Prediction of Shock-Refractory Ventricular Fibrillation During Resuscitation of Out-of-Hospital Cardiac Arrest.

BACKGROUND: Out-of-hospital cardiac arrest due to shock-refractory ventricular fibrillation (VF) is associated with relatively poor survival. The ability to predict refractory VF (requiring ≥3 shocks) in advance of repeated shock failure could enable preemptive targeted interventions aimed at improving outcome, such as earlier administration of antiarrhythmics, reconsideration of epinephrine use or dosage, changes in shock delivery strategy, or expedited invasive treatments. METHODS: We conducted a cohort study of VF out-of-hospital cardiac arrest to develop an ECG-based algorithm to predict patients with refractory VF. Patients with available defibrillator recordings were randomized 80%/20% into training/test groups. A random forest classifier applied to 3-s ECG segments immediately before and 1 minute after the initial shock during cardiopulmonary resuscitation was used to predict the need for ≥3 shocks based on singular value decompositions of ECG wavelet transforms. Performance was quantified by area under the receiver operating characteristic curve. RESULTS: Of 1376 patients with VF out-of-hospital cardiac arrest, 311 (23%) were female, 864 (63%) experienced refractory VF, and 591 (43%) achieved functional neurological survival. Total shock count was associated with decreasing likelihood of functional neurological survival, with a relative risk of 0.95 (95% CI, 0.93-0.97) for each successive shock (P<0.001). In the 275 test patients, the area under the receiver operating characteristic curve for predicting refractory VF was 0.85 (95% CI, 0.79-0.89), with specificity of 91%, sensitivity of 63%, and a positive likelihood ratio of 6.7. CONCLUSIONS: A machine learning algorithm using ECGs surrounding the initial shock predicts patients likely to experience refractory VF, and could enable rescuers to preemptively target interventions to potentially improve resuscitation outcome.

Bag-Valve-Mask Ventilation and Survival From Out-of-Hospital Cardiac Arrest: A Multicenter Study.

BACKGROUND: Few studies have measured ventilation during early cardiopulmonary resuscitation (CPR) before advanced airway placement. Resuscitation guidelines recommend pauses after every 30 chest compressions to deliver ventilations. The effectiveness of bag-valve-mask ventilation delivered during the pause in chest compressions is unknown. We sought to determine: (1) the incidence of lung inflation with bag-valve-mask ventilation during 30:2 CPR; and (2) the association of ventilation with outcomes after out-of-hospital cardiac arrest. METHODS: We studied patients with out-of-hospital cardiac arrest from 6 sites of the Resuscitation Outcomes Consortium CCC study (Trial of Continuous Compressions versus Standard CPR in Patients with Out-of-Hospital Cardiac Arrest). We analyzed patients assigned to the 30:2 CPR arm with ≥2 minutes of thoracic bioimpedance signal recorded with a cardiac defibrillator/monitor. Detectable ventilation waveforms were defined as having a bioimpedance amplitude ≥0.5 Ω (corresponding to ≥250 mL VT) and a duration ≥1 s. We defined a chest compression pause as a 3- to 15-s break in chest compressions. We compared the incidence of ventilation and outcomes in 2 groups: patients with ventilation waveforms in <50% of pauses (group 1) versus those with waveforms in ≥50% of pauses (group 2). RESULTS: Among 1976 patients, the mean age was 65 years; 66% were male. From the start of chest compressions until advanced airway placement, mean±SD duration of 30:2 CPR was 9.8±4.9 minutes. During this period, we identified 26 861 pauses in chest compressions; 60% of patients had ventilation waveforms in <50% of pauses (group 1, n=1177), and 40% had waveforms in ≥50% of pauses (group 2, n=799). Group 1 had a median of 12 pauses and 2 ventilations per patient versus group 2, which had 12 pauses and 12 ventilations per patient. Group 2 had higher rates of prehospital return of spontaneous circulation (40.7% versus 25.2%; P<0.0001), survival to hospital discharge (13.5% versus 4.1%; P<0.0001), and survival with favorable neurological outcome (10.6% versus 2.4%; P<0.0001). These associations persisted after adjustment for confounders. CONCLUSIONS: In this study, lung inflation occurred infrequently with bag-valve-mask ventilation during 30:2 CPR. Lung inflation in ≥50% of pauses was associated with improved return of spontaneous circulation, survival, and survival with favorable neurological outcome.

