Variability of extracorporeal cardiopulmonary resuscitation utilization for refractory adult out-of-hospital cardiac arrest: an international survey study.

Objective: A growing interest in extracorporeal cardiopulmonary resuscitation (ECPR) as a rescue strategy for refractory adult out-of-hospital cardiac arrest (OHCA) currently exists. This study aims to determine current standards of care and practice variation for ECPR patients in the USA and Korea. Methods: In December 2015, we surveyed centers from the Korean Hypothermia Network (KORHN) Investigators and the US National Post-Arrest Research Consortium (NPARC) on current targeted temperature management and ECPR practices. This project analyzes the subsection of questions addressing ECPR practices. We summarized survey. Results: Overall, 9 KORHN and 4 NPARC centers reported having ECPR programs and had complete survey data available. Two KORHN centers utilized extracorporeal membrane oxygenation only for postarrest circulatory support in patients with refractory shock and were excluded from further analysis. Centers with available ECPR generally saw a high volume of OHCA patients (10/11 centers care for \u3e75 OHCA a year). Location of, and providers trained for cannulation varied across centers. All centers in both countries (KORHN 7/7, NPARC 4/4) treated comatose ECPR patients with targeted temperature management. All NPARC centers and four of seven KORHN centers reported having a standardized hospital protocol for ECPR. Upper age cutoff for eligibility ranged from 60 to 75 years. No absolute contraindications were unanimous among centers. Conclusion: A wide variability in practice patterns exist between centers performing ECPR for refractory OHCA in the US and Korea. Standardized protocols and shared research databases might inform best practices, improve outcomes, and provide a foundation for prospective studies

Additional Effects of Back-Shu Electroacupuncture and Moxibustion in Cardioprotection of Rat Ischemia-Reperfusion Injury

Many preclinical studies show that electroacupuncture (EA) on PC6 and ST36 can reduce infarct size after ischemia-reperfusion (IR) injury. Yet studies to enhance the treatment effect size are limited. The purpose of this study was to explore whether EA has additional myocardial protective effects on an ischemia-reperfusion (IR) injury rat model when back-shu EA and moxibustion are added. SD rats were divided into several groups and treated with either EA only, EA + back-shu EA (B), or EA + B + moxibustion (M) for 5 consecutive days. Transthoracic echocardiography and molecular and immunohistochemical evaluations were performed. It was found that although myocardial infarct areas were significantly lower and cardiac function was also significantly preserved in the three treatment groups compared to the placebo group, there were no additional differences between the three treatment groups. In addition, HSP20 and HSP27 were expressed significantly more in the treatment groups. The results suggest that adding several treatments does not necessarily increase protection. Our study corroborates previous findings that more treatment, such as prolonging EA duration or increasing EA intensity, does not always lead to better results. Other methods of increasing treatment effect size should be explored

Variability of extracorporeal cardiopulmonary resuscitation utilization for refractory adult out-of-hospital cardiac arrest: an international survey study

Objective A growing interest in extracorporeal cardiopulmonary resuscitation (ECPR) as a rescue strategy for refractory adult out-of-hospital cardiac arrest (OHCA) currently exists. This study aims to determine current standards of care and practice variation for ECPR patients in the USA and Korea. Methods In December 2015, we surveyed centers from the Korean Hypothermia Network (KORHN) Investigators and the US National Post-Arrest Research Consortium (NPARC) on current targeted temperature management and ECPR practices. This project analyzes the subsection of questions addressing ECPR practices. We summarized survey results using descriptive statistics. Results Overall, 9 KORHN and 4 NPARC centers reported having ECPR programs and had complete survey data available. Two KORHN centers utilized extracorporeal membrane oxygenation only for postarrest circulatory support in patients with refractory shock and were excluded from further analysis. Centers with available ECPR generally saw a high volume of OHCA patients (10/11 centers care for >75 OHCA a year). Location of, and providers trained for cannulation varied across centers. All centers in both countries (KORHN 7/7, NPARC 4/4) treated comatose ECPR patients with targeted temperature management. All NPARC centers and four of seven KORHN centers reported having a standardized hospital protocol for ECPR. Upper age cutoff for eligibility ranged from 60 to 75 years. No absolute contraindications were unanimous among centers. Conclusion A wide variability in practice patterns exist between centers performing ECPR for refractory OHCA in the US and Korea. Standardized protocols and shared research databases might inform best practices, improve outcomes, and provide a foundation for prospective studies

