The agreement between jugular bulb and cerebrospinal fluid lactate levels in patients with out-of-hospital cardiac arrest

We investigated the agreement between the jugular bulb (JB) and cerebrospinal fluid (CSF) lactate levels. The study was conducted from July 2021 to June 2023 as a prospective observational cohort study at a single center. The right jugular vein was accessed, and the placement of JB catheter tip was confirmed using lateral cervical spine X-ray. A lumbar catheter was inserted between the 3rd and 4th lumbar spine of the patient. Lactate levels were measured immediately, 24 h, 48 h, and 72 h after ROSC. In patients with a good neurological prognosis, kappa between JB and CSF lactate levels measured immediately, at 24 h, 48 h, and 72 h after ROSC were 0.08, 0.36, 0.14, - 0.05 (p = 0.65, 0.06, 0.48, and 0.75, respectively). However, in patients with a poor neurological prognosis, kappa between JB and CSF lactate levels measured immediately, at 24 h, 48 h, and 72 h after ROSC were 0.38, 0.21, 0.22, 0.12 (p = 0.001, 0.04, 0.04, and 0.27, respectively). This study demonstrated that JB lactate levels exhibited significant agreement with arterial lactate levels, compared to CSF lactate levels. Therefore, this should be considered when using JB lactate to monitor cerebral metabolism.

Sex differences in in-hospital management in patients with sepsis and septic shock: a prospective multicenter observational study

Sex differences in the in-hospital management of sepsis exist. Previous studies either included patients with sepsis that was defined using previous definitions of sepsis or evaluated the 3-h bundle therapy. Therefore, this study sought to assess sex differences in 1-h bundle therapy and in-hospital management among patients with sepsis and septic shock, defined according to the Sepsis-3 definitions. This observational study used data from Korean Shock Society (KoSS) registry, a prospective multicenter sepsis registry. Adult patients with sepsis between June 2018 and December 2021 were included in this study. The primary outcome was adherence to 1-h bundle therapy. Propensity score matching (PSM) and multivariable logistic regression analyses were performed. Among 3264 patients with sepsis, 3129 were analyzed. PSM yielded 2380 matched patients (1190 men and 1190 women). After PSM, 1-h bundle therapy was performed less frequently in women than in men (13.0% vs. 19.2%; p < 0.001). Among the bundle therapy components, broad-spectrum antibiotics were administered less frequently in women than in men (25.4% vs. 31.6%, p < 0.001), whereas adequate fluid resuscitation was performed more frequently in women than in men (96.8% vs. 95.0%, p = 0.029). In multivariable logistic regression analysis, 1-h bundle therapy was performed less frequently in women than in men [adjusted odds ratio (aOR) 1.559; 95% confidence interval (CI) 1.245-1.951; p < 0.001] after adjustment. Among the bundle therapy components, broad-spectrum antibiotics were administered less frequently to women than men (aOR 1.339, 95% CI 1.118-1.605; p = 0.002), whereas adequate fluid resuscitation was performed more frequently for women than for men (aOR 0.629, 95% CI 0.413-0.959; p = 0.031). Invasive arterial blood pressure monitoring was performed less frequently in women than in men. Resuscitation fluid, vasopressor, steroid, central-line insertion, ICU admission, length of stay in the emergency department, mechanical ventilator use, and renal replacement therapy use were comparable for both the sexes. Among patients with sepsis and septic shock, 1-h bundle therapy was performed less frequently in women than in men. Continuous efforts are required to increase adherence to the 1-h bundle therapy and to decrease sex differences in the in-hospital management of patients with sepsis and septic shock.

Distribution and elimination kinetics of midazolam and metabolites after post-resuscitation care: a prospective observational study

Administration of sedatives for post-resuscitation care can complicate the determination of the optimal timing to avoid inappropriate, pessimistic prognostications. This prospective study aimed to investigate the distribution and elimination kinetics of midazolam (MDZ) and its metabolites, and their association with awakening time. The concentrations of MDZ and its seven metabolites were measured immediately and at 4, 8, 12, and 24 h after the discontinuation of MDZ infusion, using liquid chromatography-tandem mass spectrometry. The area under the time-plasma concentration curve from 0 to 24 h after MDZ discontinuation (AUClast) was calculated based on the trapezoidal rule. Of the 15 enrolled patients, seven awakened after the discontinuation of MDZ infusion. MDZ and three of its metabolites were major compounds and their elimination kinetics followed a first-order elimination profile. In the multivariable analysis, only MDZ was associated with awakening time (AUClast: R2 = 0.59, p = 0.03; AUCinf: R2 = 0.96, p < 0.001). Specifically, a 0.001% increase in MDZ AUC was associated with a 1% increase in awakening time. In the individual regression analysis between MDZ concentration and awakening time, the mean MDZ concentration at awakening time was 16.8 ng/mL. The AUC of MDZ is the only significant factor associated with the awakening time.