Assessing Physical Therapists' Outdoor Walking Recommendations and Neighborhood Walkability for Older Adults.

BACKGROUND/OBJECTIVES: Neighborhood walkability is the extent to which built and social environments support walking. Walkability influences older adults' participation in outdoor physical activity. Identifying factors that influence physical therapists' (PTs) decisions about prescribing outdoor walking is needed, especially for those who are aging in place. The purpose of this study is to describe the neighborhood walkability knowledge, perceptions, and assessment practices of PTs who work with community-dwelling older adults. METHODS: A cross-sectional survey was sent via email to 5,000 PTs nationwide. The 40-item survey assessed walking prescriptions, walkability perceptions and assessments, and gathered demographic data. Categorical variables were compared using Chi-square analyses. RESULTS: Using a total of 122 PTs who worked in outpatient geriatric physical therapy settings, a significant difference was found between perceptions of whether PTs should assess walkability and whether they actually assess walkability (χ2 = 78.7, p < .001). Decisions to prescribe outdoor walking were influenced by the availability (n = 79, 64.8%) and maintenance (n = 11, 9.0%) of sidewalks, crime (n = 9, 7.4%), terrain (n = 7, 5.7%), and aesthetics (n = 6, 4.9%). Objective walkability measures were not used by the respondents. CONCLUSION: When considering the assessment of walkability, PTs prioritize the built environment over the social environment. Although most believe it is the responsibility of the PT to assess walkability, most do not. Significance/Implications: Assessment of walkability may allow PTs to identify barriers and make more informed recommendations concerning outdoor walking for older adults. Objective measures are available for PTs when prescribing outdoor walking.

Instantaneous amplitude: Association of ventricular fibrillation waveform measures at time of shock with outcome in out-of-hospital cardiac arrest.

BACKGROUND: Prompt defibrillation is key to successful resuscitation from ventricular fibrillation out-of-hospital cardiac arrest (VF-OHCA). Preliminary evidence suggests that the timing of shock relative to the amplitude of the VF ECG waveform may affect the likelihood of resuscitation. We investigated whether the VF waveform amplitude at the time of shock (instantaneous amplitude) predicts outcome independent of other validated waveform measures. METHODS: We conducted a retrospective study of VF-OHCA patients ≥18 old. We evaluated three VF waveform measures for each shock: instantaneous amplitude at the time of shock, and maximum amplitude and amplitude spectrum area (AMSA) over a 3-s window preceding the shock. Linear mixed-effects modeling was used to determine whether instantaneous amplitude was associated with shock-specific return of organized rhythm (ROR) or return of spontaneous circulation (ROSC) independent of maximum amplitude or AMSA. RESULTS: The 566 eligible patients received 1513 shocks, resulting in ROR of 62.0% (938/1513) and ROSC of 22.3% (337/1513). In unadjusted regression, an interquartile increase in instantaneous amplitude was associated with ROR (Odds ratio [OR] [95% confidence interval] = 1.27 [1.11-1.45]) and ROSC (OR = 1.27 [1.14-1.42]). However, instantaneous amplitude was not associated with ROR (OR = 1.13 [0.97-1.30]) after accounting for maximum amplitude, nor with ROR (OR = 1.00 [0.87-1.15]) or ROSC (OR = 1.05 [0.93-1.18]) after accounting for AMSA. By contrast, AMSA and maximum amplitude remained independently associated with ROR and ROSC. CONCLUSIONS: We did not observe an independent association between instantaneous amplitude and shock-specific outcomes. Efforts to time shock to the maximal amplitude of the VF waveform are unlikely to affect resuscitation outcome.

Characterization of non-cardiac arrest PulsePoint activations in public and private settings.

