Validation of neuron-specific enolase in cardiac arrest patients with limited withdrawal of life-sustaining therapy.

Aim: We validated the prognostic performance of neuron-specific enolase (NSE) according to the recommended values in cardiac arrest (CA) survivors. Methods: We analyzed the data of adult CA survivors who underwent targeted temperature management between January 2014 and December 2020. We measured the NSE level 48 h and 72 h after CA. We performed receiver operating characteristics (ROC) and used the reference value (17 µg/L) and the guidelines-suggested value (60 µg/L) as thresholds. The primary outcome was 6-month neurological outcomes with Cerebral Performance Category (CPC), dichotomized into good (CPC 1 or 2) or poor (CPC 3-5). Results: Of the 513 included patients, 346 (67.4 %) patients had poor neurological outcomes. The area under ROC (AUC) of NSE at 48 h was 0.887 (95 % confidence intervals [CIs], 0.851-0.909) with the Youden index of 35.6 µg/L. A false positive rate (FPR) of <2 % was observed (54.1 µg/L). The thresholds values (17, 60) had a sensitivity of 86.1% and 56.7 % and a specificity of 66.7%and 98.8 %, respectively. The AUC of NSE at 72 h was 0.892 (95 % CIs, 0.849-0.920) with the Youden index of 30.4 µg/L. The threshold values (17, 60) had a sensitivity of 86.0%and 59.4 % with a specificity of 72.2%and 98.3 %, respectively. An FPR of <2 % was observed (53.6 µg/L). Among the 156 patients and 113 patients with NSE at 48 h and at 72 h ≤ 17 µg/L, respectively, 109 and 83 patients had good neurological outcomes. Conclusions: The cut-off value of NSE (60 µg/L) was acceptable to predict poor neurological outcomes with an FPR <2 % in cardiac arrest survivors, irrespective of at 48 or 72 h. NSE (17 µg/L) can function as mitigating factor to deter early WLST.

Acute kidney injury as a prognostic predictor of in-hospital mortality and neurological outcomes in patients after extracorporeal cardiopulmonary resuscitation.

INTRODUCTION: Extracorporeal cardiopulmonary resuscitation (ECPR) is increasingly being applied to patients with refractory cardiac arrest, but the survival rate to hospital discharge is only approximately 29%. Because ECPR requires intensive resources, it is important to predict outcomes. We therefore investigated the prognostic association between acute kidney injury (AKI) and ECPR to confirm the performance of AKI as a prognostic predictor of in-hospital mortality and neurological outcomes in ECPR. METHODS: We conducted a retrospective observational study on patients undergoing ECPR for cardiac etiology at Chonnam National University Hospital from 2015 to 2021. The group diagnosed with AKI in any KDIGO category within the first 48 h after ECPR was compared to that without AKI, and the primary outcome of the study was in-hospital mortality. RESULTS: Of 138 enrolled patients, 83 were studied. Hospital mortality occurred in 49 patients (59%), and 55 (66.3%) showed poor neurological outcomes. The AKI group displayed significantly elevated in-hospital mortality (77.8% vs 24.1%) and poor neurological outcomes (81.5% vs 37.9%) compared to the non-AKI group (p < 0.001). Regression analysis showed that AKI was associated with significantly higher rates of both in-hospital mortality (odds ratio (OR) range 10.75-12.88) and neurologic outcomes (OR range 5.9-6.22). CONCLUSIONS: There was a significant association of AKI with both in-hospital mortality and poor neurologic outcome in patients after ECPR, and AKI can be used as an early prognostic predictor in these patients.

The Relationship between the Ratio of Urine Osmolality to Serum Osmolality and Neurological Outcomes in Out-of-hospital Cardiac Arrest Patients.

