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Rafnsdottir S, Jang K, Halldorsdottir ST, Vinod M, Tomasdottir A, Möller K, Halldorsdottir K, Reynisdottir T, Atladottir LH, Allison KE, Ostacolo K, He J, Zhang L, Northington FJ, Magnusdottir E, Chavez-Valdez R, Anderson KJ, Bjornsson HT. SMYD5 is a regulator of the mild hypothermia response. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2023.05.11.540170. [PMID: 37333301 PMCID: PMC10274674 DOI: 10.1101/2023.05.11.540170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
The mild hypothermia response (MHR) maintains organismal homeostasis during cold exposure and is thought to be critical for the neuroprotection documented with therapeutic hypothermia. To date, little is known about the transcriptional regulation of the MHR. We utilize a forward CRISPR-Cas9 mutagenesis screen to identify the histone lysine methyltransferase SMYD5 as a regulator of the MHR. SMYD5 represses the key MHR gene SP1 at euthermia. This repression correlates with temperature-dependent levels of H3K36me3 at the SP1-locus and globally, indicating that the mammalian MHR is regulated at the level of histone modifications. We have identified 37 additional SMYD5 regulated temperature-dependent genes, suggesting a broader MHR-related role for SMYD5. Our study provides an example of how histone modifications integrate environmental cues into the genetic circuitry of mammalian cells and provides insights that may yield therapeutic avenues for neuroprotection after catastrophic events.
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Affiliation(s)
- Salvor Rafnsdottir
- Louma G. Laboratory of Epigenetic Research, Faculty of Medicine, University of Iceland; Reykjavik, Iceland
| | - Kijin Jang
- Louma G. Laboratory of Epigenetic Research, Faculty of Medicine, University of Iceland; Reykjavik, Iceland
| | - Sara Tholl Halldorsdottir
- Louma G. Laboratory of Epigenetic Research, Faculty of Medicine, University of Iceland; Reykjavik, Iceland
| | - Meghna Vinod
- Louma G. Laboratory of Epigenetic Research, Faculty of Medicine, University of Iceland; Reykjavik, Iceland
| | - Arnhildur Tomasdottir
- Louma G. Laboratory of Epigenetic Research, Faculty of Medicine, University of Iceland; Reykjavik, Iceland
| | - Katrin Möller
- Louma G. Laboratory of Epigenetic Research, Faculty of Medicine, University of Iceland; Reykjavik, Iceland
| | - Katrin Halldorsdottir
- Louma G. Laboratory of Epigenetic Research, Faculty of Medicine, University of Iceland; Reykjavik, Iceland
| | - Tinna Reynisdottir
- Louma G. Laboratory of Epigenetic Research, Faculty of Medicine, University of Iceland; Reykjavik, Iceland
| | - Laufey Halla Atladottir
- Louma G. Laboratory of Epigenetic Research, Faculty of Medicine, University of Iceland; Reykjavik, Iceland
| | | | - Kevin Ostacolo
- Louma G. Laboratory of Epigenetic Research, Faculty of Medicine, University of Iceland; Reykjavik, Iceland
- Department of Genetics and Molecular Medicine, Landspitali University Hospital; Reykjavik, Iceland
| | - Jin He
- Department of Biochemistry and Molecular Biology, College of Natural Science, Michigan State University; MI, USA
| | - Li Zhang
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine; Baltimore, MD, USA
| | - Frances J. Northington
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine; Baltimore, MD, USA
- Neuroscience Intensive Care Nursery Program, Johns Hopkins University; Baltimore, MD, USA
| | - Erna Magnusdottir
- Department of Biomedical Science and Department of Anatomy, Faculty of Medicine, University of Iceland; Reykjavík, Iceland
| | - Raul Chavez-Valdez
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine; Baltimore, MD, USA
- Neuroscience Intensive Care Nursery Program, Johns Hopkins University; Baltimore, MD, USA
| | - Kimberley Jade Anderson
- Department of Genetics and Molecular Medicine, Landspitali University Hospital; Reykjavik, Iceland
| | - Hans Tomas Bjornsson
- Louma G. Laboratory of Epigenetic Research, Faculty of Medicine, University of Iceland; Reykjavik, Iceland
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine; Baltimore, MD, USA
- Department of Pediatrics, Johns Hopkins University; Baltimore, MD, USA
- Department of Genetics and Molecular Medicine, Landspitali University Hospital; Reykjavik, Iceland
- Lead contact
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2
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Fernandez Hernandez S, Barlow B, Pertsovskaya V, Maciel CB. Temperature Control After Cardiac Arrest: A Narrative Review. Adv Ther 2023; 40:2097-2115. [PMID: 36964887 PMCID: PMC10129937 DOI: 10.1007/s12325-023-02494-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 03/08/2023] [Indexed: 03/26/2023]
Abstract
Cardiac arrest (CA) is a critical public health issue affecting more than half a million Americans annually. The main determinant of outcome post-CA is hypoxic-ischemic brain injury (HIBI), and temperature control is currently the only evidence-based, guideline-recommended intervention targeting secondary brain injury. Temperature control is a key component of a post-CA care bundle; however, conflicting evidence challenges its wide implementation across the vastly heterogeneous population of CA survivors. Here, we critically appraise the available literature on temperature control in HIBI, detail how the evidence has been integrated into clinical practice, and highlight the complications associated with its use and the timing of neuroprognostication after CA. Future clinical trials evaluating different temperature targets, rates of rewarming, duration of cooling, and identifying which patient phenotype benefits from different temperature control methods are needed to address these prevailing knowledge gaps.
