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BACKGROUND: Predominant traditional approaches for most patients who have advanced-stage oral cancer with transcervical incision lines left irreversible scars. To address this, surgeons have continuously refined minimally invasive surgery (MIS) techniques, including robot-assisted neck surgeries. This article introduces and discusses the feasibility, versatility, and availability of free-flap reconstruction via the retroauricular approach (RA), considered difficult to date. METHODS: This study retrospectively analyzed 90 consecutive patients who had free-flap reconstruction performed by a single surgeon (D.K.) in the Department of Oral and Maxillofacial Surgery, Yonsei University, from March 2021 to April 2022. The type of defects and flaps, hospitalization days, total operation time, and type of vessels and anastomoses were compared statistically. RESULTS: The type of vessels used did not differ between the RA and the transcervical approach (TA) groups, nor in duration of hospital stays. Likewise, the total reconstruction time did not differ significantly between the TA group (240 min) and the RA group (245 min) (p = 0.756). However, the total operation time was about 1 h less in the TA group, a statistically significant difference (TA group [593 ± 152 min] vs. RA group [655 ± 117 min]; p = 0.044). All flaps were successful in the RA group, whereas one flap in the TA group led to a total loss (TA group [98.3%] vs. RA group [100.0%]; p = 1.000). CONCLUSIONS: Even for patients with advanced oral cancer who require massive tumor ablation, it is feasible to obtain an aesthetic and functional surgical outcome by performing free-flap reconstruction via the retroauricular approach.
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Neoplasias Bucais , Robótica , Cirurgiões , Humanos , Esvaziamento Cervical/métodos , Estudos Retrospectivos , Neoplasias Bucais/cirurgiaRESUMO
PURPOSE: This study aimed to determine whether the blood urea nitrogen to serum albumin (B/A) ratio is a useful prognostic factor of mortality in patients with aspiration pneumonia. METHODS: The study included patients with aspiration pneumonia who had been admitted to our hospital via the emergency department (ED) between January 1, 2014 and December 31, 2018. The 28-day mortality after the ED visits was the primary end point of this study. The data of the survivors and non-survivors were compared. RESULTS: A final diagnosis of aspiration pneumonia was made for 443 patients during the study period. Significant differences were observed in age, respiratory rate, albumin levels, total protein levels, blood urea nitrogen levels, C-reactive protein levels, glucose, and Charlson comorbidity index scores between the survivor and non-survivor groups. Moreover, the B/A ratio was significantly higher in the non-survivor group than that in the survivor group. The area under the curve for the B/A ratio was 0.70 [95% confidence interval (CI) 0.65-0.74], 0.71 for the PSI (95% CI 0.67-0.76), 0.64 for CURB-65 (95% CI 0.60-0.69), and 0.65 for albumin (95% CI 0.60-0.70) on the receiver operating characteristic curve for predicting mortality within 28 days of the ED visit. Multivariable logistic regression analysis revealed that the B/A ratio (>7, OR 3.40, 95% CI 1.87-6.21, P < 0.001) was associated with mortality within 28 days of the ED visit. CONCLUSION: The B/A ratio is a simple and potentially useful prognostic factor of mortality in aspiration pneumonia patients.
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Nitrogênio da Ureia Sanguínea , Pneumonia Aspirativa/mortalidade , Albumina Sérica/análise , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Pneumonia Aspirativa/sangue , Pneumonia Aspirativa/diagnóstico , Curva ROC , Estudos RetrospectivosRESUMO
PURPOSE: We evaluated whether combining the serum albumin level and the Prediction Rule for Admission policy in Complicated urinary Tract InfeCtion LEiden (PRACTICE) class could be a prognostic predictor in elderly patients with urinary tract infection (UTI). METHODS: We retrospectively included adult patients (age ≥ 65 years) with UTI who were hospitalized in the emergency department (ED) between January 1, 2014 and December 31, 2018. We graded the serum albumin level and classified the PRACTICE score; the modified PRACTICE was defined as the sum of the albumin level grade and the PRACTICE class. We comparatively assessed the predictive value for in-hospital mortality and admission to the intensive care unit (ICU) in survivor and non-survivor groups. RESULTS: In total, the study analysis included 1159 patients, and in-hospital mortality was 3.4% (n = 39). The modified PRACTICE score (4.0 [1.4] vs 6.1 [1.2], p < 0.001) was significantly increased in the non-survivor group. The area under the curve value of factors associated with in-hospital mortality were the Modified Early Warning Score (MEWS) 0.57 (95% CI 0.54-0.60), albumin 0.83 (95% CI 0.81-0.85), PRACTICE 0.71 (95% CI 0.69-0.74), and the modified PRACTICE 0.86 (95% CI 0.84-0.88). Factors associated with ICU admission were MEWS 0.65 (95% CI 0.62-0.68), albumin 0.66 (95% CI 0.64-0.69), PRACTICE 0.66 (95% CI 0.63-0.68), and the modified PRACTICE 0.72 (95% CI 0.69-0.74). CONCLUSION: The modified PRACTICE score can be a useful prognostic predictor in elderly patients with UTI.