BACKGROUND: Geospatial smartphone application alert systems are used in some communities to crowdsource community response for out-of-hospital cardiac arrest (OHCA). Although the clinical focus of this strategy is OHCA, dispatch identification of OHCA is imperfect so that activation may occur for the non-arrest patient. The frequency and clinical profile of such non-arrest patients has not been well-investigated. METHODS: We undertook a prospective 3-year cohort investigation of patients for whom a smartphone geospatial application was activated for suspected OHCA in four United States communities (total population ~1 million). The current investigation evaluates those patients with an activation for suspected OHCA who did not experience cardiac arrest. The volunteer response cohort included off-duty, volunteer public safety personnel (verified responders) notified regardless of location (public or private) and laypersons notified to public locations. The study linked the smartphone application information with the EMS records to report the frequency, condition type, and EMS treatment for these non-arrest patients. RESULTS: Of 1779 calls where volunteers were activated, 756 had suffered OHCA, resulting in 1023 non-arrest patients for study evaluation. The most common EMS assessments were syncope (15.9%, n=163), altered mental status (15.5%, n=159), seizure (14.3%, n=146), overdose (13.0%, n=133), and choking (10.5%, n=107). The assessment distribution was similar for private and public locations. Overall, the most common EMS interventions included placement of an intravenous line (43.1%, n=441), 12-Lead ECG(27.9%, n=285), naloxone treatment (9.8%, n=100), airway or ventilation assistance (8.7%, n=89), and oxygen administration (6.6%, n=68). CONCLUSIONS: More than half of patients activated for suspected OHCA had conditions other than cardiac arrest. A subset of these conditions may benefit from earlier care that could be provided by both layperson and public safety volunteers if they were appropriately trained and equipped.

Screening recall in older cancer survivors detects differences in balance and mobility.

PURPOSE: Cognitive impairments have been reported by up to two-thirds of cancer survivors whose primary cancer did not occur in the central nervous system. Physical impairments as sequelae of cancer-related cognitive impairment (CRCI) have not been well described in previous studies. Furthermore, there is scarcity of literature describing differences among physical performance in those with and without CRCI. The purpose of this study is to examine the differences in physical function of older cancer survivors based on cognitive ability to determine if physical performance differs when different cognitive screening measures are employed. METHODS: Adults age 65 + with a history of cancer from the 2010 Health and Retirement Study (n = 1,953) were assigned to groups according to their cognitive ability. Between-group demographic, mobility, and cognitive differences were analyzed using chi-squared and t tests. Recall and orientation were used as cognitive variables, and physical performance outcomes included gait speed, balance, and grip strength. RESULTS: Respondents with Low Recall had more impaired balance (semi-tandem, tandem) (p < .05) and slower gait speeds (p < .05). Respondents that were Not-Oriented had slower gait speed (p < .05). Between-group differences in demographics were found by recall and orientation groups. CONCLUSIONS: Impairments in balance and gait speed are able to be detected when recall is screened in a population of older cancer survivors. When assessing how physical mobility is related to fall risk, a screen of cognition should go beyond just orientation.

Cerebral Oximetry during Out-of-Hospital Resuscitation: Pilot Study of First Responder Implementation.