Post-intervention Status in Patients With Refractory Myasthenia Gravis Treated With Eculizumab During REGAIN and Its Open-Label Extension

OBJECTIVE: To evaluate whether eculizumab helps patients with anti-acetylcholine receptor-positive (AChR+) refractory generalized myasthenia gravis (gMG) achieve the Myasthenia Gravis Foundation of America (MGFA) post-intervention status of minimal manifestations (MM), we assessed patients' status throughout REGAIN (Safety and Efficacy of Eculizumab in AChR+ Refractory Generalized Myasthenia Gravis) and its open-label extension. METHODS: Patients who completed the REGAIN randomized controlled trial and continued into the open-label extension were included in this tertiary endpoint analysis. Patients were assessed for the MGFA post-intervention status of improved, unchanged, worse, MM, and pharmacologic remission at defined time points during REGAIN and through week 130 of the open-label study. RESULTS: A total of 117 patients completed REGAIN and continued into the open-label study (eculizumab/eculizumab: 56; placebo/eculizumab: 61). At week 26 of REGAIN, more eculizumab-treated patients than placebo-treated patients achieved a status of improved (60.7% vs 41.7%) or MM (25.0% vs 13.3%; common OR: 2.3; 95% CI: 1.1-4.5). After 130 weeks of eculizumab treatment, 88.0% of patients achieved improved status and 57.3% of patients achieved MM status. The safety profile of eculizumab was consistent with its known profile and no new safety signals were detected. CONCLUSION: Eculizumab led to rapid and sustained achievement of MM in patients with AChR+ refractory gMG. These findings support the use of eculizumab in this previously difficult-to-treat patient population. CLINICALTRIALSGOV IDENTIFIER: REGAIN, NCT01997229; REGAIN open-label extension, NCT02301624. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that, after 26 weeks of eculizumab treatment, 25.0% of adults with AChR+ refractory gMG achieved MM, compared with 13.3% who received placebo

Minimal Symptom Expression' in Patients With Acetylcholine Receptor Antibody-Positive Refractory Generalized Myasthenia Gravis Treated With Eculizumab

The efficacy and tolerability of eculizumab were assessed in REGAIN, a 26-week, phase 3, randomized, double-blind, placebo-controlled study in anti-acetylcholine receptor antibody-positive (AChR+) refractory generalized myasthenia gravis (gMG), and its open-label extension

Letter to the Editor Comment on (Comparison of Electroacupuncture in Restrained and Unrestrained Rat Models) Authors' Contribution