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Geriatria/instrumentação , Prognóstico , Albumina Sérica/análise , Infecções Urinárias/complicações , Idoso , Idoso de 80 Anos ou mais , Área Sob a Curva , Biomarcadores/análise , Biomarcadores/sangue , Distribuição de Qui-Quadrado , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Geriatria/métodos , Geriatria/normas , Humanos , Masculino , Curva ROC , Estudos Retrospectivos , Índice de Gravidade de Doença , Estatísticas não Paramétricas , Análise de Sobrevida , Infecções Urinárias/sangue , Infecções Urinárias/diagnósticoRESUMO
BACKGROUND: Serum interleukin-6 (IL-6) is a cytokine released in response to an inflammatory stimulus or tissue injury. IL-6 levels are known to increase in patients with brain injury. OBJECTIVE: We investigated the neurologic outcomes associated with serum IL-6 levels in out-of-hospital cardiac arrest (OHCA) survivors who underwent target temperature management (TTM). METHODS: This was a prospective single-center observational study from October 2018 to November 2019 in a cohort of 45 patients. Serum inflammatory markers (IL-6, C-reactive protein, white blood cells) were determined in samples obtained immediately and at 24, 48, and 72 h after the return of spontaneous circulation (ROSC). Poor neurologic outcome, defined as Cerebral Performance Category 3-5 at 3 months after cardiac arrest, was the primary outcome. RESULTS: Among 45 patients enrolled in this study, 25 (55.6%) patients showed a poor neurologic outcome. IL-6 levels were significantly higher in the poor neurologic outcome group immediately (IL-60) after ROSC. The area under the curve (AUC) value of IL-60 was the highest among those of serum IL-6, CRP, and WBC at each time point. The IL-6 levels for predicting poor neurologic outcome had a sensitivity of 75.0%, with 80% specificity at IL-60. The AUC of IL-60 was 0.810 (95% confidence interval 0.664-0.913), with a cutoff value of 346.7 pg mL-1. CONCLUSIONS: Serum IL-6 level immediately after ROSC was a highly specific and sensitive marker for the 3-month poor neurologic outcome, and may be a useful early predictive marker of neurologic outcome in OHCA survivors treated with TTM.
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Hipotermia Induzida , Parada Cardíaca Extra-Hospitalar , Humanos , Interleucina-6 , Parada Cardíaca Extra-Hospitalar/terapia , Prognóstico , Estudos Prospectivos , Sobreviventes , TemperaturaRESUMO
PURPOSE: The technical factors which improve cosmetic outcomes and which need to be emphasized in education of junior residents have yet to be described. We compared cases in which suturing was performed by either junior emergency medicine residents or experts, in order to determine the focus of future education and training. METHODS: Wound registry data was reviewed and retrospectively analyzed from September 2015 to February 2016. Only patients who visited the emergency room with facial lacerations were enrolled, and their wound registry data sheets were reviewed. Practitioners were divided into junior resident and expert groups. We assessed the progress using the Stony Brook Scar Evaluation Scale (SBSES) 5-10â¯days following suturing. RESULTS: Sixty-six patients were enrolled; 43 (65.2%) were men. The median (interquartile range) cosmetic scores (SBSES scale) for suturing performed by junior residents or experts were 3 (2-4) and 5 (4-5), respectively (pâ¯=â¯0.001). The percentage of maximum scores for each SBSES category was significantly lower in the junior resident group than in the expert group for width (68% vs. 86%), hatch marks (68% vs. 93%), and overall appearance (41% vs. 80%) (all pâ¯<â¯0.001). CONCLUSIONS: There were significant differences in scar widths and hatch marks, which were attributable to the skill level of the practitioner who performed the suturing of facial lacerations. Junior residents should be educated about maintenance of proper tension, atraumatic technique, and performing appropriate trimming or debridement.
