Barriers to successful dispatcher-assisted cardiopulmonary resuscitation in out-of-hospital cardiac arrest in Korea.

Introduction: Dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) improves bystander CPR rates and survival outcomes. This study aimed to identify barriers to successful DA-CPR in patients with out-of-hospital cardiac arrest (OHCA). Methods: This retrospective observational study used data from a nationwide OHCA database from 2017 to 2021. Adult emergency medical services (EMS)-treated patients with OHCA with a presumed cardiac etiology were enrolled. The main exposure variable was compliance with DA-CPR. The primary outcome was good neurological recovery at hospital discharge. Multivariable logistic regression analysis was conducted to identify the major factors associated with unsuccessful DA-CPR with and without multiple imputations. Causal mediation analysis was conducted using witnessed status as a mediator. Results: In the final analysis, 49,165 patients with OHCA were included. A total of 36,865 (75.0%) patients successfully underwent DA-CPR. A higher proportion of good neurological recovery was observed in the successful DA-CPR group than in the non-successful DA-CPR group (P < 0.001). The following factors were identified as risk factors for unsuccessful DA-CPR: age > 65 years, male sex, OHCA occurring in a non-metropolitan area or private place, unwitnessed status, whether the bystander was a non-family member or non-cohabitant, female sex or had not received CPR training, and primary call dispatchers not receiving any first-aid training. Additional analyses after multiple imputations showed similar results. Mediation effect was significant for most risk factors for unsuccessful DA-CPR. Conclusions: Bystander characteristics (non-family member or non-cohabitant, female, and uneducated status for CPR) and primary call dispatchers not receiving first-aid training were identified as risk factors for unsuccessful DA-CPR.

Cardiopulmonary Bypass Blood Flow Rates and Major Adverse Kidney Events in Cardiac Surgery: A Propensity Score-adjusted Before-After Study.

OBJECTIVES: Cardiac surgery associated-acute kidney injury is a common and serious postoperative complication of cardiac surgery, which is associated with increased postoperative morbidity and mortality. This study aimed to explore the association between cardiopulmonary bypass (CPB) blood flow rate (BFR), and major adverse kidney events (MAKEs) at day 30. DESIGN: Retrospective single-center before-after observational study. Patients were divided in 2 groups according to CPB flow rates: a first group with an institutional protocol targeting a CPB-BFR of >2.2 L/min/m² (low CPB-BFR group), and a second group with a modified institutional protocol targeting a CPB-BFR of >2.4 L/min/m² (high CPB-BFR group). The primary outcome was MAKE at 30 days, defined as the composite of death, renal replacement therapy or persistent renal dysfunction. SETTING: The data were collected from clinical routines in university hospital. PARTICIPANTS: Adult patients who underwent elective and urgent cardiac surgery without severe chronic renal failure, for whom CPB duration was ≥90 minutes. INTERVENTIONS: We included 533 patients (low CPB-BFR group, n = 270; high CPB-BFR group, n = 263). MEASUREMENTS AND MAIN RESULTS: A significant decrease in MAKE at 30 days was observed in the high CPB-BFR group (3% v 8%; odds ratio [OR], 0.779; 95% confidence interval [CI], 0.661-0.919; p < 0.001) mainly mediated by a lower 30-day mortality in the high CPB-BFR group (1% v 5%; OR, 0.697; 95% CI, 0.595-0.817; p = 0.001), as was renal replacement therapy (1% v 4%; OR, 0.739; 95% CI, 0.604-0.904; p = 0.016). CONCLUSIONS: In patients undergoing cardiac surgery, increased CPB-BFR was associated with a decrease in MAKE at 30 days including mortality and renal replacement therapy.

Outcomes of an extracorporeal cardiopulmonary resuscitation (ECPR) program for in- and out-of-hospital cardiac arrest in a tertiary hospital in Spain.