Although acupuncture researchers have conducted studies using rats for decades, there is no established method for controlling the animals while performing acupuncture. Some choose to use general anesthesia Thirty-two male Sprague-Dawley rats were randomly divided into an anesthetized (AN) group and a restrained (RS) group, which were further divided into four subgroups each ( = 4 for all subgroups) consisting of (1) the sham subgroup, which had their chest opened and the heart exposed but were sutured without further intervention; (2) the IR subgroup; (3) the IR + EA subgroup (EA on PC6, ST36 for 30 min); and (4) the IR + placebo subgroup (EA on nonacupoints without conduction of electricity). On the first day, IR injury was induced in all rats (except the sham subgroups) by placing a slipknot (5-0 silk) around the left anterior descending coronary artery and releasing it after 40 min of ischemia. During the whole process, rats were anesthetized with ketamine (75 mg/kg) and xylazine (2 mg/kg) and mechanically ventilated (Harvard Apparatus, MA, USA). On the first day, the IR + EA subgroups in both AN and RS groups were anesthetized prior to surgery and preconditioned with EA on the left PC6 and ST36 starting 20 min 2 Evidence-Based Complementary and Alternative Medicine after ischemia was induced to 10 min after the snare was loosened. The IR + placebo subgroups were treated with EA on nonacupoints without conduction of electricity. From the second day to the fifth day, the IR + EA subgroup in the AN group received EA for 30 min every day under anesthesia, with additional anesthesia administered intramuscularly if needed (but to a minimum degree); the IR + EA subgroup in the RN group received the same treatment immobilized in the restrainers. Similarly, placebo EA was conducted in the IR + placebo subgroups in both the AN and RS groups. All EA stimulation was administered with acupuncture needles (0.20 × 30 mm, Dongbang Acuneedle Co, Gyeonggi-Do, Korea) with a frequency of 2 Hz for 30 min. To evaluate LV function, rats were anesthetized on the last day, and cardiac function was measured using twodimensional transthoracic echocardiography (Vivid Q; GE Medical Systems, Milwaukee, WI, USA) with a 12 MHz probe. M-mode echocardiography of the LV was performed at the papillary muscle level, guided by two-dimensional short-axis images. LV cavity size was measured during at least three beats in each projection and averaged. The m-mode images yielded systolic and diastolic wall thicknesses (anterior and posterior), and LV end-systolic and end-diastolic diameters. LV fractional shortening was calculated as (LVEDD − LVESD)/LVEDD * 100. All values are expressed as mean ± SE. Results were analyzed using the Kruskal-Wallis nonparametric test for multiple comparisons, and values less than 0.05 were considered statistically significant. In our findings, improvement in cardiac function was similar in the IR + EA subgroups of both AN and RS groups, but there were different results in the placebo subgroups. While the LVEF of the AN placebo subgroup did not improve (IR, 60.30 ± 5.49; IR + EA, 70.56 ± 4.42; IR + placebo, 54.88 ± 2.12, < 0.05), the LVEF in the RS placebo subgroup improved so that the results did not differ significantly compared to the treatment group (IR, 58.83 ± 5.80; IR + EA, 67.03 ± 3.40; IR + placebo, 60.30 ± 5.49, > 0.05). Among many possible factors that could have produced the additional effects, we believe frequent reinsertion of acupuncture needles was a significant factor. In the restrained group, the rats frequently flexed their muscles to try to escape from the restrainers, which made the acupuncture needles fall out. Although the needles at ST36 mostly stayed intact, the ones at PC6 were a problem, as the needles were inserted to a shallower depth of approximately 5 mm. Every time the needles fell out, the researchers had to stick them back in, which increased stress and produced additional somatosensory stimulation. Unlike the RS placebo subgroup, the AN placebo subgroup (which did not require reinsertions) showed no significant improvement in LVEF, and in a confirmatory trial that limited the number of reinsertions per session to less than three, the LVEF of the RS placebo subgroup did not improve. Our observation is noteworthy because in the study by Zhang et al. Much more experiments to standardize and optimize research methods in acupuncture-related preclinical studies should be conducted. Novel methods to control rats must be continuously explored and researchers should know that differences in handling techniques can unwittingly expose well-designed studies to confounding factors, reproducibility failures, and limitations. Both of the chosen methods in our study do have their limitations, sedating animals prior to every acupuncture session is not feasible, and restraining rats also induces high levels of stres

Efficacy and safety of electroacupuncture in acute decompensated heart failure: a study protocol for a randomized, patient- and assessor-blinded, sham controlled trial