Background: Anoxic brain injury is a common mode of death following out-of-hospital cardiac arrest (OHCA). We assessed the course of regional cerebral oxygen saturation (rSO2) at the outset and during first responder resuscitation to understand its relationship with return of spontaneous circulation (ROSC) and functional survival. Methods: We undertook a prospective observational investigation of adult OHCA patients treated by a first-responder EMS agency in King County, WA. Cerebral oximetry was performed using the SenSmart® Model X-100 Universal Oximetry System (Nonin Medical, Inc). We determined cerebral oximetry rSO2 overall and stratified according to ROSC and favorable survival status defined by Cerebral Performance Category (CPC) of 1-2. Results: Among the 59 OHCA cases enrolled, 47% (n = 28) achieved ROSC and 14% (n = 8) survived with CPC 1-2. On average, initial rSO2 cerebral oximetry was 41% and was not different at the outset according to return of spontaneous circulation (ROSC) or survival status. Within 5 minutes of first responder resuscitation, those who would subsequently achieve ROSC had a higher rSO2 than those who would not achieve ROSC (51% vs. 43%, p = 0.03). Among patients who achieved ROSC, those who would survive with CPC 1-2 had a higher rSO2 cerebral oximetry following ROSC than nonsurvivors (74% vs. 60%, p = 0.04 at 5 minutes post ROSC), a difference that was not evident in the minutes prior to ROSC (55% vs. 51% at 3 minutes prior to ROSC, p = 0.5). Conclusion: In this observational study, where first responders applied cerebral oximetry, higher rSO2 during the course of care predicted ROSC among all patients and predicted favorable survival among those who achieved ROSC. Future investigation should evaluate whether and how treatments might modify rSO2 and in turn may influence prognosis.

Neurocognitive and Muscular Capacities Are Associated with Frailty in Adults with Cirrhosis.

BACKGROUND: Frailty is common in cirrhosis and associated with mortality, hospitalization, and reduced quality of life. Interventions aimed at forestalling frailty are limited by a lack of understanding of underlying physiologic deficits. AIMS: This study's aim was to examine contributions of discrete sensorimotor and neurocognitive capacities to conventional frailty measures of unipedal stance time, chair stands, and grip strength. METHODS: This cross-sectional study enrolled 119 outpatients with cirrhosis (50% female, aged 62.9 ± 7.3 years). Capacities included sensory (lower limb sensation and visual contrast), neurocognitive (Number Connection Tests A and B, simple and recognition reaction time), and muscular (hip/core strength determined by lateral plank time (LPT)). Bivariate analyses and linear regression models were performed to identify significant contributors to each frailty measure. RESULTS: The average performance was 9.8 ± 3.9 chair stands, 12.7 s ±9.9 unipedal stance time, and 60.3 ± 25.6 lb grip strength. In multivariate models, factors explained 40% of variance in unipedal stance and 43% of variance in chair stands. The LPT was most strongly associated with unipedal stance and chair stands. Grip strength was associated with LPT, but did not have physiologic predictors. CONCLUSIONS: Clinically useful measures of frailty in adults with cirrhosis can be explained by disease severity but also deficits in strength and neurocognitive function. Recognition reaction time, a novel measure in cirrhosis, had a significant contribution to frailty. These findings have implications for frailty assessment and suggest that the optimal rehabilitation approach to frailty targets neurocognitive function in addition to strengthening.

Reliability and Validity of Patient-Reported, Rater-Based, and Hybrid Physical Activity Assessments in COPD: A Systematic Review.

Selecting valid and reliable PA assessments in chronic obstructive pulmonary disease (COPD) is crucial to ensure that the information obtained is accurate, valuable, and meaningful. The purpose of this systematic review was to compare the validity and reliability among PA assessments in COPD. An electronic database search of PubMed and CINAHL was completed in December 2019 using MeSH terms on physical activity, COPD, validation, and questionnaires. Transparency in reporting was assessed with the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) checklist while methodological quality was assessed with the modified Quality Appraisal tool for Reliability studies (QAREL) for reliability studies and the Quality Appraisal of Validity Studies (QAVALS) for validity studies. The search yielded fifteen different measures. The Stanford 7-day recall (PAR) demonstrated the strongest correlations with SenseWear Armband on energy expenditure (r = 0.83; p < 0.001) and moderate correlations for time spent in activity over 3 METs (r = 0.54, p < 0.001). The Multimedia Activity Recall (MARCA) also demonstrated moderate to good correlations with both SenseWear and Actigraph GT3X + accelerometers (r = 0.66-0.74). Assisted and computerized PRO measures (PAR and MARCA) and hybrid measures (C-PPAC and D-PPAC) demonstrate better psychometric properties as compared to other subjective measures and may be considered for quantification of PA in COPD. However, observations drawn from single validation studies limit strength of recommendations and further research is needed to replicate the findings.