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Cicatriz/prevenção & controle , Traumatismos Faciais/cirurgia , Internato e Residência , Lacerações/cirurgia , Técnicas de Sutura/educação , Adulto , Idoso , Competência Clínica , Desbridamento/educação , Medicina de Emergência/educação , Serviço Hospitalar de Emergência/estatística & dados numéricos , Traumatismos Faciais/patologia , Feminino , Humanos , Lacerações/patologia , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Estudos RetrospectivosRESUMO
INTRODUCTION: To reduce the time required for suture closure for central venous catheterization, a new procedure was developed using a continuous suture technique. The present study was conducted to investigate the usefulness of this method. METHOD: The study was conducted with 90 volunteers among the doctors in the university hospital. Preliminary training (using video) on the two fixation methods was given to the participants prior to the experiment. After applying the central vein of the pig skin, a suture up to the butterfly seal was prepared, and the participant was allowed to fix the suture using the classic method and the new method. The time required for suturing was measured in seconds, and the tension was determined using a tension measuring device after suturing. RESULT: When using the new "one-time method," the time required was shortened by about 20.50s on average compared with the conventional method (P<0.001). The median and quartile of the tension of the thread for the one-time method was 1.10kg (1.00-1.20kg) and of the conventional method was 1.10kg (1.00-1.20kg), which showed no statistically significant difference between the two groups (P=0.476). CONCLUSION: We found that the new one-time method provided faster and more convenient central catheterization and catheter securement than the conventional methods.
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Cateterismo Venoso Central/métodos , Cateteres Venosos Centrais , Medicina de Emergência/educação , Técnicas de Sutura/educação , Animais , Cateterismo Venoso Central/instrumentação , Humanos , Suínos , Resistência à TraçãoAssuntos
Vazamento de Resíduos Químicos/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Substâncias Perigosas , Ferimentos e Lesões/induzido quimicamente , Ferimentos e Lesões/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , República da Coreia , Adulto JovemRESUMO
BACKGROUND: Point-of-Care Ultrasound (POCUS) is a quick, useful, noninvasive, and inexpensive diagnostic tool used for the diagnosis of trauma, abdominal pain, dyspnea, and chest pain in the emergency department (ED). However, the diagnostic accuracy of ultrasound in the ED may be different from those reported in previous studies owing to the setting and time constraints in ED. METHODS: We conducted our study in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. A literature search was conducted using databases on US National Library of Medicine's database of biomedical literature, Ovid MEDLINE, online database of biomedical articles, and the collection of databases of systematic reviews and other evidence. The inclusion criteria were the use of bedside ultrasound as a diagnostic tool for acute appendicitis in the ED and the available data on diagnostic parameters such as sensitivity, specificity, and positive and negative predictive values (NPV). We constructed forest plots and summary receiver operating characteristic curves to evaluate the diagnostic accuracy of bedside ultrasound for acute appendicitis in the ED. RESULTS: A total of 21 studies that met the inclusion criteria of this study were included for analysis. The overall pooled sensitivity was 0.81 (95% CI, 0.78-0.83), whereas the pooled specificity was 0.87 (95% CI, 0.85-0.88). However, the I2 test showed 91.7% and 90.9% heterogeneity in the sensitivity and specificity values, respectively. The summary receiver operating characteristic curves showed high levels of accuracy, as evidenced by an area under the curve of 0.9249 (standard error: 0.0180). CONCLUSIONS: The use of ultrasound for the diagnosis of acute appendicitis in the ED showed that ultrasound has high overall sensitivity and specificity for the diagnosis of acute appendicitis. however, high heterogeneity among the included studies was observed.
