Out-of-hospital cardiac arrest: 30-day survival and 1-year risk of anoxic brain damage or nursing home admission according to consciousness status at hospital arrival.

AIM: To investigate the association between consciousness status at hospital arrival and long-term outcomes in out-of-hospital cardiac arrest (OHCA) patients. METHODS: OHCAs between 18-100 years of age were identified from the Danish Cardiac Arrest Registry during 2005-2014. Patients with return of spontaneous circulation (ROSC) or ongoing cardiopulmonary resuscitation (CPR) at hospital arrival were included. Thirty-day survival was evaluated using Kaplan-Meier estimates. Risk of anoxic brain damage or nursing home admission and return to work among 30-day survivors were evaluated using Aalen-Johansen estimates and cause-specific Cox regression. RESULTS: Upon hospital arrival of 13,953 OHCA patients, 776 (5.6%) had ROSC and were conscious (Glasgow Coma Score [GCS]>8), 5205 (37.3%) had ROSC, but were comatose (GCS ≤ 8), and 7972 (57.1%) had ongoing CPR. Thirty-day survival according to status at hospital arrival among patients that were conscious, comatose, or had ongoing CPR was 89.0% (95% confidence interval [CI] 86.8%-91.2%), 39.0% (95% CI 37.6%-40.3%), and 1.2% (95% CI 1.0%-1.4%), respectively. Among 30-day survivors, 1-year risks of new onset anoxic brain damage or nursing home admission according to consciousness status were 2.4% (95% CI 1.2%-3.6%), 12.9% (95% CI 11.4%-14.3%), and 19.4% (95% CI 11.3%-27.4%), respectively. Among 30-day working-age survivors, more than 65% in each group returned to work within 5 years. CONCLUSION: Consciousness status at hospital arrival was strongly associated with 30-day survival in OHCA patients. Among 30-day survivors, a minority was diagnosed with anoxic brain damage or admitted to a nursing home and the majority returned to work independent of consciousness status at hospital arrival.

Out-of-hospital cardiac arrest in patients with psychiatric disorders - Characteristics and outcomes.

AIMS: To investigate whether the recent improvements in pre-hospital cardiac arrest-management and survival following out-of-hospital cardiac arrest (OHCA) also apply to OHCA patients with psychiatric disorders. METHODS: We identified all adult Danish patients with OHCA of presumed cardiac cause, 2001-2015. Psychiatric disorders were defined by hospital diagnoses up to 10 years before OHCA and analyzed as one group as well as divided into five subgroups (schizophrenia-spectrum disorders, bipolar disorder, depression, substance-induced mental disorders, other psychiatric disorders). Association between psychiatric disorders and pre-hospital OHCA-characteristics and 30-day survival were assessed by multiple logistic regression. RESULTS: Of 27,523 OHCA-patients, 4772 (17.3%) had a psychiatric diagnosis. Patients with psychiatric disorders had lower odds of 30-day survival (0.37 95% confidence interval 0.32-0.43) compared with other OHCA-patients. Likewise, they had lower odds of witnessed status (0.75 CI 0.70-0.80), bystander cardiopulmonary resuscitation (CPR) (0.77 CI 0.72-0.83), shockable heart rhythm (0.37 95% CI, 0.33-0.40), and return of spontaneous circulation (ROSC) at hospital arrival (0.66 CI 0.59-0.72). Similar results were seen in all five psychiatric subgroups. The difference in 30-day survival between patients with and without psychiatric disorders increased in recent years: from 8.4% (CI 7.0-10.0%) in 2006 to 13.9% (CI 12.4-15.4%) in 2015 and from 7.0% (4.3-10.8%) in 2006 to 7.0% (CI 4.5-9.7%) in 2015, respectively. CONCLUSION: Patients with psychiatric disorders have lower survival following OHCA compared to non-psychiatric patients and the gap between the two groups has widened over time.

Association between bystander cardiopulmonary resuscitation and redeemed prescriptions for antidepressants and anxiolytics in out-of-hospital cardiac arrest survivors.

