Minimal Neurological Impairment Research Articles

A STUDY ON THE CORRELATION BETWEEN SERUM CORTISOL LEVELS AND SEVERITY OF ACUTE ISCHEMIC STROKE.

INTRODUCTION: There are many clinical variables like symptom severity and advanced age which are identied as potential predictors of outcome in patients with acute stroke. But there is an immense need to detect a biomarker for predicting the outcome of acute stroke. The stress response that occurs after the event of acute stroke causes the activation of the hypothalamic–pituitary–adrenal (HPA) axis. Certain studies have found that increased serum cortisol level in patients with acute stroke is related to larger infarct volume, greater stroke severity and poor outcome, including death AIM AND OBJECTIVE: To assess the relationship of single serum cortisol levels to the severity of acute ischemic stroke. MATERIALS AND METHODS: About 50 new cases of acute ischemic stroke patients, within 72 hours of the acute neurological event, who were admitted to the Chalmeda Anand Rao institute of medical sciences, Karimnagar, Telangana were included in the study. The study was conducted for 6 months.CT Brain was taken during admission to conrm acute ischemic stroke. NIHSS (National Institute of Health Stroke Scale) scores for all the patients were assessed for severity at the time of admission. Serum cortisol levels were measured the next day early morning. After 15 days, the functional outcome of the patients was assessed using the Modied Rankin Scale. The correlation between serum cortisol levels and stroke scales is assessed byChi–Square Test. All statistical analyses are performed using SPSS (software package used for statistical analysis) package. RESULTS: Of the 50 cases, the serum cortisol level of 23 cases was within normal limits(</=690nmol/L) of which 65.2% had NIHSS scores of less than or equal to 6 and 34.8% of the cases had NIHSS scores more than 6. As the NIHSS score of less than or equal to 6 is considered to be a minor stroke, it is obvious from the above ndings that most of the cases with normal cortisol levels had no major stroke. The remaining 27 cases had elevated serum cortisol levels.100% of the cases with serum cortisol levels of more than 690nmol/L had NIHSS scores above 6. With a p-value of <0.001, this is found to be statistically signicant. As the NIHSS score above 6 is considered to be moderate to severe stroke, it is obvious from the above observation that nearly all cases with elevated cortisol levels had moderate to severe stroke. Of the 50 cases, serum cortisol levels of 23 cases were within normal limits(,/=690nmol/L)of which 78.3% had MRS scores less than or equal to 3 and 21.7% had MRS scores more than 3. Since the MRS score is a measure of functional outcome and any score less than or equal to 3 is considered to have a favourable outcome, it is clear from the above ndings that most of the cases with normal serum cortisol had a favourable outcome with minimal neurological impairment. And in the remaining 27 cases which had serum cortisol levels of more than 690 nmol/L, 3.7% had an MRS score of less than or equal to 3 and 96.3% had an MRS score of more than 3. With a p-value of <0.001, this is statistically signicant. Since an MRS score of more than 3 is associated with a bad outcome, most of the cases with elevated serum cortisol had a poor outcome with severe neurological impairment. CONCLUSION: Among the patients with acute ischemic stroke, high serum cortisol levels at the time of admission correlate with, Clinical severity which is assessed by the National Institute of Health Stroke Scale and Poor prognosis and functional outcome after 15 days which is assessed by the Modied Rankin Scale

Habitual exercise provides better prognosis for cardiac arrest with coronary artery disease

