Differential Effect of Targeted Temperature Management Between 32 °C and 36 °C Following Cardiac Arrest According to Initial Severity of Illness: Insights From Two International Data Sets

BACKGROUND

Recent guidelines have emphasized actively avoiding fever to improve outcomes in patients who are comatose following resuscitation from cardiac arrest (ie, out-of-hospital cardiac arrest). However, whether targeted temperature management between 32 °C and 36 °C (TTM32-36) can improve neurologic outcome in some patients remains debated.

RESEARCH QUESTION

Is there an association between the use of TTM32-36 and outcome according to severity assessed at ICU admission using a previously derived risk score?

STUDY DESIGN AND METHODS

Data prospectively collected in the Sudden Death Expertise Center (SDEC) registry (France) between May 2011 and December 2017 and in the Resuscitation Outcomes Consortium Continuous Chest Compressions (ROC-CCC) trial (United States and Canada) between June 2011 and May 2015 were used for this study. Severity at ICU admission was assessed through a modified version of the Cardiac Arrest Hospital Prognosis (mCAHP) score, divided into tertiles of severity. The study explored associations between TTM32-36 and favorable neurologic status at hospital discharge by using multiple logistic regression as well as in tertiles of severity for each data set.

RESULTS

A total of 2,723 patients were analyzed in the SDEC data set and 4,202 patients in the ROC-CCC data set. A favorable neurologic status at hospital discharge occurred in 728 (27%) patients in the French data set and in 1,239 (29%) patients in the North American data set. Among the French data set, TTM32-36 was independently associated with better neurologic outcome in the tertile of patients with low (adjusted OR, 1.63; 95% CI, 1.15-2.30; P = .006) and high (adjusted OR, 1.94; 95% CI, 1.06-3.54; P = .030) severity according to mCAHP at ICU admission. Similar results were observed in the North American data set (adjusted ORs of 1.36 [95% CI, 1.05-1.75; P = .020] and 2.42 [95% CI, 1.38-4.24; P = .002], respectively). No association was observed between TTM32-36 and outcome in the moderate groups of the two data sets.

INTERPRETATION

TTM32-36 was significantly associated with a better outcome in patients with low and high severity at ICU admission assessed according to the mCAHP score. Further studies are needed to evaluate individualized temperature control following out-of-hospital cardiac arrest.

Safety, feasibility and performance of Valvosoft non-invasive ultrasound therapy in patients with severe symptomatic calcific aortic valve stenosis. First-in-Man

Objectives

We recently developed a unique transthoracic non-invasive ultrasound therapy device called Valvosoft to treat aortic stenosis. The therapy consists in delivering trans-thoracically precisely focused and controlled short ultrasound pulses (<20μsec) at a high acoustic intensity to produce non-thermal mechanical tissue softening of the calcified aortic valve with the ultimate aim of improving the valve opening. Ultrasound imaging enables to follow valve movements in real-time and thus targets the ultrasound waves on the valve with great precision. After having validated this concept in pre-clinical studies, we aimed at applying this technique in human. The primary objectives were to assess the safety and feasibility of this novel technique along with its performance by evaluation of the valve leaflets mobility and valve opening area.

Methods

This is a multi-center, prospective, controlled first-in-man study. Ten patients with severe symptomatic calcific aortic stenosis and not eligible for SAVR/TAVR underwent a Valvosoft ultrasound therapy. The therapy consists of 6 sessions of ultrasound therapy. The Valvosoft transducer is applied on the patient's chest and coupled at its center with an echocardiography phased array probe to allow real-time control of the therapy (cavitation bubble detection). Preselection of the region of interest is performed by echo still frame before each session. Ultrasonic evaluation was performed by an independent core lab at baseline, discharge, 30-day and 3 month follow-up along with clinical follow up.

Results

Enrolled patients were advanced in age (84.1±6.5 yrs) with severe comorbidities (8 with heart failure, 5 with coronary heart disease and 5 with kidney failure). All had extensive aortic valve calcification (mean calcification volume of 687.28 mm3) with mean AVA of 0.61±0.17 cm2 and mean pressure gradient of 37.5±10.5 mmHg (6 patients had SV<35ml/m2). No adverse events were recorded during the procedures other than some benign ventricular extrasystoles. The mean treatment time was 52 minutes. At 3 months follow-up, one patient had died due to end stage heart failure not linked to the procedure (9 weeks post procedure) and another got finally TAVI (45 days post procedure). Of the other 8 patients, 6 experienced an improvement of their NYHA status. No device or procedure related major adverse events nor deterioration of neurological status were observed at 3 months follow-up. Of the 7 patients that had echo follow-up at 3 months (one patient refused to get echo evaluation), 5 increased the AVA (between 14% and 46%) and 4 patients decreased the mean pressure gradient (from 6% to 44%). No AI or EF deterioration occurred during follow up.

