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predicted poor neurological outcomes for patients with OHCA treated with TTM when life-sustaining therapy was not withdrawn.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.

A novel cardiac arrest severity score for the early prediction of hypoxic-ischemic brain injury and in-hospital death.

INTRODUCTION: Out-of-hospital cardiac arrest (OHCA) outcomes are unsatisfactory despite postcardiac arrest care. Early prediction of prognoses might help stratify patients and provide tailored therapy. In this study, we derived and validated a novel scoring system to predict hypoxic-ischemic brain injury (HIBI) and in-hospital death (IHD). METHODS: We retrospectively analyzed Korean Hypothermia Network prospective registry data collected from in Korea between 2015 and 2018. Patients without neuroprognostication data were excluded, and the remaining patients were randomly divided into derivation and validation cohorts. HIBI was defined when at least one prognostication predicted a poor outcome. IHD meant all deaths regardless of cause. In the derivation cohort, stepwise multivariate logistic regression was conducted for the HIBI and IHD scores, and model performance was assessed. We then classified the patients into four categories and analyzed the associations between the categories and cerebral performance categories (CPCs) at hospital discharge. Finally, we validated our models in an internal validation cohort. RESULTS: Among 1373 patients, 240 were excluded, and 1133 were randomized into the derivation (n = 754) and validation cohorts (n = 379). In the derivation cohort, 7 and 8 predictors were selected for HIBI (0-8) and IHD scores (0-11), respectively, and the area under the curves (AUC) were 0.85 (95% CI 0.82-0.87) and 0.80 (95% CI 0.77-0.82), respectively. Applying optimum cutoff values of ≥6 points for HIBI and ≥7 points for IHD, the patients were classified as follows: HIBI (-)/IHD (-), Category 1 (n = 424); HIBI (-)/IHD (+), Category 2 (n = 100); HIBI (+)/IHD (-), Category 3 (n = 21); and HIBI (+)/IHD (+), Category 4 (n = 209). The CPCs at discharge were significantly different in each category (p < 0.001). In the validation cohort, the model showed moderate discrimination (AUC 0.83, 95% CI 0.79-0.87 for HIBI and AUC 0.77, 95% CI 0.72-0.81 for IHD) with good calibration. Each category of the validation cohort showed a significant difference in discharge outcomes (p < 0.001) and a similar trend to the derivation cohort. CONCLUSIONS: We presented a novel approach for assessing illness severity after OHCA. Although external prospective studies are warranted, risk stratification for HIBI and IHD could help provide OHCA patients with appropriate treatment.

Impact of COVID-19 pandemic on patients with cardio/cerebrovascular disease who visit the emergency department.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic situation is a state that has had a great impact on the medical system and society. To respond to the pandemic situation, various methods, such as a pre-triage system, are being implemented in the emergency medical field. However, there are insufficient studies on the effects of this pandemic situation on patients visiting the emergency department (ED), especially those with cardio/cerebrovascular diseases (CVD)1 classified as time-dependent emergencies. METHODS: We performed a retrospective analysis of a cohort of patients from April 2020 to December 2020 (April 2020 was when the pre-triage system was established) compared to a parallel comparison patient cohort from 2019. The primary outcome was in-hospital mortality. CVD was defined by the patient's final diagnosis. RESULTS: During the same period, the number of patients who had visited the ED after COVID-19 had decreased to 79.1% of the number of patients who had visited the ED before COVID-19. The overall patient mortality and the mortality in the patients cardiovascular disease had both increased, while the mortality from cerebrovascular disease did not increase. Meanwhile, the ED length of stay had increased in all patients but did not increase in the patients with cardiovascular disease. CONCLUSION: As with prior studies conducted in other regions, in our study, the total number of ED visits were decreased compared to before COVID-19. The overall mortality had increased, particularly in the patients with cardiovascular disease.

The association between L1 skeletal muscle index derived from routine CT and in-hospital mortality in CAP patients in the ED.