Abstract Background Although regular physical activity has beneficial cardiovascular effects, exercise can trigger sudden cardiac arrest (SCA). Coronary artery disease (CAD) was identified as the most common cause of an exercise-related out-of-hospital cardiac arrest (OHCA). Regular exercise has been reported to reduce the risk of plaque rupture in animal studies and basic research. Therefore, we compared the coronary artery findings in CAD-OHCA patients with and without habitual exercise. There have been few reports on whether regular exercise changes the prognosis in OHCA due to CAD (CAD-OHCA). We investigated the association between the better clinical outcome and the regular exercise in patients with CAD-OHCA. Methods This is a single-center retrospective analysis from 2006 to 2019. The consecutive 397 patients with OHCA due to myocardial ischemia underwent coronary angiography (CAG). After excluding 73 patients with vasospastic angina, the remaining 324 patients with CAD were enrolled in this study. We divided these patients into two groups according to whether they were habitually exercising (Exercise group: N=37) or not/unknown (Non-Exercise group: N=287). Clinical outcome was a 30-day survival with minimal neurologic impairment represented by a Glasgow-Pittsburgh Cerebral Performance Categories Scale value 1 or 2. Results The patients in the Exercise Group were significantly younger (exercise vs. non-exercise, 57±12 vs. 64±12 years; P<0.01) than those in the non-exercise group. The Exercise group had a lower incidence of diabetes mellitus (22% vs. 42%; P=0.02) and a higher incidence of dyslipidemia (81% vs. 62%; P=0.02) than the non-exercise group. The time from collapse to cardiopulmonary resuscitation (1.4±4.0 vs. 3.0±4.8min) and from collapse to return of spontaneous circulation (11.9±10.0 vs. 28.0±25.3min) were shorter in Exercise group (all p<0.05). The ST-segment elevation was recorded on electrocardiography in fewer of the Exercise group (22% vs. 63%; P<0.01). The finding of culprit lesion in the coronary arteries on arrival resulted significant differences between the 2groups (good collateral and/or TIMI3 flow: 62% vs. 25%, the plaque rupture and/or thrombus: 22% vs. 73%) (all p<0.01) (Figure 1). Kaplan-Meier curve showed Exercise group has better neurological outcome at 30days compared than Non-Exercise (95% vs 51%; P<0.001, log-rank test) (Figure 2). Multivariable Cox proportional hazards models revealed that a habitual exercise was one of the predictors of a good neurological outcome (HR 0.21, 95% CI 0.05–0.92; P=0.039). Conclusions The patients with habitual exercise had less plaque rupture, less coronary thrombosis than non-exercise. The patients with regular exercise had better clinical outcomes than non-exercise after CAD-OHCA. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Tokyo Metropolitan Goverment Figure 1. Findings of the culprit lesion in coronar arteriesFigure 2. Kaplan-Meier analysis

Abstract 388: Long-Distance Running Races Supported by Running Doctors Provide Better Clinical Outcomes for Runners With Cardiac Arrest

Background: Approximately 10million people enjoy running in Japan annually. It is reported that the risk of an out-of-hospital cardiac arrest (OHCA) is temporarily increased during running. Several races in Japan supported by Running Doctors (RD) respond to runners with OHCA. The RDs are doctors who belong to the Japan Medical Joggers Association. The RDs participate in running races as general runners, perform medical monitoring from the inside of the running course, and if they encounter a serious health problem, especially OHCA, with a runner, they cancel their race and make an initial response. For example, 49 RDs cooperated in Tokyo Marathon 2019. However, the effectiveness of their activities is unclear. We investigated whether their activities were effective. Methods: A cohort of 8,884 patients with OHCA were admitted with return of spontaneous circulation (ROSC) or on-going resuscitation at our hospital arrival from 2006 to 2018. The 13 runners with OHCA which occurred during long distance running races were analyzed from the medical records and interviews of survivors and relatives. We divided runners into two groups depending on whether RD responded: RD group (n=7) and non-RD group (n=6). The clinical outcome was 30-day survival with minimal neurologic impairment. Results; Overall, the 12 (92%) runners were male. The RD group was older than Non-RD group (RD vs. Non-RD, 52±9 vs. 35±17 years old; P=0.04). The time interval between collapse and starting cardiopulmonary resuscitation (0.4±0.5 vs. 4.2±3.6 min; P=0.02) and between collapse and ROSC (6.6±2.9 vs. 23.3±19.3 min ; P=0.04) were significantly shorter in RD group. On Kaplan-Meier analysis, runners with OHCA in RD group were better clinical outcome than Non-RD group (100% vs. 67%; P=0.11; log-rank test). (Figure) Conclusion; The long-distance running races supported by running doctors provided early response to runners with OHCA. This might lead to better clinical outcomes for runners with OHCA.

Extravasation control with preserved vessel patency after wire perforation during neurothrombectomy: Case report and literature review

Parallel to a more widespread application of endovascular neurothrombectomy in acute ischemic stroke, it is critical to understand the nature and management of associated complications, including wire perforation of the middle cerebral artery (MCA). Sacrifice of the perforated vessel may be necessary to avoid fatal intra-cranial hemorrhage. Here we describe a case of right MCA distribution ischemia complicated by a right MCA perforation. Using super selective injection of contrast through a microcatheter, the point of extravasation was located and sealed with liquid embolic agent (Onyx) while preserving patency of the MCA. By avoiding vessel sacrifice, blood perfusion to distal areas was preserved and therefore the patient was discharged with minimal neurological impairment. Causes of perforation and technical aspects to control extravasation are further discussed.