Conclusion

Non-invasive ultrasound therapy is feasible and safe in patients with severe aortic valve stenosis and is able to improve AVA and pressure gradient in some patient. Larger studies with longer follow up will need to be conducted.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Cardiawave SA, Paris, France

Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a registry study

Aims

Out-of-hospital cardiac arrest (OHCA) without return of spontaneous circulation (ROSC) despite conventional resuscitation is common and has poor outcomes. Adding extracorporeal membrane oxygenation (ECMO) to cardiopulmonary resuscitation (extracorporeal-CPR) is increasingly used in an attempt to improve outcomes.

Methods and results

We analysed a prospective registry of 13 191 OHCAs in the Paris region from May 2011 to January 2018. We compared survival at hospital discharge with and without extracorporeal-CPR and identified factors associated with survival in patients given extracorporeal-CPR. Survival was 8% in 525 patients given extracorporeal-CPR and 9% in 12 666 patients given conventional-CPR (P = 0.91). By adjusted multivariate analysis, extracorporeal-CPR was not associated with hospital survival [odds ratio (OR), 1.3; 95% confidence interval (95% CI), 0.8–2.1; P = 0.24]. By conditional logistic regression with matching on a propensity score (including age, sex, occurrence at home, bystander CPR, initial rhythm, collapse-to-CPR time, duration of resuscitation, and ROSC), similar results were found (OR, 0.8; 95% CI, 0.5–1.3; P = 0.41). In the extracorporeal-CPR group, factors associated with hospital survival were initial shockable rhythm (OR, 3.9; 95% CI, 1.5–10.3; P = 0.005), transient ROSC before ECMO (OR, 2.3; 95% CI, 1.1–4.7; P = 0.03), and prehospital ECMO implantation (OR, 2.9; 95% CI, 1.5–5.9; P = 0.002).

Conclusions

In a population-based registry, 4% of OHCAs were treated with extracorporeal-CPR, which was not associated with increased hospital survival. Early ECMO implantation may improve outcomes. The initial rhythm and ROSC may help select patients for extracorporeal-CPR.

P3647Spontaneous coronary artery dissection: new insights on presentation, clinical and angiographic characteristics from the French multicenter registry DISCO study

Background

Spontaneous coronary artery dissection (SCAD) is an underdiagnosed and poorly understood cause of acute coronary syndrome (ACS). Clinical, angiographic features and management remain to be better defined in large cohorts.

Purpose

The aim of this study was to evaluate clinical, angiographic characteristics, treatment modalities and prognosis of patients with SCAD from a multicenter national registry.

Methods

From 2016 to 2018, SCAD patients were enrolled retrospectively and prospectively in the French multicenter regristry DISCO study in 61 cardiology interventional centers. All coronary angiograms were reviewed by 2 experienced cardiologists for diagnosis confirmation and classified according to current angiographic SCAD classification.

Results

A total of 373 confirmed SCAD patients were included, 45.6% prospectively, 54.4% retrospectively. Mean age was 51.5±10.3 years, with 90.6% women of whom 51.2% were postmenauposal. Ninety percent of patients had ≤2 cardiovascular risk factors, 96.2% presented with ACS, with a positive troponin in 95.4%, and ST-segment elevation in 45.0%. Precipitating emotional stress factors were reported in 46.0% and a physical trigger in 12.4%. Systemic inflammatory disease was present in 5 patients (1.4%). Peripartum SCAD accounted for only 4.4% of cases. The majority of patients (75.1%) had type 2 angiographic SCAD (diffuse long smooth tubular lesions due to intramural hematoma), with only 13.8% and 8.9% having type 1 (longitudinal filling defect) and type 3 (multiple focal tubular lesions due to intramural hematoma) respectively. Multivessel SCAD occurred in 6.2%. While 84.2% of SCAD patients were initially treated conservatively, 15.5% underwent percutaneous coronary intervention as the initial strategy and 1 patient (0.3%) required surgical implantation of a left ventricular assist device. Repeat angiogram was conducted in 288 patients (median 38 [8–70] days) showing improvement of the culprit lesion in 81.9%. At 1 year follow-up, recurrent SCAD occurred in 2.5%, major adverse cardiac events (stroke, myocardial infarction, and revascularization) in 7.7%, and all patients survived.