Background: Progressive ischemic brain injury after cardiac arrest can cause damage to the hypothalamic-pituitary axis, particularly the pituitary gland. This may impact serum osmolality (SOsm) and urine osmolality (UOsm) in patients who have experienced out-of-hospital cardiac arrest (OHCA). We assumed that a low ratio of UOsm to SOsm (USR) is related to poor outcomes among OHCA patients. Therefore, the present study was designed to evaluate the association between the USR within 72 h after the restoration of spontaneous circulation (ROSC) and 6-month neurological outcomes in OHCA patients. Methods: This prospective, observational study included OHCA patients with targeted temperature management at Chonnam National University Hospital in Gwangju, Korea, between January 2016 and December 2022. We collected SOsm and UOsm data at admission (T0) and 24 (T1), 48 (T2), and 72 h (T3) after ROSC. The primary outcome was a poor neurological outcome at 6 months defined by cerebral performance categories 3, 4, or 5. Results: This study included 319 patients. The mean UOsm and USRs at T0, T1, T2, and T3 of patients with poor outcomes were lower than those of patients with good outcomes. Multivariable analysis indicated that the USRs at T1 (odds ratio [OR], 0.363; 95% confidence interval [CI], 0.221-0.594), T2 (OR, 0.451; 95% CI, 0.268-0.761), and T3 (OR, 0.559; 95% CI, 0.357-0.875) were associated with a poor outcome. The areas under the receiver operating characteristic curves of USRs at T0, T1, T2, and T3 for predicting poor outcomes were 0.615 (95% CI, 0.559-0.669), 0.711 (95% CI, 0.658-0.760), 0.724 (95% CI, 0.671-0.772), and 0.751 (95% CI, 0.699-0.797), respectively. Conclusions: The USRs within 72 h of ROSC were associated with poor neurological outcomes at 6 months in OHCA patients.

The Association between Troponin-I Clearance after the Return of Spontaneous Circulation and Outcomes in Out-of-Hospital Cardiac Arrest Patients.

Background: Elevated levels of troponin-I (TnI) are common in out-of-hospital cardiac arrest (OHCA) patients. However, studies evaluating the prognostic value of TnI clearance in OHCA patients are lacking. We aimed to examine how TnI clearance (TnI-C) differed according to the neurological outcome group and mortality group at 6 months. Methods: This retrospective observational study involved adults ( ≥ 18 years) who were treated for an OHCA between January 2019 and December 2022. The TnI-Cs were calculated for days 1 to 2 (TnI-C1st) and 2 to 3 (TnI-C2nd) after the return of spontaneous circulation (ROSC). The primary outcome was a poor neurological outcome at 6 months, defined by cerebral performance categories 3, 4, and 5. The secondary outcome was 6-month mortality. Results: A total of 227 patients were included. A poor neurological outcome and mortality at 6-months were reported in 150 (66.1%) and 118 (52.0%) patients, respectively. The TnI-C1st was significantly lower in patients with a poor outcome compared with good outcome patients (neurological outcome at 6 months, 54.4% vs. 42.3%; 6-month mortality, 52.1% vs. 42.7%, respectively). In the multivariable analyses, a TnI-C1st < 50% was associated with a poor neurological outcome (odds ratio [OR] 2.078, 95% confidence interval [CI] 1.080-3.995, p = 0.028) and mortality (OR 2.131, 95% CI 1.114-4.078, p = 0.022) at 6 months. Conclusions: After ROSC, TnI-C1st < 50% was associated with a poor neurological outcome and mortality at 6 months in OHCA patients.

Grey-to-White Matter Ratio Values in Early Head Computed Tomography (CT) as a Predictor of Neurologic Outcomes in Survivors of Out-of-Hospital Cardiac Arrest Based on Severity of Hypoxic-Ischemic Brain Injury.

BACKGROUND: Hypoxic-ischemic brain injury (HIBI) is a common complication of out-of-hospital cardiac arrest (OHCA). OBJECTIVES: We investigated whether grey-to-white matter ratio (GWR) values, measured using early head computed tomography (HCT), were associated with neurologic outcomes based on the severity of HIBI in survivors of OHCA. METHODS: This retrospective multicenter study included adult comatose OHCA survivors who underwent an HCT scan within 2 h after the return of spontaneous circulation. HIBI severity was assessed using the revised post-Cardiac Arrest Syndrome for Therapeutic hypothermia (rCAST) scale (low, moderate, and severe). Poor neurologic outcomes were defined as Cerebral Performance Categories 3 to 5 at 6 months after OHCA. RESULTS: Among 354 patients, 27% were women and 224 (63.3%) had poor neurologic outcomes. The distribution of severity was 19.5% low, 47.5% moderate, and 33.1% severe. The area under the receiver operating curves of the GWR values for predicting rCAST severity (low, moderate, and severe) were 0.52, 0.62, and 0.79, respectively. The severe group had significantly higher predictive performance than the moderate group (p = 0.02). Multivariate logistic regression analysis revealed a significant association between GWR values and poor neurologic outcomes in the moderate group (adjusted odds ratio = 0.012, 95% CI 0.0-0.54, p = 0.02). CONCLUSIONS: In this cohort study, GWR values measured using early HCT demonstrated variations in predicting neurologic outcomes based on HIBI severity. Furthermore, GWR in the moderate group was associated with poor neurologic outcomes.