Giant Schwannoma of the Median Nerve: A Case Report and Literature Review

Peripheral nerve sheath tumors (PNST) develop sporadically or are associated with genetic disorders and affect individuals mainly between the third and sixth decades of life. PNST affect one or multiple fascicles. The benign ones have slow and painless growth, preceding in years the diagnosis. Diagnosis is often confused with other soft tissue tumors, such as fibroids and lipomas. We present a rare case of giant schwannoma of the median nerve. The patient had a progressive local growth with minimal neurological impairment.

Exercise-related resuscitated out-of-hospital cardiac arrest due to presumed myocardial ischemia: Result from coronary angiography and intravascular ultrasound

AimPossible causes of exercise-related out-of-hospital cardiac arrest (OHCA) in people with coronary artery disease (CAD) include atherosclerotic plaque rupture (PR) and intra-coronary thrombosis, exercise-induced myocardial ischaemia and other triggers. We investigated whether there are differences in the incidence of PR and/or intra-coronary thrombus and in clinical outcome between ‘exercise-related’ and ‘non-exercise-related’ OHCA. Methods219 consecutive resuscitated patients with CAD diagnosed by emergency coronary angiography (CAG) were enrolled. They were divided into the exercise group (≥6 METs; n = 35) and non-exercise group (<6 METs; n = 184), according to estimated METs immediately before OHCA using 2011 Compendium of Physical Activities. We investigated whether culprit lesions had PR and/or thrombus using CAG and intravascular ultrasound. The clinical outcome was 30-day survival with minimal neurologic impairment. ResultsAcute PR and/or thrombus occurred in fewer of the exercise group than the non-exercise group (11% vs. 90%; P < 0.001). The exercise group had a higher incidence of favorable neurological outcome (94% vs. 47%; P < 0.001) than the non-exercise group. Multivariable Cox proportional hazards models revealed that exercise immediately before OHCA was one of the predictors of a good neurological outcome (HR, 0.19; P = 0.025). ConclusionThe incidence of PR and/or thrombosis was lower in the group taking higher levels of exercise, than in the group taking less or no exercise. “Exercise-related” OHCA with CAD has better clinical outcomes than “non-exercise-related” with a greater proportion of witnessed arrests and early return of spontaneous circulation.

JM-20 Treatment After MCAO Reduced Astrocyte Reactivity and Neuronal Death on Peri-infarct Regions of the Rat Brain.

Stroke is frequently associated with severe neurological decline and mortality, and its incidence is expected to increase due to aging population. The only available pharmacological treatment for cerebral ischemia is thrombolysis, with narrow therapeutic windows. Efforts aimed to identify new therapeutics are crucial. In this study, we look into plausible molecular and cellular targets for JM-20, a new hybrid molecule, against ischemic stroke in vivo. Male Wistar rats were subjected to 90min middle cerebral artery occlusion (MCAO) following 23h of reperfusion. Animals treated with 8mg/kg JM-20 (p.o., 1h after reperfusion) showed minimal neurological impairment and lower GABA and IL-1β levels in CSF when compared to damaged rats that received vehicle. Immunocontent of pro-survival, phosphorylated Akt protein decreased in the cortex after 24h as result of the ischemic insult, accompanied by decreased number of NeuN+ cells in the peri-infarct cortex, cornu ammonis 1 (CA1) and dentate gyrus (DG) areas. Widespread reactive astrogliosis in both cortex and hippocampus (CA1, CA3, and DG areas) was observed 24h post-ischemia. JM-20 prevented the activated Akt reduction, neuronal death, and astrocytes reactivity throughout the brain. Overall, the results reinforce the pharmacological potential of JM-20 as neuroprotective agent and provide important evidences about its molecular and cellular targets in this model of cerebral ischemia.