Abstract Background The purpose of this trial is to evaluate the effectiveness and safety of electroacupuncture in the treatment of acute decompensated heart failure compared with sham electroacupuncture. Methods This protocol is for a randomized, sham controlled, patient- and assessor-blinded, parallel group, single center clinical trial that can overcome the limitations of previous trials examining acupuncture and heart failure. Forty-four acute decompensated heart failure patients admitted to the cardiology ward will be randomly assigned into the electroacupuncture treatment group (n = 22) or the sham electroacupuncture control group (n = 22). Participants will receive electroacupuncture treatment for 5 days of their hospital stay. The primary outcome of this study is the difference in total diuretic dose between the two groups during hospitalization. On the day of discharge, follow-up heart rate variability, routine blood tests, cardiac biomarkers, high-sensitivity C-reactive protein (hs-CRP) level, and N-terminal pro b-type natriuretic peptide (NT-pro BNP) level will be assessed. Four weeks after discharge, hs-CRP, NT-pro BNP, heart failure symptoms, quality of life, and a pattern identification questionnaire will be used for follow-up analysis. Six months after discharge, major cardiac adverse events and cardiac function measured by echocardiography will be assessed. Adverse events will be recorded during every visit. Discussion The result of this clinical trial will offer evidence of the effectiveness and safety of electroacupuncture for acute decompensated heart failure. Trial registration Clinical Research Information Service: KCT0002249

Brain correlates to facial motor imagery and its somatotopy in the primary motor cortex

Motor imagery (MI) has attracted increased interest for motor rehabilitation as many studies have shown that MI shares the same neural networks as motor execution (ME). Nevertheless, MI in terms of facial movement has not been studied extensively; thus, in the present study, we investigated shared neural networks between facial motor imagery (FMI) and facial motor execution (FME). In addition, FMI somatotopy within-face was investigated between the forehead and the mouth. Functional MRI was used to examine 34 healthy individuals with ME and MI paradigms for the forehead and the mouth. The general linear model and a paired t-test were performed to define the facial area in the primary motor cortex (M1) and this area has been used to investigate somatotopy between the forehead and mouth FMI. FMI recruited similar brain motor areas as FME, but showed less neural activity in all activated regions. The facial areas in M1 were distinguishable from other body movements such as finger movement. Further investigation of this area showed that forehead and mouth imagery tended to lack a somatotopic representation for position on M1, and yet had distinct characteristics in terms of neural activity level. FMI showed different characteristics from general MI as the former exclusively activated facial processing areas. In addition, FME and FMI showed different characteristics in terms of BOLD signal level, while sharing the same neural areas. The results imply a potential usefulness of MI training for rehabilitation of facial motor disease considering that forehead and mouth somatotopy showed no clear position difference, and yet showed a significant BOLD signal intensity variation

Effects of Acupuncture on Cardiac Remodeling in Patients with Persistent Atrial Fibrillation: Results of a Randomized, Placebo-Controlled, Patient- and Assessor-Blinded Pilot Trial and Its Implications for Future Research

Background and Objectives: In this study, we attempted to determine the effects of acupuncture on cardiac remodeling and atrial fibrillation (AF) recurrence rates in patients with AF after electrical cardioversion (EC). Materials and Methods: We randomly assigned 44 patients with persistent AF to an acupuncture group or a sham acupuncture group. An electroacupuncture treatment session was administered once weekly for 12 weeks at four acupuncture points (left PC5, PC6, ST36, and ST37). Results: Among the 44 recruited participants, 16 (treatment group) and 15 (control group) completed the trial. The three-month AF recurrence rate (primary outcome) was not significantly different between the two groups. Following the completion of treatment, patients who had been treated with acupuncture had a significant reduction in left atrial volume index (42.2 ± 13.9 to 36.1 ± 9.7 mL/m2; p = 0.028), whereas no change in atrial size was observed in the sham acupuncture group. No serious adverse events were observed. The AF recurrence rate and cardiac function did not differ significantly between the two groups. At three months, the acupuncture treatment group showed more favorable atrial structural remodeling compared to the sham acupuncture group. Conclusion: In future research on acupuncture in AF management, it is recommended that the inclusion criteria be amended to include only symptomatic AF, that an appropriate control group is designed, and that the acupuncture treatment frequency is increased to several times per week