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Hyperglycemia is commonly observed in critically ill patients and postcardiac arrest patients, with higher glucose levels and variability associated with poorer outcomes. In this study, we aim to compare glucose control in diabetic and nondiabetic patients using glycated hemoglobin (HbA1c) levels, providing insights for better glucose management strategies. This retrospective observational study was conducted at Seoul St. Mary's Hospital from February 2009 to May 2022. Blood glucose levels were measured hourly for 48 h after return of spontaneous circulation (ROSC), and a glucose management protocol was followed to maintain arterial blood glucose levels between 140 and 180 mg/dL using short-acting insulin infusion. Patients were categorized into four groups based on diabetes status and glycemic control. The primary outcomes assessed were neurological outcome and mortality at 6 months after cardiac arrest. Among the 332 included patients, 83 (25.0%) had a previous diabetes diagnosis, and 114 (34.3%) had an HbA1c of 6.0% or higher. At least one hyperglycemic episode was observed in 314 patients (94.6%) and hypoglycemia was found in 63 patients (19.0%) during 48 h. After the categorization, unrecognized diabetes was noticed in 51 patients with median HbA1c of 6.3% (interquartile range [IQR] 6.1-6.6). Patients with inadequate diabetes control had the highest initial HbA1c level (7.0%, IQR 6.5-7.8) and admission glucose (314 mg/dL, IQR 257-424). Median time to target glucose in controlled diabetes was significantly shorter with the slowest glucose reducing rate. The total insulin dose required to reach the target glucose level and cumulative insulin requirement during 48 h were different among the categories (p <0.001). Poor neurological outcomes and mortality were more frequently observed in patients with diagnosed diabetes. Occurrence of a hypoglycemic episode during the 48 h after ROSC was independently associated with poor neurologic outcomes (odds ratio [OR] 3.505; 95% confidence interval [CI], 2.382-9.663). Surviving patients following cardiac arrest exhibited variations in glucose hemodynamics and outcomes according to the categories based on their preexisting diabetes status and glycemic condition. Specifically, even experiencing a single episode of hypoglycemia during the acute phase could have an influence on unfavorable neurological outcomes. While the classification did not directly affect neurological outcomes, the present results indicate the need for a customized approach to glucose control based on these categories.
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Diabetes Mellitus , Paro Cardíaco , Hipoglucemia , Hipotermia Inducida , Humanos , Glucemia , Hemoglobina Glucada , Insulina , Hipoglucemia/tratamiento farmacológico , Paro Cardíaco/tratamiento farmacológico , Hipoglucemiantes/uso terapéuticoRESUMEN
INTRODUCTION: The role of lactate measurement in out-of-hospital cardiac arrest (OHCA) survivors remains controversial. We assessed the association between early lactate-related variables, OHCA characteristics, and long-term neurological outcome. METHODS: In OHCA patients who received targeted temperature management, lactate levels were measured at 0, 12, and 24 h after the return of spontaneous circulation. We calculated lactate clearance and time-weighted cumulative lactate (TWCL), which represent the area under the time-lactate curve. The area under the receiver operating characteristic curve (AUC) and the adjusted odds ratios (AORs) of lactate-related variables for predicting 6-month poor outcome (Cerebral Performance Category 3-5) were evaluated. Interactions between lactate variables and characteristics of OHCA were evaluated by a multivariable logistic model with interaction terms and subgroup analysis. RESULTS: A total of 347 OHCA patients were included. After adjustment, higher lactate levels at the three time points were associated with a poor outcome (AOR 1.10 [95% CI, 1.03-1.18], AOR 1.15 [95% CI, 1.02-1.29], and AOR 1.36 [95% CI, 1.15-1.60], respectively), while TWCL was the only lactate kinetics variable associated with a poor outcome (AOR 1.29 [95% CI, 1.12-1.49]). We identified several interactions between lactate-related variables and OHCA characteristics. In particular, the AUC of TWCL was excellent in cases of noncardiac etiology (AUC 0.92 [95% CI, 0.86-0.96] but only moderate in cardiac etiology (AUC 0.69 [95% CI, 0.62-0.75]). CONCLUSIONS: Early lactate levels, especially at 24 h, and TWCL were independent predictors of neurologic outcome in these patients, whereas lactate clearance was not. The prognostic ability of lactate-related variables varied depending on the OHCA characteristics.