INTRODUCTION: Low muscle mass is associated with an increased mortality risk due to medical comorbidities such as chronic obstructive pulmonary disease, cardiovascular disease, and cerebrovascular disease. Computed tomography (CT) has been identified as the gold standard for measuring body composition. We evaluated the relationship between the L1 SMI measured from CT and in-hospital mortality in patients with community-acquired pneumonia (CAP). METHODS: From January 2015 to June 2015, 311 patients who were diagnosed with CAP and underwent CT in the ED were retrospectively analyzed. Multivariate binary logistic regression analysis was used to assess independent predictors of in-hospital mortality. All variables with a significance level < 0.1 by univariate analysis were included in a multivariate logistic regression model. The primary outcome was all-cause in-hospital mortality. RESULTS: Among the 311 patients, 33 (10.6%) died. We divided the patients into two groups based on the optimal sex-specific cut-off value of the L1 SMI (45 cm2/m2 in males and 40 cm2/m2 in females). A low L1 SMI was present in 90 (28.9%) of the 311 patients. In multivariate analysis, low L1 SMI, diabetes mellitus, albumin and APACHE II score were significantly associated with in-hospital mortality (aOR 3.39, 3.73, 0.09 and 1.10, respectively). CONCLUSION: SMI assessment at L1 is achievable in patients with CAP receiving routine chest CT, and the L1 SMI is associated with high in-hospital mortality, more hospitalizations and ventilator application in patients with CAP in the ED. This could help establish an early strategy for critical care of patients with L1 SMI obtained by chest CT for diagnosis in CAP patients in the ED.

Neutrophil to lymphocyte ratio is associated with in-hospital mortality in older adults admitted to the emergency department.

BACKGROUND: The objective of this study was to test the hypothesis that an elevated neutrophil to lymphocyte ratio (NLR) at admission is associated with and increased risk of mortality in older patients admitted to the emergency department (ED). METHODS: We performed a retrospective analysis of patients admitted to the ED between November 2016 and February 2017. We included patients who were older than 65 years who visited the ED with any medical problem. We excluded patients with hematologic malignancy. Baseline NLR values were measured at the time of admission to the ED. The primary outcome was all-cause in-hospital mortality. A multivariate logistic analysis was performed. RESULTS: A total of 2777 patients were included in this study. The median age was 75 years (IQR 70-81), and 1359 (48.9%) patients were male. The in-hospital mortality rate was 5.0% (140 patients). The NLR value was higher in nonsurvivors (median, 8.08, IQR 4.29-15.25) than in survivors (median, 3.69, IQR 2.1-6.92, P < 0.001). In the multivariate logistic regression analysis, the NLR was associated with all cause in-hospital mortality after adjusting for confounding factors (OR = 1.03, 95% CI = 1.014-1.046). CONCLUSIONS: These results show that the NLR at admission is associated with in-hospital mortality among patients older than 65 years without hematologic malignancy. Thus, NLR at admission may represent a surrogate marker of disease severity.

Factors Associated with Delay of Emergency Medical Services Activation in Patients with Acute Stroke.

BACKGROUND: The poor prognosis of acute stroke may be largely attributed to delays in treatment. Emergency medical services (EMS) usage is associated with a significant reduction in the delay in stroke treatment. The aims of this study were to identify factors associated with the delay in EMS activation for patients with acute stroke. METHODS: This study was conducted at 26 Fire Safety Centers in five districts of Seoul, Korea. Patients with acute stroke transferred by EMS and admitted to a tertiary referral hospital from January 2014 to December 2018 were enrolled. In this cross-sectional study, the dependent variable was the time from stroke onset to EMS activation time. Patients were divided into two groups, onset-to-alarm time ≤ 30 min and onset-to-alarm time > 30 min, and previously collected patient data were analyzed. We performed logistical regression analyses of characteristics differing significantly between groups. RESULTS: Out of 480 patients, 197 (41%) had onset-to-alarm times > 30 min. Significant variables in the logistical analysis were alert mental state (adjusted odds ratio [aOR]: 2.77; 95% confidence interval [CI]: 1.31-6.13), pre-stroke mRS ≥ 2 (aOR: 2.46; 95% CI: 1.26-4.95), onset occurrence at private space (aOR: 2.31; 95% CI: 1.23-4.41), recognizing symptoms between 0 and 8 am (aOR: 2.30; 95% CI: 1.25-4.31), ischemic stroke (aOR: 1.88; 95% CI: 1.04-3.43), and witnessed by others (aOR: 0.32; 95% CI: 0.18-0.55). CONCLUSIONS: Delay in EMS activation for acute stroke cases is possibly related to difficult situations to recognize stroke symptoms, such as alert mental state, pre-stroke mRS ≥ 2, onset occurrence at private space, recognizing symptoms between 0 and 8 am, and unwitnessed by others.