Why Do Individuals with Cirrhosis Fall? A Mechanistic Model for Fall Assessment, Treatment, and Research.

Falls are prevalent for people with cirrhosis and commonly lead to loss of independence, reduced quality of life, and mortality. Despite a critical need for fall prevention in this population, cirrhosis-specific fall-related mechanisms are not well understood. We posit that most falls in this patient population are due to a coalescence of discrete subclinical impairments that are not typically detected at the point of care. The combined effect of these subtle age- and disease-related neurocognitive and muscular impairments leads to the inability to respond successfully to a postural perturbation within the available 300 to 400 ms. This article provides a conceptual model of physiological resilience to avoid a fall that focuses on attributes that underlie the ability to withstand a postural perturbation and their clinical evaluation. Evidence supporting this model in cirrhosis and other high fall risk conditions will be synthesized and suggestions for fall assessment and treatment will be discussed.

Strategy to Address Private Location Cardiac Arrest: A Public Safety Survey.

OBJECTIVE: Most cardiac arrests occur in the private setting where response is often delayed and outcomes are poor. We surveyed public safety personnel to determine if they would volunteer to respond into private locations and/or be equipped with a personal automated external defibrillator (AED) as part of a vetted responder program that would use smart geospatial technology. METHODS: We conducted an anonymized survey among personnel from fire-based emergency medical services (EMS) and search and rescue organizations from Washington State. The goal of the survey was to evaluate whether there was interest among cardiopulmonary resuscitation (CPR)-trained, public safety personnel to respond with or without an AED to private-residence cardiac arrest outside of working hours using a smartphone platform. We used a 5-point Likert scale to assess responses. RESULTS: Overall the response rate was 73.7% (527/715). Two-thirds of respondents were between the ages of 30-59 with a similar proportion certified as a firefighter-emergency medical technician (EMT). Most were male (80%). As a vetted volunteer responder, the majority would "almost always" or "often" respond to private (79.7%) or public locations (85.2%) outside of work hours. The majority (54.1%) would store the AED in their vehicle while 38% would plan to keep the AED on their person. A total of 83% were "definitely' or "probably interested" in participating in the program. CONCLUSION: The results of this survey indicate that public safety personnel are willing to respond to suspected cardiac arrest during off-hours using geospatial smart technology to private locations with or without an AED.

Ventricular fibrillation waveform measures combined with prior shock outcome predict defibrillation success during cardiopulmonary resuscitation.

AIM: Amplitude Spectrum Area (AMSA) and Median Slope (MS) are ventricular fibrillation (VF) waveform measures that predict defibrillation shock success. Cardiopulmonary resuscitation (CPR) obscures electrocardiograms and must be paused for analysis. Studies suggest waveform measures better predict subsequent shock success when combined with prior shock success. We determined whether this relationship applies during CPR. METHODS: AMSA and MS were calculated from 5-second pre-shock segments with and without CPR, and compared to logistic models combining each measure with prior return of organized rhythm (ROR). RESULTS: VF segments from 692 patients were analyzed during CPR before 1372 shocks and without CPR before 1283 shocks. Combining waveform measures with prior ROR increased areas under receiver operating characteristic curves for AMSA/MS with CPR (0.66/0.68 to 0.73/0.74, p<0.001) and without CPR (0.71/0.72 to 0.76/0.76, p<0.001). CONCLUSIONS: Prior ROR improves prediction of shock success during CPR, and may enable waveform measure calculation without chest compression pauses.

The influence of ageism, experience, and relationships with older adults on physical therapy students' perception of geriatrics.