Conclusion

Our study confirms that SCAD predominantly affects early middle-aged women with few cardiovascular risk factors, with peripartum SCAD accounting for a minority of cases. Type 2 angiographic SCAD which is difficult to recognize was the most frequent angiographic appearance. This may contribute to the underestimation of SCAD in clinical practice. The majority of patients were treated conservatively with favorable outcomes. Longer-term follow-up of this large cohort and further investigations on physiopathology are warranted to improve management and risk stratification of patients.

Acknowledgement/Funding

Fondation Coeur et Recherche, French Coronary Atheroma and Interventional Cardiology Group, French Society of Cardiology

Indications et heure de la coronarographie après un arrêt cardiaque extrahospitalier sans cause extracardiaque évidente

Les lésions coronaires instables sont la première cause des arrêts cardiaques extrahospitaliers. L’angioplastie coronaire semble améliorer la survie de ces patients. En l’absence de données randomisées, les recommandations actuelles sont fondées sur des données de registre. Une coronarographie immédiate, dès l’admission du patient, est recommandée s’il existe un sus-décalage du segment ST sur l’électrocardiogramme réalisé après retour d’une activité circulatoire spontanée. Dans les autres cas, il est conseillé de rechercher en premier une cause extracardiaque, notamment par la réalisation d’un scanner cérébral et thoracique. Si aucune cause extracardiaque n’a été retrouvée, la coronarographie doit être réalisée rapidement, moins de deux heures après l’admission. Si une lésion coronaire responsable de l’arrêt peut être identifiée, une angioplastie est réalisée au mieux par voie radiale et en utilisant des endoprothèses actives. Une nouvelle coronarographie à distance peut être indiquée chez les survivants pour réaliser une revascularisation complémentaire ou pour rechercher un spasme coronaire chez les patients dont la première coronarographie était normale.

[Sudden cardiac death and coronary thrombus]

Out-of-hospital cardiac arrest is most often due to an acute coronary artery occlusion. The cause of coronary thrombosis in cardiac arrest is debated. Plaque erosion could be a trigger leading to immediate thrombus formation followed by ventricular fibrillation or rapid ventricular tachycardia. Coronary artery spasm is frequent: spasm provocation tests should be performed in survivors with normal coronary arteries. Use of drugs such as cocaine can lead to sudden death and blood sampling at arrival is recommended in survivors of out-of-hospital cardiac arrest. Delivery of immediate and effective basic life support remains the most important predictive factor for survival in out-of-hospital cardiac arrest.

[Sudden cardiac death: Are women different?]

Sudden cardiac death is a major public health problem with around 40,000 cases per year in France. Epidemiological, clinical and prognostic differences according to gender have been described in most cardiovascular diseases, including sudden cardiac death. In this article, we will review gender differences in sudden cardiac death incidence, circumstance of occurrence, management, and prognosis.

Base excess and lactate as prognostic indicators for patients treated by extra corporeal life support after out hospital cardiac arrest due to acute coronary syndrome

OBJECTIVE

To examine whether values of arterial base excess or lactate taken 3 h after starting ECLS indicate poor prognosis and if this can be used as a screening tool to follow Extra Corporeal Life Support after Out Hospital Cardiac Arrest due to acute coronary syndrome.

DESIGN

Single Centre retrospective observational study.

SETTING

University teaching hospital general adult intensive care unit.

PATIENTS

15 consecutive patients admitted to the intensive care unit after refractory Out Hospital Cardiac Arrest due to acute coronary syndrome treated by Extra Corporeal Life Support.

INTERVENTIONS

Arterial base excess and lactate concentrations were measured immediately after starting ECLS and every 3 h after.

RESULTS

Both base excess and arterial lactate measured 3 h after starting ECLS effectively predict multi-organ failure occurrence and mortality in the following 21 h (area under the curve on receiver operating characteristic analysis of 0.97, 0.95 respectively). The best predictive values were obtained with a base excess level measured 3 h after starting ECLS of less than -10 mmol/l and lactate concentrations greater than 12 mmol/l. The combination of these two markers measured 3 h after starting ECLS predicted multiorgan failure occurrence and mortality in the following 21 h with a sensitivity of 70% and a specificity of 100%.