OBJECTIVE: To analyze if the implementation of a multidisciplinary extracorporeal cardiopulmonary resuscitation (ECPR) program in a tertiary hospital in Spain is feasible and could yield survival outcomes similar to international published experiences. DESIGN: Retrospective observational cohort study. SETTING: One tertiary referral university hospital in Spain. PATIENTS: All adult patients receiving ECPR between January 2019 and April 2023. INTERVENTIONS: Prospective collection of variables and follow-up for up to 180 days. MAIN VARIABLES OF INTEREST: To assess outcomes, survival with good neurological outcome defined as a Cerebral Performance Categories scale 1-2 at 180 days was used. Secondary variables were collected including demographics and comorbidities, cardiac arrest and cannulation characteristics, ROSC, ECMO-related complications, survival to ECMO decannulation, survival at Intensive Care Unit (ICU) discharge, survival at 180 days, neurological outcome, cause of death and eligibility for organ donation. RESULTS: Fifty-four patients received ECPR, 29 for OHCA and 25 for IHCA. Initial shockable rhythm was identified in 27 (50%) patients. The most common cause for cardiac arrest was acute coronary syndrome [29 (53.7%)] followed by pulmonary embolism [7 (13%)] and accidental hypothermia [5 (9.3%)]. Sixteen (29.6%) patients were alive at 180 days, 15 with good neurological outcome. Ten deceased patients (30.3%) became organ donors after neuroprognostication. CONCLUSIONS: The implementation of a multidisciplinary ECPR program in an experienced Extracorporeal Membrane Oxygenation center in Spain is feasible and can lead to good survival outcomes and valid organ donors.

Alpha-Gal Syndrome and Cardiac Surgery.

Galactose-alpha-1,3-galactose (alpha-gal) is a carbohydrate expressed by all mammals except for humans and certain old-world primates. It can be found in a plethora of products derived from mammals, including milk, organs, skeletal muscle and gelatin, in addition to products prepared with mammalian cells or constituents. In the late 2000s, an association between tick bites and the development of immunoglobulin E antibodies to the alpha-gal carbohydrate was discovered. The term "alpha-gal syndrome" (AGS) was then coined to describe allergic reactions to mammalian meat or other alpha-gal-containing products derived from mammals. Symptoms are often delayed several hours from consumption and can be urticarial and/or gastrointestinal. Medications and bioprosthetic inserts derived from mammals were also noted to cause allergic reactions in affected patients. Cardiac surgery, in particular, is considered high risk, given that unfractionated heparin has a bovine or porcine origin and is administered in large doses for cardiopulmonary bypass. Bioprosthetic valves have similar origins and risks. Awareness of AGS in cardiac surgery patients can lead to decreased risk preoperatively and inform management perioperatively and postoperatively. In this narrative review, we have reviewed the published literature relevant to AGS in patients undergoing cardiac surgery and shared our treatment approach.

A training programme for novice extracorporeal resuscitation providers.

Introduction: The use of extracorporeal cardiopulmonary resuscitation (ECPR) for refractory cardiac arrest is increasing globally. However, providing equity of access to all patients is challenging, and to date, access has been limited to inner city areas surrounding major hospitals. To increase the availability of ECPR in our jurisdiction, we sought to train pre-hospital physicians with no experience in extracorporeal membrane oxygenation cardiopulmonary resuscitation (ECPR). To enable this, we sort to develop and teach a syllabus that would provide novice ECPR providers the skill to perform ECPR safely and effectively in the pre-hospital environment. Methods: This training programme consisted of 11 pre-hospital physicians and six critical care paramedics. All participants had no prior hospital experience instituting or managing ECPR patients. The training programme was multimodal utilising a porcine model of heart failure to teach time pressured dynamic physiological troubleshooting, cadaver labs to teach cannulation, didactic teaching and simulation. Key knowledge and skill domains were identified. Each learning framework was built upon with a final focus on integrating all skill domains required to successfully initiate ECPR. Results: The training program was completed from February 2022 to August 2023. Knowledge progression was assessed at key stages via written and practical examination. Each participant demonstrated clear knowledge and skill progression at the key stages of the training programme. At the end of the training programme, participants met the pre-defined standards to progress to ECPR provision in the pre-hospital environment. Conclusion: We present a training program for novice ECPR providers performing ECPR in the pre-hospital setting. The outcomes of this training program can provide a training framework for both novices, low volume ECMO centres and pre-hospital clinicians.

Prospective, multicenter, Turkish out-of-hospital cardiac arrest study: TROHCA.