Blood-brain barrier permeability for the first 24 hours in hypoxic-ischemic brain injury following cardiac arrest

BACKGROUND

This study aimed to explore the changes in blood-brain barrier (BBB) permeability and intracranial pressure (ICP) for the first 24 h after the return of spontaneous circulation (ROSC) and their association with injury severity of cardiac arrest.

METHODS

This prospective study analysed the BBB permeability assessed using the albumin quotient (Qa) and ICP every 2 h for the first 24 h after ROSC. The injury severity of cardiac arrest was assessed using Pittsburgh Cardiac Arrest Category (PCAC) scores. The primary outcome was the time course of changes in the BBB permeability and ICP for the first 24 h after ROSC and their association with injury severity (PCAC scores of 1-4).

RESULTS

Qa and ICP were measured 274 and 197 times, respectively, in 32 enrolled patients. Overall, the BBB permeability increased progressively over time after ROSC, and then it increased significantly at 18 h after ROSC compared with the baseline. In contrast, the ICP revealed non-significant changes for the first 24 h after ROSC. The Qa in the PCAC 2 group was < 0.01, indicating normal or mild BBB disruption at all time points, whereas the PCAC 3 and 4 groups showed a significant increase in BBB permeability at 14 and 22 h, and 12 and 14 h after ROSC, respectively.

CONCLUSION

BBB permeability increased progressively over time for the first 24 h after ROSC despite post-resuscitation care, whereas ICP did not change over time. BBB permeability has an individual pattern when stratified by injury severity.

Combination strategy for prognostication in patients undergoing post-resuscitation care after cardiac arrest

This study investigated the prognostic performance of combination strategies using a multimodal approach in patients treated after cardiac arrest. Prospectively collected registry data were used for this retrospective analysis. Poor outcome was defined as a cerebral performance category of 3-5 at 6 months. Predictors of poor outcome were absence of ocular reflexes (PR/CR) without confounding factors, a highly malignant pattern on the most recent electroencephalography, defined as suppressed background with or without periodic discharges and burst-suppression, high neuron-specific enolase (NSE) after 48 h, and diffuse injury on imaging studies (computed tomography or diffusion-weighted imaging [DWI]) at 72-96 h. The prognostic performances for poor outcomes were analyzed for sensitivity and specificity. A total of 130 patients were included in the analysis. Of these, 68 (52.3%) patients had poor outcomes. The best prognostic performance was observed with the combination of absent PR/CR, high NSE, and diffuse injury on DWI [91.2%, 95% confidence interval (CI) 80.7-97.1], whereas the combination strategy of all available predictors did not improve prognostic performance (87.8%, 95% CI 73.8-95.9). Combining three of the predictors may improve prognostic performance and be more efficient than adding all tests indiscriminately, given limited medical resources.

Quantitative analysis of early apparent diffusion coefficient values from MRIs for predicting neurological prognosis in survivors of out-of-hospital cardiac arrest: an observational study

BACKGROUND

This study aimed to quantitatively analyse ultra-early brain diffusion-weighted magnetic resonance imaging (DW-MRI) findings to determine the apparent diffusion coefficient (ADC) threshold associated with neurological outcomes in comatose survivors of out-of-hospital cardiac arrest (OHCA).

METHODS

This retrospective study included adult survivors of comatose OHCA who underwent DW-MRI imaging scans using a 3-T MRI scanner within 6 h of the return of spontaneous circulation (ROSC). We investigated the association between neurological outcomes and ADC values obtained through voxel-based analysis on DW-MRI. Additionally, we constructed multivariable logistic regression models with pupillary light reflex (PLR), serum neuron-specific enolase (NSE), and ADC values as independent variables to predict poor neurological outcomes. The primary outcome was poor neurological outcome 6 months after ROSC, determined by the Cerebral Performance Category 3-5.

