Neuron-specific enolase (NSE) improves clinical risk scores for prediction of neurological outcome and death in cardiac arrest patients: Results from a prospective trial.

AIM: Neuron-specific enolase (NSE) increases in response to brain injury and is recommended for outcome prediction in cardiac arrest patients. Our aim was to investigate whether NSE measured at different days after a cardiac arrest and its kinetics would improve the prognostic ability of two cardiac arrest specific risk scores. METHODS: Within this prospective observational study, we included consecutive adult patients after cardiac arrest. We calculated the Out-of-hospital cardiac arrest (OHCA) score and the Cardiac Arrest Hospital Prognosis (CAHP) score upon ICU admission and measured serum NSE upon admission and days 1, 2, 3, 5 and 7. We calculated logistic regression models to study associations of scores and NSE levels with neurological outcome defined by Cerebral Performance Category (CPC) scale and in-hospital death. RESULTS: From 336 included patients, 180 (54%) survived until hospital discharge, of which 150 (45%) had a good neurological outcome. NSE at day 3 showed the highest prognostic accuracy (discrimination) for neurological outcome (area under the curve (AUC) 0.89) and in-hospital mortality (AUC 0.88). These results were robust in reclassification statistics and across different subgroups. NSE kinetics with admission levels serving as a baseline did not further improve prognostication. NSE on day 3 significantly improved discrimination of both clinical risk scores (CAHP from AUC 0.81 to 0.91; OHCA from AUC 0.79 to 0.89). CONCLUSION: NSE measured at day 3 significantly improves clinical risk scores for outcome prediction in cardiac arrest patients and may thus add to clinical decision making about escalation or withdrawal of therapy in this vulnerable patient population.

Depression and anxiety in relatives of out-of-hospital cardiac arrest patients: Results of a prospective observational study.

PURPOSE: Relatives of patients admitted to the intensive care unit (ICU) with out-of-hospital cardiac arrest (OHCA) may suffer from adverse psychological outcomes. We assessed prevalence and risk factors for depression and anxiety in such relatives 90 days after ICU admission. MATERIALS AND METHODS: This study included consecutive relatives of OHCA patients admitted to the ICU of University Hospital in Basel, Switzerland. Relatives were interviewed upon admission regarding psychosocial risk factors and satisfaction with communication. Symptoms of depression and anxiety were assessed by Hospital Anxiety and Depression Scale (HADS) 90 days after inclusion. RESULTS: Of 101 included relatives, 17% and 13% of relatives reported symptoms of depression and anxiety, respectively. Witnessing cardiopulmonary resuscitation was associated with depression (gender- and age-adjusted odds ratio [OR] 6.71; 95%CI 1.27 to 35.34; p = .025). Satisfaction with information and decision-making was associated with lower risk of depression (adjusted OR 0.95; 95%CI 0.91 to 0.99; p = .013). Unemployment (adjusted OR 10.42; 95%CI 1.18 to 92.35; p = .035) and lower perceived health status were associated with anxiety (adjusted OR 0.93; 95%CI 0.87 to 0.99; p = .025). CONCLUSIONS: Many relatives of OHCA patients report symptoms of depression and anxiety after 90 days. Improving initial care and communication may help to reduce these risks.

Effect of Bedside vs. Non-bedside Patient Case Presentation During Ward Rounds: a Systematic Review and Meta-analysis.

BACKGROUND: Ward rounds are important for communicating with patients, but it is unclear whether bedside or non-bedside case presentation is the better approach. METHODS: We conducted a comprehensive search up to July 2018 to identify randomized controlled trials (RCTs) comparing bedside and non-bedside case presentations. Data was abstracted independently by two researchers and study quality was assessed using the Cochrane Risk of Bias Tool. Our primary outcome was patient's satisfaction with ward rounds. Our main secondary outcome was patient's understanding of disease and the management plan. RESULTS: Among 1647 identified articles, we included five RCTs involving 655 participants with overall moderate trial quality. We found no difference in having low patient's satisfaction between bedside and non-bedside case presentations (risk ratio [RR], 0.85; 95% CI, 0.66 to 1.09). We also found no impact on patient's understanding of their disease and management plan (RR, 0.92; 95% CI, 0.67 to 1.28). Trial sequential analysis (TSA) indicated low power of our main analysis. DISCUSSION: We found no differences in patient-relevant outcomes between bedside and non-bedside case presentations with a lack of statistical power among current trials. There is a need for larger studies to find the optimal approach to patient case presentation during ward rounds.