Quantitative analysis of apparent diffusion coefficients to predict neurological prognosis in cardiac arrest survivors: an observational derivation and internal-external validation study.

BACKGROUND: This study aimed to validate apparent diffusion coefficient (ADC) values and thresholds to predict poor neurological outcomes in out-of-hospital cardiac arrest (OHCA) survivors by quantitatively analysing the ADC values via brain magnetic resonance imaging (MRI). METHODS: This observational study used prospectively collected data from two tertiary academic hospitals. The derivation cohort comprised 70% of the patients randomly selected from one hospital, whereas the internal validation cohort comprised the remaining 30%. The external validation cohort used the data from another hospital, and the MRI data were restricted to scans conducted at 3 T within 72-96 h after an OHCA experience. We analysed the percentage of brain volume below a specific ADC value at 50-step intervals ranging from 200 to 1200 × 10-6 mm2/s, identifying thresholds that differentiate between good and poor outcomes. Poor neurological outcomes were defined as cerebral performance categories 3-5, 6 months after experiencing an OHCA. RESULTS: A total of 448 brain MRI scans were evaluated, including a derivation cohort (n = 224) and internal/external validation cohorts (n = 96/128, respectively). The proportion of brain volume with ADC values below 450, 500, 550, 600, and 650 × 10-6 mm2/s demonstrated good to excellent performance in predicting poor neurological outcomes in the derivation group (area under the curve [AUC] 0.89-0.91), and there were no statistically significant differences in performances among the derivation, internal validation, and external validation groups (all P > 0.5). Among these, the proportion of brain volume with an ADC below 600 × 10-6 mm2/s predicted a poor outcome with a 0% false-positive rate (FPR) and 76% (95% confidence interval [CI] 68-83) sensitivity at a threshold of > 13.2% in the derivation cohort. In both the internal and external validation cohorts, when using the same threshold, a specificity of 100% corresponded to sensitivities of 71% (95% CI 58-81) and 78% (95% CI 66-87), respectively. CONCLUSIONS: In this validation study, by consistently restricting the MRI types and timing during quantitative analysis of ADC values in brain MRI, we observed high reproducibility and sensitivity at a 0% FPR. Prospective multicentre studies are necessary to validate these findings.

Good outcome prediction after out-of-hospital cardiac arrest: A prospective multicenter observational study in Korea (the KORHN-PRO registry).

AIM: To assess the ability of clinical examination, biomarkers, electrophysiology and brain imaging, individually or in combination to predict good neurological outcomes at 6 months after CA. METHODS: This was a retrospective analysis of the Korean Hypothermia Network Prospective Registry 1.0, which included adult out-of-hospital cardiac arrest (OHCA) patients (≥18 years). Good outcome predictors were defined as both pupillary light reflex (PLR) and corneal reflex (CR) at admission, Glasgow Coma Scale Motor score (GCS-M) >3 at admission, neuron-specific enolase (NSE) <17 µg/L at 24-72 h, a median nerve somatosensory evoked potential (SSEP) N20/P25 amplitude >4 µV, continuous background without discharges on electroencephalogram (EEG), and absence of anoxic injury on brain CT and diffusion-weighted imaging (DWI). RESULTS: A total of 1327 subjects were included in the final analysis, and their median age was 59 years; among them, 412 subjects had a good neurological outcome at 6 months. GCS-M >3 at admission had the highest specificity of 96.7% (95% CI 95.3-97.8), and normal brain DWI had the highest sensitivity of 96.3% (95% CI 92.9-98.4). When the two predictors were combined, the sensitivities tended to decrease (ranging from 2.7-81.1%), and the specificities tended to increase, ranging from81.3-100%. Through the explorative variation of the 2021 European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) prognostication strategy algorithms, good outcomes were predicted, with a specificity of 83.2% and a sensitivity of 83.5% in patients by the algorithm. CONCLUSIONS: Clinical examination, biomarker, electrophysiology, and brain imaging predicted good outcomes at 6 months after CA. When the two predictors were combined, the specificity further improved. With the 2021 ERC/ESICM guidelines, the number of indeterminate patients and the uncertainty of prognostication can be reduced by using a good outcome prediction algorithm.