INTRODUCTION: Increased exposure to geriatrics throughout a student's professional education has been reported to improve the desire to work in this area; however, factors that influence the perception of geriatric physical therapy may prohibit students from actively seeking those experiences. PURPOSE: The purpose of this study was to examine the perceptions of geriatric physical therapy by first-year graduate physical therapy students. DESIGN: A qualitative case study research approach was performed. METHOD: Three focus groups were completed using students enrolled in their second semester of a graduate-level physical therapy program. Dialogue was reviewed and coded by three raters. Twenty-five subcategories of open-coding terms were triangulated and grouped into 4 themes via axial coding. RESULTS: Four themes emerged: (1) ageism exists in health care, (2) personal and professional experiences serve as a framework for students' perception of geriatrics, (3) interpersonal relationships formed within geriatric practice are highly valued, and (4) additional contextual barriers exist in geriatrics. CONCLUSIONS: To meet the needs of a highly skilled geriatric workforce, students should participate in enhanced geriatric experiences in didactic coursework as well as within interprofessional geriatric clinics throughout their education.

Selenide Targets to Reperfusing Tissue and Protects It From Injury.

OBJECTIVES: Since blood selenium levels decrease after ischemia and reperfusion injury, and low blood selenium correlates with negative outcome, we designed and performed experiments to determine how selenium distribution is affected by ischemia reperfusion injury. Furthermore, we tested whether different chemical forms of selenium would affect outcome after ischemia and reperfusion injury. We also examined the metabolic effects of selenide administration. DESIGN: Laboratory investigation. SETTING: Animal research laboratory. SUBJECTS: Adult male C57BL/6 mice. INTERVENTIONS: To determine selenium localization, we administered tracer doses of radioactive selenium 75 in the form of selenite or selenide and measured blood and tissue selenium levels after ischemia and reperfusion injury. Anesthetized mice were subjected to myocardial ischemia reperfusion injury (coronary artery occlusion for 60 min followed by 5 min of reperfusion after occlusion was removed) or hindlimb ischemia reperfusion injury (left leg tourniquet for 90 min followed by 5 min reperfusion after tourniquet removal). To determine whether exogenous selenium administration could reduce ischemia reperfusion injury, we synthesized and administered sodium hydroselenide and sodium selenite solutions (0.05-2.4 mg/kg). Solutions were administered at the end of coronary artery occlusion but before reperfusion. In order to determine the metabolic effects of selenide administration, we exposed mice to hydrogen selenide gas (0-5 ppm) mixed into air (20.95% oxygen) for up to 3 hours. MEASUREMENTS AND MAIN RESULTS: In targeting assays, we measured blood and tissue selenium levels. We observed that blood selenium decreases after myocardial ischemia reperfusion and displays an inverse correlation with injury severity; selenium accumulation in heart correlates directly with injury severity. We also measured whether oxidized selenium, selenite, and reduced selenium, selenide, would target to injured heart tissue in myocardial ischemia reperfusion and injured leg muscle in a hindlimb model of ischemia reperfusion. Only selenide targets to injured tissue. We also measured damage after myocardial ischemia reperfusion injury using morphometry, neutrophil accumulation, blood cardiac troponin levels, and echocardiography and observed in all assays that selenide reduced damage to the heart; selenite was not effective. And finally, to assay metabolism, we measured oxygen consumption, carbon dioxide production, and body core temperature before, during, and after hydrogen selenide administration. All measurements indicate that selenide decreases metabolism. CONCLUSIONS: Selenide targets to reperfusing tissue and reduces reperfusion injury perhaps by affecting oxygen metabolism.