CONCLUSIONS

Combination of base excess and lactate, measured 3 h after starting ECLS, can be used to predict multiorgan failure occurrence and mortality in the following 21 h in patients admitted to an intensive care unit for refractory Out Hospital Cardiac Arrest due to acute coronary syndrome treated by Extra Corporeal Life Support. These parameters can be obtained simply and rapidly and help in the decision process to continue ECLS for refractory CA.

Acute myocardial infarction secondary to platelet apheresis in a 57-year healthy donor

Platelet donation by plateletpheresis is known to induce platelet and coagulation activation but there is no clear relationship between this acquired pre-thrombotic state and acute coronary syndrome in healthy donors. We report an acute myocardial infarction immediately following plateletpheresis in a 57-year-old donor with low atherosclerotic risk profile and no angiographic evidence of atherosclerotic disease strongly suggesting a causal relationship.

[Large coronary aneurysm diagnosed during an acute coronary syndrome. A case report and review of the literature]

Coronary aneurysm is an uncommon variant of coronary atherosclerosis. It usually involves the right coronary artery and is often associated with significant coronary stenosis. It may be revealed by an acute coronary syndrome (ACS). We report the case of a 49 year-old woman in whom a large coronary aneurysm of the left anterior descending artery was revealed by an ACS. Coronary angiography remains the gold standard diagnosis procedure, but spiral computed tomography may be of interest to specify the location and nature of the aneurysm, and thus guide surgical or percutaneous treatment.

[Management of chest pain by the Emergency Ambulance Service: the DOLORES register]

Pre-hospital management of chest pain is a difficult problem. The emergency doctor has to take triage decisions based on instantaneous data whereas the decisional rationale of the many pathologies concerned, including acute coronary syndromes, is often based on observation over several hours. There have been few studies of the efficacy of pre-hospital management of chest pain by an emergency ambulance service. Therefore, the DOLORES register was set up to assess this problem over a 6 month period by the emergency ambulance service of Necker Hospital in Paris. Between January and June 2004, the Necker emergency ambulance service was called out on 205 occasions for chest pain. Forty-three patients had acute coronary syndromes (ACS) with ST elevation. Of the remaining 162 patients, 32 stayed at home, 2 were admitted the following day by cardiologists for coronary angiography, 52 were admitted for observation to the emergency unit and 76 were admitted to the coronary care unit. In the latter two groups, the final diagnosis of ACS without ST elevation was retained in 11/52 and 57/76 patients respectively. Finally, 2 patients were admitted directly to the catheter laboratory. The clinical and paraclinical data noted by the emergency ambulance service and at hospital admission was concordant in all cases. Pre-hospital triage by the emergency ambulance service seems to be effective. These results require confirmation with a large scale study.

[Acute myocardial infarction complicating primary antiphospholipid syndrome after aspirin and steroids withdrawal]

A 24-year-old woman, with known antiphospholid antibodies (APS), presented with an acute myocardial infarction (AMI) that occurred three months after delivery. No risk factors for arteriosclerosis and no past history of arterial/venous thrombosis were noted. During pregnancy, aspirin prophylaxis was prescribed and followed by steroids after caesarian section. Steroids withdrawal was followed by AMI. Immediate coronary angiography revealed thrombotic occlusion of the left descending coronary artery; PTCA was successfully performed. She was discharged with an antiplatelet and anticoagulant regimen. No recurrent coronary event occurred during follow-up.

[Iodic allergic reaction with vasospasm occluded coronary during coronarography]

Coronary vasospasm is infrequent during anaphylaxis reaction. The authors describe a severe coronary spasm following iodine allergic reaction and then should to explain the physiopathology of this complication.

The role of community advisory boards: involving communities in the informed consent process

Ethical research involving human subjects mandates that individual informed consent be obtained from research participants or from surrogates when participants are not able to consent for themselves. The existing requirements for informed consent assume that all study participants have personal autonomy; fully comprehend the purpose, risks, and benefits of the research; and volunteer for projects that disclose all relevant information. Yet contemporary examples of lapses in the individual informed consent process have been reported. The authors propose the use of community advisory boards, which can facilitate research by providing advice about the informed consent process and the design and implementation of research protocols. These activities could help reduce the number of individual informed consent lapses, benefiting study participants and the scientific integrity of the research in question.

Prehospital use of minimally invasive direct cardiac massage (MID-CM): a pilot study

BACKGROUND

Internal cardiac compressions are more efficient than closed chest compressions (CCC) in cardiac arrest (CA).

