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.

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.

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.

Novel serum biomarkers for predicting neurological outcomes in postcardiac arrest patients treated with targeted temperature management.

OBJECTIVE: To determine the clinical feasibility of novel serum biomarkers in out-of-hospital cardiac arrest (OHCA) patients treated with target temperature management (TTM). METHODS: This study was a prospective observational study conducted on OHCA patients who underwent TTM. We measured conventional biomarkers, neuron­specific enolase and S100 calcium-binding protein (S-100B), as well as novel biomarkers, including tau protein, neurofilament light chain (NFL), glial fibrillary acidic protein (GFAP), and ubiquitin C-terminal hydrolase-L1 (UCH-L1), at 0, 24, 48, and 72 h after the return of spontaneous circulation identified by SIMOA immunoassay. The primary outcome was poor neurological outcome at 6 months after OHCA. RESULTS: A total of 100 patients were included in this study from August 2018 to May 2020. Among the included patients, 46 patients had good neurologic outcomes at 6 months after OHCA. All conventional and novel serum biomarkers had the ability to discriminate between the good and poor neurological outcome groups (p < 0.001). The area under the curves of the novel serum biomarkers were highest at 72 h after cardiac arrest (CA) (0.906 for Tau, 0.946 for NFL, 0.875 for GFAP, and 0.935 for UCH-L1). The NFL at 72 h after CA had the highest sensitivity (77.1%, 95% CI 59.9-89.6) in predicting poor neurological outcomes while maintaining 100% specificity. CONCLUSION: Novel serum biomarkers reliably predicted poor neurological outcomes for patients with OHCA treated with TTM when life-sustaining therapy was not withdrawn. Cutoffs from two large existing studies (TTM and COMACARE substudy) were externally validated in our study. The predictive power of the novel biomarkers was the highest at 72 h after CA.

Association of ultra-early diffusion-weighted magnetic resonance imaging with neurological outcomes after out-of-hospital cardiac arrest.

BACKGROUND: This study aimed to investigate the association between ultra-early (within 6 h after return of spontaneous circulation [ROSC]) brain diffusion-weighted magnetic resonance imaging (DW-MRI) and neurological outcomes in comatose survivors after out-of-hospital cardiac arrest. METHODS: We conducted a registry-based observational study from May 2018 to February 2022 at a Chungnam national university hospital in Daejeon, Korea. Presence of high-signal intensity (HSI) (PHSI) was defined as a HSI on DW-MRI with corresponding hypoattenuation on the apparent diffusion coefficient map irrespective of volume after hypoxic ischemic brain injury; absence of HSI was defined as AHSI. The primary outcome was the dichotomized cerebral performance category (CPC) at 6 months, defined as good (CPC 1-2) or poor (CPC 3-5). RESULTS: Of the 110 patients (30 women [27.3%]; median (interquartile range [IQR]) age, 58 [38-69] years), 48 (43.6%) had a good neurological outcome, time from ROSC to MRI scan was 2.8 h (IQR 2.0-4.0 h), and the PHSI on DW-MRI was observed in 46 (41.8%) patients. No patients in the PHSI group had a good neurological outcome compared with 48 (75%) patients in the AHSI group. In the AHSI group, cerebrospinal fluid (CSF) neuron-specific enolase (NSE) levels were significantly lower in the group with good neurological outcome compared to the group with poor neurological outcome (20.1 [14.4-30.7] ng/mL vs. 84.3 [32.4-167.0] ng/mL, P < 0.001). The area under the curve for PHSI on DW-MRI was 0.87 (95% confidence interval [CI] 0.80-0.93), and the specificity and sensitivity for predicting a poor neurological outcome were 100% (95% CI 91.2%-100%) and 74.2% (95% CI 62.0-83.5%), respectively. A higher sensitivity was observed when CSF NSE levels were combined (88.7% [95% CI 77.1-95.1%]; 100% specificity). CONCLUSIONS: In this cohort study, PHSI findings on ultra-early DW-MRI were associated with poor neurological outcomes 6 months following the cardiac arrest. The combined CSF NSE levels showed higher sensitivity at 100% specificity than on DW-MRI alone. Prospective multicenter studies are required to confirm these results.

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.

Early identified risk factors and their predictive performance of brain death in out-of-hospital cardiac arrest survivors.