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Apendicite , Humanos , Apendicite/diagnóstico por imagem , Sensibilidade e Especificidade , Curva ROC , Dispneia , Ultrassonografia , Serviço Hospitalar de Emergência , Doença AgudaRESUMO
BACKGROUND: The purpose of this study was to present a systematic review and meta-analysis of the diagnostic accuracy of magnetic resonance imaging (MRI) in the diagnosis of acute appendicitis in pregnant women. METHODS: A literature search was conducted using the databases of PubMed, Ovid MEDLINE, EMBASE, and the Cochrane Library. The inclusion criteria were the use of MRI, as a diagnostic protocol for acute appendicitis in pregnant women, and the availability of diagnostic parameters, such as sensitivity and specificity. For each selected study, the basic demographic information and measures of diagnostic accuracy, such as sensitivity, specificity, and positive and negative predictive values, were extracted. Forest plots and summary receiver operating characteristic curves (SROC) were also obtained for diagnostic accuracy of MRI for acute appendicitis during pregnancy. RESULTS: A total of 22 studies and the data of 2392 patients were analyzed. Most studies had high sensitivity, with the exception of a few that had sensitivities of 0.18, 0.5, and 0.6. With respect to specificity, most results were close to 1.0, and the lowest result was 0.92. The SROC curves showed high levels of accuracy, as evidenced by an area under the curve value of 0.9922. CONCLUSION: MRI showed overall high accuracy for diagnosing acute appendicitis in pregnant women. Therefore, it is a good diagnostic tool as a first-line imaging method for suspected appendicitis in pregnant women.
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Apendicite/diagnóstico por imagem , Imageamento por Ressonância Magnética , Complicações Infecciosas na Gravidez/diagnóstico por imagem , Doença Aguda , Feminino , Humanos , Gravidez , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: Acute pulmonary embolism (APE) is a major cause of death from cardiovascular disease. Right ventricular systolic dysfunction (RVD) caused by APE is closely related to a poor outcome. Early risk stratification of APE is a vital step in prognostic assessment. The objective of this study was to investigate the usefulness of computed tomographic pulmonary angiography (CTPA) measured right ventricular (RV)/ left ventricular (LV) diameter ratio by the emergency department (ED) specialists for early risk stratification of APE patients in ED. METHODS: The retrospective data of 229 APE patients were reviewed. Two ED specialists measured both RV and LV diameters on a single transverse scan perpendicular to the long axis of the heart. The patients were divided into two groups, RV/LV diameter ratio <1 and ratio >1. CTPA measured RV/LV diameter ratio were analyzed and compared with sPESI score, cardiac biomarkers such as N-Terminal Pro-B-Type Natriuretic Peptide (NT-pro-BNP), high sensitivity cardiac troponin T (hs-cTnT), and RVD measured by echocardiography (Echo). RESULTS: The mean age in RV/LV > 1 group was significantly higher than that of the other group (67.81±2.7 years vs. 60.68±3.2 years). Also, there were more hypertension patients (44.4% vs. 33.3%), and mean arterial pressure (MAP) was lower. A significantly higher ICU admission rate (28.05% vs. 11.61%) was shown in RV/LV >1 group, and five patients expired only in RV/LV > 1 group. RVD by Echo demonstrated the highest sensitivity, specificity, and negative predictive value (NPV) (values of 94.3%, 81.1%, 95.5%). RV/LV >1 diameter ratio by CTPA showed usefulness equivalent to cardiac biomarkers. RV/LV >1 patients' cardiac enzymes were higher, and there were more RVD in RV/LV >1 group. CONCLUSION: Simple measurement of RV/LV diameter ratio by ED specialist would be a help to the clinicians in identifying and stratifying the risk of the APE patients presenting in the ED.
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Angiografia por Tomografia Computadorizada/métodos , Serviços Médicos de Emergência/métodos , Ventrículos do Coração/diagnóstico por imagem , Embolia Pulmonar/diagnóstico por imagem , Idoso , Biomarcadores , Ecocardiografia/métodos , Serviço Hospitalar de Emergência , Feminino , Ventrículos do Coração/patologia , Humanos , Hipertensão/complicações , Masculino , Pessoa de Meia-Idade , Peptídeo Natriurético Encefálico/sangue , Tamanho do Órgão , Fragmentos de Peptídeos/sangue , Embolia Pulmonar/sangue , Embolia Pulmonar/mortalidade , Embolia Pulmonar/patologia , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Método Simples-Cego , Avaliação de Sintomas/métodos , Troponina T/sangueRESUMO
AIM: We evaluated the prognostic value of serum- and cerebrospinal fluid (CSF)-ubiquitin carboxyl-terminal esterase L1 protein (UCHL1) measurements in post- post-out of hospital cardiac arrest (OHCA) patients treated with target temperature management (TTM), to predict neurologic outcome. METHODS: This was a prospective single-centre observational cohort study, conducted from April 2018 to September 2019. Serum- and CSF-UCHL1 were obtained immediately (UCHL1initial), 24â¯h (UCHL124), 48â¯h (UCHL148), and 72â¯h (UCHL172) after return of spontaneous circulation (ROSC). The area under the receiver operating characteristic curves (AUROC) and Delong method were used to identify cut-off values of serum- and CSF-UCHL1initial, UCHL124, UCHL148, UCHL172 for predicting neurologic outcomes. RESULTS: Of 38 patients enrolled, 16 comprised the poor outcome group. The AUROCs for serum- and CSF-UCHL1initial were 0.71 and 0.93 in predicting poor neurological outcomes, respectively (pâ¯=â¯0.01). The AUROCs for serum- and CSF-UCHL124 were 0.85 and 0.91 (pâ¯=â¯0.24). The AUROCs for serum- and CSF-UCHL148 were 0.90 and 0.97 (pâ¯=â¯0.07). The AUROCs for serum- and CSF-UCHL172 were 0.94 and 0.98 (pâ¯=â¯0.25). CONCLUSION: Findings of this study demonstrate that CSF-UCHL1 measured immediately, 24, 48, and 72â¯h after ROSC is a valuable predictor for evaluating neurologic outcomes, whereas serum-UCHL1 measured at 24, 48, and 72â¯h after ROSC showed a significant performance in the prognostication of poor outcomes in post-OHCA patients treated with TTM.