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Reanimación Cardiopulmonar , Hipotermia Inducida , Paro Cardíaco Extrahospitalario , Humanos , Ácido Láctico , Paro Cardíaco Extrahospitalario/terapia , Paro Cardíaco Extrahospitalario/complicaciones , Pronóstico , Modelos LogísticosRESUMEN
Prognostication studies of cardiac arrest patients have mainly focused on poor neurological outcomes. However, an optimistic prognosis for good outcome could provide both justification to maintain and escalate treatment and evidence-based support to persuade family members or legal surrogates after cardiac arrest. The aim of the study was to evaluate the utility of clinical examinations performed after return of spontaneous circulation (ROSC) in predicting good neurological outcomes in out-of-hospital cardiac arrest (OHCA) patients treated with targeted temperature management (TTM). This retrospective study included OHCA patients treated with TTM from 2009 to 2021. Initial clinical examination findings related to the Glasgow coma scale (GCS) motor score, pupillary light reflex, corneal reflex (CR) and breathing above the set ventilator rate were assessed immediately after ROSC and before the initiation of TTM. The primary outcome was good neurological outcome at 6 months after cardiac arrest. Of 350 patients included in the analysis, 119 (34%) experienced a good neurological outcome at 6 months after cardiac arrest. Among the parameters of the initial clinical examinations, specificity was the highest for the GCS motor score, and sensitivity was the highest for breathing above the set ventilator rate. A GCS motor score of >2 had a sensitivity of 42.0% (95% confidence interval [CI] = 33.0-51.4) and a specificity of 96.5% (95% CI = 93.3-98.5). Breathing above the set ventilator rate had a sensitivity of 84.0% (95% CI = 76.2-90.1) and a specificity of 69.7% (95% CI = 63.3-75.6). As the number of positive responses increased, the proportion of patients with good outcomes increased. Consequently, 87.0% of patients for whom all four examinations were positive experienced good outcomes. As a result, the initial clinical examinations predicted good neurological outcomes with a sensitivity of 42.0-84.0% and a specificity of 69.7-96.5%. When more examinations with positive results are achieved, a good neurological outcome can be expected.
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Reanimación Cardiopulmonar , Hipotermia Inducida , Paro Cardíaco Extrahospitalario , Humanos , Hipotermia Inducida/métodos , Pronóstico , Estudios Retrospectivos , Paro Cardíaco Extrahospitalario/diagnóstico , Paro Cardíaco Extrahospitalario/terapia , Escala de Coma de Glasgow , Reanimación Cardiopulmonar/métodosRESUMEN
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.
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Comprehensive prediction of urolithiasis using available factors obtained in the emergency department may aid in patient-centered diagnostic imaging decisions. This retrospective study analyzed the clinical factors, blood chemistry and urine parameters of patients who underwent nonenhanced urinary computed tomography for suspected urolithiasis. A scoring system was developed from a logistic regression model and was tested using the area under the curve (AUC). The prevalence of urolithiasis and important possible causes in the three risk subgroups were determined. Finally, the scoring model was validated. In the derivation cohort (n = 673), 566 patients were diagnosed with urolithiasis. Age > 35 years, history of urolithiasis, pain duration < 8 h, nausea/vomiting, costovertebral angle tenderness, serum creatinine ≥ 0.92 mg/dL, erythrocytes ≥ 10/high power field, no leukocytes ≤ + , and any crystalluria were retained in the final multivariable model and became part of the score. This scoring model demonstrated good discrimination (AUC 0.808 [95% CI, 0.776-0.837]). In the validation cohort (n = 336), the performance was similar (AUC 0.803 [95% CI, 0.756-0.844]), surpassing that of the STONE score (AUC 0.654 [95% CI, 0.601-0.705], P < 0.001). This scoring model successfully stratified patients according to the probability of urolithiasis. Further validation in various settings is needed.
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Líquidos Corporales , Urolitiasis , Humanos , Adulto , Estudios Retrospectivos , Urinálisis , Urolitiasis/diagnóstico , Urolitiasis/epidemiología , Área Bajo la CurvaRESUMEN
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.
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Hipotermia Inducida , Paro Cardíaco Extrahospitalario , Humanos , Pronóstico , Biomarcadores , Paro Cardíaco Extrahospitalario/complicaciones , Paro Cardíaco Extrahospitalario/terapia , Proteínas S100RESUMEN
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.