BACKGROUND: Early prediction of brain death (BD) after the return of spontaneous circulation (ROSC) in patients with cardiac arrest would be useful for the proper distribution of good quality transplantable organs and medical resources. We aimed to early identify independent risk factors of BD and their predictive performance in out-of-hospital cardiac arrest (OHCA) survivors. METHODS: This retrospective observational study included adult OHCA survivors from May 2018 to February 2021. Independent risk factors for progression to BD were identified by performing multivariate logistic regression analysis, including clinical, laboratory, biological parameters and prognostic factors, obtained within 6 h after ROSC. Neuron-specific enolase (NSE) level were categorized into quartile. The primary outcome was BD occurrence. RESULTS: Overall, 108 patients were included in this analysis, 31 (29%) of whom had BD. In multivariate logistic regression analysis, initial serum NSE levels in the fourth quartile compared to the first quartile (odds ratio [OR], 88.5; 95% confidence interval [CI]: 7.0-1113.6) and absence of pupil light reflex (PLR) (OR, 40.3; 95% CI: 3.8-430.3) were independently associated with BD. According to the receiver operating characteristic curve analysis, initial serum NSE levels and PLR showed good-to-excellent and fair-to-good prognostic performance, respectively (area under the curve [AUC], 0.90; 95% CI: 0.83-0.95 vs. 0.81; 95% CI: 0.72-0.88). Additionally, the combination of both the risk factors (AUC, 0.96; 95% CI: 0.90-0.99) showed significantly higher predictive performance for BD than when using them individually (P = 0.04 and P < 0.01, respectively). CONCLUSION: High levels of initial serum NSE and PLR obtained within 6 h after ROSC may help early predict progression to BD in OHCA survivors. A large prospective multicenter study should be conducted to confirm these results.

Early ECMO initiation in the emergency department for refractory hypoxemic respiratory failure caused by NaDCC intoxication.

We describe a case of acute respiratory failure caused by inhalation of gas formed from a reaction of intentional dissolution of sodium dichloroisocyanurate (NaDCC) tablets in water. A patient had refractory respiratory failure despite the use of conventional therapy, including lung-protective mechanical ventilation. Early veno-venous extracorporeal membrane oxygenation (VV-ECMO) support was initiated in the emergency department (ED). The patient was weaned from ECMO on hospital day 6 and discharged from the ICU on hospital day 27. Cases of severe inhalation injury with acute respiratory failure refractory to conventional treatments and mechanical ventilator support may benefit from VV-ECMO. Literature on early initiation of ED-VV-ECMO in NaDCC-induced refractory respiratory failure is rare. This case may be used as a guide in the management of subsequent cases as it shows that early initiation of ED-VV-ECMO was beneficial to the patient.

Efficacy of cardiopulmonary resuscitation performance while wearing a powered air-purifying respirator.

BACKGROUND: The use of personal protective equipment for respiratory infection control during cardiopulmonary resuscitation (CPR) is a physical burden to healthcare providers. The duration for which CPR quality according to recommended guidelines can be maintained under these circumstances is important. We investigated whether a 2-min shift was appropriate for chest compression and determined the duration for which chest compression was maintained in accordance with the recommended guidelines while wearing personal protective equipment. METHODS: This prospective crossover simulation study was performed at a single center from September 2020 to October 2020. Five indicators of CPR quality were measured during the first and second sessions of the study period. All participants wore a Level D powered air-purifying respirator (PAPR), and the experiment was conducted using a Resusci Anne manikin, which can measure the quality of chest compressions. Each participant conducted two sessions. In Session 1, the sequence of 2 min of chest compressions, followed by a 2-min rest, was repeated twice; in Session 2, the sequence of 1-min chest compressions followed by a 1-min rest was repeated four times. RESULTS: All 34 participants completed the study. The sufficiently deep compression rate was 65.9 ± 31.1% in the 1-min shift group and 61.5 ± 30.5% in the 2-min shift group. The mean compression depth was 52.8 ± 4.3 mm in the 1-min shift group and 51.0 ± 6.1 mm in the 2-min shift group. These two parameters were significantly different between the two groups. There was no significant difference in the other values related to CPR quality. CONCLUSIONS: Our findings indicated that 1 min of chest compressions with a 1-min rest maintained a better quality of CPR while wearing a PAPR.

Lactate dehydrogenase to albumin ratio as a prognostic factor in lower respiratory tract infection patients.