RESULTS

Overall, 131 patients (26% female) were analysed, of whom 74 (57%) showed poor neurological outcomes. The group with a poor neurological outcome had lower mean whole brain ADC values (739.1 vs. 787.1 × 10-6 mm/s) and higher percentages of voxels with ADC below threshold in all ranges (250-1150) (all P < 0.001). The mean whole brain ADC values (area under the receiver operating characteristic curve [AUC] 0.83) and the percentage of voxels with ADC below 600 (AUC 0.81) had the highest sensitivity of 51% (95% confidence interval [CI] 39.4-63.1; cut-off value ≤ 739.2 × 10-6 mm2/s and > 17.2%, respectively) when the false positive rate (FPR) was 0%. In the multivariable model, which also included PLR, NSE, and mean whole brain ADC values, poor neurological outcome was predicted with the highest accuracy (AUC 0.91; 51% sensitivity). This model showed more accurate prediction and sensitivity at an FPR of 0% than did the combination of PLR and NSE (AUC 0.86; 30% sensitivity; P = 0.03).

CONCLUSIONS

In this cohort study, early voxel-based quantitative ADC analysis after ROSC was associated with poor neurological outcomes 6 months after cardiac arrest. The mean whole brain ADC value demonstrated the highest sensitivity when the FPR was 0%, and including it in the multivariable model improved the prediction of poor neurological outcomes.

Differences in Cerebral Metabolism between Moderate- and High-Severity Groups of Patients with Out-of-Hospital Cardiac Arrest Undergoing Target Temperature Management

The aim of this study was to investigate the differences in cerebral metabolism and the prognostic value of cerebrospinal fluid (CSF) lactate 24 h after the return of spontaneous circulation (ROSC) in patients with out-of-hospital cardiac arrest (OHCA). CSF lactate and pyruvate levels were measured immediately and every 2 h for 24 h after the ROSC. The distribution of cerebral mitochondrial dysfunction (MD) and cerebral ischemia was also evaluated. In the moderate-severity group, the absence of cerebral MD or ischemia was observed in six patients (40.0%) immediately after ROSC and in nine patients (60.0%) 24 h after the ROSC. In the high-severity group, the absence of cerebral MD or ischemia was observed in four patients (30.8%) immediately after ROSC and in three patients (23.1%) 24 h after the ROSC. The distribution of cerebral metabolism over time varied depending on the severity of the OHCA. The predictive value of CSF lactate levels for a poor neurological prognosis was better for patients in the moderate-severity group than for the overall patient cohort. Therefore, the severity in the patients with OHCA should be considered when studying cerebral metabolism or using CSF lactate as a prognostic tool.

Acute contralateral reexpansion pulmonary edema within a few hours of pleural drainage

We report a case of an 83-year-old male patient with massive tuberculous pleural effusion. Percutaneous drainage was performed following a diagnosis of tuberculous pleurisy. Fifteen minutes into the procedure, the patient's condition deteriorated suddenly, necessitating mechanical ventilatory support. A chest radiograph performed after intubation showed partial collapse of the affected lung with pneumothorax. Despite sufficient air drainage and lung expansion, the patient's oxygen demand remained high. A repeat chest radiograph performed 30 minutes after chest tube insertion revealed partial expansion of the affected lung and severe infiltrative patterns in the unaffected lung, suggesting contralateral reexpansion pulmonary edema.

Preliminary Prognostication for Good Neurological Outcomes in the Early Stage of Post-Cardiac Arrest Care

We investigated prognostic strategies for predicting good outcomes in the early stage of post-cardiac-arrest care using multiple prognostic tests that are available until 24 h after the return of spontaneous circulation (ROSC). A retrospective analysis was conducted on 138 out-of-hospital cardiac-arrest patients who underwent prognostic tests, including the gray-white-matter ratio (GWR-BG), the Glasgow Coma Scale motor (GCS-M) score before sedative administration, and the neuron-specific enolase (NSE) level measured at 24 h after the ROSC. We investigated the prognostic performances of the tests as single predictors and in various combination strategies. Classification and regression-tree analysis were used to provide a reliable model for the risk stratification. Out of all the patients, 55 (44.0%) had good outcomes. The NSE level showed the highest prognostic performance as a single prognostic test and provided improved specificities (>70%) and sensitivities (>98%) when used in combination strategies. Low NSE levels (≤32.1 ng/mL) and high GCS-M (≥4) scores identified good outcomes without misclassification. The overall accuracy for good outcomes was 81.8%. In comatose patients with low NSE levels or high GCS-M scores, the premature withdrawal of life-sustaining therapy should be avoided, thereby complying with the formal prognostication-strategy algorithm after at least 72 h from the ROSC.