Role of the National Early Warning score and Modified Early Warning score for predicting mortality in geriatric patients with non-traumatic coma.

Geriatric patients arriving in a non-traumatic coma (NTC) at the emergency department (ED) present substantial risks and necessitate prompt and appropriate care. The National Early Warning Score (NEWS) is a promising tool that can efficiently evaluate this vulnerable population. Current study was designed to assess the effectiveness of the NEWS for predicting the severity of illness in geriatric patients with NTC and identifying those at highest risk. Current study was performed involving geriatric patients (aged ≥65 years) with NTC who visited Chonnam National University Hospital between January and December 2022. NEWS and Modified Early Warning Scores (MEWS) were calculated at ED visits. The association of NEWS and MEWS for in-hospital death was evaluated by multivariable analysis. Out of 683 patients, 202 were non-survivors (29.6%). The NEWS and MEWS values of non-survivors were higher than those of survivors (NEWS, 7 [5-10] vs. 10 [8-12]; MEWS, 5 [4-6] vs. 7 [5-8]). The NEWS (adjusted odds ratio [aOR]; 1.253, 95% confidence interval [CI]: 1.181-1.329) and MEWS (aOR; 1.323, 95% CI: 1.206-1.451) were also significantly associated with in-hospital death. The area under the curve for the NEWS and MEWS was 0.721 (95% CI: 0.685-0.754) and 0.695 (95% CI: 0.659-0.730), respectively. The NEWS can be an effective tool for predicting severity of illness via in-hospital death in geriatric patients with NTC.

Association between quantitative analysis of cerebral edema using CT imaging and neurological outcomes in cardiac arrest survivors.

BACKGROUND: To determine if the density distribution proportion of Hounsfield unit (HUdp) in head computed tomography (HCT) images can be used to quantitatively measure cerebral edema in survivors of out-of-hospital cardiac arrest (OHCA). METHODS: This retrospective observational study included adult comatose OHCA survivors who underwent HCT within 6 h (first) and 72-96 h (second), all performed using the same CT scanner. Semi-automated quantitative analysis was used to identify differences in HUdp at specific HU ranges across the intracranial component based on neurological outcome. Cerebral edema was defined as the increased displacement of the sum of HUdp values (ΔHUdp) at a specific range between two HCT scans. Poor neurological outcome was defined as cerebral performance categories 3-5 at 6 months after OHCA. RESULTS: Twenty-three (42%) out of 55 patients had poor neurological outcome. Significant HUdp differences were observed between good and poor neurological outcomes in the second HCT scan at HU = 1-14, 23-35, and 39-56 (all P < 0.05). Only the ΔHUdp = 23-35 range showed a significant increase and correlation in the poor neurological outcome group (4.90 vs. -0.72, P < 0.001) with the sum of decreases in the other two ranges (r = 0.97, P < 0.001). Multivariate logistic regression analysis demonstrated a significant association between ΔHUdp = 23-35 range and poor neurological outcomes (adjusted OR, 1.12; 95% CI: 1.02-1.24; P = 0.02). CONCLUSION: In this cohort study, the increased displacement in ΔHUdp = 23-35 range is independently associated with poor neurological outcome and provides a quantitative assessment of cerebral edema formation in OHCA survivors.

Feasibility of Magnetic Resonance-Based Conductivity Imaging as a Tool to Estimate the Severity of Hypoxic-Ischemic Brain Injury in the First Hours After Cardiac Arrest.

BACKGROUND: Early identification of the severity of hypoxic-ischemic brain injury (HIBI) after cardiac arrest can be used to help plan appropriate subsequent therapy. We evaluated whether conductivity of cerebral tissue measured using magnetic resonance-based conductivity imaging (MRCI), which provides contrast derived from the concentration and mobility of ions within the imaged tissue, can reflect the severity of HIBI in the early hours after cardiac arrest. METHODS: Fourteen minipigs were resuscitated after 5 min or 12 min of untreated cardiac arrest. MRCI was performed at baseline and at 1 h and 3.5 h after return of spontaneous circulation (ROSC). RESULTS: In both groups, the conductivity of cerebral tissue significantly increased at 1 h after ROSC compared with that at baseline (P = 0.031 and 0.016 in the 5-min and 12-min groups, respectively). The increase was greater in the 12-min group, resulting in significantly higher conductivity values in the 12-min group (P = 0.030). At 3.5 h after ROSC, the conductivity of cerebral tissue in the 12-min group remained increased (P = 0.022), whereas that in the 5-min group returned to its baseline level. CONCLUSIONS: The conductivity of cerebral tissue was increased in the first hours after ROSC, and the increase was more prominent and lasted longer in the 12-min group than in the 5-min group. Our findings suggest the promising potential of MRCI as a tool to estimate the severity of HIBI in the early hours after cardiac arrest.