Oncologist recommendation matters!-Predictors of psycho-oncological service uptake in oncology outpatients.

OBJECTIVE: Highly distressed cancer patients often do not use psycho-oncological services (POS). Research on predictors of POS uptake has mainly focused on patient-related variables and less on communication variables, so we examined the link between patient-oncologist communication (ie, talking about psychosocial distress, providing detailed information, and recommending POS) and POS uptake. METHODS: We conducted a prospective, observational study in an Oncology Outpatient Clinic in Switzerland. Predictors (ie, patient-related variables and patient's reports of the patient-oncologist communication) were assessed via semistructured interviews, and information on outpatient POS uptake was assessed after 4 months. For statistical analysis, a multivariate logistic regression was performed. RESULTS: Of 333 participants (mean age 61 years; 55% male; 54% distress thermometer ≥5), 77 (23%) had used POS during a 4-month period. Patients who reported an oncologist-recommended POS (odds ratio [OR] = 6.27, 95% confidence interval [CI] = 3.14-12.85) and those who were not sure if they had received a recommendation (OR = 4.64, 95% CI = 1.83-11.97) were more likely to attend POS than those who reported receiving no recommendation. Talking about psychosocial distress (OR = 0.74, 95% CI = 0.38-1.46) and providing detailed information about POS did not predict POS uptake (OR = 1.06, 95% CI = 0.46-2.38). CONCLUSIONS: Oncologists' expert recommendations to attend POS were strongly associated with patients' uptake of POS. The central role played by oncologists should be accounted for in stepped psycho-oncological care when POS referral pathways are defined.

Performance of clinical risk scores to predict mortality and neurological outcome in cardiac arrest patients.

AIM: Several scores are available to predict mortality and neurological outcome in cardiac arrest patients admitted to the intensive care unit (ICU). The aim of the study was to externally validate the prognostic value of four previously published risk scores. METHODS: For this observational, single-center study, we prospectively included 349 consecutive adult cardiac arrest patients upon ICU admission. We calculated two cardiac arrest specific risk scores (OHCA and CAHP) and two general severity of illness scores (APACHE II and SAPS II). The primary endpoint was in-hospital mortality. Secondary endpoints were neurological outcome at hospital discharge and 30-day mortality. RESULTS: 170 patients (49%) died until hospital discharge. All scores were independently associated with outcomes in logistic regression analysis and showed acceptable discrimination for in-hospital mortality with highest AUCs of the cardiac arrest specific risk scores (OHCA: 0.80 (95%CI 0.75-0.85) and CAHP: 0.84 (95%CI 0.79-0.88) compared to the severity of illness scores (APACHE II: 0.78 (95%CI 0.73-0.83) and SAPS II: 0.77 (95%CI 0.72-0.82). Results were robust in subgroup analysis except for worse performance in elderly patients (>75 years) and patients with respiratory cause of cardiac arrest. Results were similar for 30-days mortality and slightly higher for neurological outcome. CONCLUSIONS: This study confirms the good prognostic performance of cardiac arrest specific scores to predict mortality and neurological outcomes in cardiac arrest patients. Routine use of OHCA or CAHP score helps to objectively risk stratify these vulnerable patients and thereby may improve therapeutic decisions.

Routine blood markers from different biological pathways improve early risk stratification in cardiac arrest patients: Results from the prospective, observational COMMUNICATE study.