AIM OF THE STUDY

To evaluate the prehospital feasibility of performing a new method of minimally invasive direct cardiac massage (MID-CM TheraCardia Inc.).

METHODS

Prospective non-randomized open study, after ethical committee approval. Inclusion of 18-85 years old patients in witnessed CA if BLS>5 min and unsuccessful ACLS>20 min after CA. The MID-CM is an atraumatic manual cardiac pumping system deployed in the thoracic cavity through a small incision. Evaluation of: ease of insertion and performing MID-CM, complications, end-tidal CO(2) (PETCO(2)), non invasive arterial blood pressure (NIBP) and return of spontaneous circulation (ROSC). Values are mean+/-SD (min-max).

RESULTS

Twenty-five patients included. Mean age 59+/-16 years (26-85); BLS started at 8+/-5 min (0-20), compressions started at 47+/-10 min (29-74) after CA. Dissection and insertion was fast and easy (<1 min). Deployment of the MID-CM was difficult in two patients because of pericardium adhesions and cardiomegaly. In six patients compressions were more difficult because of a 'stone heart' phenomenon. Compressions were possible during ambulance transport of four patients. There was a good palpable carotid pulse in all patients receiving internal compressions. There was a trend in increase of PETCO(2) compared to CCC. NIBP could be measured during MID-CM compressions in 9 patients (systolic>85 mmHg), never during CCC. Seven patients had a ROSC, but only four patients were admitted alive. There was no long term survival. One patient had a serious complication (heart rupture).

DISCUSSION

Prehospital use of MID-CM is possible, but it is not comparable to any other resuscitation technique. Training of medical teams is mandatory to obtain good skills and to avoid complications. Further studies are necessary to evaluate efficiency and survival compared to closed chest compressions.

Flow cytometry detection of platelet procoagulation activity and microparticles in patients with unstable angina treated by percutaneous coronary angioplasty and stent implantation

Platelet activation is known to participate to the pathogenesis of acute coronary syndromes. Aminophospholipid exposure and microparticles shedding are hallmarks of full platelet activation and may account for the dissemination of prothrombotic seats. Using flow cytometry analysis of annexin V binding to externalized aminophospholipids, we followed platelet procoagulant activity (PPA) and platelet microparticles (PMP) shedding in venous and coronary whole blood samples from 30 patients with unstable angina before and after percutaneous coronary angioplasty (PTCA) and stent implantation. Baseline values of PPA and PMP were significantly more elevated in patients than in control subjects (p < 0.005). PMP percentage was significantly higher in coronary than in venous blood, and in coronary blood of patients with proximal instead of mid/distal lesions of coronary arteries. No enhancement of platelet reactivity to TRAP and collagen was induced by procedure. Whereas activated GpIIb-IIIa and P-selectin expression decreased 24 h and 48 h after procedure, PPA and PMP remained as elevated as before. Thus, flow cytometry is a reliable method for detection of fully activated platelets in whole blood samples. Annexin V binding analysis demonstrates the persistance of in vivo platelet activation, despite the use of antiaggregating agents.

Medical training debt and service commitments: the rural consequences

This study assesses how student loan debt and scholarships, loan repayment and related programs with service requirements influence the incomes young physicians seek and attain, influence whether they choose to work in rural practice settings and affect the number of Medicaid-covered and uninsured patients they see. Data are from a 1999 mail survey of a national probability sample of 468 practicing family physicians, general internists and pediatricians who graduated from U.S. medical schools in 1988 and 1992. A majority of these generalist physicians recalled "moderate" or "great" concern for their financial situations before, during and after their training. Eighty percent financed all or part of their training with loans, and one-quarter received support from federal, state or community-sponsored scholarship, loan repayment and similar programs with service obligations. In their first job after residency, family physicians and pediatricians with greater debt reported caring for more patients insured under Medicaid and uninsured than did those with less debt. For no specialty was debt associated with physicians' income or likelihood of working in a rural area. Physicians serving commitments in exchange for training cost support, compared to those without obligations, were more likely to work in rural areas (33 vs. 7 percent, respectively, p < 0.001) and provided care to more Medicaid-covered and uninsured patients (53 vs. 29 percent, p < 0.001), but did not differ in their incomes ($99,600 vs. $93,800, p = 0.11). Thus, among physicians who train as generalists, the high costs of medical education appear to promote, not harm, national physician work force goals by prompting participation in service-requiring financial support programs and perhaps through increasing student borrowing. These positive outcomes for generalists should be weighed against other known and suspected negative consequences of the high costs of training, such as discouraging some poor students from medical careers altogether and perhaps influencing some medical students with high debt not to pursue primary care careers.