High incidence of acute kidney injury in extracorporeal resuscitation, Leading to poor prognosis.

Background: Extracorporeal membrane oxygenation (ECMO) patients have a high incidence of acute kidney injury (AKI). Extracorporeal cardiopulmonary resuscitation (ECPR) patients are more likely to develop AKI than ECMO patients because of serious injury during cardiac arrest (CA). Objectives: This study aims to assess the occurrence and outcomes of AKI in ECPR and ECMO, and to identify specific risk factors and clinical implications of AKI in ECPR. Methods: This is a retrospective observational study from a single tertiary care hospital in Gwangju, Korea. Adults (≥18 years) who received ECMO with cardiac etiology in the emergency and inpatient departments from January 2015 to December 2021 were included. The patients (n = 169) were divided into two groups, ECPR and ECMO without CA, and the occurrence of AKI was investigated. The primary outcome of the study was in-hospital mortality, and the secondary outcomes were six-month cerebral performance category (CPC) and AKI during hospitalization. Results: The incidence of AKI was significantly higher with ECPR (67.5 %) than with ECMO without CA (38.4 %). ECPR was statistically significant for Expire (adjusted OR (aOR) 2.45, 95 % CI 1.28-4.66) and Poor CPC (2.59, 1.32-5.09). AKI was also statistically significant for Expire (6.69, 3.37-13.29) and Poor CPC (5.45, 2.73-10.88). AKI was the determining factor for the outcomes of ECPR (p = 0.01). Conclusions: ECPR patients are more likely to develop AKI than ECMO without CA patients. In ECPR patients, AKI leads to poor outcomes. Therefore, clinicians should be careful not to develop AKI in ECPR patients.

Quantitative analysis of early apparent diffusion coefficient values from MRIs for predicting neurological prognosis in survivors of out-of-hospital cardiac arrest: an observational study.

BACKGROUND: This study aimed to quantitatively analyse ultra-early brain diffusion-weighted magnetic resonance imaging (DW-MRI) findings to determine the apparent diffusion coefficient (ADC) threshold associated with neurological outcomes in comatose survivors of out-of-hospital cardiac arrest (OHCA). METHODS: This retrospective study included adult survivors of comatose OHCA who underwent DW-MRI imaging scans using a 3-T MRI scanner within 6 h of the return of spontaneous circulation (ROSC). We investigated the association between neurological outcomes and ADC values obtained through voxel-based analysis on DW-MRI. Additionally, we constructed multivariable logistic regression models with pupillary light reflex (PLR), serum neuron-specific enolase (NSE), and ADC values as independent variables to predict poor neurological outcomes. The primary outcome was poor neurological outcome 6 months after ROSC, determined by the Cerebral Performance Category 3-5. RESULTS: Overall, 131 patients (26% female) were analysed, of whom 74 (57%) showed poor neurological outcomes. The group with a poor neurological outcome had lower mean whole brain ADC values (739.1 vs. 787.1 × 10-6 mm/s) and higher percentages of voxels with ADC below threshold in all ranges (250-1150) (all P < 0.001). The mean whole brain ADC values (area under the receiver operating characteristic curve [AUC] 0.83) and the percentage of voxels with ADC below 600 (AUC 0.81) had the highest sensitivity of 51% (95% confidence interval [CI] 39.4-63.1; cut-off value ≤ 739.2 × 10-6 mm2/s and > 17.2%, respectively) when the false positive rate (FPR) was 0%. In the multivariable model, which also included PLR, NSE, and mean whole brain ADC values, poor neurological outcome was predicted with the highest accuracy (AUC 0.91; 51% sensitivity). This model showed more accurate prediction and sensitivity at an FPR of 0% than did the combination of PLR and NSE (AUC 0.86; 30% sensitivity; P = 0.03). CONCLUSIONS: In this cohort study, early voxel-based quantitative ADC analysis after ROSC was associated with poor neurological outcomes 6 months after cardiac arrest. The mean whole brain ADC value demonstrated the highest sensitivity when the FPR was 0%, and including it in the multivariable model improved the prediction of poor neurological outcomes.