PURPOSE: To verify the role of lactate dehydrogenase to albumin (LDH/ALB) ratio as an independent prognostic factor for mortality due to the lower respiratory tract infection (LRTI) in the emergency department (ED). METHODS: We reviewed the electronic medical records of patients who were admitted to the ED for the management of LRTI between January 2018 and December 2020. Initial vital signs, laboratory data, and patient severity scores in the ED were collected. The LDH/ALB ratio was compared to other albumin-based ratios (blood urea nitrogen to albumin ratio, C-reactive protein to albumin ratio, and lactate to albumin ratio) and severity scales (pneumonia severity index, modified early warning score, CURB-65 scores), which are being used as prognostic factors for in-hospital mortality. Multivariable logistic regression was performed to identify independent risk factors. RESULTS: The LDH/ALB ratio was higher in the non-survivor group than in the survivor group (median [interquartile range]: 217.6 [160.3;312.0] vs. 126.4 [100.3;165.1], p < 0.001). In the comparison of the area under the receiver operating characteristic curve (AUC) for predicting in-hospital mortality, the AUC of the LDH/ALB ratio (0.808, 95% confidence interval: 0.757-0.842, p < 0.001) was wider than other albumin-based ratios and severity scales, except the blood urea nitrogen to albumin ratio. In the multivariable logistic regression analysis, the LDH/ALB ratio independently affected in-hospital mortality. CONCLUSION: The LDH/ALB ratio may serve as an independent prognostic factor for in-hospital mortality in patients with LRTI.

Detection of Testicular Torsion With Preserved Intratesticular Flow By Point of Care Ultrasound in the Emergency Department: A Case Report.

BACKGROUND: Ultrasonography is an effective diagnostic tool for testicular torsion (TT), which is typically characterized by the absence of blood flow in the affected testicle on color Doppler mode. However, there are a few reported cases of TT with symmetrical preserved flow. We report a case of TT with the preserved intratesticular flow on color Doppler ultrasound. CASE REPORT: A 14-year-old boy was admitted due to sudden-onset right scrotal pain. Point-of-care ultrasound (POCUS) revealed that the right testicle was larger than the left. The intratesticular flow in both testicles was preserved. Radiology-performed ultrasound confirmed the preserved intratesticular flow observed on POCUS, but also demonstrated a whirlpool sign of the right spermatic cord. TT was confirmed surgically. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should investigate the presence of intratesticular blood flow and the whirlpool sign of the spermatic cord or other ultrasound features suggestive of TT, even if testicular blood flow is preserved. Suspicion of TT from POCUS findings warrants further evaluation to preserve the patient's fertility.

Utility of the blood urea nitrogen to serum albumin ratio as a prognostic factor of mortality in aspiration pneumonia patients.

PURPOSE: This study aimed to determine whether the blood urea nitrogen to serum albumin (B/A) ratio is a useful prognostic factor of mortality in patients with aspiration pneumonia. METHODS: The study included patients with aspiration pneumonia who had been admitted to our hospital via the emergency department (ED) between January 1, 2014 and December 31, 2018. The 28-day mortality after the ED visits was the primary end point of this study. The data of the survivors and non-survivors were compared. RESULTS: A final diagnosis of aspiration pneumonia was made for 443 patients during the study period. Significant differences were observed in age, respiratory rate, albumin levels, total protein levels, blood urea nitrogen levels, C-reactive protein levels, glucose, and Charlson comorbidity index scores between the survivor and non-survivor groups. Moreover, the B/A ratio was significantly higher in the non-survivor group than that in the survivor group. The area under the curve for the B/A ratio was 0.70 [95% confidence interval (CI) 0.65-0.74], 0.71 for the PSI (95% CI 0.67-0.76), 0.64 for CURB-65 (95% CI 0.60-0.69), and 0.65 for albumin (95% CI 0.60-0.70) on the receiver operating characteristic curve for predicting mortality within 28 days of the ED visit. Multivariable logistic regression analysis revealed that the B/A ratio (>7, OR 3.40, 95% CI 1.87-6.21, P < 0.001) was associated with mortality within 28 days of the ED visit. CONCLUSION: The B/A ratio is a simple and potentially useful prognostic factor of mortality in aspiration pneumonia patients.

Cerebrospinal Fluid Lactate Levels, Brain Lactate Metabolism and Neurologic Outcome in Patients with Out-of-Hospital Cardiac Arrest.