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Affiliation(s)
| | - Brooke Barlow
- Department of Pharmacy, Memorial Hermann the Woodlands Medical Center, The Woodlands, TX, USA
| | - Vera Pertsovskaya
- The George Washington University School of Medicine and Health Sciences, Washington, DC, 20037, USA
| | - Carolina B Maciel
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, 32611, USA
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, 32611, USA
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Department of Neurology, University of Utah, Salt Lake City, UT, 84132, USA
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3
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Li P, Sun Z, Tian T, Yu D, Tian H, Gong P. Recent developments and controversies in therapeutic hypothermia after cardiopulmonary resuscitation. Am J Emerg Med 2023; 64:1-7. [PMID: 36435004 DOI: 10.1016/j.ajem.2022.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 10/23/2022] [Accepted: 11/01/2022] [Indexed: 11/13/2022] Open
Abstract
Therapeutic hypothermia was recommended as the only neuroprotective treatment in comatose patients after return of spontaneous circulation (ROSC). With new evidence suggesting a similar neuroprotective effect of 36 °C and 33 °C, the term "therapeutic hypothermia" was substituted by "targeted temperature management" in 2011, which in turn was replaced by the term "temperature control" in 2022 because of new evidence of the similar effects of target normothermia and 33 °C. However, there is no clear consensus on the efficacy of therapeutic hypothermia. In this article, we provide an overview of the recent evidence from basic and clinical research related to therapeutic hypothermia and re-evaluate its application as a post-ROSC neuroprotective intervention in clinical settings.
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Affiliation(s)
- Peijuan Li
- Department of Emergency, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China; Dalian Medical University, Dalian, Liaoning, China
| | - Zhangping Sun
- Department of Emergency, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China; Dalian Medical University, Dalian, Liaoning, China
| | - Tian Tian
- Department of Emergency, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China; Dalian Medical University, Dalian, Liaoning, China
| | - Dongping Yu
- Department of Emergency, Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Hui Tian
- Department of Emergency, Dalian Municipal Central Hospital, Dalian, Liaoning, China
| | - Ping Gong
- Department of Emergency, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China; Department of Emergency, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China.