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Lesiones Encefálicas , Paro Cardíaco Extrahospitalario , Humanos , Mortalidad Hospitalaria , Estudios Retrospectivos , Paro Cardíaco Extrahospitalario/terapia , PronósticoRESUMEN
BACKGROUND: During cardiac arrest (CA) and after cardiopulmonary resuscitation, activation of blood coagulation and inadequate endogenous fibrinolysis occur. The aim of this study was to describe the time course of coagulation abnormalities after out-of-hospital CA (OHCA) and to examine the association with clinical outcomes in patients undergoing targeted temperature management (TTM) after OHCA. METHODS: This prospective, multicenter, observational cohort study was performed in eight emergency departments in Korea between September 2018 and September 2019. Laboratory findings from hospital admission and 24 hours after return of spontaneous circulation (ROSC) were analyzed. The primary outcome was cerebral performance category (CPC) at discharge, and the secondary outcome was in-hospital mortality. RESULTS: A total of 170 patients were included in this study. The lactic acid, prothrombin time (PT), activated partial thrombin time (aPTT), international normalized ratio (INR), and D-dimer levels were higher in patients with poor neurological outcomes at admission and 24 h after ROSC. The lactic acid and D-dimer levels decreased over time, while fibrinogen increased over time. PT, aPTT, and INR did not change over time. The PT at admission and D-dimer levels 24 h after ROSC were associated with neurological outcomes at hospital discharge. Coagulation-related factors were moderately correlated with the duration of time from collapse to ROSC. CONCLUSION: The time-dependent changes in coagulation-related factors are diverse. Among coagulation-related factors, PT at admission and D-dimer levels 24 h after ROSC were associated with poor neurological outcomes at hospital discharge in patients treated with TTM.
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Reanimación Cardiopulmonar , Paro Cardíaco Extrahospitalario , Humanos , Resultado del Tratamiento , Estudios Prospectivos , Coagulación Sanguínea , Ácido LácticoRESUMEN
PURPOSE: Using simulation in continuing professional development (CPD) courses for local practitioners is uncommon in Korea. The aim of our study was to evaluate the responses of the local practitioners for a simulation-based short CPD course. METHODS: Following the targeted needs assessment of local practitioners, we developed and implemented a 3-hour simulation-based CPD course for the first 5 minutes of cardiac arrest in the resource-limited local clinics. We evaluated the participant's responses to the course using a questionnaire. RESULTS: During the 3-year implementation period, 115 practitioners participated in 10 courses, and 113 (98%) responded to the questionnaire. The overall course satisfaction (10-point scale) was very positive (10 in 93 [82.3%], 9 in 19 [16.8%], and 8 in 1 [0.8%]). The level (5-point scale) of recommendation to the others was also high (5 in 103 [91.2%] and 4 in 10 [8.8%]). Many participants positively commented on the authentic practical experience of the uncommon crisis in their contexts. CONCLUSION: A simulation-based short CPD course for in-hospital cardiac arrest could provide an authentic practical experience for local practitioners working in resource-limited clinics.
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Paro Cardíaco , Humanos , República de Corea , Evaluación de NecesidadesRESUMEN
BACKGROUND: Among comatose survivors of out-of-hospital cardiac arrest (OHCA), targeted temperature management (TTM) has improved neurological outcomes. However, although the target temperature shifted from 33°C to 33°C~36°C, the optimal target temperature is still unclear. The goal of this study was to evaluate neurological outcomes at 6 months at target temperatures of 33°C and 36°C. MATERIALS AND METHODS: We analyzed OHCA survivors who underwent TTM and were recorded in the Korean Hypothermia Network, a prospective multicenter registry, from October 2015 to December 2018. The primary outcome was good neurological outcome at six months, defined as a cerebral performance category of 1-2, and the secondary outcome was survival at 6 months. RESULTS: A total of 1339 patients were treated with TTM in twenty-two emergency departments. Of those, 1054 were treated at 33°C, and 285 were treated at 36°C. There was no significant difference in good neurological outcomes at 6 months (30.6% vs. 31.2%, p = 0.850, adjusted OR 0.97, 95% CI = 0.73-1.29]) and survival at six months (41.4% vs. 38.7%, p = 0.401, adjusted HR 1.08, 95% CI = 0.91-1.28]) between TTM 33°C and TTM 36°C. After propensity score matching, good neurological outcomes at 6 months (OR 0.93, 95% CI = 0.74-1.18) and survival at 6 months (HR 1.05, 95% CI = 0.92-1.21) were still not associated with TTM 33°C and TTM 36°C. CONCLUSION: In this study, patients treated with a target temperature of 33°C had similar good neurological outcomes and survival at six months compared with those treated with a target temperature of 36°C.