AIM: This study aimed to examine rates of redeemed prescriptions of antidepressants and anxiolytics, used as markers for cerebral dysfunction in out-of-hospital cardiac arrest (OHCA) survivors, and examine the association between bystander CPR and these psychoactive drugs. METHODS: We included all 30-day survivors of OHCA in Denmark between 2001 and 2011, who had not redeemed prescriptions for antidepressants or anxiolytics in the last six months prior to OHCA. Main outcome measures were redeemed prescriptions of antidepressants and anxiolytics within one year after OHCA. RESULTS: Among 2,001 30-day survivors, 174 (8.6% died and 12.0% redeemed a first prescription for an antidepressant and 8.2% for an anxiolytic drug within one year after arrest. The corresponding frequencies for redeemed prescribed drugs among age- and sex-matched population controls were 7.5% and 5.2%, respectively. Among survivors who received bystander CPR, prescriptions for antidepressants and anxiolytics were redeemed in 11.1% [95% CI 9.2-13.3%] and 6.3% [95% CI 4.9-8.0%] of the cases, respectively, versus 17.2% [95% CI 13.9-21.1%] and 13.4% [95% CI 10.5-17.0%], respectively, among patients who had not received bystander CPR. Adjusted for age, sex, year of arrest, comorbidity, witnessed status and socioeconomic status, bystander CPR was associated with significant reductions in redeemed prescriptions for antidepressants, Hazard Ratio (HR) 0.71 [95% CI 0.52-0.98], P=0.031; and anxiolytics, HR 0.55 [95% CI 0.38-0.81], P=0.002. CONCLUSION: Relative to no bystander CPR, redeemed prescriptions for antidepressants and anxiolytics were significantly lower among 30-day survivors of OHCA who received bystander CPR, suggesting a cerebral dysfunction-lowering potential of bystander CPR.

Early chest tube removal following cardiac surgery is associated with pleural and/or pericardial effusions requiring invasive treatment.

OBJECTIVES: Different opinions exist as to when chest tube removal should be performed following cardiac surgery. The aim of this study was to compare early chest tube removal with removal of the tubes in the morning day 1 postoperatively. Primary combined end point was the risk of postoperative accumulation of fluid in the pericardial and/or pleural cavities requiring invasive treatment. METHODS: A retrospective observational cohort study was performed among patients undergoing coronary artery bypass grafting (CABG) and/or conventional valve surgery between July 2010 and June 2013. Patients in whom chest tube output was <150 ml around midnight during the last 4 h were included in the study. These patients were divided into two groups: Group 1 had their chest tubes removed around midnight on the day of surgery, whereas Group 2 kept their tubes until next morning. Using Poisson regression, we estimated crude and adjusted relative risks (RRs) for developing postoperative pleural and/or pericardial effusion within 14 days requiring interventional treatment. RESULTS: A total of 1232 patients underwent CABG, conventional valve or combined surgery during the study period. Of these, 782 patients fulfilled the criteria for early chest tube removal, which was performed in 385 of the patients. A total of 76 patients in Group 1 (20%) and 51 patients in Group 2 (13%) developed postoperative pleural and/or pericardial effusions requiring invasive treatment (P = 0.011). A positive association between early chest tube removal and the development of pleural and/or pericardial effusions was seen [crude RR: 1.54 (95% CI: 1.11-2.13); adjusted RR: 1.70 (95% CI: 1.24-2.33)]. The association became stronger investigating pleural effusions alone (adjusted RR = 1.77; 95% CI: 1.27-2.46), whereas the association with pericardial effusions was less clear. CONCLUSIONS: Removal of all chest tubes around midnight on the day of surgery is associated with an increased risk of postoperative pleural and/or pericardial effusions requiring invasive treatment even if chest tube output during the last 4 h is <150 ml compared with removal of the tubes next morning.

Parathyroid hormone PTH(1-34) increases the volume, mineral content, and mechanical properties of regenerated mineralizing tissue after distraction osteogenesis in rabbits.