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4
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Affiliation(s)
- Erik Sveberg Dietrichs
- Experimental and Clinical Pharmacology Research Group, Department of Medical Biology, UiT, The Arctic University of Norway, Hansine Hansens vei 14, N-9037 Tromsø, Norway
- Center for Psychopharmacology, Diakonhjemmet Hospital, Forskningsveien 13, N-0373 Oslo, Norway
| | - Rachel Myles
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, West Medical Building, Glasgow G12 8QQ, UK
| | - Godfrey Smith
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, West Medical Building, Glasgow G12 8QQ, UK
- Corresponding author. Tel: +44 141 330 5963; fax: +44 141 330 4612, E-mail:
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Mohyuddin R, Dietrichs ES, Sundaram P, Kondratiev T, Figenschou MF, Sieck GC, Tveita T. Cardiovascular Effects of Epinephrine During Experimental Hypothermia (32°C) With Spontaneous Circulation in an Intact Porcine Model. Front Physiol 2021; 12:718667. [PMID: 34552506 PMCID: PMC8450451 DOI: 10.3389/fphys.2021.718667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 06/25/2021] [Indexed: 01/05/2023] Open
Abstract
Aims: Rewarming from accidental hypothermia and therapeutic temperature management could be complicated by cardiac dysfunction. Although pharmacologic support is often applied when rewarming these patients, updated treatment recommendations are lacking. There is an underlying deficiency of clinical and experimental data to support such interventions and this prevents the development of clinical guidelines. Accordingly, we explored the clinical effects of epinephrine during hypothermic conditions. Materials and methods: Anesthetized pigs were immersion cooled to 32°C. Predetermined variables were compared at temperature/time-point baseline, after receiving 30 ng/kg/min and 90 ng/kg/min epinephrine infusions: (1) before and during hypothermia at 32°C, and after rewarming to 38°C (n = 7) and (2) a time-matched (5 h) normothermic control group (n = 5). Results: At 32°C, both stroke volume and cardiac output were elevated after 30 ng/kg/min administration, while systemic vascular resistance was reduced after 90 ng/kg/min. Epinephrine infusion did not alter blood flow in observed organs, except small intestine flow, and global O2 extraction rate was significantly reduced in response to 90 ng/kg/min infusion. Electrocardiographic measurements were unaffected by epinephrine infusion. Conclusion: Administration of both 30 ng/kg/min and 90 ng/kg/min at 32°C had a positive inotropic effect and reduced afterload. We found no evidence of increased pro-arrhythmic activity after epinephrine infusion in hypothermic pigs. Our experiment therefore suggests that β₁-receptor stimulation with epinephrine could be a favorable strategy for providing cardiovascular support in hypothermic patients, at core temperatures >32°C.
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Affiliation(s)
- Rizwan Mohyuddin
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway, Tromsø, Norway
| | - Erik Sveberg Dietrichs
- Experimental and Clinical Pharmacology Research Group, Department of Medical Biology, UiT, The Arctic University of Norway, Tromsø, Norway.,Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
| | - Predip Sundaram
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway, Tromsø, Norway
| | - Timofey Kondratiev
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway, Tromsø, Norway
| | - Marie Fjellanger Figenschou
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway, Tromsø, Norway.,Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
| | - Gary C Sieck
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MI, United States
| | - Torkjel Tveita
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway, Tromsø, Norway.,Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway.,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MI, United States
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6
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Dietrichs ES, McGlynn K, Allan A, Connolly A, Bishop M, Burton F, Kettlewell S, Myles R, Tveita T, Smith GL. Moderate but not severe hypothermia causes pro-arrhythmic changes in cardiac electrophysiology. Cardiovasc Res 2021; 116:2081-2090. [PMID: 32031595 PMCID: PMC7584464 DOI: 10.1093/cvr/cvz309] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/08/2019] [Accepted: 02/04/2020] [Indexed: 12/15/2022] Open
Abstract
Aims Treatment of arrhythmias evoked by hypothermia/rewarming remains challenging, and the underlying mechanisms are unclear. This in vitro experimental study assessed cardiac electrophysiology in isolated rabbit hearts at temperatures occurring in therapeutic and accidental hypothermia. Methods and results Detailed ECG, surface electrogram, and panoramic optical mapping were performed in isolated rabbit hearts cooled to moderate (31°C) and severe (17°C) hypothermia. Ventricular activation was unchanged at 31°C while action potential duration (APD) was significantly prolonged (176.9 ± 4.2 ms vs. 241.0 ± 2.9 ms, P < 0.05), as was ventricular repolarization. At 17°C, there were proportionally similar delays in both activation and repolarization. These changes were reflected in the QRS and QT intervals of ECG recordings. Ventricular fibrillation threshold was significantly reduced at 31°C (16.3 ± 3.1 vs. 35 ± 3.5 mA, P < 0.05) but increased at 17°C (64.2 ± 9.9, P < 0.05). At 31°C, transverse conduction was relatively unchanged by cooling compared to longitudinal conduction, but at 17°C both transverse and longitudinal conduction were proportionately reduced to a similar extent. The gap junction uncoupler heptanol had a larger relative effect on transverse than longitudinal conduction and was able to restore the transverse/longitudinal conduction ratio, returning ventricular fibrillation threshold to baseline values (16.3 ± 3.1 vs. 36.3 ± 4.3 mA, P < 0.05) at 31°C. Rewarming to 37°C restored the majority of the electrophysiological parameters. Conclusions Moderate hypothermia does not significantly change ventricular conduction time but prolongs repolarization and is pro-arrhythmic. Further cooling to severe hypothermia causes parallel changes in ventricular activation and repolarization, changes which are anti-arrhythmic. Therefore, relative changes in QRS and QT intervals (QR/QTc) emerge as an ECG-biomarker of pro-arrhythmic activity. Risk for ventricular fibrillation appears to be linked to the relatively low temperature sensitivity of ventricular transmural conduction, a conclusion supported by the anti-arrhythmic effect of heptanol at 31°C.