OBJECTIVES: There is no sufficient data to provide a clear picture of out-of-hospital cardiac arrest (OHCA) across Türkiye. This study is the first to present the prognostic outcomes of OHCA cases and the factors associated with these outcomes. MATERIALS AND METHODS: The study was conducted in a prospective, observational, multicenter design under the leadership of the Emergency Medicine Association of Turkey Resuscitation Study Group. OHCA cases aged 18 years and over who were admitted to 28 centers from Türkiye were included in the study. Survived event, return of spontaneous circulation (ROSC), survival to hospital discharge, and neurological outcome at discharge were investigated as primary outcomes. RESULTS: One thousand and three patients were included in the final analysis. 61.1% of the patients were male, and the average age was 67.0 ± 15.2. Cardiopulmonary resuscitation (CPR) was performed on 86.5% of the patients in the prehospital period by emergency medical service, and bystander CPR was performed on only 2.9% by nonhealth-care providers. As a result, the survived event rate was found to be 6.9%. The survival rate upon hospital discharge was 4.4%, with 2.7% of patients achieving a good neurological outcome upon discharge. In addition, the overall ROSC and sustained ROSC rates were 45.2% and 33.4%, respectively. In the multiple logistic regression analysis, male gender, initial shockable rhythm, a shorter prehospital duration of CPR, and the lack of CPR requirement in the emergency department were determined to be independent predictors for the survival to hospital discharge. CONCLUSION: Compared to global data, survival to hospital discharge and good neurological outcome rates appear to be lower in our study. We conclude that this result is related to low bystander CPR rates. Although not the focus of this study, inadequate postresuscitative care and intensive care support should also be discussed in this regard. It is obvious that this issue should be carefully addressed through political moves in the health and social fields.

Views and perceptions of advanced life support practitioners on initiating, withholding and terminating resuscitation in out-of-hospital cardiac arrest in the Emergency Medical Services of South Africa.

Introduction: This study aimed to explore the views and perceptions of Advanced Life Support (ALS) practitioners in two South African provinces on initiating, withholding, and terminating resuscitation in OHCA. Methodology: Semi-structured one-on-one interviews were conducted with operational ALS practitioners working within the prehospital setting in the Western Cape and Free State provinces. Recorded interviews were transcribed and subjected to inductive-dominant, manifest content analysis. After familiarisation with the data, meaning units were condensed, codes were applied and collated into categories that were then assessed, reviewed, and refined repeatedly. Results: A total of 18 ALS providers were interviewed. Five main categories were developed from the data analysis: 1) assessment of prognosis, 2) internal factors affecting decision-making, 3) external factors affecting decision-making, 4) system challenges, and 5) ideas for improvement. Factors influencing the assessment of prognosis were history, clinical presentation, and response to resuscitation. Internal factors affecting decision-making were driven by emotion and contemplation. External factors affecting decision-making included family, safety, and disposition. System challenges relating to bystander response and resources were identified. Ideas for improvement in training and support were brought forward. Conclusion: Many factors influence OHCA decision-making in the Western Cape and Free State provinces, and numerous system challenges have been identified. The findings of this study can be used as a frame of reference for prehospital emergency care personnel and contribute to the development of context-specific guidelines.

A clinical comparison of glycol and water-based heater-cooler systems for cardiopulmonary bypass.

INTRODUCTION: While newer heater-cooler technologies using ethylene glycol-based (GB) solutions during cardiothoracic surgery have become commercially available, there is a paucity of clinical data describing their effectiveness during cardiopulmonary bypass (CPB) support. This analysis aimed to compare clinical characteristics and procedural outcomes using water-based (WB) and GB heater-cooler systems. METHODS: A retrospective analysis was performed on consecutive adult patients undergoing CPB from June to October 2022 comparing WB or GB groups. The primary outcome was a composite of operative death or major morbidity. Secondary endpoints included transfusion requirements on CPB, patient cooling and warming rates, and vasoactive-inotropic scores (VIS) at case completion. P-control charts were used to monitor the weekly incidence of the composite outcome. A sub-analysis was performed to evaluate the primary outcome for cardiac surgery cases indexed by the Society of Thoracic Surgeons (STS). RESULTS: There were 167 patients included for analysis; 87 (52.1%) underwent CPB with a WB system and 80 (47.9%) with a GB system. GB procedure subjects were younger (p = .01), experienced longer CPB times (p = .034), and were more likely to receive thoracic transplant or aortic surgery (p = 0.015). The composite outcome of operative mortality or major morbidity occurred in 29.9% and 24% of the WB and GB groups, respectively (p = .372). P-control charts indicated a weekly mean incidence of 30% during WB practice, which decreased to 24% with GB practice. Among 106 STS-indexed cardiac surgery cases, mean composite outcome incidence decreased from 19% to 6% following our GB transition. Additionally, cooling, and warming rates indexed to patient BSA and VIS at case completion were not significantly different. CONCLUSION: Our analysis demonstrated a safe transition from WB to GB heater-cooler technologies in our practice. This early analysis suggests that GB heater coolers may be safely adopted to mitigate the risks of nontuberculous mycobacterium infections for cardiac surgical patients.