Impact of changes in resuscitation practice on survival and neurological outcome after out-of-hospital cardiac arrest resulting from nonshockable arrhythmias.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) claims millions of lives worldwide each year. OHCA survival from shockable arrhythmias (ventricular fibrillation/ tachycardia) improved in several communities after implementation of American Heart Association resuscitation guidelines that eliminated "stacked" shocks and emphasized chest compressions. "Nonshockable" rhythms are now the predominant presentation of OHCA; the benefit of such treatments on nonshockable rhythms is uncertain. METHODS AND RESULTS: We studied 3960 patients with nontraumatic OHCA from nonshockable initial rhythms treated by prehospital providers in King County, Washington, over a 10-year period. Outcomes during a 5-year intervention period after adoption of new resuscitation guidelines were compared with the previous 5-year historical control period. The primary outcome was 1-year survival. Patient demographics and resuscitation characteristics were similar between the control (n=1774) and intervention (n=2186) groups, among whom 471 of 1774 patients (27%) versus 742 of 2186 patients (34%), respectively, achieved return of spontaneous circulation; 82 (4.6%) versus 149 (6.8%) were discharged from hospital, 60 (3.4%) versus 112 (5.1%) with favorable neurological outcome; 73 (4.1%) versus 135 (6.2%) survived 1 month; and 48 (2.7%) versus 106 patients (4.9%) survived 1 year (all P≤0.005). After adjustment for potential confounders, the intervention period was associated with an improved odds of 1.50 (95% confidence interval, 1.29-1.74) for return of spontaneous circulation, 1.53 (95% confidence interval, 1.14-2.05) for hospital survival, 1.56 (95% confidence interval, 1.11-2.18) for favorable neurological status, 1.54 (95% confidence interval, 1.14-2.10) for 1-month survival, and 1.85 (95% confidence interval, 1.29-2.66) for 1-year survival. CONCLUSION: Outcomes from OHCA resulting from nonshockable rhythms, although poor by comparison with shockable rhythm presentations, improved significantly after implementation of resuscitation guideline changes, suggesting their potential to benefit all presentations of OHCA.

Associations Between Cognitive Function, Balance, and Gait Speed in Community-Dwelling Older Adults with COPD.

BACKGROUND AND PURPOSE: Older adults with chronic obstructive pulmonary disease (COPD) are at risk for physical and cognitive impairment. Cognitive function is associated with falls in older adults. However, it is unknown whether a relationship exists between cognitive function and falls in patients with COPD. The aim of this study was to examine the relationships between cognitive function, balance, and gait speed in older adults with COPD. PATIENTS AND METHODS: A secondary analysis was performed using data from the 2010 wave of the Health and Retirement Study (HRS). Cognitive (immediate and delayed recall, executive function) and physical (gait speed, tandem balance time) measure data were extracted for older adults with COPD (n = 382) and an age-matched control group without COPD (n = 382) who met inclusion/exclusion criteria. Multivariate linear regression modeling was performed to examine associations between cognitive function and mobility or balance while controlling for age, gender, body mass index, grip strength, and education. RESULTS: In older adults with COPD, delayed recall was significantly associated with tandem balance performance (ß= 1.42, P < .05). Other cognitive measures were not associated with gait speed or balance. CONCLUSION: In older adults with COPD, one of four cognitive functions was associated with a static standing balance task. Screening of cognitive function, specifically delayed recall, should be a part of the management of falls in this population.

Determinants of acute care discharge in adults with chronic obstructive pulmonary disease.

CONCLUSIONS: In adults with COPD basic mobility scores on the AM-PAC "6-clicks" measure completed at discharge had the best sensitivity and specificity for predicting discharge to home and need for rehab services.

Balance performance and grip strength as predictors of cognitive function among community-dwelling older adults in the USA.

Objectives: To investigate how balance and grip strength predicts the probability of cognitive function impairment (i.e., executive function: mild and mild-to-moderate impairment, and delayed recall) over eight years in community-dwelling older adults in the US, controlling for sex and race/ethnicity. Methods: The National Health and Aging Trends Study dataset (2011 - 2018) was employed. Dependent variables included the Clock Drawing Test (Executive Function) and Delayed Word Recall Test. Longitudinal ordered logistic regression examined the association between cognitive function and predictors (i.e., balance and grip strength) over eight waves (n=9800, 1,225 per wave). Results: Those who could complete side-by-side standing and semi-tandem tasks were 33% and 38% less likely to have mild or mild-to-moderate executive function impairment, respectively, relative to those who could not complete these tests. One score decrease in grip strength increased the executive function impairment risk by 13% (Odds Ratio: 0.87, CI: 0.79-0.95). Those who completed the side-by-side tasks were 35% (Odds Ratio: 0.65, CI: 0.44-0.95) less likely to experience delayed recall impairments than those who could not complete this test. With one score decrease in grip strength, the risk of delayed recall impairment was increased by 11% (OR: 0.89, CI: 0.80-1.00). Conclusions: A combination of these two simple tests (i.e., semi-tandem stance and grip strength) can screen for cognitive impairment among community-dwelling older adults to identify people with mild and mild-to-moderate cognitive impairment in clinical settings.