Morphological Control of Cells on 3-Dimensional Multi-Layer Nanotopographic Structures.

The extracellular matrix (ECM) environment is known to play an important role in the process of various cell regulatory mechanisms. We have investigated the ability of 3-dimensional ECM geometries to induce morphological changes in cells. Bi-layer polymeric structures with submicron scale stripe patterns were fabricated using a two-step nano-imprinting technique, and the orientation angle (θ(α)) of the upper layer was controlled by changing its alignment with respect to the orientation of the bottom layer. When cells were grown on the mono-layer stripe structure with a single orientation, they elongated along the direction of the stripe pattern. On bi-layer polymer structures, the cell morphologies gradually changed and became rounded, with an increase of θα up to 90 degrees, but the polarities of these cells were still aligned along the orientation of the upper layer. As a result, we show that the polarity and the roundness of cells can be independently regulated by adjusting the orientation of 3-dimensional hierarchical ECM topography.

Lipase-mediated lipid removal from propolis extract and its antiradical and antimicrobial activity.

BACKGROUND: Propolis contains many antioxidants such as polyphenols and flavonoids. However, propolis-derived lipid components interrupt an efficient isolation of antioxidants from propolis extract. We examined the effectiveness of various lipase treatments for the removal of lipids from propolis extract and evaluated the biological features of the extract. RESULTS: Lipase OF and Novozyme 435 treatments did not reduce fatty acid level in propolis extract. However, Lipozyme TL IM-treated propolis extract showed a significant decrease in fatty acid level, suggesting the removal of lipids. Lipozyme RM IM also significantly decreased the fatty acid level of the extract, but was accompanied by the reduction of polyphenols and flavonoids, which are antioxidants. In Lipozyme TL IM treatment, an increase in active flavonoids, such as Artepillin C and kaempferide, was observed, with a slight increase of ferric reducing/antioxidant power (FRAP) radical-scavenging activity. In addition, antimicrobial activity towards skin health-related bacteria such as Staphylococcus epidermidis and Propionibacterium acnes was enhanced by Lipozyme TL IM treatment. CONCLUSION: Lipozyme TL IM treatment effectively removes lipids from propolis extract and enhances antibacterial activity. Therefore, we suggest that Lipozyme TL IM is a useful lipase for lipid removal of propolis extract.

Yeast hydrolysate protects cartilage via stimulation of type II collagen synthesis and suppression of MMP-13 production.

Type II collagen (COL II) is one of the primary components of hyaline cartilage and plays a key role in maintaining chondrocyte function. COL II is the principal target of destruction, and matrix metalloproteases (MMPs) have a major role in arthritis. In the present study, we investigated the chondroctye protection effects of specific fraction of yeast hydrolysate ((10-30 kDa molecular weight peptides). The mRNA expression of COL II was significantly increased in the YH-treated group compared to the control at concentrations above 50 µg/ml, respectively. The 200 µg/ml YH-treated group (3.43 ± 0.23 µg/ml) showed significantly reduced glycosaminoglycan (GAG) degradation relative to that in the interleukin-1ß (IL-1ß)-treated control group (4.72 ± 0.05 µg/ml). In the YH-treated group, MMP-13 level was significantly decreased in a dose-dependent manner compared to the IL-1ß-treated group without YH treatment. However, MMP-1 and MMP-3 level were not different from that of control. Under the same conditions, we also examined mRNA levels of COL II. The mRNA expression of COL II was significantly higher in the YH-treated group than in the IL-1ß-treated control group at concentrations above 100 µg/ml. In conclusion, YH stimulated COL II synthesis and significantly inhibited MMP-13 and GAG degradation caused by IL-1ß treatment.

Serum spectrin breakdown product and neurofilament heavy in predicting outcome after cardiac arrest: A diagnostic accuracy study.

