcomes in patients with type 2 diabetes. METHODS In this double-blind, randomized trial, we assigned patients with type 2 diabetes and albuminuric chronic kidney disease to receive canagliflozin, an oral SGLT2 inhibitor, at a dose of 100 mg daily or placebo. All the patients had an estimated glomerular filtration rate (GFR) of 30 to <90 ml per minute per 1.73 m2 of body-surface area and albuminuria (ratio of albumin [mg] to creatinine [g], >300 to 5000) and were treated with renin–angiotensin system blockade. The primary outcome was a composite of end-stage kidney disease (dialysis, transplantation, or a sustained estimated GFR of <15 ml per minute per 1.73 m2), a doubling of the serum creatinine level, or death from renal or cardiovascular causes. Prespecified secondary outcomes were tested hierarchically. RESULTS The trial was stopped early after a planned interim analysis on the recommendation of the data and safety monitoring committee. At that time, 4401 patients had undergone randomization, with a median follow-up of 2.62 years. The relative risk of the primary outcome was 30% lower in the canagliflozin group than in the placebo group, with event rates of 43.2 and 61.2 per 1000 patient-years, respectively (hazard ratio, 0.70; 95% confidence interval [CI], 0.59 to 0.82; P=0.00001). The relative risk of the renal-specific composite of end-stage kidney disease, a doubling of the creatinine level, or death from renal causes was lower by 34% (hazard ratio, 0.66; 95% CI, 0.53 to 0.81; P<0.001), and the relative risk of end-stage kidney disease was lower by 32% (hazard ratio, 0.68; 95% CI, 0.54 to 0.86; P=0.002). The canagliflozin group also had a lower risk of cardiovascular death, myocardial infarction, or stroke (hazard ratio, 0.80; 95% CI, 0.67 to 0.95; P=0.01) and hospitalization for heart failure (hazard ratio, 0.61; 95% CI, 0.47 to 0.80; P<0.001). There were no significant differences in rates of amputation or fracture. CONCLUSIONS In patients with type 2 diabetes and kidney disease, the risk of kidney failure and cardiovascular events was lower in the canagliflozin group than in the placebo group at a median follow-up of 2.62 years

Pseudoaneurysm after sutureless repair of left ventricular free wall rupture: Sequential magnetic resonance imaging demonstration

Sutureless repair is an effective procedure for acute left ventricular free wall rupture; however, it may be complicated with a left ventricular pseudoaneurysm during the late postoperative period. We present a case of a large ventricular pseudoaneurysm that occurred after the sutureless repair of an inferior myocardial infarction with oozing left ventricular free wall rupture. The patient underwent aneurysmectomy successfully. Serial magnetic resonance imaging (MRI) indicated that the necrotic left ventricular wall, which was covered by Teflon felt, had ruptured and developed a pseudoaneurysm. Therefore, after simple gluing for a left ventricular free wall rupture, patients should undergo careful follow-up evaluation for potential pseudoaneurysm. Moreover, early detection by MRI and prompt surgical repair of the complication are important in patients with left ventricular free wall rupture. Copyright (C) 2013, Asian Surgical Association. Published by Elsevier Taiwan LLC. All rights reserved

Pseudoaneurysm after sutureless repair of left ventricular free wall rupture: Sequential magnetic resonance imaging demonstration

Sutureless repair is an effective procedure for acute left ventricular free wall rupture, however, it may be complicated with a left ventricular pseudoaneurysm during the late postoperative period. We present a case of a large ventricular pseudoaneurysm that occurred after the sutureless repair of an inferior myocardial infarction with oozing left ventricular free wall rupture. The patient underwent aneurysmectomy successfully. Serial magnetic resonance imaging (MRI) indicated that the necrotic left ventricular wall, which was covered by Teflon felt, had ruptured and developed a pseudoaneurysm. Therefore, after simple gluing for a left ventricular free wall rupture, patients should undergo careful follow-up evaluation for potential pseudoaneurysm. Moreover, early detection by MRI and prompt surgical repair of the complication are important in patients with left ventricular free wall rupture