Effects of advanced life support on patients who suffered cardiac arrest outside of hospital and were defibrillated

BackgroundThe effects and relative benefits of advanced airway management and epinephrine on patients with out-of-hospital cardiac arrest (OHCA) who were defibrillated are not well understood. MethodsThis was a prospective observational study. Using data of all out-of-hospital cardiac arrest cases occurring between 2005 and 2013 in Japan, hierarchical logistic regression and conditional logistic regression along with time-dependent propensity matching were performed. Outcome measures were survival and minimal neurological impairment [cerebral performance category (CPC) 1 or 2] at 1month after the event. ResultsWe analyzed 37,873 cases that met the inclusion criteria. Among propensity-matched patients, advanced airway management and/or prehospital epinephrine use was related to decreased rates of 1-month survival (adjusted odds ratio 0.88, 95% confidence interval 0.80 to 0.97) and CPC (1, 2) (adjusted odds ratio 0.56, 95% confidence interval 0.48 to 0.66). Advanced airway management was related to decreased rates of 1-month survival (adjusted odds ratio 0.89, 95% confidence interval 0.81to 0.98) and CPC (1, 2) (adjusted odds ratio 0.54, 95% confidence interval 0.46 to 0.64) in patients who did not receive epinephrine, whereas epinephrine use was not related to the outcome measures. ConclusionsIn defibrillated patients with OHCA, advanced airway management and/or epinephrine are related to reduced long-term survival, and advanced airway management is less beneficial than epinephrine. However, the proportion of patients with OHCA who responded to an initial shock was very low in the study subjects, and the external validity of our findings might be limited.

Early preclinical evaluation of dihydropyrimidin(thi)ones as potential anticonvulsant drug candidates

Although significant advances are occurring in epilepsy research, about 30% of epileptic patients are still inadequately controlled by standard drug therapy. For this reason, it continues to be important to develop new chemical entities through which epilepsy could be effectively controlled. In this study, the anticonvulsant activity of forty-two dihydropyrimidin(thi)ones was explored and their efficacy was evaluated in rodents against the maximal electroshock seizure (MES) and subcutaneous pentylenetetrazole tests. The results of preliminary pharmacological screening after intraperitoneal injection in mice revealed that twenty-four compounds showed protection in half or more of the animals tested in the MES seizure model, being nine of them active at the lowest dose tested (30mg/kg). Structurally, the most promising compounds (both urea and thiourea derivatives) presented smaller lateral chains and unsubstituted or para-substituted phenyl ring with a methyl group. Compounds 4, 5 and 11 also protected against MES-induced seizures in 50–75% of rats after oral administration at 30mg/kg. Moreover, the minimal motor and/or neurological impairment evaluated through the rotarod assay showed that around 52% of the compounds presented lower toxicity than the antiepileptic drugs lamotrigine, carbamazepine and phenytoin. In addition, the most active compounds did not show notable cytotoxicity in in vitro experiments conducted in several cell lines (relative cell proliferation higher than 50% at 30μM), which can be relevant due to the fact that the toxicity is a common problem of the available antiepileptic drugs. Furthermore, additional computational studies indicated that all compounds respected the Lipinski's rule of five, which, together with the data of efficacy and toxicity, make them attractive compounds to be developed in the future as potential anticonvulsant agents.

Resuscitation outcomes of reproductive-age females who experienced out-of-hospital cardiac arrest.

Although some studies have shown that women in their reproductive years have better resuscitation outcomes of out-of-hospital cardiac arrest (OHCA), conflicting results and methodological problems have also been noted. Thus, we evaluated the resuscitation outcomes of OHCA of females by age. This was a prospective observational study using registry data from all OHCA cases between 2005 and 2012 in Japan. The subjects were females aged 18-110 years who suffered an out-of-hospital cardiac arrest. Logistic regression analyses were performed using total and propensity-matched patients. There were 381,123 OHCA cases that met the inclusion criteria. Among propensity-matched patients, females aged 18-49 and 50-60 years of age had similar rates of return of spontaneous circulation before hospital arrival and 1-month survival (all p>0.60). In contrast, females aged 18-49 years of age had significantly lower rates of 1-month survival with minimal neurological impairment than did females aged 50-60 years of age (after adjusting for selected variables: Cerebral Performance Category scale 1 or 2 (CPC (1, 2)), OR=0.45, p=0.020; Overall Performance Category scale 1 or 2 (OPC (1, 2)): OR=0.42, p= 0.014; after adjustment for all variables: CPC (1, 2), OR=0.27, p= 0.008; OPC (1, 2), OR=0.29, p=0.009). Women of reproductive age did not show improved resuscitation outcomes in OHCA. Additionally, women in their reproductive years showed worse neurological outcomes one month after the event, which may be explained by the negative effects of estrogen. These findings need to be verified in further studies.