Objectives: Spectrin breakdown products 145 kDa (SBDP145) and neurofilament heavy chain (Nf-H) have been identified as potential biomarkers of neuronal injury. However, their ability to predict hypoxic-ischemic brain injury following cardiac arrest in humans is not well understood. This study aimed to investigate whether SBDP145 and Nf-H could be used as biomarkers to predict neurological outcomes after cardiac arrest. Methods: This prospective study was conducted at two academic hospitals and included adults who survived after cardiac arrest. Blood samples were collected at 0, 24, and 48 h after the return of spontaneous circulation, and biomarker analyses were performed to measure SBDP145 and Nf-H. Poor neurological outcome was defined as a modified Rankin Score of 4-6, and diagnostic performance was determined by receiver-operating characteristics analysis. Results: A total of 56 patients were included in this study. There were no significant differences in levels of SBDP145 or Nf-H between the poor and good outcome groups at any time point. Areas under the receiver-operating characteristics curve of SBDP145 and Nf-H were small, ranging from 0.51 to 0.7. At 0, 24, and 48 h, SBDP145 showed very low sensitivity (18.61 %, 13.89 %, and 13.79 %, respectively) and accuracy (33.93 %, 36.74 %, and 39.02 %, respectively) at a cut-off value for 100 % specificity. Nf-H also showed very low sensitivity (9.30 %, 16.67 %, and 0 %, respectively) and accuracy (29.09 %, 36.74 %, and 30.95 %, respectively). Conclusions: SBDP145 and Nf-H were found to be poor predictors of poor neurological outcomes six months after cardiac arrest.

Effects of yeast hydrolysate on hepatic lipid metabolism in high-fat-diet-induced obese mice: yeast hydrolysate suppresses body fat accumulation by attenuating fatty acid synthesis.

AIMS: We observed whether the anti-obesity activity of yeast hydrolysate (YH) was due to the alteration of lipid-regulating enzyme activities. METHODS: Male ICR mice were divided into four groups: a normal diet group (ND; 4.2% fat), a high-fat diet group (HF; 27.7% fat), an HF group treated orally with 0.5% or 1% YH in the drinking water (HF+YH0.5; 27.7% fat and HF+YH1; 27.7% fat). RESULTS: After 5 weeks, the YH groups (HF+YH0.5=3.92±0.17 g/100 g BW and HF+YH1=3.76±0.13 g/100 g BW) had significantly lower levels of epididymal fats compared to the HF group (4.91±0.29 g/100 g BW; p<0.05). YH supplementation produced a decrease in serum triglycerides and low-density lipoprotein cholesterol concentrations and body weight gain, and produced a dose-dependent significant increase in serum ghrelin compared with the HF group (p<0.05). Hepatic glucose-6-phosphate dehydrogenase (G6PD) activity was inhibited by YH supplementation compared with the HF group, and mice treated orally with 1% YH exhibited a significant decrease in hepatic malic enzyme (ME) activity compared to obese mice treated with the vehicle (HF=10.44±2.74 nmol/min/mg protein vs. HF+YH1=6.68±2.23 nmol/min/mg protein; p<0.05). CONCLUSIONS: YH supplementation suppressed body fat accumulation by attenuating fatty acid synthesis through the downregulation of hepatic G6PD and ME activities.

Anti-complementary activity of enzyme-treated traditional Korean rice wine (Makgeolli) hydrolysates.

BACKGROUND: Makgeolli brewed from rice contains about 150 g kg(-1) alcohol and has a fragrance as well as an acidic and sweet taste. During the brewing process, by-products such as rice bran and brewery cake are produced. At the end of fermentation the matured mash is transferred to a filter cloth and the Makgeolli is squeezed out from the cake, leaving the lees of the mash. These by-products have continued to increase every year, resulting in an ecological problem. It is therefore important to develop new uses for them. The objective of this study was to use the by-products from the brewing of Makgeolli as a valuable functional food or nutraceutical. RESULTS: The anti-complementary activities of crude polysaccharides isolated from Cytolase hydrolysates of Makgeolli lees at concentrations of 1000 and 500 µg mL(-1) were 84.15 and 78.70% respectively. The activity of polysaccharide krestin (PSK) was 60.00% at 1000 µg mL(-1). The active polysaccharide obtained with Cytolase comprised mainly glucose and mannose (molar ratio 1.00:0.62). CONCLUSION: Glucose- and mannose-rich crude polysaccharides were isolated from the Cytolase hydrolysate of Makgeolli lees. The polysaccharides retain anti-complementary activity to enhance the immune system as a functional food or nutraceutical.