Assessment of the Effects of Sodium Nitroprusside Administered Via Intracranial Subdural Catheters on the Cerebral Blood Flow and Lactate Using Dynamic Susceptibility Contrast Magnetic Resonance Imaging and Proton Magnetic Resonance Spectroscopy in a Pig Cardiac Arrest Model.

Background Cerebral blood flow (CBF) is impaired in the early phase after return of spontaneous circulation. Sodium nitroprusside (SNP) administration via intracranial subdural catheters improves cerebral cortical microcirculation. We determined whether the SNP treatment improves CBF in the subcortical tissue and evaluated the effects of this treatment on cerebral lactate. Methods and Results Sixty minutes after return of spontaneous circulation following 14 minutes of untreated cardiac arrest, 14 minipigs randomly received 4 mg SNP or saline via intracranial subdural catheters. CBF was measured in regions of interest within the cerebrum and thalamus using dynamic susceptibility contrast-magnetic resonance imaging. After return of spontaneous circulation, CBF was expressed as a percentage of the baseline value. In the saline group, the %CBF in the regions of interest within the cerebrum remained at approximately 50% until 3.5 hours after return of spontaneous circulation, whereas %CBF in the thalamic regions of interest recovered to approximately 73% at this time point. The percentages of the baseline values in the cortical gray matter and subcortical white matter were higher in the SNP group (group effect P=0.026 and 0.025, respectively) but not in the thalamus. The cerebral lactate/creatine ratio measured using magnetic resonance spectroscopy increased over time in the saline group but not in the SNP group (group-time interaction P=0.035). The thalamic lactate/creatine ratio was similar in the 2 groups. Conclusions SNP administered via intracranial subdural catheters improved CBF not only in the cortical gray matter but also in the subcortical white matter. The CBF improvement by SNP was accompanied by a decrease in cerebral lactate.

Expert opinion on evidence after the 2020 Korean Cardiopulmonary Resuscitation Guidelines: a secondary publication.

Considerable evidence has been published since the 2020 Korean Cardiopulmonary Resuscitation Guidelines were reported. The International Liaison Committee on Resuscitation (ILCOR) also publishes the Consensus on CPR and Emergency Cardiovascular Care Science with Treatment Recommendations (CoSTR) summary annually. This review provides expert opinions by reviewing the recent evidence on CPR and ILCOR treatment recommendations. The authors reviewed the CoSTR summary published by ILCOR in 2021 and 2022. PICO (patient, intervention, comparison, outcome) questions for each topic were reviewed using a systemic or scoping review methodology. Two experts were appointed for each question and reviewed the topic independently. Topics suggested by the reviewers for revision or additional description of the guidelines were discussed at a consensus conference. Forty-three questions were reviewed, including 15 on basic life support, seven on advanced life support, two on pediatric life support, 11 on neonatal life support, six on education and teams, one on first aid, and one related to COVID-19. Finally, the current Korean CPR Guideline was maintained for 28 questions, and expert opinions were suggested for 15 questions.

Different neuroprognostication thresholds of neuron-specific enolase in shockable and non-shockable out-of-hospital cardiac arrest: a prospective multicenter observational study in Korea (the KORHN-PRO registry).