Early outcomes of experience warm surgery in children undergoing complete repair of tetralogy of Fallot in developing countries.

OBJECTIVES: While significant evidence supports the benefits of normothermic cardiopulmonary bypass (NCPB) over hypothermic techniques, many institutions in developing countries, including ours, continue to employ hypothermic methods. This study aimed to assess the early postoperative outcomes of normothermic cardiopulmonary bypass (NCPB) for complete surgical repair via the Tetralogy of Fallot (TOF) within our national context. METHODS: We conducted this study in the Pediatric Cardiac Intensive Care Unit (PCICU) at the University Children's Hospital. One hundred patients who underwent complete TOF repair were enrolled and categorized into two groups: the normothermic group (n = 50, temperature 35-37 °C) and the moderate hypothermic group (n = 50, temperature 28-32 °C). We evaluated mortality, morbidity, and postoperative complications in the PCICU as outcome measures. RESULTS: The demographic characteristics were similar between the two groups. However, the cardiopulmonary bypass (CPB) time and aortic cross-clamp (ACC) time were notably longer in the hypothermic group. The study recorded seven deaths, yielding an overall mortality rate of 7%. No significant differences were observed between the two groups concerning mortality, morbidity, or postoperative complications in the PCICU. CONCLUSIONS: Our findings suggest that normothermic procedures, while not demonstrably effective, are safe for pediatric cardiac surgery. Further research is warranted to substantiate and endorse the adoption of this technique.

A Case Report on the Utilization of a Hemostasis Analyzer System in the Management of a Patient With Essential Thrombocythemia.

Essential thrombocythemia (ET) is a myeloproliferative neoplasm characterized by persistent elevation of platelet count due to abnormal proliferation of megakaryocytes. While some cases may be asymptomatic, the condition is associated with an increased risk of complications such as thrombosis and bleeding tendencies, necessitating appropriate management tailored to individual cases. Hemostasis analyzer systems are automated analytical devices designed for comprehensive evaluation of blood coagulation function. These systems enable rapid and accurate measurement of multiple parameters, including coagulation time, platelet function, and fibrin formation, thus facilitating a holistic assessment of hemostatic function. A 76-year-old male patient presented to our hospital. At the age of 65, he received treatment for promyelocytic leukemia and achieved remission. At 75 years, he developed leukocytosis, thrombocytosis, and progressive anemia. A comprehensive examination, including bone marrow biopsy and genetic testing, revealed a JAK2 mutation, leading to the diagnosis of ET. At the age of 76 years, he complained of chest discomfort during exertion. Further investigation revealed severe aortic valve stenosis and two-vessel coronary artery disease. The patient underwent aortic valve replacement and three-vessel coronary artery bypass grafting. A hemostasis analyzer system was used to monitor coagulation function throughout the procedure. Compared with the normal range, his coagulation profile showed a tendency toward hypercoagulability. Intraoperative and postoperative transfusions were performed as required. The patient's postoperative course was uneventful without any complications related to bleeding or thrombosis.

Human Orthohantavirus disease prevalence and genotype distribution in the U.S., 2008-2020: a retrospective observational study.

