Acute myocardial infarction due to simultaneous spasm of 3 coronary arteries that worsened over time

Coronary artery spasm (CAS) rarely worsens from single-vessel to simultaneous multivessel CAS naturally, and simultaneous multivessel CAS leads to serious conditions such as cardiopulmonary arrest (CPA). A 77-year-old Japanese man who took medications for CAS was transferred to our hospital due to persistent chest pain. On arrival, his vital signs were stable, but his electrocardiogram (ECG) showed ST-segment elevation in leads II, III and aVF. Ventricular fibrillation developed suddenly. Although routine cardiopulmonary resuscitation (CPR) including intravenous administration of epinephrine was performed immediately, he could not be resuscitated. After initiation of percutaneous cardiopulmonary support (PCPS), there was a return of spontaneous circulation. His ECG showed exacerbation of myocardial ischemia with ST-segment elevation in leads I, II, III, aVL, aVF and V3–V6. Emergency coronary angiography revealed severe CAS of the right and left coronary arteries, which was relieved completely by intracoronary administration of nitrates. He was diagnosed with acute myocardial infarction due to simultaneous 3-vessel CAS that progressed over time. About 6 h after arrival, he developed hemodynamic instability and died. CAS worsened from single-vessel to simultaneous 3-vessel spasm, and intracoronary administration of nitrates was effective in relieving CAS, which was documented by the ECG and coronary angiogram. Since CAS can progress over time, nitrates must be administered immediately. When CAS leads to CPA, epinephrine may be ineffective in CPR because of its vasoconstrictive effect on coronary arteries; therefore, PCPS should be initiated, and intracoronary nitrates should be administered.     

Impact of drug-eluting stent-associated coronary artery spasm on 3-year clinical outcomes: A propensity score matching analysis

BackgroundIt has been reported that significant endothelial dysfunction or clinically evident vasospasm can be associated with drug-eluting stents (DESs). However, the impact of DES associated coronary artery spasm (CAS) on long-term clinical outcomes has not been fully elucidated as compared with those of patients with vasospastic angina.MethodsA total of 2797 consecutive patients without significant coronary artery lesion (<70%), who underwent the Acetylcholine (Ach) provocation test, were enrolled between Nov 2004 and Oct 2010. DES-associated spasm was defined as significant CAS in proximal or distal to previously implanted DES site at follow-up angiography with Ach test. Patients were divided into two groups (DES-CAS; n = 108, CAS; n = 1878). For adjustment, propensity score matching (PSM) was done (C-statistics = 0.766, DES-CAS; n = 102, CAS; n = 102). SPSS 20 (Inc., Chicago, Illinois) was used to analyze this data.ResultsBaseline characteristics were worse in the DES-CAS group. After PSM, both baseline characteristics and the Ach test results were balanced except higher incidence of diffuse CAS and ECG change in the DES-CAS group. During Ach test, the incidence of diffuse spasm (93.1% vs. 81.3%, p = 0.012) and ST-T change (10.7% vs. 1.9%, p = 0.010) were higher in the DES-CAS group. At 3-year, before and after adjustment, the DES-CAS group showed a higher incidence of coronary revascularization (9.8% vs. 0.0%, p = 0.001), recurrent chest pain requiring follow up coronary angiography (CAG, 24.5% vs. 7.8%, p = 0.001) and major adverse cardiac events (MACEs, 9.8% vs. 0.9%, p < 0.005).ConclusionIn this study, DES associated CAS was associated with higher incidence of diffuse spasm, ST-T change and adverse 3-year clinical outcomes. Special caution should be exercised in this particular subset of patients.     

How to tackle complications in radial procedures: Tip and tricks

Transradial interventions (TRI) are becoming increasingly popular because of accumulating recent evidence suggesting improved survival and reduced morbidity. Complications, though rare, do occur, especially for operators on their learning curve. The complications are best prevented by utilization of proper technique. Forearm hematoma are preventable and easy to treat, but a delay in detecting and managing them can lead to disastrous consequences compartment syndrome being the most dreaded one. This review deals with tips and tricks to prevent as also treat the common and rare complications.     