Time-course relationship between cerebrospinal fluid and serum concentrations of midazolam and albumin in patients with cardiac arrest undergoing targeted temperature management

AIM

To understand the serum and cerebrospinal fluid (CSF) distribution of midazolam is important for proper timing of neurological prognostication of targeted temperature management(TTM) patients. Midazolam binds extensively to albumin in serum although non protein bound form exist in CSF. We investigated the time-course of CSF, serum concentrations of midazolam and albumin in patients with cardiac arrest who underwent TTM.

METHODS

This prospective, single-center, observational study was conducted between May 2020 and April 2022. Midazolam and albumin concentrations in CSF and serum were quantified 0, 24, 48, and 72 h after the return of spontaneous circulation for comparison between the good (Cerebral Performance Category (CPC) 1 and 2) and poor (CPC 3, 4, and 5) neurologic outcome groups. The CSF/serum (C/S) ratios of midazolam and albumin concentrations were determined, along with their correlation coefficients.

RESULTS

Of the 19 enrolled patients, 13 experienced poor outcomes. At 0 h, serum midazolam concentrations were the lowest, whereas serum albumin levels were the highest; in the CSF, the concentrations of both peaked at 24 h. There were no significant inter-group differences in midazolam concentrations in CSF or serum. The C/S ratios of midazolam and albumin significantly differed between the groups. Moderate to strong positive correlations were observed between the midazolam and albumin C/S ratios.

CONCLUSION

In CSF, midazolam and albumin concentrations peaked 24 h post-cardiac arrest. Midazolam and albumin C/S ratios were significantly higher in the poor outcome group and positively correlated with each other, suggesting blood-brain barrier disruption 24 h post-cardiac arrest.

Tailored versus conventional surgical debridement in complex facial lacerations in emergency department: A retrospective study

Surgical debridement is an essential step in treating complex facial lacerations (CFL). As the CFL severity increases, conventional surgical debridement (CSD) of wound edges becomes difficult and may be insufficient. Because the severity and shape of each CFL vary, it is necessary to tailor the customized pre-excisional design, that is, tailored surgical debridement (TSD), for each case before performing surgical debridement. The use of TSD can enable effective debridement of CFL with higher severity. This study aimed to compare the cosmetic outcomes and complication incidence of CSD versus TSD according to CFL severity. In this retrospective observational study, eligible patients with CFL who visited the emergency department between August 2020 and December 2021 were examined. CFL severity was graded as Grades I and II. The outcomes of CSD and TSD were compared using the scar cosmesis assessment and rating (SCAR) scale, wherein a good cosmetic outcome was defined as a SCAR score of ≤ 2. The percentage of good cosmetic outcomes between the 2 groups was compared. The SCAR score and percentage of good cosmetic outcomes between the 2 groups were compared overall and by severity. For analyzing complication incidence, asymmetry, infection, and dehiscence incidence were compared. In total, 252 patients were enrolled [121 (48.0%) CSD and 131 (52.0%) TSD]. The median SCAR scores were 3 (1-5) and 1 (0-2) in all enrolled patients (P < .001), 2 (0-4), and 1 (0-1) in Grade I patients (P < .01), and 5 (4-6) and 1 (1-2) in Grade II patients (P < .001) in the CSD and TSD groups, respectively. The percentage of good cosmetic outcomes was 46.3% and 84.0% overall (P < .001), 59.6% and 85.0% in Grade I patients (P < .01), and 9.4% and 83.5% in Grade II patients (P < .001) in the CSD and TSD groups, respectively. The incidence of complications was significantly higher in the CSD group than in the TSD group, but this was limited to asymmetry. No significant difference was noted in infection or dehiscence. Compared with CSD, TSD can lead to an objectively good cosmetic prognosis at higher CFL severity and can reduce facial asymmetry occurrence.

Association of ultra-early diffusion-weighted magnetic resonance imaging with neurological outcomes after out-of-hospital cardiac arrest

BACKGROUND

This study aimed to investigate the association between ultra-early (within 6 h after return of spontaneous circulation [ROSC]) brain diffusion-weighted magnetic resonance imaging (DW-MRI) and neurological outcomes in comatose survivors after out-of-hospital cardiac arrest.