Background: In the United States (U.S.), hantavirus pulmonary syndrome (HPS) and non-HPS hantavirus infection are nationally notifiable diseases. Criteria for identifying human cases are based on clinical symptoms (HPS or non-HPS) and acute diagnostic results (IgM+, rising IgG+ titers, RT-PCR+, or immunohistochemistry (IHC)+). Here we provide an overview of diagnostic testing and summarize human Hantavirus disease occurrence and genotype distribution in the U.S. from 2008 to 2020. Methods: Epidemiological data from the national hantavirus registry was merged with laboratory diagnostic testing results performed at the CDC. Residual hantavirus-positive specimens were sequenced, and the available epidemiological and genetic data sets were linked to conduct a genomic epidemiological study of hantavirus disease in the U.S. Findings: From 1993 to 2020, 833 human hantavirus cases have been identified, and from 2008 to 2020, 335 human cases have occurred. Among New World (NW) hantavirus cases detected at the CDC diagnostic laboratory (representing 29.2% of total cases), most (85.0%) were detected during acute disease, however, some convalescent cases were detected in states not traditionally associated with hantavirus infections (Connecticut, Missouri, New Jersey, Pennsylvania, Tennessee, and Vermont). From 1993 to 2020, 94.9% (745/785) of U.S. hantaviruses cases were detected west of the Mississippi with 45.7% (359/785) in the Four Corners region of the U.S. From 2008 to 2020, 67.7% of NW hantavirus cases were detected between the months of March and August. Sequencing of RT-PCR-positive cases demonstrates a geographic separation of Orthohantavirus sinnombreense species [Sin Nombre virus (SNV), New York virus, and Monongahela virus]; however, there is a large gap in viral sequence data from the Northwestern and Central U.S. Finally, these data indicate that commercial IgM assays are not concordant with CDC-developed assays, and that "concordant positive" (i.e., commercial IgM+ and CDC IgM+ results) specimens exhibit clinical characteristics of hantavirus disease. Interpretation: Hantaviral disease is broadly distributed in the contiguous U.S, viral variants are localised to specific geographic regions, and hantaviral disease infrequently detected in most Southeastern states. Discordant results between two diagnostic detection methods highlight the need for an improved standardised testing plan in the U.S. Hantavirus surveillance and detection will continue to improve with clearly defined, systematic reporting methods, as well as explicit guidelines for clinical characterization and diagnostic criteria. Funding: This work was funded by core funds provided to the Viral Special Pathogens Branch at CDC.

Perioperative Management of Pediatric Combined Heart and Liver Transplantation: A 17 year single center experience.

BACKGROUND: An increasing number of centers are undertaking combined heart and liver transplantation in adult and pediatric patients with congenital heart disease. AIM: The primary aim of this study was to describe the perioperative management of a single center cohort, identifying challenges and potential solutions. METHODS: We conducted a retrospective review of all patients undergoing combined heart and liver transplantation at Stanford Children's Hospital from 2006 to 2022. Preoperative information included cardiac diagnosis, hemodynamics, and severity of liver disease. Intraoperative data included length of surgery, cardiopulmonary bypass time, and blood products transfused. Postoperative data included blood products transfused in the intensive care unit, time to extubation, length of intensive care unit stay, survival outcomes and 30-day adverse events. RESULTS: Eighteen patients underwent en bloc combined heart and liver transplantation at Stanford Children's Hospital from 2006 to 2022, and the majority 15 (83%) were transplanted for failing Fontan circulation with Fontan Associated Liver Disease. Median surgical procedure time was 13.4 [11.5, 14.5] h with a cardiopulmonary bypass time of 4.3 [3.9, 5.8] h. Median total blood products transfused in the operating room post cardiopulmonary bypass was 89.4 [63.9, 127.0] mLs/kg. Nine patients (50%) had vasoplegia during cardiopulmonary bypass. Activated prothrombin complex concentrates were used post cardiopulmonary bypass in 15 (83%) patients with a 30-day thromboembolism rate of 22%. Median time to extubation was 4.0 [2.8, 6.5] days, median intensive care unit length of stay 20.0 [7.8, 48.3] days and median hospital length of stay 54.0 [30.5, 68.3] days. Incidence of renal replacement therapy was 11%; however, none required renal replacement therapy by the time of hospital discharge. Neurological events within 30 days were 17% and the 30 day and 1 year survival was 89%. CONCLUSIONS: Perioperative challenges include major perioperative bleeding, unstable hemodynamics, and end organ injury including acute kidney injury and neurological events. Successful outcomes for en bloc combined heart and liver transplantation are possible with careful multidisciplinary planning, communication, patient selection, and integrated peri-operative management.

Cardiopulmonary exercise testing in long covid shows the presence of dysautonomia or chronotropic incompetence independent of subjective exercise intolerance and fatigue.