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Hipotermia Induzida , Parada Cardíaca Extra-Hospitalar , Humanos , Parada Cardíaca Extra-Hospitalar/terapia , Prognóstico , Estudos Prospectivos , Ubiquitina TiolesteraseRESUMO
Incidences of brain death due to nicotine overdose by e-cigarettes have been increasing. In such cases, liver donation has been not reported because of the secondary damage to the liver due to metabolism of large amounts of nicotine. However, kidneys have been considered acceptable for transplant. Here, we present a successful case of liver transplant from a brain-dead donor due to intentional nicotine ingestion who did not have extensive steatosis. To the best of our knowledge, this is the first report of such a case.
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Sistemas Eletrônicos de Liberação de Nicotina , Cirrose Hepática/cirurgia , Transplante de Fígado , Nicotina/intoxicação , Agonistas Nicotínicos/intoxicação , Suicídio , Doadores de Tecidos , Adulto , Morte Encefálica , Seleção do Doador , Evolução Fatal , Humanos , Cirrose Hepática/diagnóstico , Masculino , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
AIM: We presented the cut-off value of a diffusion-weighted image (DWI) scoring system to predict poor neurologic outcome using DWI taken 72-96â¯h after out-of-hospital cardiac arrest (OHCA) patients underwent target temperature management (TTM). METHODS: This was a prospective single-centre observational study, conducted from March 2018 to April 2020 in OHCA patients after TTM. Neurological status was assessed 6 months after return of spontaneous circulation (ROSC) using the Glasgow-Pittsburgh cerebral performance categories (CPC) scale. CPC of 1-2 demonstrated good neurologic outcomes whilst a CPC of 3-5 was related to poor neurologic outcomes. The receiver operating characteristic curves and DeLong method were used to evaluate the cut-off value of the DWI scoring system to predict poor neurologic outcome. RESULTS: The good and poor neurologic outcome groups consisted of 38 (54.3%) and 32 (45.7%) patients, respectively. The area under the receiver operating characteristic curve (AUROC) of the overall, cortex, deep grey nuclei, and cortex plus deep grey nuclei scores, white matter, brainstem, and cerebellum measured 72-96â¯h after ROSC were 0.96, 0.96, 0.97, 0.96, 0.95, 0.95, and 0.93 respectively. For 100.0% specificity to predict poor neurologic outcome, the overall scores of the DWI scoring system measured 72-96â¯h after ROSC with a cut-off value of 52 had a sensitivity of 81.3% (95% CI: 63.6-92.8). CONCLUSION: This study demonstrated that the DWI scoring systems measured between 72 and 96â¯h after ROSC were valuable tools to predict poor neurologic outcome in post-OHCA patients treated with TTM.