Age, sex, and survival following ventricular fibrillation cardiac arrest: A mechanistic evaluation of the ECG waveform.

BACKGROUND: Studies of outcome differences by sex in out-of-hospital cardiac arrest (OHCA) have produced mixed results that may depend on age, a potential surrogate for menopausal status. OBJECTIVE: We used quantitative measures of ventricular fibrillation (VF) waveforms - indicators of the myocardium's physiology - to assess whether survival differences according to sex and age group may be mediated via a biologic mechanism. METHODS: We conducted a cohort study of VF-OHCA in a metropolitan EMS system. We used multivariable logistic regression to assess the association of survival to hospital discharge with sex and age group (<55, ≥55 years). We determined the proportion of outcome difference mediated by VF waveform measures: VitalityScore and amplitude spectrum area (AMSA). RESULTS: Among 1526 VF-OHCA patients, the average age was 62 years, and 29% were female. Overall, younger women were more likely to survive than younger men (survival 67% vs 54%, p = 0.02), while survival among older women and older men did not differ (40% vs 44%, p = 0.3). Adjusting for Utstein characteristics, women <55 compared to men <55 had greater odds of survival to hospital discharge (OR = 1.93, 95% CI 1.23-3.09), an association not observed between the ≥55 groups. Waveform measures were more favorable among women and mediated some of the beneficial association between female sex and survival among those <55 years: 47% for VitalityScore and 25% for AMSA. CONCLUSIONS: Women <55 years were more likely to survive than men <55 years following VF-OHCA. The biologic mechanism represented by VF waveform mediated some, though not all, of the outcome difference.

THE COMPENSATORY RESERVE INDEX FOR PREDICTING HEMORRHAGIC SHOCK IN PREHOSPITAL TRAUMA.

ABSTRACT: Background: The compensatory reserve index (CRI) is a noninvasive, continuous measure designed to detect intravascular volume loss. CRI is derived from the pulse oximetry waveform and reflects the proportion of physiologic reserve remaining before clinical hemodynamic decompensation. Methods: In this prospective, observational, prehospital cohort study, we measured CRI in injured patients transported by emergency medical services (EMS) to a single Level I trauma center. We determined whether the rolling average of CRI values over 60 s (CRI trend [CRI-T]) predicts in-hospital diagnosis of hemorrhagic shock, defined as blood product administration in the prehospital setting or within 4 h of hospital arrival. We hypothesized that lower CRI-T values would be associated with an increased likelihood of hemorrhagic shock and better predict hemorrhagic shock than prehospital vital signs. Results: Prehospital CRI was collected on 696 adult trauma patients, 21% of whom met our definition of hemorrhagic shock. The minimum CRI-T was 0.14 (interquartile range [IQR], 0.08-0.31) in those with hemorrhagic shock and 0.31 (IQR 0.15-0.50) in those without ( P = <0.0001). The positive likelihood ratio of a CRI-T value <0.2 predicting hemorrhagic shock was 1.85 (95% confidence interval [CI], 1.55-2.22). The area under the ROC curve (AUC) for the minimum CRI-T predicting hemorrhagic shock was 0.65 (95% CI, 0.60-0.70), which outperformed initial prehospital HR (0.56; 95% CI, 0.50-0.62) but underperformed EMS systolic blood pressure and shock index (0.74; 95% CI, 0.70-0.79 and 0.72; 95% CI, 0.67-0.77, respectively). Conclusions: Low prehospital CRI-T predicts blood product transfusion by EMS or within 4 hours of hospital arrival but is less prognostic than EMS blood pressure or shock index. The evaluated version of CRI may be useful in an austere setting at identifying injured patients that require the most significant medical resources. CRI may be improved with noise filtering to attenuate the effects of vibration and patient movement.