BACKGROUND: After COVID-19 infection, 10-20% of patients suffer from varying symptoms lasting more than 12 weeks (Long COVID, LC). Exercise intolerance and fatigue are common in LC. The aim was to measure the maximal exercise capacity of the LC patients with these symptoms and to analyze whether this capacity was related to heart rate (HR) responses at rest and during exercise and recovery, to find out possible sympathetic overactivity, dysautonomia or chronotropic incompetence. METHODS: Cardiopulmonary exercise test was conducted on 101 LC patients, who were admitted to exercise testing. The majority of them (86%) had been treated at home during their acute COVID-19 infection. Peak oxygen uptake (VO2peak), maximal power during the last 4 min of exercise (Wlast4), HRs, and other exercise test variables were compared between those with or without subjective exercise intolerance, fatigue, or both. RESULTS: The measurements were performed in mean 12.7 months (SD 5.75) after COVID-19 infection in patients with exercise intolerance (group EI, 19 patients), fatigue (group F, 31 patients), their combination (group EI + F, 37 patients), or neither (group N, 14 patients). Exercise capacity was, in the mean, normal in all symptom groups and did not significantly differ among them. HRs were higher in group EI + F than in group N at maximum exercise (169/min vs. 158/min, p = 0.034) and 10 min after exercise (104/min vs. 87/min, p = 0.028). Independent of symptoms, 12 patients filled the criteria of dysautonomia associated with slightly decreased Wlast4 (73% vs. 91% of sex, age, height, and weight-based reference values p = 0.017) and 13 filled the criteria of chronotropic incompetence with the lowest Wlast4 (63% vs. 93%, p < 0.001), VO2peak (70% vs. 94%, p < 0.001), the lowest increase of systolic blood pressure (50 mmHg vs. 67 mmHg, p = 0.001), and the greatest prevalence of slight ECG-findings (p = 0.017) compared to patients without these features. The highest prevalence of chronotropic incompetence was seen in the group N (p = 0.022). CONCLUSIONS: This study on LC patients with different symptoms showed that cardiopulmonary exercise capacity was in mean normal, with increased sympathetic activity in most patients. However, we identified subgroups with dysautonomia or chronotropic incompetence with a lowered exercise capacity as measured by Wlast4 or VO2peak. Subjective exercise intolerance and fatigue poorly foresaw the level of exercise capacity. The results could be used to plan the rehabilitation from LC and for selection of the patients suitable for it.

Nomogram for intraoperatively acquired pressure injuries in children undergoing cardiac surgery with cardiopulmonary bypass: a retrospective study.

BACKGROUND: We aimed to develop and validate a nomogram for predicting the risk of intraoperatively acquired pressure injuries (IAPIs) in children undergoing cardiac surgery with cardiopulmonary bypass (CPB). METHODS: This study retrospectively included 208 children aged 21 days to 8 years who underwent cardiac surgery with CPB in a tertiary hospital in China between January 2020 and October 2023. All patients' data were collected from the hospital's medical record system and randomly divided into the training (n = 146) and validation (n = 62) cohorts by a ratio of 7:3. Logistic regression analysis was conducted in the training cohort to identify independent risk factors and establish the nomogram. Finally, calibration curves, receiver operating characteristic (ROC) curves, and decision curve analysis (DCA) were performed in both cohorts to validate the predictive ability of the nomogram. RESULTS: 43 (14.7%) children developed IAPIs. Multivariate analysis showed that low Braden Q scores, use of steroids, skin abnormalities, and low intraoperative SpO2 were independent risk factors for IAPIs. A nomogram integrating the 4 factors was established. The areas under the curve (AUCs) of the nomogram were 0.836 and 0.903 in the training and validation cohorts, respectively. Furthermore, calibration curves and DCA demonstrated good calibration and clinical applicability of the nomogram. CONCLUSION: We constructed a reliable nomogram based on specific risk factors for children undergoing cardiac surgery with CPB, which could be used as an effective and convenient tool for prevention of IAPIs.

Based on Cardiopulmonary Exercise Testing to Construct and Validate Nomogram of Long-Term Prognosis Within 12 Months for NSCLC.