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Reanimación Cardiopulmonar , Hipotermia Inducida , Paro Cardíaco Extrahospitalario , Humanos , Hipotermia Inducida/efectos adversos , Estudios Prospectivos , Sistema de Registros , TemperaturaRESUMEN
We analyzed the prognostic performance of optic nerve sheath diameter (ONSD) on thin-slice (0.6 mm) brain computed tomography (CT) reconstruction images as compared to routine-slice (4 mm) images. We conducted a retrospective analysis of brain CT images taken within 2 h after cardiac arrest. The maximal ONSD (mONSD) and optic nerve sheath area (ONSA) were measured on thin-slice images, and the routine ONSD (rONSD) and gray-to-white matter ratio (GWR) were measured on routine-slice images. We analyzed their area under the receiver operator characteristic curve (AUC) and the cutoff values for predicting a poor 6-month neurological outcome (a cerebral performance category score of 3-5). Of the 159 patients analyzed, 113 patients had a poor outcome. There was no significant difference in rONSD between the outcome groups (p = 0.116). Compared to rONSD, mONSD (AUC 0.62, 95% CI: 0.54-0.70) and the ONSA (AUC 0.63, 95% CI: 0.55-0.70) showed better prognostic performance and had higher sensitivities to determine a poor outcome (mONSD, 20.4% [95% CI, 13.4-29.0]; ONSA, 16.8% [95% CI, 10.4-25.0]; rONSD, 7.1% [95% CI, 3.1-13.5]), with specificity of 95.7% (95% CI, 85.2-99.5). A combined cutoff value obtained by both the mONSD and GWR improved the sensitivity (31.0% [95% CI, 22.6-40.4]) of determining a poor outcome, while maintaining a high specificity. In conclusion, rONSD was clinically irrelevant, but the mONSD had an increased sensitivity in cutoff having acceptable specificity. Combination of the mONSD and GWR had an improved prognostic performance in these patients.
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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.
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COVID-19 , Enfermedades Cardiovasculares , Trastornos Cerebrovasculares , COVID-19/epidemiología , Enfermedades Cardiovasculares/epidemiología , Trastornos Cerebrovasculares/epidemiología , Servicio de Urgencia en Hospital , Humanos , Pandemias , Estudios Retrospectivos , SARS-CoV-2RESUMEN
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.
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Reanimación Cardiopulmonar , Hipotermia Inducida , Paro Cardíaco Extrahospitalario , Adulto , Índice de Masa Corporal , Temperatura Corporal , Humanos , Hipotermia Inducida/efectos adversos , Estudios Prospectivos , Estudios Retrospectivos , Sobrevivientes , Delgadez/etiologíaRESUMEN
OBJECTIVE: The surgical method for treating spontaneous intracranial hemorrhage (ICH) is not well established despite ICH's high prevalence and poor prognosis. Minimally invasive surgery has recently received attention; however, literature on this method is scarce. In particular, the appropriate location of the catheter in the hematoma has not been described. We examined whether the catheter position affects the hematoma reduction in a hematoma ï¼50 cc. METHODS: We investigated the prognoses of 36 patients with ICH who underwent stereotactic aspiration and hematoma drainage using urokinase from January 2010 to December 2018 and the hematoma reduction rates according to the tube position. Two methods evaluated the position of the catheter. In the first method, the hematoma was an imaginary sphere. The center point was set as the operation target. We evaluated the catheter position by determining whether it was in the deep part or the outer part of the half point from that location to the hematoma margin. In the second method, we evaluated whether the catheter was located 1 cm inside the hematoma margin. RESULTS: In both the first and second evaluations, there were no differences in age, midline shift, intraventricular hemorrhage status, hematoma volume on admission, Glasgow Coma Scale score on admission, time to operation after symptom onset, and systolic blood pressure. The rates of decrease in bleeding and the prognoses were also not significantly different. CONCLUSIONS: If the catheter is in the hematoma, the rate of hematoma reduction at any position is similar.
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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.