INTRODUCTION: Prognostication of cardiac arrest patients admitted to the intensive care unit (ICU) may influence treatment decision, but remains challenging. We evaluated the incremental usefulness of routine blood markers from different biological pathways for predicting fatal outcome and neurological deficits in cardiac arrest patients. METHODS: We prospectively included consecutive, adult cardiac arrest patients upon ICU admission. We recorded initial clinical parameters and measured blood markers of cardiac injury/stress (troponin, BNP, CK), inflammation/infection (WBC, CRP, procalcitonin) and shock (lactate, creatinine, urea). The primary and secondary endpoints were all-cause in-hospital mortality and bad neurological outcome defined by the Cerebral Performance Category (CPC) score. RESULTS: Mortality in the 321 included patients was 49% (n = 156). Procalcitonin (adjusted odds ratio 1.84, 95%CI 1.34 to 2.53, p < 0.001; AUC 0.73) and lactate (adjusted odds ratio 7.29, 95%CI 3.05 to 17.42, p < 0.001; AUC 0.70) were identified as independent prognostic factors for mortality and significantly improved discrimination of a parsimonious clinical model including resuscitation measures (no-flow time, shockable rhythm) and initial vital signs (Glasgow coma scale, respiratory rate) from an AUC of 0.79 to 0.84 (p < 0.001). Cardiac markers did not further improve the model. Results for neurological outcome were similar with model improvements by procalcitonin and lactate from AUC 0.83 to 0.87 (p = 0.004). CONCLUSION: Assessment of routine markers of inflammation/infection and shock provide significant improvements for prognostication of cardiac arrest patients, while cardiac markers did not further improve statistical models. Combination of blood markers and clinical parameters may help to improve initial management decisions in this vulnerable patient population.

Employing open/hidden administration in psychotherapy research: A randomized-controlled trial of expressive writing.

Psychotherapy has been shown to be effective, but efforts to prove specific effects by placebo-controlled trials have been practically and conceptually hampered. We propose that adopting open/hidden designs from placebo research would offer a possible way to establish specificity in psychotherapy. Therefore, we tested the effects of providing opposing treatment rationales in an online expressive writing intervention on affect in healthy subjects. Results indicate that it was possible to conduct the expressive writing intervention both covertly and openly, but that participants in the hidden administration condition did not fully benefit from the otherwise effective expressive writing intervention in the long-run. Effect sizes between open and hidden administration groups were comparable to pre-post effect sizes of the intervention. While this finding is important for the understanding of psychotherapy's effects per se, it also proves that alternative research approaches to establish specificity are feasible and informative in psychotherapy research. TRIAL REGISTRATION: German Clinical Trials Register DRKS00009428.

Understanding why cancer patients accept or turn down psycho-oncological support: a prospective observational study including patients' and clinicians' perspectives on communication about distress.

BACKGROUND: International standards prioritize introducing routine emotional distress screening in cancer care to accurately identify patients who most need psycho-oncological treatment, and ensure that patients can access appropriate supportive care. However, only a moderate proportion of distressed patients accepts referrals to or uses psycho-oncological support services. Predictors and barriers to psycho-oncological support service utilization are under-studied. We know little about how patients and oncologists perceive the discussions when oncologists assess psychosocial distress with a screening instrument. We aim to 1) assess the barriers and predictors of uptake of in-house psycho-oncological support along the distress screening pathway in cancer patients treated at a University Oncology Outpatient Clinic and, 2) determine how patients and clinicians perceive communication about psychosocial distress after screening with the Distress Thermometer. METHODS: This is a quantitative prospective observational study with qualitative aspects. We will examine medical and demographic variables, cancer patient self-reports of various psychological measures, and aspects of the patient-clinician communication as variables that potentially predict uptake of psycho-oncological support service. We will also assess the patients' reasons for accepting or refusing psycho-oncological support services. We assess at three points in time, based on paper-and-pencil questionnaires and two patient interviews during the study period. We will monitor outcomes (psycho-oncology service uptake) four months after study entry. DISCUSSION: The study will improve our understanding of characteristics of patients who accept or refuse psycho-oncological support, and help us understand how patients' and oncologists perceive communication about psychosocial distress, and referral to a psycho-oncologist. We believe this is the first study to focus on factors that affect uptake or rejection of psycho-oncological support services along the screening and referral pathway. The study 1) combines standard assessment with qualitative data collection, 2) embraces patient and oncologist perspectives, and, 3) focuses on patient-clinician communication about psychosocial issues raised by a standard screening instrument. Our results may improve routine practices and eliminate barriers to adequate health care, and make it easier to recognize patients with high distress levels who underuse the service.