BACKGROUND/OBJECTIVE: Cerebrospinal fluid (CSF) and serum lactate levels were assessed to predict poor neurologic outcome 3 months after return of spontaneous circulation (ROSC). We compared arterio-CSF differences in the lactate (ACDL) levels between two neurologic outcome groups. METHODS: This retrospective observational study involved out-of-hospital cardiac arrest (OHCA) survivors who had undergone target temperature management. CSF and serum samples were obtained immediately (lactate0), and at 24 (lactate24), 48 (lactate48), and 72 (lactate72) h after ROSC, and ACDL was calculated at each time point. The primary outcome was poor 3-month neurologic outcome (cerebral performance categories 3-5). RESULTS: Of 45 patients, 27 (60.0%) showed poor neurologic outcome. At each time point, CSF lactate levels were significantly higher in the poor neurologic outcome group than in the good neurologic outcome group (6.97 vs. 3.37, 4.20 vs. 2.10, 3.50 vs. 2.00, and 2.79 vs. 2.06, respectively; all P < 0.05). CSF lactate's prognostic performance was higher than serum lactate at each time point, and lactate24 showed the highest AUC values (0.89, 95% confidence interval, 0.75-0.97). Over time, ACDL decreased from - 1.30 (- 2.70-0.77) to - 1.70 (- 3.2 to - 0.57) in the poor neurologic outcome group and increased from - 1.22 (- 2.42-0.32) to - 0.64 (- 2.31-0.15) in the good neurologic outcome group. CONCLUSIONS: At each time point, CSF lactate showed better prognostic performance than serum lactate. CSF lactate24 showed the highest prognostic performance for 3-month poor neurologic outcome. Over time, ACDL decreased in the poor neurologic outcome group and increased in the good neurologic outcome group.

The Association Between Neurological Prognosis and the Degree of Blood-Brain Barrier Disruption in Cardiac Arrest Survivors Who Underwent Target Temperature Management.

BACKGROUND: This study aimed to compare day-specific associations of blood-brain barrier (BBB) disruption with neurological outcome in survivors of out-of-hospital cardiac arrest (OHCA) treated with target temperature management (TTM) and lumbar drainage. METHODS: This retrospective single-center study included 68 survivors of OHCA who underwent TTM between April 2018 and December 2019. The albumin quotient (QA) was calculated as QA = albumincerebrospinal fluid/albuminserum immediately (day 1) and 24 (day 2), 48 (day 3), and 72 h (day 4) after the return of spontaneous circulation. The degree of BBB disruption was weighted using the following scoring system: QA value of 0.007 or less (normal), QA value greater than 0.007-0.01 (mild), QA value greater than 0.01-0.02 (moderate), and QA value greater than 0.02 (severe). Points were assigned as follows: 0 (normal), 1 (mild), 4 (moderate), and 9 (severe). Neurological outcome was determined at 6 months after the return of spontaneous circulation, as well as cerebral performance category (CPC), dichotomized as good (CPC score 1-2) and poor (CPC score 3-5) outcome. RESULTS: We enrolled 68 patients (48 men, 71%); 37 (54%) patients had a poor neurological outcome. The distributions of poor versus good outcomes at 6 months in patients with moderate and severe BBB disruption were 19 of 22 (80%) vs. 18 of 46 (50%) on day 1, 31 of 37 (79%) vs. 6 of 31 (32%) on day 2, 32 of 37 (81%) vs. 5 of 31 (30%) on day 3, and 32 of 39 (85%) vs. 5 of 29 (30%) on day 4 (P < 0.001), respectively. Using receiver operating characteristic analyses, optimal cutoff values (sensitivity, specificity) of QA levels for the prediction of neurological outcome were as follows: day 1, greater than 0.009 (56.8%, 87.1%); day 2, greater than 0.012 (81.1%, 87.1%); day 3, greater than 0.013 (83.8%, 87.1%); day 4, greater than 0.013 (86.5%, 87.1%); the sum of all time points, greater than 0.039 (89.5%, 79.4%); and scoring system, greater than 9 (91.9%, 87.1%). CONCLUSIONS: In this proof of concept study, QA was associated with poor neurological outcome in survivors of OHCA treated with TTM with no contraindication to lumbar drainage. A large multicenter prospective study is needed to validate the utility of BBB disruption as a prognosticator of neurological outcome.

Measuring global impairment of cerebral perfusion using dynamic susceptibility contrast perfusion-weighted imaging in out-of-hospital cardiac arrest survivors: A prospective preliminary study.