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Hipotermia Induzida , Parada Cardíaca Extra-Hospitalar , Encéfalo/diagnóstico por imagem , Humanos , Parada Cardíaca Extra-Hospitalar/terapia , Prognóstico , Estudos Prospectivos , TemperaturaRESUMO
AIM: In a previous study, low and high-normal arterial carbon dioxide tension (PaCO2) were not associated with serum neuron-specific enolase (NSE) in cardiac arrest survivors. We assessed the effect of PaCO2 on NSE in cerebrospinal fluid (CSF) and serum. METHODS: This was a retrospective study. PaCO2 for the first 24â¯h was analysed in four means, qualitative exposure state (qES), time-weighted average (TWA), median, and minimum-maximum (Min-Max). These subgroups were divided into low (LCO2) and high PaCO2 (HCO2) groups defined as PaCO2â¯≤â¯35.3 and PaCO2â¯>â¯43.5â¯mmHg, respectively. NSE was measured at 24, 48, and 72â¯h (sNSE24,48,72 and cNSE24,48,72) from return of spontaneous circulation (ROSC). The primary outcome was the association between PaCO2 and the NSE measured at 24â¯h after ROSC. RESULTS: Forty-two subjects (male, 33; 78.6%) were included in total cohort. PaCO2 in TWA subgroup was associated with cNSE24,48,72, while PaCO2 in the other subgroup were only associated with cNSE24. PaCO2 and cNSE in qES subgroup showed good correlation (râ¯=â¯-0.61; pâ¯<â¯0.01), and in TWA, median, and Min-Max subgroup showed moderate correlations (râ¯=â¯-0.57, râ¯=â¯-0.48, and râ¯=â¯-0.60; pâ¯<â¯0.01). Contrastively, sNSE was not associated and correlated with PaCO2 in all analysis. Poor neurological outcome in LCO2 was significantly higher than HCO2 in qES, TWA, and median subgroups (pâ¯<â¯0.01, pâ¯<â¯0.01, and pâ¯=â¯0.02). CONCLUSION: Association was found between NSE and PaCO2 using CSF, despite including normocapnic ranges; TWA of PaCO2 may be most strongly associated with CSF NSE levels. A prospective, multi-centre study is required to confirm our results.
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Hipotermia Induzida , Parada Cardíaca Extra-Hospitalar , Biomarcadores , Dióxido de Carbono , Humanos , Masculino , Parada Cardíaca Extra-Hospitalar/terapia , Pressão Parcial , Fosfopiruvato Hidratase , Estudos Prospectivos , Estudos RetrospectivosRESUMO
PURPOSE: Cerebrospinal fluid (CSF) lactate dehydrogenase (LDH) levels increase in patients with brain injury. We investigated neurologic outcomes associated with CSF LDH levels in out-of-hospital cardiac arrest (OHCA) survivors who underwent target temperature management (TTM). MATERIALS AND METHODS: This was a prospective single-centre observational study from April 2018 to May 2019 on a cohort of 41 patients. CSF and serum LDH samples were obtained immediately (LDH0) and at 24 (LDH24), 48 (LDH48), and 72 h (LDH72) after return of spontaneous circulation (ROSC). Neurologic outcomes were assessed at 3 months after ROSC using the Cerebral Performance Category scale. RESULTS: Twenty-one patients had a poor neurologic outcome. CSF LDH levels were significantly higher in the poor neurologic outcome group at each time point. The area under the curve (AUC) of CSF LDH48 was 0.941 (95% confidence interval [CI], 0.806-0.992). With a cut off value of 250 U/L, CSF LDH48 had a high sensitivity (94.1%; 95% CI, 71.3-99.9) at 100% specificity. CONCLUSIONS: CSF LDH level at 48 h was a highly specific and sensitive marker for 3-month poor neurologic outcome. This may constitute a useful predictive marker for neurologic outcome in OHCA survivors treated with TTM.
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Hipotermia Induzida/métodos , Parada Cardíaca Extra-Hospitalar/líquido cefalorraquidiano , Parada Cardíaca Extra-Hospitalar/terapia , Adulto , Idoso , Área Sob a Curva , Biomarcadores/sangue , Biomarcadores/líquido cefalorraquidiano , Feminino , Humanos , L-Lactato Desidrogenase/sangue , L-Lactato Desidrogenase/líquido cefalorraquidiano , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/sangue , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , Sobreviventes , Temperatura , Resultado do TratamentoRESUMO
We examined whether combining biomarkers measurements and brain images early after the return of spontaneous circulation improves prognostic performance compared with the use of either biomarkers or brain images for patients with cardiac arrest following target temperature management (TTM). This retrospective observational study involved comatose out-of-hospital cardiac arrest survivors. We analyzed neuron-specific enolase levels in serum (NSE) or cerebrospinal fluid (CSF), grey-to-white matter ratio by brain computed tomography, presence of high signal intensity (HSI) in diffusion-weighted imaging (DWI), and voxel-based apparent diffusion coefficient (ADC). Of the 58 patients, 33 (56.9%) had poor neurologic outcomes. CSF NSE levels showed better prognostic performance (area under the curve (AUC) 0.873, 95% confidence interval (CI) 0.749-0.950) than serum NSE levels (AUC 0.792, 95% CI 0.644-0.888). HSI in DWI showed the best prognostic performance (AUC 0.833, 95% CI 0.711-0.919). Combining CSF NSE levels and HSI in DWI had better prognostic performance (AUC 0.925, 95% CI 0.813-0.981) than each individual method, followed by the combination of serum NSE levels and HSI on DWI and that of CSF NSE levels and the percentage of voxels of ADC (AUC 0.901, 95% CI 0.792-0.965; AUC 0.849, 95% CI 0.717-0.935, respectively). Combining CSF/serum NSE levels and HSI in DWI before TTM improved the prognostic performance compared to either each individual method or other combinations.