Dynamic Nature of Postpartal Carotid Artery Dissection

Abstract Craniocervical carotid artery dissection (CCAD) is an important cause of stroke in young adults, but it has rarely been reported as a cause of stroke in puerperium. We report the case of a 27-year-old female with a history of migraine who presented with unilateral left headache, transient episodes of dysphasia and right hemiparesis 30 days after vaginal delivery. The first symptoms started six days after the prolonged childbirth. The first magnetic resonance angiography revealed dissection in the supraclinoid and a cavernous segment of the left Internal carotid artery (ICA). We followed up the patient for two years and she had an unstable course. During this time, she had occlusion of the supraclinoid segment of the left ICA, with caudal extension on the extracranial segment and recanalisation one month later. Two months later, she had intracranial extension with dissection of the left anterior cerebral artery. During this time, she suffered from two strokes with minimal neurological impairment and good clinical recovery. The pathophysiology of CCAD appears to be multifactorial. Vessel wall injury related to the Valsalva manoeuvre during labour, as well as hemodynamic and hormonal changes of the vessel wall related to pregnancy in a patient with a history of migraine, may be causes of postpartum spontaneous craniocervical artery dissection in healthy women.

Spontaneous Resolution of Sequestrated Lumbar Disc Herniation: A Prospective Cohort Study

ObjectiveSpontaneous regression of sequestrated lumbar disc well known entity. But, the current reports about this scenario are confined to case reports or small case series. To assess the chance of complete spontaneous resolution of sequestrated lumbar disc herniation and to report the outcome of regressed cases in a prospective study. MethodFrom January 2010 to July 2015, 103 patients with acute lower limb mono-radiculopathy, but without neurological motor deficit secondary to a migrated lumbar disc herniation thought to be a sequestrated free disc fragment were prospectively studied for the possibility of their spontaneous regression with time. All the qualified patients initially fulfilled the study criteria. But seven patients were lost to follow up and 9 more cases preferred to do surgery within a few days to three weeks after clinical trial. Eighty seven patients remained for clinical evaluation and periodic magnetic resonance imaging for the possibility of spontaneous regression. These patients include 39 males and 48 females. The age of the patients ranged from 22 to67 years with the mean of 42.96, SD= 10.65. ResultsIn 75 of these cases complete resolution of the offending disc occurred. This was associated with marked improvement or even disappearance of pain intensity in short and mid-term follow-up. Furthermore, where a case of same level contralateral disc herniation was seen, not a single case of same level same side recurrence could be encountered. The cost of treatment and work status of the patients were significantly better than surgically treated patients according to previously published reports. In mid-term follow, recovery rate (McNab Criteria %) of these 75 patients was either good or excellent. All these were satisfied and recommend this type of treatment for similar patients. The remaining 12 patients, ultimately underwent surgery. Surprisingly, all had subligamentous location ConclusionThis study clarifies that conservative management might be considered as an appropriated cost-effective option in treatment of sequestrated lumbar disc herniation in the patients with minimal neurological impairment, with probably high chance of spontaneous regression of the offending disc. However, to compare conservative versus surgery, in this sub-type of disc herniation, further clinical trials are recommended.

Survival After Ventricular Fibrillation Cardiac Arrest in the Sao Paulo Metropolitan Subway System: First Successful Targeted Automated External Defibrillator (AED) Program in Latin America.

BackgroundTargeted automated external defibrillator (AED) programs have improved survival rates among patients who have an out‐of‐hospital cardiac arrest (OHCA) in US airports, as well as European and Japanese railways. The Sao Paulo (Brazil) Metro subway carries 4.5 million people per day. A targeted AED program was begun in the Sao Paulo Metro with the objective to improve survival from cardiac arrest.Methods and ResultsA prospective, longitudinal, observational study of all cardiac arrests in the Sao Paulo Metro was performed from September 2006 through November 2012. This study focused on cardiac arrest by ventricular arrhythmias, and the primary endpoint was survival to hospital discharge with minimal neurological impairment. A total of 62 patients had an initial cardiac rhythm of ventricular fibrillation. Because no data on cardiac arrest treatment or outcomes existed before beginning this project, the first 16 months of the implementation was used as the initial experience and compared with the subsequent 5 years of full operation. Return of spontaneous circulation was not different between the initial 16 months and the subsequent 5 years (6 of 8 [75%] vs. 39 of 54 [72%]; P=0.88). However, survival to discharge was significantly different once the full program was instituted (0 of 8 vs. 23 of 54 [43%]; P=0.001).ConclusionsImplementation of a targeted AED program in the Sao Paulo Metro subway system saved lives. A short interval between arrest and defibrillation was key for good long‐term, neurologically intact survival. These results support strategic expansion of targeted AED programs in other large Latin American cities.