Brain Death and Its Prediction in Out-of-Hospital Cardiac Arrest Patients Treated with Targeted Temperature Management.

Evolution toward brain death (BD) in out-of-hospital cardiac arrest patients with targeted temperature management (TTM) provides opportunities for organ donation. However, knowledge regarding BD in these patients is limited. We retrospectively analyzed the TTM registry of one hospital where life-sustaining therapy was not withdrawn. In-hospital death patients were categorized into BD and non-BD groups. We explored the process of evolution toward BD and its predictors by comparing the serial measurements of clinical variables and the results of various prognostic tests between the two groups. Of the 121 patients who died before hospital discharge, 19 patients (15.7%) developed BD at a median of 6 (interquartile range, 5.0-7.0) days after cardiac arrest. Four patients with pupillary light reflexes at 48 h eventually developed BD. The area under the curves of the gray-to-white matter ratio (GWR) on early brain computed tomography images and the level of S100 calcium-binding protein B (S100B) at 72 h were 0.67 (95% CI, 0.55-0.77) and 0.70 (95% CI, 0.55-0.83), respectively. In conclusion, approximately one-sixth of all in-hospital deaths were diagnosed with BD at a median of 6 days after cardiac arrest. The use of GWR and serial S100B measurements may help to screen potential BD.

The relationship between body mass index and neurologic outcomes in survivors of out-of-hospital cardiac arrest treated with targeted temperature management.

BACKGROUND: The association of body mass index with outcome in patients treated with targeted temperature management (TTM) after out-of-hospital cardiac arrest (OHCA) is unclear. The purpose of this study was to examine the effect of body mass index (BMI) on neurological outcomes and mortality in resuscitated patients treated with TTM after OHCA. METHODS: This multicenter, prospective, observational study was performed with data from 22 hospitals included in the Korean Hypothermia Network KORHN-PRO registry. Comatose adult patients treated with TTM after OHCA between October 2015 and December 2018 were enrolled. The BMI of each patient was calculated and classified according to the criteria of the World Health Organization (WHO). Each group was analyzed in terms of demographic characteristics and associations with six-month neurologic outcomes and mortality after cardiac arrest (CA). RESULTS: Of 1,373 patients treated with TTM identified in the registry, 1,315 were included in this study. One hundred two patients were underweight (BMI <18.5 kg/m2), 798 were normal weight (BMI 18.5-24.9 kg/m2), 332 were overweight (BMI 25-29.9 kg/m2), and 73 were obese (BMI ≥ 30 kg/m2). The higher BMI group had younger patients and a greater incidence of diabetes and hypertension. Six-month neurologic outcomes and mortality were not different among the BMI groups (p = 0.111, p = 0.234). Univariate and multivariate analyses showed that BMI classification was not associated with six-month neurologic outcomes or mortality. In the subgroup analysis, the underweight group treated with TTM at 33°C was associated with poor neurologic outcomes six months after CA (OR 2.090, 95% CI 1.010-4.325, p = 0.047), whereas the TTM at 36°C group was not (OR 0.88, 95% CI 0.249-3.112, p = 0.843). CONCLUSIONS: BMI was not associated with six-month neurologic outcomes or mortality in patients surviving OHCA. However, in the subgroup analysis, underweight patients were associated with poor neurologic outcomes when treated with TTM at 33°C.

Stimulation of osteoblastic differentiation and mineralization in MC3T3-E1 cells by yeast hydrolysate.

In a previous study, it was reported that yeast hydrolysate (YH) was effective in promoting bone growth in Sprague-Dawley (SD) rats. To further clarify the mechanism of YH, the effects of YH on proliferation, differentiation and gene expression in vitro were investigated using osteoblastic cell lines (MC3T3-E1). Cell proliferation increased significantly as much as 110% of the basal value when cells were treated with 100 µg/mL of YH. Alkaline phosphatase (ALP) activity increased significantly with a YH concentration of 25-100 µg/mL, and the activity increased 152% that of the control at 100 µg/mL. The calcium content increased as much as 129% at 100 µg/mL YH. The gene expression levels of ALP and collagen type II (COL II) significantly increased approximately 1.3-fold and 1.7-fold of control, respectively, at 100 µg/mL. YH increased significantly the mRNA level of bone sialoprotein (BSP) but not in a dose-dependent manner. The mRNA levels of bone morphogenetic proteins (BMP)-2, BMP-4, collagen type I (COL I) and osteonectin (ON) did not increase. In summary, YH increased the proliferation of osteoblasts and directly stimulated ALP and bone matrix proteins (e.g. BSP, COL II), and these increases trigger osteoblastic differentiation (e.g. mineralized nodule formation).