BACKGROUND AND PURPOSE: This study aimed to assess the global impairment and prognostic performance of cerebral perfusions (CP) measured by dynamic susceptibility contrast perfusion-weighted imaging (DSC-PWI) in out-of-hospital cardiac arrest (OHCA) patients after sustained restoration of spontaneous circulation (ROSC). MATERIALS AND METHODS: This is a single-centre, prospective observational study. OHCA patients performed DSC-PWI within 8 h after ROSC were enrolled. We quantified the CP parameters, such as cerebral blood volume (CBV), cerebral blood flow (CBF), mean transit time (MTT), time to peak (TTP), and time to maximum of the residue function (Tmax) either by normalization or arterial input function (AIF). The primary and secondary outcomes were survival to discharge and comparison of prognostic performance between CP parameters and serum neuron-specific enolase (NSE) using area under the receiver operating characteristic (AUROC) and sensitivity values. RESULTS: Thirty-one patients were included in this study. CBV and TTP quantified by normalization, and MTT and Tmax quantified by AIF showed significantly higher CP values in the non-survival group (p = 0.02, 0.03, 0.02, and <0.01, respectively). Their AUROCs and 100% specific sensitivities were 0.74/25.0%, 0.60/33.3%, 0.75/56.3%, and 0.79/43.8%, respectively. MTT quantified by AIF showed sensitivity in predicting mortality at an early stage of PCA care, comparable with NSE. CONCLUSION: Hyperaemia and delayed CP were generally observed in OHCA patients regardless of outcomes. MTT and Tmax quantified by AIF have prognostic performance in predicting mortality, comparable with NSE. Further prospective multicentre studies are required to confirm our results.

A novel predictive tool for prognosis in elderly patients with urinary tract infection: Modified PRACTICE.

PURPOSE: We evaluated whether combining the serum albumin level and the Prediction Rule for Admission policy in Complicated urinary Tract InfeCtion LEiden (PRACTICE) class could be a prognostic predictor in elderly patients with urinary tract infection (UTI). METHODS: We retrospectively included adult patients (age ≥ 65 years) with UTI who were hospitalized in the emergency department (ED) between January 1, 2014 and December 31, 2018. We graded the serum albumin level and classified the PRACTICE score; the modified PRACTICE was defined as the sum of the albumin level grade and the PRACTICE class. We comparatively assessed the predictive value for in-hospital mortality and admission to the intensive care unit (ICU) in survivor and non-survivor groups. RESULTS: In total, the study analysis included 1159 patients, and in-hospital mortality was 3.4% (n = 39). The modified PRACTICE score (4.0 [1.4] vs 6.1 [1.2], p < 0.001) was significantly increased in the non-survivor group. The area under the curve value of factors associated with in-hospital mortality were the Modified Early Warning Score (MEWS) 0.57 (95% CI 0.54-0.60), albumin 0.83 (95% CI 0.81-0.85), PRACTICE 0.71 (95% CI 0.69-0.74), and the modified PRACTICE 0.86 (95% CI 0.84-0.88). Factors associated with ICU admission were MEWS 0.65 (95% CI 0.62-0.68), albumin 0.66 (95% CI 0.64-0.69), PRACTICE 0.66 (95% CI 0.63-0.68), and the modified PRACTICE 0.72 (95% CI 0.69-0.74). CONCLUSION: The modified PRACTICE score can be a useful prognostic predictor in elderly patients with UTI.

Cerebrospinal Fluid Dynamics and Partial Pressure of Carbon Dioxide as Prognostic Indicators in Hypoxic-Ischemic Brain Injury Following Cardiac Arrest.

Changes in cerebrospinal fluid (CSF) dynamics can have adverse effects on neuronal function. We hypothesized that patients with hypoxic-ischemic brain injury (HIBI) showing poor neurological outcomes after cardiac arrest (CA) would exhibit changes in CSF dynamics, leading to abnormalities in gas diffusion within the CSF. Therefore, we investigated the prognostic value of the CSF partial pressure of carbon dioxide (PcsfCO2) in CA survivors who underwent targeted temperature management (TTM). We retrospectively analyzed the 6-month neurological outcomes, CSF, and arterial blood gas parameters of 67 CA survivors. Patients were divided into good and poor neurological outcome groups, and the predictive value of PcsfCO2 for poor neurological outcomes was assessed using receiver operating characteristic curve analysis. Among all patients, 39 (58.2%) had poor neurological outcomes. Significant differences in PcsfCO2 levels between the groups were observed, with lower PcsfCO2 levels on Day 1 showing the highest predictive value at a cutoff of 30 mmHg (area under the curve, sensitivity, and specificity were 0.823, 77.8%, and 79.0%, respectively). These results suggest that PcsfCO2 might serve not only as a unique marker for the severity of hypoxic-ischemic brain injury (HIBI), independent of extracorporeal CO2 levels, but also as an objective indicator of changes in CSF dynamics. This study highlights the potential prognostic and diagnostic utility of PcsfCO2 during TTM in CA survivors, emphasizing its importance in evaluating CSF dynamics and neurological recovery post CA. However, larger multicenter studies are warranted to address potential limitations associated with sample size and outcome assessment methods.