Making sense of clinical outcomes following cardiac arrest.

To provide a summary of the recent literature on clinical outcomes in adults with cardiac arrest, focusing on the impact of patient-specific factors in combination with cardio-pulmonary resuscitation (CPR) related, and postresuscitative-related factors. Cardiac arrest is a major cause of morbidity and mortality worldwide. Despite the use of conventional cardiopulmonary resuscitation, rates of return of spontaneous circulation and survival with minimal neurologic impairment remain low. A number of recent studies have examined the impact of patient-specific factors (duration of cardiac arrest, initial rhythm, age, premorbid states), CPR-related (the use of mechanical CPR, the use of impedance threshold device, vasopressors, extra-corporeal membrane oxygenation, active compression-decompression, and impedance threshold device), and postresuscitative-related factors (hypothermia, coronary angiography, hyperoxia, hyper/hypocapnia, mean arterial blood pressure) on cardiac arrest outcomes. Further studies, namely randomized controlled trials, assessing the impact of advanced therapies are warranted to evaluate their impact on survival and neurologic function in adults with cardiac arrest.

Venoarterial Extracorporeal Membrane Oxygenation in Adults With Cardiac Arrest.

Cardiac arrest (CA) is a major cause of morbidity and mortality worldwide. Despite the use of conventional cardiopulmonary resuscitation (CPR), rates of return of spontaneous circulation and survival with minimal neurologic impairment remain low. Utilization of venoarterial extracorporeal membrane oxygenation (ECMO) for CA in adults is steadily increasing. Propensity-matched cohort studies have reported outcomes associated with ECMO use to be superior to that of conventional CPR alone in in-hospital patients with CA. In this review, we discuss the mechanism, indications, complications, and evidence for ECMO in CA in adults.

Abstract 60: Survival After Ventricular Fibrillation in Sao Paulo Metro

Background: Automated external defibrillators (AEDs) in public places can improve the rate of survival among patients who have had an out-of-hospital cardiac arrest (OHCA). Sao Paulo Metro carries about 4.5 million people per day and since 2006, the security officials of metro (lays rescuers) are trained in cardiopulmonary resuscitation (CPR) and handling of AED. This program also included the installation of AEDs in every metro station. Methods: From September 1, 2006, through November 31, 2012, we conducted a prospective, longitudinal, observational study involving patients who had cardiac arrest in Sao Paulo Metro and were attempted by security officials of metro. The outcome of each patient was followed through medical records of the hospitals to which patients were referred. Reading the AED registration of each patient was performed. The primary end-point was minimal neurologic impairment after hospital discharge. Results: A total of 102 sudden collapses were included in the study; 86 were cardiac arrest and 62 of these patients had ventricular fibrillation with initial cardiac rhythm. The percentage of patients who achieved sustained return of spontaneous circulation was 45 (73%), 34 (55%) of patients arrived alive at the hospital and 23 (37%) were discharged and were alive at 1 year with minimal neurologic impairment. Comparing the periods of the Sep/2006-Nov/2009 with Oct/2009-Nov/2012, respectively, the rate of patients without neurological impairment before discharge and at 1 year was 22% versus 45% (p=0.072). Multivariate logistic regression analysis revealed that the time interval in minutes between collapse and first shock was the only variable independently associated with the primary end point (odds ratio = 0.13, 95 % CI 0.05 to 0.38, p &lt;0.0001). Conclusion: The study supports a significant beneficial impact of implementation of PAD program in Sao Paulo Metro. Shorter intervals between arrest and defibrillation are necessary to achieve the highest survival rates. These results support strategic expansion of PAD programs in similar places in Brazil.