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Affiliation(s)
- Erik S Dietrichs
- Experimental and Clinical Pharmacology, Department of Medical Biology, UiT, The Arctic University of Norway, 9037 Tromsø, Norway.,Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway, Norway.,Divisions of Diagnostic Services and Surgical Medicine and Intensive Care, University Hospital of Northern Norway, Tromsø, Norway
| | - Karen McGlynn
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, UK
| | - Andrew Allan
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, UK
| | - Adam Connolly
- Division of Imaging Sciences & Biomedical Engineering, Department of Biomedical Engineering, Kings College London, UK
| | - Martin Bishop
- Division of Imaging Sciences & Biomedical Engineering, Department of Biomedical Engineering, Kings College London, UK
| | - Francis Burton
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, UK
| | - Sarah Kettlewell
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, UK
| | - Rachel Myles
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, UK
| | - Torkjel Tveita
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway, Norway.,Divisions of Diagnostic Services and Surgical Medicine and Intensive Care, University Hospital of Northern Norway, Tromsø, Norway
| | - Godfrey L Smith
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, UK
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7
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Dietrichs ES, Selli AL, Kondratiev T, McGlynn K, Smith G, Tveita T. Resistance to ventricular fibrillation predicted by the QRS/QTc - Ratio in an intact rat model of hypothermia/rewarming. Cryobiology 2021; 98:33-38. [PMID: 33412156 DOI: 10.1016/j.cryobiol.2021.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 11/29/2020] [Accepted: 01/01/2021] [Indexed: 01/19/2023]
Abstract
Accidental hypothermia is associated with increased risk for arrhythmias. QRS/QTc is proposed as an ECG-marker, where decreasing values predict hypothermia-induced ventricular arrhythmias. If reliable it should also predict nonappearance of arrhythmias, observed in species like rat that regularly tolerate prolonged hypothermia. A rat model designed for studying cardiovascular function during cooling, hypothermia and subsequent rewarming was chosen due to species-dependent resistance to ventricular arrhythmias. ECG was recorded throughout the protocol. No ventricular arrhythmias occurred during experiments. QRS/QTc increased throughout the cooling period and remained above normothermic baseline until rewarmed. Different from the high incidence of hypothermia-induced ventricular arrhythmias in accidental hypothermia patients, where QRS/QTc ratio is decreased in moderate hypothermia; hypothermia and rewarming of rats is not associated with increased risk for ventricular fibrillation. This resistance to lethal hypothermia-induced arrhythmias was predicted by QRS/QTc.
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Affiliation(s)
- Erik Sveberg Dietrichs
- Experimental and Clinical Pharmacology, Department of Medical Biology, UiT, The Arctic University of Norway, 9037, Tromsø, Norway; Division of Diagnostic Services, University Hospital of Northern Norway, Tromsø, Norway.