Blood-brain barrier permeability for the first 24 hours in hypoxic-ischemic brain injury following cardiac arrest.

BACKGROUND: This study aimed to explore the changes in blood-brain barrier (BBB) permeability and intracranial pressure (ICP) for the first 24 h after the return of spontaneous circulation (ROSC) and their association with injury severity of cardiac arrest. METHODS: This prospective study analysed the BBB permeability assessed using the albumin quotient (Qa) and ICP every 2 h for the first 24 h after ROSC. The injury severity of cardiac arrest was assessed using Pittsburgh Cardiac Arrest Category (PCAC) scores. The primary outcome was the time course of changes in the BBB permeability and ICP for the first 24 h after ROSC and their association with injury severity (PCAC scores of 1-4). RESULTS: Qa and ICP were measured 274 and 197 times, respectively, in 32 enrolled patients. Overall, the BBB permeability increased progressively over time after ROSC, and then it increased significantly at 18 h after ROSC compared with the baseline. In contrast, the ICP revealed non-significant changes for the first 24 h after ROSC. The Qa in the PCAC 2 group was < 0.01, indicating normal or mild BBB disruption at all time points, whereas the PCAC 3 and 4 groups showed a significant increase in BBB permeability at 14 and 22 h, and 12 and 14 h after ROSC, respectively. CONCLUSION: BBB permeability increased progressively over time for the first 24 h after ROSC despite post-resuscitation care, whereas ICP did not change over time. BBB permeability has an individual pattern when stratified by injury severity.

The agreement between jugular bulb and cerebrospinal fluid lactate levels in patients with out-of-hospital cardiac arrest.

We investigated the agreement between the jugular bulb (JB) and cerebrospinal fluid (CSF) lactate levels. The study was conducted from July 2021 to June 2023 as a prospective observational cohort study at a single center. The right jugular vein was accessed, and the placement of JB catheter tip was confirmed using lateral cervical spine X-ray. A lumbar catheter was inserted between the 3rd and 4th lumbar spine of the patient. Lactate levels were measured immediately, 24 h, 48 h, and 72 h after ROSC. In patients with a good neurological prognosis, kappa between JB and CSF lactate levels measured immediately, at 24 h, 48 h, and 72 h after ROSC were 0.08, 0.36, 0.14, - 0.05 (p = 0.65, 0.06, 0.48, and 0.75, respectively). However, in patients with a poor neurological prognosis, kappa between JB and CSF lactate levels measured immediately, at 24 h, 48 h, and 72 h after ROSC were 0.38, 0.21, 0.22, 0.12 (p = 0.001, 0.04, 0.04, and 0.27, respectively). This study demonstrated that JB lactate levels exhibited significant agreement with arterial lactate levels, compared to CSF lactate levels. Therefore, this should be considered when using JB lactate to monitor cerebral metabolism.

Distribution and elimination kinetics of midazolam and metabolites after post-resuscitation care: a prospective observational study.

Administration of sedatives for post-resuscitation care can complicate the determination of the optimal timing to avoid inappropriate, pessimistic prognostications. This prospective study aimed to investigate the distribution and elimination kinetics of midazolam (MDZ) and its metabolites, and their association with awakening time. The concentrations of MDZ and its seven metabolites were measured immediately and at 4, 8, 12, and 24 h after the discontinuation of MDZ infusion, using liquid chromatography-tandem mass spectrometry. The area under the time-plasma concentration curve from 0 to 24 h after MDZ discontinuation (AUClast) was calculated based on the trapezoidal rule. Of the 15 enrolled patients, seven awakened after the discontinuation of MDZ infusion. MDZ and three of its metabolites were major compounds and their elimination kinetics followed a first-order elimination profile. In the multivariable analysis, only MDZ was associated with awakening time (AUClast: R2 = 0.59, p = 0.03; AUCinf: R2 = 0.96, p < 0.001). Specifically, a 0.001% increase in MDZ AUC was associated with a 1% increase in awakening time. In the individual regression analysis between MDZ concentration and awakening time, the mean MDZ concentration at awakening time was 16.8 ng/mL. The AUC of MDZ is the only significant factor associated with the awakening time.