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Paro Cardíaco , Hipotermia Inducida , Tronco Encefálico , Potenciales Evocados , Potenciales Evocados Auditivos , Potenciales Evocados Somatosensoriales , Potenciales Evocados Visuales , Paro Cardíaco/terapia , Humanos , PronósticoRESUMEN
Obesity is associated with autoimmunity, a phenomenon considered as harmful. Here we show that obese mice and humans produce IgG-type autoantibodies that specifically recognize apolipoprotein B-100 (ApoB100), its native epitope p210, and the synthetic p210 mimotope pB1. By contrast, antibodies against epitopes p45 and p240, which have been associated with atherosclerosis, were not detected in either the humans or mice. In a longitudinal analysis of high fat diet-fed mice, autoantibody production rose with increasing body weight, then decreased and plateaued at morbid obesity. Likewise, in a cross-sectional analysis of sera from 148 human volunteers spanning a wide BMI range and free of comorbidities, the immunoreactivity increased and then decreased with increasing BMI. Thus, the obesity-related ApoB100-specific natural autoantibodies characteristically showed the same epitope recognition, IgG-type, and biphasic serum levels in humans and mice. We previously reported that a pB1-based vaccine induces similar antibodies and can prevent obesity in mice. Therefore, our present results suggest that autoantibodies directed against native ApoB100 may mitigate obesity, and that the vaccination approach may be effective in humans.
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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.
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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.
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Servicio de Urgencia en Hospital , Mortalidad Hospitalaria , Linfocitos , Neutrófilos , Anciano , Femenino , Humanos , Recuento de Leucocitos , Masculino , Estudios Retrospectivos , Factores de RiesgoRESUMEN
BACKGROUND: Prognostication after cardiac arrest (CA) needs a multimodal approach, but the optimal method is not known. We tested the hypothesis that the combination of neuron-specific enolase (NSE) and neuroimaging could improve outcome prediction after CA treated with targeted temperature management (TTM). METHODS: A retrospective observational cohort study was performed on patients who underwent at least one NSE measurement between 48 and 72 hr; received both a brain computed tomography (CT) scan within 24 hr and diffusion-weighted magnetic resonance imaging (DW-MRI) within 7 days after return of spontaneous circulation (ROSC); and were treated with TTM after out-of-hospital CA between 2009 and 2017 at the Seoul St. Mary's Hospital in Korea. The primary outcome was a poor neurological outcome at 6 months after CA, defined as a cerebral performance category of 3-5. RESULTS: A total of 109 subjects underwent all three tests and were ultimately included in this study. Thirty-four subjects (31.2%) experienced good neurological outcomes at 6 months after CA. The gray matter to white matter attenuation ratio (GWR) was weakly correlated with the mean apparent diffusion coefficient (ADC), PV400 and NSE (Spearman's rho: 0.359, -0.362 and -0.263, respectively). NSE was strongly correlated with the mean ADC and PV400 (Spearman's rho: -0.623 and 0.666, respectively). Serum NSE had the highest predictive value among the single parameters (area under the curve (AUC) 0.912, sensitivity 70.7% for maintaining 100% specificity). The combination of a DWI parameter (mean ADC or PV400) and NSE had better prognostic performance than the combination of the CT parameter (GWR) and NSE. The addition of the GWR to a DWI parameter and NSE did not improve the prediction of neurological outcomes. CONCLUSION: The GWR (≤ 24 hr) is weakly correlated with the mean ADC (≤ 7 days) and NSE (highest between 48 and 72 hr). The combination of a DWI parameter and NSE has better prognostic performance than the combination of the GWR and NSE. The addition of the GWR to a DWI parameter and NSE does not improve the prediction of neurological outcomes after CA treatment with TTM.
Asunto(s)
Paro Cardíaco/diagnóstico por imagen , Paro Cardíaco/terapia , Neuroimagen , Neuronas/enzimología , Fosfopiruvato Hidratasa/metabolismo , Temperatura , Adulto , Anciano , Femenino , Sustancia Gris/diagnóstico por imagen , Sustancia Gris/patología , Sustancia Gris/fisiopatología , Paro Cardíaco/patología , Paro Cardíaco/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Tomografía Computarizada por Rayos X , Sustancia Blanca/diagnóstico por imagen , Sustancia Blanca/patología , Sustancia Blanca/fisiopatologíaRESUMEN
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.