| | - Anders Lund Selli
- Experimental and Clinical Pharmacology, Department of Medical Biology, UiT, The Arctic University of Norway, 9037, Tromsø, Norway
| | - Timofei Kondratiev
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway, 9037, Tromsø, Norway
| | - Karen McGlynn
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, UK
| | - Godfrey Smith
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, UK
| | - Torkjel Tveita
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway, 9037, Tromsø, Norway; Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, 9038, Tromsø, Norway
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8
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Sultan S, Acharya Y, Barrett N, Hynes N. A pilot protocol and review of triple neuroprotection with targeted hypothermia, controlled induced hypertension, and barbiturate infusion during emergency carotid endarterectomy for acute stroke after failed tPA or beyond 24-hour window of opportunity. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1275. [PMID: 33178807 PMCID: PMC7607101 DOI: 10.21037/atm-2020-cass-14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
An alternative to tissue plasminogen activator (tPA) failure has been a daunting challenge in ischemic stroke management. As tPA is time-dependent, delays can occur in definitive treatment while passively waiting to observe a clinical response to intravenous thrombolysis. Until today, uncertainty exists in the management strategy of wake-up stroke patients or those presenting beyond the therapeutic tPA window. Clinical dilemmas in these situations can prolong the transitional period of inertia, resulting in an adverse neurological outcome. We propose and review an innovative approach called triple neuro-protection (TNP), which encompasses three technical domains-targeted hypothermia, systemic induced hypertension, and barbiturates infusion, to protect the brain during carotid endarterectomy after failed tPA and/or beyond the 24-hour therapeutic mechanical thrombectomy window. This proposal assimilates discussion on the clinical evidence of the individual domains of TNP with our own clinical experience with TNP. Our first TNP was successfully employed in a 55-year-old man in 2015 while performing emergency carotid endarterectomy after he was referred to us 72 hours post tPA failure. The patient had a successful clinical outcome despite being in therapeutic inertia with 90–99% ipsilateral carotid stenosis and contralateral occlusion on presentation. In the last five years, we have safely used TNP in 25 selected cases with favourable clinical outcomes.
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Affiliation(s)
- Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland.,Department of Vascular & Endovascular Surgery, Galway Clinic, Royal College of Surgeons of Ireland/National University of Ireland Affiliated Teaching Hospitals, Doughiska, Galway, Ireland
| | - Yogesh Acharya
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Nora Barrett
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Niamh Hynes
- Department of Vascular & Endovascular Surgery, Galway Clinic, Royal College of Surgeons of Ireland/National University of Ireland Affiliated Teaching Hospitals, Doughiska, Galway, Ireland
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9
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Islam A, Kim SE, Yoon JC, Jawad A, Tian W, Yoo YJ, Kim IS, Ahn D, Park BY, Hwang Y, Lee JH, Tae HJ, Cho JH, Kim K. Protective effects of therapeutic hypothermia on renal injury in an asphyxial cardiac arrest rat model. J Therm Biol 2020; 94:102761. [PMID: 33293002 DOI: 10.1016/j.jtherbio.2020.102761] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 10/10/2020] [Indexed: 12/30/2022]
Abstract
Cardiac arrest (CA) is a leading cause of mortality worldwide. Most of post-resuscitation related deaths are due to post-cardiac arrest syndrome (PCAS). After cardiopulmonary resuscitation (CPR), return of spontaneous circulation (ROSC) leads to renal ischemia-reperfusion injury, also known as PCAS. Many studies have focused on brain and heart injuries after ROSC, but renal failure has largely been ignored. Therefore, we investigated the protective effects of therapeutic hypothermia (TH) on asphyxial CA-induced renal injury in rats. Thirty rats were randomly divided into five groups: 1) the control group (sham); 2) the normothermic CA (nor.); 3) a normothermic CA group that received TH immediately within 2 h after CPR (Hypo. 2 hrs); 4) a normothermic CA group that received TH within 4 h after CPR (Hypo. 4 hrs); and 5) a normothermia CA group that received TH within 6 h after CPR (Hypo. 6 h). One day after CPR, all rats were sacrificed. Compared with the normothermic CA group, the TH groups demonstrated significantly increased survival rate (P < 0.05); decreased serum blood urea nitrogen, creatinine, and lactate dehydrogenase levels; and lower histological damage degree and malondialdehyde concentration in their renal tissue. Terminal deoxynucleotidyl transferase dUTP nick end labeling stain revealed that the number of apoptotic cells significantly decreased after 4 h and 6 h of TH compared to the results seen in the normothermic CA group. Moreover, TH downregulated the expression of cyclooxygenase-2 in the renal cortex compared to the normothermic CA group one day after CPR. These results suggest that TH exerts anti-apoptotic, anti-inflammatory, and anti-oxidative effects immediately after ROSC that protect against renal injury.