D-dimer testing as the initial test for suspected pulmonary embolism. Appropriateness of prescription and physician compliance to guidelines

OBJECTIVES

Recent studies have shown that strategies for pulmonary embolism diagnosis which have included D-dimer testing have been most cost effective. The objective of this study is to evaluate the impact of a new strategy for pulmonary embolism diagnosis based on D-dimer results.

METHODS

A prospective survey was conducted in the emergency ward and three medical departments of a university teaching hospital. Guidelines for diagnosis of PE were established and implemented through an educational intervention and a specific order form. D-dimer (ELISA) was required for all patients suspected of having PE. A result above 500 ng/ml was to be followed by an a pulmonary imaging procedure. Appropriateness of prescription of D-dimer and non-compliance with guidelines (absence of diagnostic imaging procedure following D-dimer results above 500 ng/ml) were evaluated.

RESULTS

One-hundred sixty patients were studied. D-dimer test was performed in 154 patients (96.3%) suspected of PE during a two-month period. Test results were above 500 ng/ml in 111 cases. PE was confirmed in 20 cases. Twenty percent (31/154) of the D-dimer prescriptions were inappropriate. Among those with D-dimer results above 500 ng/ml, 45% (50/111) of the patients experienced no imaging procedure.

CONCLUSIONS

Despite implementation of clinical guidelines for its use, D-dimer was excessively prescribed. A large proportion of results was not taken in consideration by prescribers. Often new technologies have good experimental results, but behave differently when used routinely in ordinary care settings. It is important that field studies be developed to evaluate the effectiveness of new technologies.

[Anomalous origin of coronary arteries from three separate ostia in the right sinus of valsalva. A case port and review of the literature]

The authors report the case of a patient undergoing coronary angiography for a lateral myocardial infarction related with atherosclerosic lesions but associated with a rare anomalous origin of all three coronary arteries from separate ostia in the right sinus of Valsalva. Anomalous origin of coronary arteries from the opposite sinus are potentially serious especially among young subjects and when a vessel runs between the aorta and pulmonary artery. Clinical presentation, angiographic diagnostic and treatment strategies are discussed.

State scholarship, loan forgiveness, and related programs: the unheralded safety net

CONTEXT

In the mid-1980s, states expanded their initiatives of scholarships, loan repayment programs, and similar incentives to recruit primary care practitioners into underserved areas. With no national coordination or mandate to publicize these efforts, little is known about these state programs and their recent growth.

OBJECTIVES

To identify and describe state programs that provide financial support to physicians and midlevel practitioners in exchange for a period of service in underserved areas, and to begin to assess the magnitude of the contributions of these programs to the US health care safety net.

DESIGN

Cross-sectional, descriptive study of data collected by telephone, mail questionnaires, and through other available documents, (eg, program brochures, Web sites).

SETTING AND PARTICIPANTS

All state programs operating in 1996 that provided financial support in exchange for service in defined underserved areas to student, resident, and practicing physicians; nurse practitioners; physician assistants; and nurse midwives. We excluded local community initiatives and programs that received federal support, including that from the National Health Service Corps.

MAIN OUTCOME MEASURES

Number and types of state support-for-service programs in 1996; trends in program types and numbers since 1990; distribution of programs across states; numbers of participating physicians and other practitioners in 1996; numbers in state programs relative to federal programs; and basic features of state programs.

RESULTS

In 1996, there were 82 eligible programs operating in 41 states, including 29 loan repayment programs, 29 scholarship programs, 11 loan programs, 8 direct financial incentive programs, and 5 resident support programs. Programs more than doubled in number between 1990 (n = 39) and 1996 (n = 82). In 1996, an estimated 1306 physicians and 370 midlevel practitioners were serving obligations to these state programs, a number comparable with those in federal programs. Common features of state programs were a mission to influence the distribution of the health care workforce within their states' borders, an emphasis on primary care, and reliance on annual state appropriations and other public funding mechanisms.

CONCLUSIONS

In 1996, states fielded an obligated primary care workforce comparable in size to the better-known federal programs. These state programs constitute a major portion of the US health care safety net, and their activities should be monitored, coordinated, and evaluated. State programs should not be omitted from listings of safety-net initiatives or overlooked in future plans to further improve health care access. JAMA. 2000;284:2084-2092.