OBJECTIVE: Construction nomogram was to effectively predict long-term prognosis in patients with non-small cell lung cancer (NSCLC). MATERIALS AND METHODS: The nomogram is developed by a retrospective study of 347 patients with NSCLC who underwent cardiopulmonary exercise testing (CPET) before surgery from May 2019 to February 2022. Cross-validation divided the data into a training cohort and validation cohort. The discrimination and accuracy ability of the nomogram were proofed by concordance index (C-index), calibration curve, receiver operating characteristic (ROC) curve, the area under the curve (AUC), and time-dependent ROC in validation cohort. RESULTS: Age, intraoperative blood loss, VO2 peak, and VE/VCO2 slope were included in the model of nomogram. The model demonstrated good discrimination and accuracy with C-index of 0.770 (95% CI: 0.712-0.822). AUC of 6 (AUC: 0.789, 95% CI: 0.726-0.851) and 12 months (AUC: 0.787, 95% CI: 0.724-0.850) were shown in ROC. Time-independent ROC maintains a good effect within 12 months. CONCLUSION: We developed a nomogram based on CPET. This model has a good ability of discrimination and accuracy. It could help clinicians to make treatment decision in clinical decision.

Hyperfibrinolysis: potential guidance for decision-making to avoid futile extracorporeal cardiopulmonary resuscitation.

Out-of-hospital cardiac arrest (OHCA) is associated with very poor outcomes. Extracorporeal cardiopulmonary resuscitation (eCPR) for selected patients is a potential therapeutic option for refractory cardiac arrest. However, randomised controlled studies applying eCPR after refractory OHCA have demonstrated conflicting results regarding survival and good functional neurological outcomes. eCPR is an invasive, labour-intensive, and expensive therapeutic approach with associated side-effects. A rapid monitoring device would be valuable in facilitating selection of appropriate patients for this expensive and complex treatment. To this end, rapid diagnosis of hyperfibrinolysis, or premature clot dissolution, diagnosed by viscoelastic testing might represent a feasible option. Hyperfibrinolysis is an evolutionary response to low or no-flow states. Studies in trauma patients demonstrate a high mortality rate in those with established hyperfibrinolysis upon emergency room admission. Similar findings have now been reported for the first time in OHCA patients. Hyperfibrinolysis upon admission diagnosed by rotational thromboelastometry was strongly associated with mortality and poor neurological outcomes in a small cohort of patients treated with extracorporeal membrane oxygenation.

Effects and trend of steroid dosage reduction during cardiac surgery: A three-year retrospective analysis at a tertiary medical center.

BACKGROUND: Current adult cardiac surgery guidelines recommend against the routine use of prophylactic intravenous corticosteroids during cardiopulmonary bypass (CPB) due to concerns about myocardial injury, despite their potential to reduce postoperative atrial fibrillation. Traditionally, a high dose of 1,000 mg of methylprednisolone was used to attenuate the inflammatory response associated with CPB. Our institution aligned with guideline recommendations and gradually reduced methylprednisolone dosages; thus, we reevaluated the impact on postoperative clinical outcomes. METHODS: Our study reviewed 1341 cases from a total of 1680 adult cardiac surgeries performed between June 2019 and May 2022 after excluding cases with off-pump procedures, ventricular assist device implantations, heart transplants, and aortic surgeries requiring systemic circulatory arrest. The study timely sorted periods including a baseline data from 2018, and other three periods since 2019 to analyze the effects of three different methylprednisolone dosage: 0 mg, 500 mg, and 1000 mg. We assessed the annual trends in methylprednisolone administration and compared morbidity and mortality rates across the groups. RESULTS: We observed a significant decline in steroid use, with no-steroid surgeries increasing from 23% to 66.5% by period 3. Despite the decreased use of steroids, our study showed no increase in mortality, new-onset atrial fibrillation, acute kidney injury, cerebrovascular event and prolonged ventilation when compared to baseline data. Notably, less surgical site infection rate was observed in the no-steroid group. CONCLUSION: The data indicates that a reduction or discontinuation of steroids during CPB can be performed without compromising patient outcomes. This could support a transition towards a more conservative use of steroids in adult cardiac surgery, aligning with current guidelines, and potentially reducing certain postoperative complications.

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.

Knowledge, attitude, practice, and associated factors of health professionals towards cardiopulmonary resuscitation at Ayder Comprehensive Specialized Hospital, 2023, Tigray, Ethiopia.