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Affiliation(s)
- Anowarul Islam
- College of Veterinary Medicine and Bio-safety Research Institute, Jeonbuk National University, Iksan, 54596, South Korea.
| | - So Eun Kim
- Department of Emergency Medicine of Jeonbuk National University Medical School, Jeonbuk National University Hospital, Jeonju, 54907, South Korea; Research Institute of Clinical Medicine of Jeonbuk National University and Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, 54907, South Korea.
| | - Jae Chol Yoon
- Department of Emergency Medicine of Jeonbuk National University Medical School, Jeonbuk National University Hospital, Jeonju, 54907, South Korea; Research Institute of Clinical Medicine of Jeonbuk National University and Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, 54907, South Korea.
| | - Ali Jawad
- College of Veterinary Medicine and Bio-safety Research Institute, Jeonbuk National University, Iksan, 54596, South Korea.
| | - Weishun Tian
- College of Veterinary Medicine and Bio-safety Research Institute, Jeonbuk National University, Iksan, 54596, South Korea.
| | - Yeo-Jin Yoo
- College of Veterinary Medicine and Bio-safety Research Institute, Jeonbuk National University, Iksan, 54596, South Korea.
| | - In-Shik Kim
- College of Veterinary Medicine and Bio-safety Research Institute, Jeonbuk National University, Iksan, 54596, South Korea.
| | - Dongchoon Ahn
- College of Veterinary Medicine and Bio-safety Research Institute, Jeonbuk National University, Iksan, 54596, South Korea.
| | - Byung-Yong Park
- College of Veterinary Medicine and Bio-safety Research Institute, Jeonbuk National University, Iksan, 54596, South Korea.
| | - Yong Hwang
- Department of Emergency Medicine, School of Medicine, Wonkwang University, Iksan, 54538, South Korea.
| | - Jeong Ho Lee
- Sunchang Research Institute of Health and Longevity, Sunghang-gun, 56015, South Korea.
| | - Hyun-Jin Tae
- College of Veterinary Medicine and Bio-safety Research Institute, Jeonbuk National University, Iksan, 54596, South Korea.
| | - Jeong-Hwi Cho
- College of Veterinary Medicine and Bio-safety Research Institute, Jeonbuk National University, Iksan, 54596, South Korea.
| | - Kyunghwa Kim
- Research Institute of Clinical Medicine of Jeonbuk National University and Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, 54907, South Korea; Department of Thoracic and Cardiovascular Surgery, Jeonbuk National University Medical School, Jeonbuk National University Hospital, Jeonju, 54907, South Korea.
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10
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Safety of Triple Neuroprotection with Targeted Hypothermia, Controlled Induced Hypertension, and Barbiturate Infusion during Emergency Carotid Endarterectomy for Acute Stroke after Missing the 24 Hours Window Opportunity. Ann Vasc Surg 2020; 69:163-173. [PMID: 32473308 DOI: 10.1016/j.avsg.2020.05.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 04/30/2020] [Accepted: 05/02/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND The aim of this study is to establish the initial safety of triple neuroprotection (TNP) in an acute stroke setting in patients presenting outside the window for systemic tissue plasminogen activator (tPA). METHODS Over 12,000 patients were referred to our vascular services with carotid artery disease, of whom 832 had carotid intervention with a stroke rate of 0.72%. Of these, 25 patients presented (3%), between March 2015 and 2019, with acute dense stroke. These patients had either failed tPA or passed the recommended timing for acute stroke intervention. Fifteen (60%) had hemi-neglect with evidence of acute infarct on magnetic resonance imaging of the brain and a Rankin score of 4 or 5. Ninety-six percent had an 80-99% stenosis on the symptomatic side. Mean ABCD3-I score was 11.35. All patients underwent emergency carotid endarterectomy (CEA) with therapeutically induced hypothermia (32-34°C), targeted hypertension (systolic blood pressure 180-200 mm Hg), and brain suppression with barbiturate. RESULTS There were no cases of myocardial infarction, death, cranial nerve injury, wound hematoma, or procedural bleeding. Mean hospital stay was 8.4 (±9.5) days. All cases had resolution of neurological symptoms, except 3 who had failed previous thrombolysis. Eighty percent had a postoperative Rankin score of 0 on discharge and 88% of patients were discharged home with 3 requiring rehabilitation. CONCLUSIONS Positive neurological outcomes and no serious adverse events were observed using TNP during emergency CEA in patients with acute brain injury. We recommend TNP for patients who are at an increased risk of stroke perioperatively, or who have already suffered from an acute stroke beyond the recommended window of 24 hr. Certainly, the positive outcomes are not likely reproducible outside of high-volume units and patients requiring this surgery should be transferred to experienced surgeons in appropriate tertiary referral centers.