八髎穴治疗出口梗阻型便秘的机制探讨

出口梗阻型便秘(outlet obstruction constipation,OOC)已经成为影响现代人生活质量的重要疾病之一。本文就近年来国内外有关OOC的发病机制及针刺八髎穴治疗OOC的研究进行了回顾,发现针刺八髎穴可能通过提高神经节内板状末梢改善机械扩张的敏感性,升高血清胆囊收缩素水平,抑制脊髓前角的γ-运动神经元、脊髓内侧角的交感中枢的兴奋性及减少5-羟色胺、组织胺的释放等多途径达到治疗OOC的作用。深入探讨八髎穴治疗OOC的作用机制,可为寻找更为特异和有效的治疗靶点提供实验依据和理论基础。     

Clinical tests for confirming tracheal intubation or excluding oesophageal intubation: a diagnostic test accuracy systematic review and meta-analysis

Unrecognised oesophageal intubation causes preventable serious harm to patients undergoing tracheal intubation. When capnography is unavailable or doubted, clinicians still use clinical findings to confirm tracheal intubation, or exclude oesophageal intubation, and false reassurance from clinical examination is a recurring theme in fatal cases of unrecognised oesophageal intubation. We conducted a systematic review and meta-analysis of the diagnostic accuracy of five clinical examination tests and the oesophageal detector device when used to confirm tracheal intubation. We searched four databases for studies reporting index clinical tests against a reference standard, from inception to 28 February 2023. We included 49 studies involving 10,654 participants. Methodological quality was overall moderate to high. We looked at misting (three studies, 115 participants); lung auscultation (three studies, 217 participants); combined lung and epigastric auscultation (four studies, 506 participants); the oesophageal detector device (25 studies, 3024 participants); ‘hang-up’ (two non-human studies); and chest rise (one non-human study). The reference standards used were capnography (22 studies); direct vision (10 studies); and bronchoscopy (three studies). When used to confirm tracheal intubation, misting has a false positive rate (95%CI) of 0.69 (0.43–0.87); lung auscultation 0.14 (0.08–0.23); five-point auscultation 0.18 (0.08–0.36); and the oesophageal detector device 0.05 (0.02–0.09). Tests to exclude events that invariably lead to severe damage or death must have a negligible false positive rate. Misting or auscultation have too high a false positive rate to reliably exclude oesophageal intubation and there is insufficient evidence to support the use of ‘hang-up’ or chest rise. The oesophageal detector device may be considered where other more reliable means are not available, though waveform capnography remains the reference standard for confirmation of tracheal intubation.     

益气温阳—养阴解痉中药治疗中风偏瘫肢体痉挛随机平行对照研究

[目的]观察益气温阳,养阴解痉中药治疗中风偏瘫肢体痉挛疗效。[方法]使用随机平行对照方法,将30例住院及门诊患者按诊顺序号方法分为两组。对照组15例巴氯芬,5mg/次,1次/d,口服。治疗组15例益气温阳,养阴解痉(黄芪、党参、白芍、石斛、桂枝、桑枝、地龙、甘草等),1剂/d,水煎400m L,早晚温服。两组均连续治疗28d为1疗程。观测临床症状、血液生化指标、《Barthel氏ADL指数法》评分、不良反应。治疗1疗程,判定疗效。[结果]治疗组痉挛疗效显效4例,有效9例,无效2例,总有效率86.70%。对照组显效3例,有效8例,无效4例,总有效率73.33%。治疗组疗效优于对照组(P0.05)。Bathel指数变化治疗组优于对照组(P0.01)[结论]益气温阳,养阴解痉中药治疗中风偏瘫肢体痉挛效果显著,值得推广。     

Terlipressin (Triglycyl-Lysine Vasopressin) Controls Acute Bleeding Oesophageal Varices: A Double-Blind,Randomized, Placebo-Controlled Trial

The haemostatic effect of terlipressin (triglycyl-lysine vasopressin; Glypressin^®) on bleeding from oesophageal varices was evaluated in a placebo-controlled, double-blind, randomized clinical trial. Patients with clinically suspected liver cirrhosis were included in the study if they had been admitted to hospital with an extensive haemorrhage within the last 24 h before diagnostic endoscopy. The patients randomized after stratification for severity of liver disease. Terlipressin or placebo was administered as intravenous bolus injections every 4th h during a period of 24 to 36 h or until the clinical course necessitated active intervention (failure or withdrawal). Sixty patients entered the study; 31 patients were allocated to receive terlipressin, and 29 patients to receive placebo. Bleeding from varices was arrested in 28 of the 31 receiving terlipressin, as compared with 17 of the 29 receiving placebo (p < 0.01). Patients receiving active drug required significantly fewer blood transfusions (p < 0.05). Most of the side effects were classified as mild and were registered in the terlipressin group.     

Replacement of tenofovir with adefovir may result in reactivation of hepatitis B virus replication

Ten investigations of acid reflux by means of 12-hour continuous pH monitoring at the distal end of the oesophagus, and 10 acid-clearing tests were performed within 6 weeks on the same volunteer with the purpose of examining the reproducibility of the results of these tests. Intragastric pH was studied over 12 hours and proved to be under 3 during the whole period of investigation. For the acid reflux test the coefficient of variation was 0.61-0.94, depending on the criteria for reflux. For the acid-clearing test the coefficient of variation was 0.22. For both tests the results of the separate investigations varied within normal ranges.