Background: Cardiopulmonary resuscitation (CPR) is a crucial medical technique that is performed manually to preserve intact brain function. Early initiation of CPR manoeuvres and activation of the chain of survival are key factors in the prognosis of patients with cardiorespiratory arrest (CRA). Inadequacy in any step of CPR due to a lack of knowledge or skill is associated with a poor return of spontaneous circulation and a decreased survival rate. Objective: To assess the knowledge, attitude, practice, and factors associated with health towards CPR at Ayder Comprehensive Specialized Hospital 2023. Methods: Institution-based cross-sectional study was conducted to assess the knowledge, attitude, and practice of health professionals towards cardiopulmonary CPR in Ayder Comprehensive Specialized Hospital Of Tigray, Ethiopia from 1 May to 30 August 2023. Data were collected using structured questionnaires by Two BSC anaesthesia staff and One MSc. as supervisor. A stratified random sampling technique was used to select the study participants. The Data were entered and analyzed using SPSS version 23. Variables with P value less than 0.20 were fitted into multivariate logistic regression. Descriptive statistics such as frequencies, median, interquartile range, percentages, tables, graphs and charts were used to present the results. Result: A total of 262 Of 277 healthcare providers were included in the study, with a response rate of 93.3%. Knowledge, attitude, practice of health professionals towards CPR was 22.5%, 39% and 31.5%, respectively. MSc degree in level of education [adjusted odds ratio (AOR): 8.561 95% CI=2.109-34.746], CPR training (AOR: 2.157, 95%, 1.005, 4.631), and Work experience 6-10years and more than 10 (AOR =0.195, 95% CI, 0.071-0.539) and AOR =0.148 195 95% CI, 0.017, 1.285) were significantly associated with knowledge. The Anaesthetist and Medical doctors were 5.5 times (AOR, 5.50, 95% CI 1.263-23.93) and 2.125 times (AOR: 2.125, 95% CI, 0.865-5.216) respectively more likely to have favourable attitude than the midwives. Regarding to practice participants with CPR training (AOR: 1.804 95% CI=0.925-3.518), good knowledge (AOR: 2.766 95% CI=1.312-5.836) and favourable attitude (AOR: 1.931, 95% CI=0.995-3.749) were significantly associated with safe practice. Conclusion and recommendation: The overall level of health professionals, knowledge, attitude, practices, and factors associated towards CPR in Ayder Comprehensive Specialized Hospital at Tigray, Ethiopia were insufficient, favourable and safe enough. Regular CPR training is recommended to increase the knowledge, attitude, and practice of healthcare professionals towards CPR.

Gender difference in long-term effect of cardiac rehabilitation; data from CRAGE-extra study.

Introduction: The positive effect of cardiac rehabilitation (CR) is demonstrated in younger and older patients. However, it is quite debated whether the beneficial effect is similarly maintained in both genders during follow-up. Aim: to determine if the improvement obtained after CR remained significant at 1-year follow-up in older population, testing the influence of gender on this outcome. Methods: All patients aged 75+ years consecutively referred to Cardiac Rehabilitation outpatient Unit at Careggi University Hospital were screened for eligibility. All patients attended a CR program, based on 5-day-per-week aerobic training sessions for 4 weeks and they were evaluated at the end of CR at 6 and 12 months of follow-up. Results: 361 patients with a mean age 80.6 ± 4.4 years with a complete 1-year follow-up were enrolled in the study, 87.5 % of them had an acute coronary event, and 27.6 % were females. The increase in exercise capacity at the end of CR and at 1-year follow-up was statistically significant (VO2 peak: +8.7 % in males p < 0.001, +8.5 % in females p < 0.001; distance walked at 6-min test: +7.3 % in males p < 0.001, +10.2 % in females p < 0.001, respectively); the trajectory of exercise improvement at 6 and 12 months of FU was similar in men and women without significant decrease (VO2 peak-ml/kg/min: CR discharge vs 1 year FU = 15.2 vs 15,0 p: NS; distance walked-meters: CR discharge vs 1 year FU = 445.5 vs 440.6, p: NS) from end of CR to 1-year. Conclusions: the improvement in exercise tolerance obtained with CR program is still maintained at 1-year FU without significant influence of gender in our very old population.