[Prevention of sudden death due to coronary disease]

Out-of-hospital cardiac arrest remains a serious clinical problem with a survival rate of less than 5%. A recent study showed that acute coronary artery occlusion is found in almost half of survivors of out-of-hospital cardiac arrest and occurs most often in patients with no past history of coronary artery disease. Detection and management of risk factors for coronary artery disease and screening of high-risk patients may therefore be effective in reducing the rate of sudden death. Furthermore, optimal management of patients with overt coronary artery disease including changes in life style, up-to-date drug regimens, revascularization when necessary and implantable defibrillators in selected cases may also lower the incidence of sudden death. Primary and secondary prevention of coronary artery disease should be included in out-of-hospital cardiac arrest training programs to increase their efficacy and diffusion.

[Cardiac arrest outside the hospital]

Out-of-hospital cardiac arrest remains a clinical problem with a survival rate of less than 5%. Prompt initiation of cardiopulmonary resuscitation and rapid delivery of advanced cardiac-life procedures are required. Combined in-hospital management by experienced cardiologists and intensive care specialists is recommended. Acute coronary-artery occlusion is frequent and poorly predicted by clinical and electrocardiographic findings. Accurate diagnosis by immediate coronary angiography can be followed if necessary by coronary angioplasty. Survivors undergo extensive work-up to determine the indications of an implantable defibrillator or coronary revascularization.

[Treatment of stable angina. Coronary angioplasty versus medical treatment]

Stable angina is a common clinical condition in everyday practice. Several studies (ACME, MASS, RITA 2) compared the efficacy of angioplasty with medical management in this context with concordant results: significant reduction in the frequency of angina and improved exercise capacity, without reduction in the number of serious events (death, infarction). Even though developments in the field of angioplasty have provided better clinical results, especially with the use of stents, the indication of dilatation should be clearly defined by a series of clinical and angiographic parameters. Although resistance to well conducted medical treatment is an indication for revascularisation when possible, the indications should be reconsidered if persistent ischaemia with medical therapy has not been proved.

Resistance to apoptosis in human CD8+ T cells that reach replicative senescence after multiple rounds of antigen-specific proliferation

We have established an in vitro culture model of cellular aging in which antigen-specific T cells are stimulated repeatedly to divide until they reach the irreversible state of growth arrest known as "replicative senescence." T lymphocytes that reach replicative senescence in culture show complete loss of CD28 expression, shortened telomeres, undetectable telomerase, and reduced ability to produce heat shock proteins. We now document that in response to treatment with apoptotic stimuli, senescent CD8+ T-cell cultures show reduced apoptosis and diminished caspase 3 activity compared with quiescent early passage cultures from the same donor. Our results suggest that the progressive accumulation of T cells showing many of the hallmarks of replicative senescence during aging, chronic infection, and autoimmune disease may, in part, reflect the diminished capacity of such cells to undergo normal programmed cell death.

[Angioplasty with stent of the common trunk of the left coronary artery with abnormal origin at the level of the right anterior sinus and with a retro-aortic trajectory]

The authors report a case of angioplasty with implantation of a stent in an anomalous left main coronary artery arising from the right anterior sinus of Valsalva with a retro-aortic trajectory. The introduction of stenting has made angioplasty of anomalous coronary arteries a possible alternative to surgery with the reserve of a high risk of restenosis when the lesion is distal and situated at a bifurcation.

Hemorrhagic necrosis due to peliosis hepatis: imaging findings and pathological correlation

Peliosis hepatis is an uncommon liver condition characterized by blood-filled cavities. We report the CT, angiographic and MR features of a case of peliosis hepatis with no obvious etiology and spontaneously regressing hemorrhagic necrosis. Helical CT showed multiple peripheral low-density regions with foci of spontaneous high density suggesting the presence of blood component. On MR imaging, the multiple peripheral lesions were hypointense on T1-weighted and hyperdense on T2-weighted images, with bright foci on all sequences suggesting subacute blood. Angiography showed no evidence of tumor or vascular malformation; multiple nodular vascular lesions filling in the parenchymal phase and persisting in the venous phase suggested blood-filled cavities. Pathological examination showed blood-filled spaces with no endothelial lining, characteristic of the parenchymal type of peliosis. Knowledge of the imaging features of hemorrhagic necrosis due to peliosis hepatis is important since it can be responsive to antibiotic therapy. Furthermore, differentiating hemorrhagic necrosis from hepatic abscess avoids dangerous and sometimes fatal percutaneous drainage.