Early Identification of Resuscitated Patients with a Significant Coronary Disease in Out-of-Hospital Cardiac Arrest Survivors without ST-Segment Elevation.

This study aimed to develop a machine learning (ML)-based model for identifying patients who had a significant coronary artery disease among out-of-hospital cardiac arrest (OHCA) survivors without ST-segment elevation (STE). This multicenter observational study used data from the Korean Hypothermia Network prospective registry (KORHN-PRO) gathered between October 2015 and December 2018. We used information available before targeted temperature management (TTM) as predictor variables, and the primary outcome was a significant coronary artery lesion in coronary angiography (CAG). Among 1373 OHCA patients treated with TTM, 331 patients without STE who underwent CAG were enrolled. Among them, 127 patients (38.4%) had a significant coronary artery lesion. Four ML algorithms, namely regularized logistic regression (RLR), random forest classifier (RF), CatBoost classifier (CBC), and voting classifier (VC), were used with data collected before CAG. The VC model showed the highest accuracy for predicting significant lesions (area under the curve of 0.751). Eight variables (older age, male, initial shockable rhythm, shorter total collapse duration, higher glucose and creatinine, and lower pH and lactate) were significant to ML models. These results showed that ML models may be useful in developing early predictive tools for identifying high-risk patients with a significant stenosis in CAG.

Prognostic value of brainstem auditory and visual evoked potentials in cardiac arrest patients with targeted temperature management.

PURPOSE: We analysed the prognostic value of somatosensory, brainstem auditory and visual evoked potentials (SSEPs, BAEPs and VEPs, respectively) for outcome prediction in cardiac arrest patients with targeted temperature management (TTM) and assessed whether BAEP and VEP measurements conferred added value to SSEP measurements. METHODS: Cases with SSEPs and VEPs or BAEPs were reviewed in a TTM registry. We focused on whether the following responses were clearly discernible: N20 for SSEPs, V for BAEPs, and P100 for VEPs. Each type of evoked potential was classified as absent, present or indeterminable. Neurological outcomes after 6 months were dichotomized as good (Cerebral Performance Category [CPC] 1-2) or poor (CPC 3-5). RESULTS: From 185 patients, 185 SSEPs, 172 BAEPs and 178 VEPs were included. None of the patients with a good outcome had absent SSEP, BAEP or VEP responses. Absent SSEP, BAEP and VEP responses yielded sensitivities of 42.3% (95% confidence interval [CI], 33.7-51.3%), 9.4% (95% CI, 4.6-16.7%) and 54.4% (95% CI, 46.0-62.5%) for poor outcomes, respectively. For the overall cohort, the addition of VEP measurements improved the sensitivities of single SSEP measurements (65.8% [95% CI, 57.7-73.3%] versus 36.2% [95% CI, 28.6-44.4%] and multimodal prognostication using SSEPs, brainstem reflex and brain computed tomography (75.7% [95% CI, 68.0-82.3%] versus 60.5% [95% CI, 52.3-68.4%]). CONCLUSIONS: The prognostic value of VEPs was comparable to that of SSEPs, but the use of BAEPs was limited due to their low sensitivity. Additional VEP measurements can reduce prognostic uncertainty.

Which Out-of-Hospital Cardiac Arrest Patients without ST-Segment Elevation Benefit from Early Coronary Angiography? Results from the Korean Hypothermia Network Prospective Registry.