Pseudoaneurysm after sutureless repair of left ventricular free wall rupture: Sequential magnetic resonance imaging demonstration

Sutureless repair is an effective procedure for acute left ventricular free wall rupture; however, it may be complicated with a left ventricular pseudoaneurysm during the late postoperative period. We present a case of a large ventricular pseudoaneurysm that occurred after the sutureless repair of an inferior myocardial infarction with oozing left ventricular free wall rupture. The patient underwent aneurysmectomy successfully. Serial magnetic resonance imaging (MRI) indicated that the necrotic left ventricular wall, which was covered by Teflon felt, had ruptured and developed a pseudoaneurysm. Therefore, after simple gluing for a left ventricular free wall rupture, patients should undergo careful follow-up evaluation for potential pseudoaneurysm. Moreover, early detection by MRI and prompt surgical repair of the complication are important in patients with left ventricular free wall rupture

Enhancing Microkernel Performance on VLIW DSP Processors via Multiset Context Switch ⋆

Abstract. High-performance and low-power VLIW DSP processors are increasingly being deployed in mobile devices to process video and multimedia applications. The diverse applications of such systems has led to recent research efforts focusing on their resource management and kernel scheduling. In this paper, we address the enhancing the performance of the microkernel for a VLIW DSP processor, called PAC architectures. In order to reduce the number of read and write ports in register files of VLIW architectures, so as to reduce both the power consumption and implementation costs, a distributed register file and multibank register architectures are being adopted in PAC architectures. These methods present challenges for microkernel designs in terms of reducing context switch overhead. In our work, we propose a multiset descriptor mechanism with compiler support to reduce the context switch overheads associated with the use of registers. The experiments were done with the microkernel system called pCore which has an efficient and tiny design that prunes its code size down under 11 Kbytes. Experimental results show that our multiset context-switching mechanism may reduce the context switch overhead up to 30%.

The value of total protein in guiding management of infectious parapneumonic effusion by using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry

Background/PurposeInfectious parapneumonic effusion (PE) contains proteins originating from circulation as well as proteins locally released by inflammatory pulmonary cells. The purpose of this study was to investigate the value of total protein analysis in guiding management of infectious PE by using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry.MethodsFifty-seven children with pneumonia followed by PE were consecutively enrolled into our study. Protein profiles generated by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry after fractionating samples with functionalized magnetic beads (C8) were used for differentiating complicated PE (CPE) from non-CPE. A training set was used to generate classification models and the clinical efficacy of these models in detecting CPE and the need for intervention was then evaluated in an independent set.ResultsThe MS spectra derived from PE were analyzed, and classification models were constructed in the training set. A total of 123 mass/charge (m/z) values were identified and 23 m/z values which were significant with p < 0.05 were used as classifiers. An optimized genetic algorithm model containing enforced selection of three significant downregulated m/z values (2127, 2232, and 2427) was able to classify CPE with 100% positive predictive value and predict the need of aggressive therapeutic intervention with 77% positive predictive value.ConclusionA diagnostic model construction comprising three potential biomarkers can predict CPE and need for surgical intervention rapidly and precisely. Pleural fluid proteins downregulated during the progression of pneumonia could potentially guide the management of infectious PE

Tricuspid valve infective endocarditis complicated with multiple lung abscesses and thoracic empyema as different pathogens: a case report

Abstract Background Only 4.1% of tricuspid valve IE cases require surgical intervention. The complication after tricuspid valve IE with lung abscess and empyema is rare. Case presentation We report the case of a 38-year-old male (an intravenous drug abuser) diagnosed with tricuspid valve IE who underwent tricuspid valve replacement. The case was complicated by multiple lung abscesses and thoracic empyema. The pathogens causing the lung abscesses and empyema were Acinetobacter baumannii complex and Candida albicans, which were different from those causing the endocarditis. After 4 weeks of antibiotic treatment, chest X-ray revealed bilateral clear lung markings with only mild blunting of the right costophrenic angle. Conclusion The pathogen causing the lung abscess is not always compatible with that causing the endocarditis. Thoracoscopic incision of the abscess with 4 to 6 weeks of broad-spectrum antibiotic treatment is effective and safe