BACKGROUND: Serum neuron-specific enolase (NSE) is the only recommended biomarker for multimodal prognostication in postcardiac arrest patients, but low sensitivity of absolute NSE threshold limits its utility. This study aimed to evaluate the prognostic performance of serum NSE for poor neurologic outcome in out-of-hospital cardiac arrest (OHCA) survivors based on their initial rhythm and to determine the NSE cutoff values with false positive rate (FPR) < 1% for each group. METHODS: This study included OHCA survivors who received targeted temperature management (TTM) and had serum NSE levels measured at 48 h after return of spontaneous circulation in the Korean Hypothermia Network, a prospective multicenter registry from 22 university-affiliated teaching hospitals in South Korea between October 2015 and December 2018. The primary outcome was poor outcome at 6 month, defined as a cerebral performance category of 3-5. RESULTS: Of 623 patients who underwent TTM with NSE measured 48 h after the return of spontaneous circulation, 245 had an initial shockable rhythm. Median NSE level was significantly higher in the non-shockable group than in the shockable group (104.6 [40.6-228.4] vs. 25.9 [16.7-53.4] ng/mL, P < 0.001). Prognostic performance of NSE assessed by area under the receiver operating characteristic curve to predict poor outcome was significantly higher in the non-shockable group than in the shockable group (0.92 vs 0.86). NSE cutoff values with an FPR < 1% in the non-shockable and shockable groups were 69.3 (sensitivity of 42.1%) and 102.7 ng/mL (sensitivity of 76%), respectively. CONCLUSION: NSE prognostic performance and its cutoff values with FPR < 1% for predicting poor outcome in OHCA survivors who underwent TTM differed between shockable and non-shockable rhythms, suggesting postcardiac arrest survivor heterogeneity. Trial registration KORHN-PRO, NCT02827422. Registered 11 September 2016-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02827422.

The association between lactate to albumin ratio and outcomes at early phase in patients with traumatic brain injury.

BACKGROUND: The majority of traumatic brain injury (TBI) cases result in death in the early phase; predicting short-term progno-sis of affected patients is necessary to prevent this. This study aimed to examine the association between the lactate-to-albumin ratio (LAR) on admission and outcomes in the early phase of TBI. METHODS: This retrospective observational study included patients with TBI who visited our emergency department between January 2018 and December 2020. TBI was considered as an head abbreviated injury scale (AIS) score of 3 or higher and other AIS of 2 or lower. The primary and secondary outcomes were 24-h mortality and massive transfusion (MT), respectively. RESULTS: In total, 460 patients were included. The 24-h mortality was 12.6% (n=28) and MT was performed in 31 (6.7%) patients. In the multivariable analysis, LAR was associated with 24-h mortality (odds ratio [OR], 2.021; 95% confidence interval [CI], 1.301-3.139) and MT (OR, 1.898; 95% CI, 1.288-2.797). The areas under the curve of LAR for 24-h mortality and MT were 0.805 (95% CI, 0.766-0.841) and 0.735 (95% CI, 0.693-0.775), respectively. CONCLUSION: LAR was associated with early-phase outcomes in patients with TBI, including 24-h mortality and MT. LAR may help predict these outcomes within 24 h in patients with TBI.

Inverse Association of the Adequacy and Balance Scores in the Modified Healthy Eating Index with Type 2 Diabetes in Women.

Type 2 diabetes (T2DM) has markedly increased among Asians as their diets and lifestyles become more westernized. We, therefore, investigated the hypothesis that the Korean healthy eating index (KHEI) scores are associated with gender-specific T2DM risk in adults. The hypothesis was tested using the data from the Korea National Health and Nutrition Examination Survey-VI (2013-2017) with a complex sample survey design. Along with the KHEI scores, the modified KHEI (MKHEI) scores for the Korean- (KSD) and Western-style diets (WSD) were used as independent parameters, calculated using a validated semi-quantitative food-frequency questionnaire (SQFFQ). We estimated the association between the KHEI or MKHEI and the T2DM risk using logistic regression after adjusting for T2DM-related covariates. The adults with T2DM were more frequently older men who were less educated, married, on a lower income, and living in rural areas compared to those without T2DM. Not only the fasting serum glucose concentrations but also the waist circumferences and serum triglyceride concentrations were much higher in adults with T2DM than in those without T2DM in both genders. Serum HDL concentrations in the non-T2DM subjects exhibited a greater inverse relationship to serum glucose than in the T2DM group in both genders. Twenty-four-hour recall data revealed that women, but not men, had higher calcium, vitamin C, saturated and monounsaturated fatty acids, retinol, and vitamin B2 intakes than the T2DM group. Furthermore, overall, the KHEI score and the adequacy and balance scores among its components were significantly higher in the non-T2DM group than in the T2DM group, but only in women. The KHEI scores were inversely associated with T2DM only in women. The mixed grain intake score was higher in the non-T2DM than the T2DM group only in men. However, there were no differences between the groups in the MKHEI scores for KSD and WSD. In conclusion, high KHEI scores in the adequacy and balance components might prevent and/or delay T2DM risk, but only in women.