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11
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Udekwu P, Vincent R, Petrarca D, Farrell M, Roy S. Predictors of Futility in Near-Hanging and Therapeutic Hypothermia. Ther Hypothermia Temp Manag 2018; 9:184-189. [PMID: 30376419 DOI: 10.1089/ther.2018.0029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Favorable neurologic outcomes have been reported in near-hanging (NH) victims treated with therapeutic hypothermia (TH), but variable methods and small samples sizes limit interpretability. This study examines the relationship between clinical predictors, TH, and outcomes in NH patients. A risk profile was created by examining relationships between variables. Categorical predictors were assessed with chi-square tests and continuous variables were assessed with t-tests. Logistic regression was conducted to evaluate the unique effect of TH. Thirty-seven NH patients were treated, 22 with cardiac arrest (CA). Poor outcome was significantly associated with age, Glasgow Coma Scale-Motor (GCS-M), pupillary response, and out-of-hospital CA (OHCA) (p's < 0.02). Patients with poor neurologic outcomes were older (M = 40.2 vs. M = 27.6) and had lower GCS-M scores (M = 1.1 vs. M = 4.1). Poor outcome probability was 76% in patients with GCS-M <3, 100% with nonreactive pupils, and 72.1% with OHCA. TH was associated with a worse outcome overall that was not significant after adjusting for GCS-M. Our study demonstrates no impact of TH on NH outcome when controlling for variables associated with poor outcome and relative certainty of poor outcome with CA, GCS-M 1, and nonreactive pupils. Study findings could assist in decisions on the utilization of TH.
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Affiliation(s)
- Pascal Udekwu
- WPP General Surgery/Trauma, WakeMed Health and Hospitals, Raleigh, North Carolina
| | - Rhonda Vincent
- WPP General Surgery/Trauma, WakeMed Health and Hospitals, Raleigh, North Carolina
| | - Debra Petrarca
- WPP General Surgery/Trauma, WakeMed Health and Hospitals, Raleigh, North Carolina
| | - Meagan Farrell
- WPP General Surgery/Trauma, WakeMed Health and Hospitals, Raleigh, North Carolina
| | - Sara Roy
- WPP General Surgery/Trauma, WakeMed Health and Hospitals, Raleigh, North Carolina
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Dietrichs ES, Sager G, Tveita T. Altered pharmacological effects of adrenergic agonists during hypothermia. Scand J Trauma Resusc Emerg Med 2016; 24:143. [PMID: 27919274 PMCID: PMC5139099 DOI: 10.1186/s13049-016-0339-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 11/29/2016] [Indexed: 01/02/2023] Open
Abstract
Rewarming from accidental hypothermia is often complicated by hypothermia-induced cardiac dysfunction, calling for immediate pharmacologic intervention. Studies show that although cardiac pharmacologic support is applied when rewarming these patients, a lack of updated treatment recommendations exist. Mainly due to lack of clinical and experimental data, neither of the international guidelines includes information about pharmacologic cardiac support at temperatures below 30 °C. However, core temperature of accidental hypothermia patients is often reduced below 30 °C. Few human studies exploring effects of adrenergic drugs during hypothermia have been published, and therefore prevailing information is collected from pre-clinical studies. The most prominent finding in these studies is an apparent depressive effect of adrenaline on cardiac function when used in doses which elevate cardiac output during normothermia. Also noradrenaline and isoprenaline largely lacked positive cardiac effects during hypothermia, while dopamine is a more promising drug for supporting cardiac function during rewarming. Data and information from these studies are in support of the prevailing notion; not to use adrenergic drugs at core temperatures below 30 °C.
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Affiliation(s)
- Erik Sveberg Dietrichs
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway, 9037, Tromsø, Norway. .,Department of Research and Education, Norwegian Air Ambulance Foundation, 1441, Drøbak, Norway.
| | - Georg Sager
- Experimental and Clinical Pharmacology, Department of medical biology, UiT, The Arctic University of Norway, 9037, Tromsø, Norway
| | - Torkjel Tveita
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway, 9037, Tromsø, Norway.,Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, 9038, Tromsø, Norway
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