The effect of early coronary angiography (CAG) in out-of-hospital cardiac arrest (OHCA) patients without ST-elevation (STE) is still controversial. It is not known which subgroups of patients without STE are the most likely to benefit. The objective of this study was to evaluate the association between emergency CAG and neurologic outcomes and identify subgroups with improved outcomes when emergency CAG was performed. This prospective, multicenter, observational cohort study was based on data from the Korean Hypothermia Network prospective registry (KORHN-PRO) 1.0. Adult OHCA patients who were treated with targeted temperature management (TTM) without any obvious extracardiac cause were included. Patients were dichotomized into early CAG (≤24 h) and no early CAG (>24 h or not performed) groups. High-risk patients were defined as having the Global Registry of Acute Coronary Events (GRACE) score > 140, time from collapse to return of spontaneous circulation (ROSC) > 30 min, lactate level > 7.0 mmol/L, arterial pH < 7.2, cardiac enzyme elevation and ST deviation. The primary outcome was good neurologic outcome at 6 months after OHCA. Of the 1373 patients from the KORHN-PRO 1.0 database, 678 patients met the inclusion criteria. The early CAG group showed better neurologic outcomes at 6 months after cardiac arrest (CA) (adjusted odds ratio: 2.21 (1.27-3.87), p = 0.005). This was maintained even after propensity score matching (adjusted odds ratio: 2.23 (1.39-3.58), p < 0.001). In the subgroup analysis, high-risk patients showed a greater benefit from early CAG. In contrast, no significant association was found in low-risk patients. Early CAG was associated with good neurologic outcome at 6 months after CA and should be considered in high-risk patients.

Use of the National Early Warning Score for predicting in-hospital mortality in older adults admitted to the emergency department.

OBJECTIVE: The National Early Warning Score (NEWS), based on the patients' vital signs, detects clinical deterioration in critically ill patients and is used to reduce the incidence of in-hospital cardiac arrest. However, although mortality prediction based on vital signs may be difficult in older patients, the effectiveness of the NEWS has not yet been evaluated in this population. This study aimed to test the hypothesis that an elevated NEWS at admission increases the mortality risk in older patients admitted to the emergency department (ED). METHODS: We conducted a single-center retrospective study, including patients admitted to the ED between November 2016 and February 2017. We included patients aged >65 years who were admitted to the ED for any medical problem. The NEWS was calculated at the time of ED admission. The primary outcome was in-hospital mortality. RESULTS: In total, 3,169 patients were included in this study. Median age was 75 years (interquartile range [IQR], 70 to 80 years), and 1,557 (49.1%) patients were male. The in-hospital mortality rate was 5.1% (161 patients). Median NEWS was higher in non-survivors than in survivors (5 [IQR, 3-8] vs. 1 [IQR, 0-3], P<0.001). Multivariate logistic analysis showed that the NEWS was associated with in-hospital mortality, after adjusting for other confounders. The area under the curve of the NEWS for predicting in-hospital mortality was 0.820 (95% confidence interval, 0.806 to 0.833). CONCLUSION: Our results show that the NEWS at admission is associated with in-hospital mortality among patients aged >65 years.

Nanoparticles up-regulate tumor necrosis factor-alpha and CXCL8 via reactive oxygen species and mitogen-activated protein kinase activation.

Evaluating the toxicity of nanoparticles is an integral aspect of basic and applied sciences, because imaging applications using traditional organic fluorophores are limited by properties such as photobleaching, spectral overlaps, and operational difficulties. This study investigated the toxicity of nanoparticles and their biological mechanisms. We found that nanoparticles, quantum dots (QDs), considerably activated the production of tumor necrosis factor (TNF)-alpha and CXC-chemokine ligand (CXCL) 8 through reactive oxygen species (ROS)- and mitogen-activated protein kinases (MAPKs)-dependent mechanisms in human primary monocytes. Nanoparticles elicited a robust activation of intracellular ROS, phosphorylation of p47phox, and nicotinamide adenine dinucleotide phosphate oxidase activities. Blockade of ROS generation with antioxidants significantly abrogated the QD-mediated TNF-alpha and CXCL8 expression in monocytes. The induced ROS generation subsequently led to the activation of MAPKs, which were crucial for mRNA and protein expression of TNF-alpha and CXCL8. Furthermore, confocal and electron microscopy analyses showed that internalized QDs were trapped in cytoplasmic vesicles and compartmentalized inside lysosomes. Finally, several repeated intravenous injections of QDs caused an increase in neutrophil infiltration in the lung tissues in vivo. These results provide novel insights into the QD-mediated chemokine induction and inflammatory toxic responses in vitro and in vivo.