Acute hemodynamic interaction of aspirin and ticlopidine with enalapril: results of a double-blind, randomized comparative trial

BACKGROUND

Coprescription of aspirin and ACE inhibitors is frequent in heart failure caused by coronary artery disease. Negative interaction between aspirin and enalapril has been reported, presumably through inhibition by aspirin of ACE inhibitor-induced prostaglandin synthesis. Ticlopidine is a potent antiplatelet agent without interaction with prostaglandin synthesis.

METHODS AND RESULTS

The objective of this study was to compare the influence of a coadministration of ticlopidine or aspirin on the hemodynamic effects of an ACE inhibitor (enalapril) in patients with chronic heart failure. Twenty patients with severe heart failure were enrolled in a double-blind comparative trial and allocated to ticlopidine (500 mg daily, 12 patients) or aspirin (325 mg daily, 8 patients). Hemodynamic evaluation was performed after 7 days of treatment, every hour for 4 hours after an oral administration of 10 mg of enalapril. Significant reductions in systemic vascular resistance were observed in the ticlopidine group, in contrast to no significant decrease in the aspirin group. A significant (P=0.03) time-by-treatment interaction indicated significant aspirin-enalapril drug interaction. Total pulmonary resistance decreased significantly in both groups, with no difference between patients assigned to aspirin or ticlopidine.

CONCLUSIONS

Enalapril reduced systemic vascular resistance more effectively when given in combination with ticlopidine than with aspirin. In contrast, the reduction in total pulmonary resistance is similar when enalapril is administered in combination with aspirin or ticlopidine. Negative aspirin-enalapril interaction on prostaglandin synthesis presumably alters vasodilatation in systemic vessels, whereas prostaglandin-independent actions of ACE inhibition such as pulmonary arterial vasodilatation are maintained.

Topical lidocaine-prilocaine cream (EMLA) versus local infiltration anesthesia for radial artery cannulation

In a randomized trial, we compared topical anesthesia by a lidocaine-prilocaine cream (EMLA; Laboratorie ASTRA, Manterre, France) with subcutaneous local lidocaine infiltration for radial artery cannulation. Patients included 538 adults scheduled for coronary angiography using a radial approach. EMLA was applied 2 h before radial cannulation, and lidocaine infiltration was performed 5 min before cannulation. The primary end point was pain as assessed by a verbal numerical scale (0 = no pain, 10 = extreme pain). Pain was less severe in the EMLA group than in the lidocaine infiltration group (Score of 2 vs 7; P = 0.0001). Additional lidocaine infiltration was required significantly less frequently in the EMLA group (relative risk 0.19). The failure rate of cannulation was significantly lower in the EMLA group (relative risk 0.38), and insertion time was shorter (4 versus 6 min). We conclude that EMLA, compared with lidocaine infiltration, reduces pain associated with radial artery cannulation and improves the success rate of the procedure. Routine application of EMLA should be performed in awake patients 2 h before radial artery cannulation.

IMPLICATIONS

In a randomized trial, we compared topical anesthesia by a lidocaine-prilocaine cream (EMLA) with subcutaneous local lidocaine infiltration for radial artery cannulation in 538 adults patients. EMLA reduced pain associated with radial artery cannulation and improved the success rate of the procedure.

[Transluminal coronary angioplasty in the acute phase of myocardial infarction]

The objective of the treatment of myocardial infarction is to reestablish patency of the occluded artery as soon as possible. Two methods have been validated: intravenous thrombolysis which is easy to perform, and transluminal coronary angioplasty requiring expensive infrastructures and a skilled medical team but which has a higher success rate of restoring arterial patency. Angioplasty is indicated in cardiogenic shock and cases in which there is diagnostic uncertainty or a contraindication to thrombolysis. In addition, its superiority over thrombolysis has been clearly demonstrated in the following indications: 1) primary angioplasty if proper facilities with an experienced team are available in less than 45 minutes and 2) after failed thrombolysis (rescue angioplasty). The use of stents improves the results of primary angioplasty. Angioplasty and thrombolysis are not rival techniques: the choice depends on local conditions (proximity to a catheterization laboratory with a trained medical team) and the clinical context (presence of "high-risk" criteria). Their association (prehospital thrombolysis followed by immediate angioplasty) is the object of prospective clinical trials.