BACKGROUND AND PURPOSE: Parathyroid hormone (PTH) has attracted considerable interest as a bone anabolic agent. Recently, it has been suggested that PTH can also enhance bone repair after fracture and distraction osteogenesis. We analyzed bone density and strength of the newly regenerated mineralized tissue after intermittent treatment with PTH in rabbits, which undergo Haversian bone remodeling similar to that in humans. METHODS: 72 New Zealand White rabbits underwent tibial mid-diaphyseal osteotomy and the callus was distracted 1 mm/day for 10 days. The rabbits were divided into 3 groups, which received injections of PTH 25 microg/kg/day for 30 days, saline for 10 days and PTH 25 microg/kg/day for 20 days, or saline for 30 days. At the end of the study, the rabbits were killed and the bone density was evaluated with DEXA. The mechanical bone strength was determined by use of a 3-point bending test. RESULTS: In the 2 PTH-treated groups the regenerate callus ultimate load was 33% and 30% higher, absorbed energy was 100% and 65% higher, BMC was 61% and 60% higher, and callus tissue volume was 179% and 197% higher than for the control group. INTERPRETATION: We found that treatment with PTH during distraction osteogenesis resulted in substantially higher mineralized tissue volume, mineral content, and bending strength. This suggests that treatment with PTH may benefit new bone formation during distraction osteogenesis and could form a basis for clinical application of this therapy in humans.

Effects of parathyroid hormone on newly regenerated bone during distraction osteogenesis in a rabbit tibial lengthening model. A pilot study.

OBJECTIVE: The overall purpose of the study is to determine the effects of parathyroid hormone (PTH) (1-34) on bone formation in regenerated and surrounding bone of distracted callus during limb lengthening in rabbits. Additionally the aim of the pilot study is to titrate the optimal dose of PTH for distraction osteogenesis treatment in rabbits' tibial lengthening model. MATERIALS AND METHODS: A total of 18 rabbits underwent right tibia lengthening by callus distraction. Lengthening was started 5 days postoperatively 1 mm/day for a 10-day period and consolidation of 20 days followed. Rabbits were divided into three groups: group I received PTH (1-34) treatment at a dose of 5 microg/kg/day, group II received treatment with PTH (1-34) at a dose of 25 microg/kg/day; group III rabbits were treated with saline. After euthanasia, tibiae of both legs were dissected free, kept frozen and underwent x-ray analysis, dual x-ray absorptiometry-scanning, microcomputed tomography scanning and three-dimensional evaluation and mechanical test followed. RESULTS: Over all, during distraction osteogenesis in a new regenerated bone, PTH (1-34) treatment with two different doses of 5 microg/kg/day and 25 microg/kg/day increased callus cross-sectional area, callus bone mineral density and bone mineral content, bone volume density; dramatically increased trabecular number with slight increase in trabecular thickness, whereas decreased trabecular separation, bone surface density and decreased degree of anisotropy when compared to control group animals. CONCLUSION: PTH (1-34) treatment improved mineralization, structural indices of regenerated distracted rabbits' tibiae, whereas treatment at a dose of 25 microg/kg/day PTH (1-34) was significantly more effective than 5 microg/kg/day PTH(1-34) dose treatment when compared to control group. Bigger dose has been chosen for the main study.

Effects of locally applied vascular endothelial growth factor (VEGF) and VEGF-inhibitor to the rabbit tibia during distraction osteogenesis.

INTRODUCTION: Therapeutic angiogenesis, a novel concept in tissue engineering, is neo-formation of blood vessels in a tissue upon delivery of an angiogenic growth factor to the tissue. We hypothesised that therapeutic angiogenesis could enhance bone formation and challenged the hypothesis in an experimental model of distraction osteogenesis. METHODS: Rabbits, divided into three equal groups of 12, had their right tibia lengthened by distraction osteogenesis. A mini-osmotic pump delivered to the osteotomy gap either recombinant human vascular endothelial growth factor (VEGF), VEGF-inhibitor, or vehicle alone during the latency and distraction phase. After consolidation, we assessed bone blood flow by radioactive microsphere entrapment, measured torsional stiffness and bone mineral content, and did histomorphometry. RESULTS: VEGF and VEGF-inhibitor treatment failed to influence bone blood flow, torsional stiffness, bone mineral content and histomorphometric indices of the bone regenerate. However, VEGF treatment increased the blood flow in bone of the distracted limb and VEGF-inhibitor treatment decreased bone blood flow. CONCLUSION: The regenerate was unresponsive to VEGF and VEGF-inhibitor treatment in contrast to the neighbouring bone, which implies different biological properties of the vasculature in native and regenerating bone. VEGF is not recommended for enhancement of bone formation in this setting.