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AIM: This study examined whether the presence of cortical necrosis (CN) on ultra-early diffusion-weighted imaging (DWI) and the severity of cytotoxic oedema (CytE) with cerebral oedema (CbrE), measured using quantitative analysis of apparent diffusion coefficient (ADC), could predict neurological outcomes before targeted temperature management in out-of-hospital cardiac arrest survivors (OHCAs). METHODS: In this retrospective study, the first DWI with ADC scans was performed within 6â¯h; the second was obtained between 72 and 96â¯h after return of spontaneous circulation. The primary outcome was neurological outcomes at 6 months after OHCA. The % voxels of ADC value (PV) was calculated; CbrE and CytE values wereâ¯>â¯orâ¯<â¯than 650-6â¯mm2/s, respectively. The best performance PV was obtained from CytE (thld-CytE) and CbrE values (thld-CbrE). Prognostic performances of CN, thld-CytE, thld-CbrE, and converted scores were calculated in combination. The changes in DWI findings and the difference between the PV (ΔPV) from the first and second DWI were analysed. RESULTS: Thirty-six patients were included. CN (area under receiver operating characteristic curve [AUC]â¯=â¯0.800), thld-CytE (PV420; AUCâ¯=â¯0.730), and thld-CbrE (PV1090; AUCâ¯=â¯0.775) showed meaningful performance, and the combined score showed best performance for poor outcome prediction (AUCâ¯=â¯0.956). DWI findings of CN patients was worse at the second DWI. ΔPV significantly increased in the poor outcome group, CN patients, and the group including both, thld-CytE and thld-CbrE. CONCLUSIONS: In OHCAs, ultra-early DWI with ADC could successfully predict poor neurological outcomes by combining scores of CN, thld-CytE, and thld-CbrE.
Assuntos
Parada Cardíaca Extra-Hospitalar , Imagem de Difusão por Ressonância Magnética , Humanos , Parada Cardíaca Extra-Hospitalar/diagnóstico por imagem , Parada Cardíaca Extra-Hospitalar/terapia , Prognóstico , Curva ROC , Estudos Retrospectivos , SobreviventesRESUMO
We aimed to compare the relationship of mean arterial pressure (MAP) and intracranial pressure (ICP) to predict the neurological prognosis in cardiac arrest (CA) survivors. We retrospectively examined out-of-hospital CA patients treated with targeted temperature management. ICP was measured using cerebrospinal fluid (CSF) pressure, whereas MAP was measured as blood pressure monitored through the radial or femoral artery during CSF pressure measurement. Primary outcome was 6-month neurological outcome. Of 92 enrolled patients, the favorable outcome group comprised 31 (34%) patients. The median and interquartile range of MAP were significantly higher and ICP was significantly lower in patients with favorable neurological outcomes than in those with unfavorable neurological outcomes (94.3 mmHg [80.0-105.3] vs. 82.0 mmHg [65.3-96.3], p = 0.021 and 9.4 mmHg [10.8-8.7] vs. 18.8 mmHg [20.0-15.7], p < 0.001, respectively). ICP showed the higher area under the receiver operating characteristic curve (area under curve [AUC] = 0.953, 95% confidence interval [CI] = 0.888-0.986) for neurological outcome prediction. MAP showed the lower AUC (0.648, 95% CI = 0.541-0.744). Higher accurate prognosis was predicted by ICP than MAP, and the prognostic performance was good. Prospective multicenter studies are required to confirm these results.