Results of the implementation of hands-only CPR for cardiac arrest in Sao Paulo Metro

Introduction: Sao Paulo's Subway carries about 4.5 million people per day. Since November 2009, the employees (lays rescuers) from Sao Paulo's Subway facilities conduct continuous training (at least every two years) in cardiopulmonary resuscitation (CPR), instructed to perform hands only (HO) CPR and handling of the automatic external defibrillator (AED). Previously (September 2006 to October 2009), patients were treated by conventional CPR and obtained a survival rate of 22%, with minimal neurologic impairment one year after cardiac arrest (CA).

Results of the implementation of hands-only CPR for cardiac arrest care in Sao Paulo

Introduction: Sao Paulo's Subway carries about 4.5 million people per day. Since November 2009, the employees (lays rescuers) from Sao Paulo's Subway facilities conduct continuous training (at least every two years) in cardiopulmonary resuscitation (CPR), instructed to perform hands only (HO) CPR and handling of the automatic external defibrillator (AED). Previously (September 2006 to October 2009), patients were treated by conventional CPR and obtained a survival rate of 22%, with minimal neurologic impairment one year after cardiac arrest (CA).

Two-year survival and neurological outcome of in-hospital cardiac arrest patients rescued by extracorporeal cardiopulmonary resuscitation

The clinical benefit of extracorporeal cardiopulmonary resuscitation (E-CPR) has been proved in short-term follow-up studies. However, the benefit of E-CPR beyond 1 year has been not known. We investigated 2-year outcome of patients who received E-CPR or conventional CPR (C-CPR). We analyzed a total of 406 adult in-hospital cardiac arrest victims who underwent CPR for more than 10 min from 2003 to 2009. The two-year survival and neurological outcome of E-CPR (n=85) and C-CPR (n=321) were compared using propensity score-matched analysis. The 2-year survival with minimal neurological impairment was 4-fold higher in the E-CPR group than the C-CPR group (23.5% versus 5.9%, hazard ratio (HR)=0.57, 95% confidence interval (CI)=0.43-0.75, p<0.001) by unadjusted analysis. After propensity-score matching, it was still 4-fold higher in the E-CPR group than the C-CPR group (20.0% versus 5.0%, HR=0.53, 95% CI=0.36-0.80, p=0.002). In the E-CPR group, the independent predictors associated with minimal neurological impairment were age ≤65 years (HR=0.46; 95% CI=0.26-0.81; p=0.008), CPR duration ≤35 min (HR=0.37; 95% CI=0.18-0.76; p=0.007), and subsequent cardiovascular intervention including coronary intervention or cardiac surgery (HR=0.36; 95% CI=0.18-0.68; p=0.002). The initial survival benefit of E-CPR for cardiac arrest patients persisted at 2 years.

Comparison of Outcomes After Use of Biphasic or Monophasic Defibrillators Among Out-of-Hospital Cardiac Arrest Patients

The use and popularity of the biphasic waveform defibrillator as a replacement for the monophasic waveform defibrillator are increasing, but it is unclear whether this can improve the rate of survival among out-of-hospital cardiac arrest patients. This study aimed to verify the hypothesis that the outcome of out-of-hospital cardiac arrest patients who received defibrillation shock with the biphasic waveform defibrillator was better than that of patients who received defibrillation shock with the monophasic defibrillator. This prospective, nationwide, population-based, observational study included 21 172 out-of-hospital cardiac arrest patients with initial ventricular fibrillation or pulseless ventricular tachycardia from January 1, 2005, through December 31, 2007. Defibrillation shock was performed by monophasic defibrillator on 8224 (39%) patients and by biphasic defibrillator on 12 948 (61%) patients. The rate of survival at 1 month with minimal neurological impairment was 11.6% (951/8192) in the monophasic defibrillator group and 12.8% (1653/12 928) in the biphasic defibrillator group. Hierarchical logistic regression analysis using a generalized estimation equation showed no significant difference between the biphasic and monophasic groups in 1-month survival with minimal neurological impairment (adjusted odds ratio, 1.07; 95% confidence interval, 0.91-1.26; P=0.42). Confirmatory propensity score analyses showed similar results. Although monophasic defibrillators are being replaced by biphasic defibrillators, our nationwide population-based observational study failed to demonstrate a statistically significant association between defibrillation waveform and 1-month survival rate with minimal neurological impairment.