METHODS

We conducted a registry-based observational study from May 2018 to February 2022 at a Chungnam national university hospital in Daejeon, Korea. Presence of high-signal intensity (HSI) (P_HSI) was defined as a HSI on DW-MRI with corresponding hypoattenuation on the apparent diffusion coefficient map irrespective of volume after hypoxic ischemic brain injury; absence of HSI was defined as A_HSI. The primary outcome was the dichotomized cerebral performance category (CPC) at 6 months, defined as good (CPC 1-2) or poor (CPC 3-5).

RESULTS

Of the 110 patients (30 women [27.3%]; median (interquartile range [IQR]) age, 58 [38-69] years), 48 (43.6%) had a good neurological outcome, time from ROSC to MRI scan was 2.8 h (IQR 2.0-4.0 h), and the P_HSI on DW-MRI was observed in 46 (41.8%) patients. No patients in the P_HSI group had a good neurological outcome compared with 48 (75%) patients in the A_HSI group. In the A_HSI group, cerebrospinal fluid (CSF) neuron-specific enolase (NSE) levels were significantly lower in the group with good neurological outcome compared to the group with poor neurological outcome (20.1 [14.4-30.7] ng/mL vs. 84.3 [32.4-167.0] ng/mL, P < 0.001). The area under the curve for P_HSI on DW-MRI was 0.87 (95% confidence interval [CI] 0.80-0.93), and the specificity and sensitivity for predicting a poor neurological outcome were 100% (95% CI 91.2%-100%) and 74.2% (95% CI 62.0-83.5%), respectively. A higher sensitivity was observed when CSF NSE levels were combined (88.7% [95% CI 77.1-95.1%]; 100% specificity).

CONCLUSIONS

In this cohort study, P_HSI findings on ultra-early DW-MRI were associated with poor neurological outcomes 6 months following the cardiac arrest. The combined CSF NSE levels showed higher sensitivity at 100% specificity than on DW-MRI alone. Prospective multicenter studies are required to confirm these results.

Serum total cholesterol level as a potential predictive biomarker for neurological outcomes in cardiac arrest survivors who underwent target temperature management

Cholesterol is an essential substance to maintain cell membranes. Low levels of total cholesterol (TC) are associated with poor prognosis in critically ill patients. Cardiac arrest-induced whole-body ischemia and reperfusion injury cause a sepsis-like syndrome. The Cholesterol level in post-cardiac arrest patients may indicate the degree of endotoxemia or inflammation caused by ischemic and reperfusion injury. We aimed to investigate the association of TC levels with neurologic outcome of out-of-hospital cardiac arrest (OHCA) survivors who underwent target temperature management (TTM). This was a retrospective single-center observational study from May 2018 to April 2021 on a cohort of 106 patients. TC levels were determined in samples obtained immediately and at 24, 48, and 72 hours after the return of spontaneous circulation (ROSC). The primary outcome was poor neurologic outcome at 3 months after ROSC. Poor neurologic outcome was defined by cerebral performance categories 3 to 5. Sixty patients had a poor neurologic outcome. TC levels were significantly lower in the poor neurologic outcome group at each time point. The TC levels for predicting poor neurologic outcome had a sensitivity of 80.8%, with 67.6% specificity at 48 hours (TC48) after ROSC. The areas under the curve value of TC48 was 0.771 (0.670-0.853), with a cutoff value of 114 mg/dL. TC level at 48 hours after ROSC was a helpful marker for the 3-month poor neurologic outcome. This might be an easily accessible predictive marker of neurologic outcome in OHCA survivors treated with TTM.

Comparison of intracranial pressure changes in out-of-hospital cardiac arrest patients with and without malignant blood-brain barrier disruption

OBJECTIVE

In the present study, intracranial pressure (ICP) changes were investigated in out-ofhospital cardiac arrest (OHCA) patients with and without malignant blood-brain barrier (BBB) disruption who underwent target temperature management.

METHODS

This prospective, single-center, observational study was conducted from June 2019 to December 2021. ICP and albumin quotient values were measured on days 1, 2, 3, and 4 of hospitalization. Malignant BBB disruption was defined as the sum of scores for the degree of BBB disruption ≥9 on days 1 to 4.

RESULTS

ICP in OHCA patients without malignant BBB disruption on days 1, 2, 3, and 4 of hospitalization was 9.58±0.53, 12.32±0.65, 14.39±0.76, and 13.88±0.87 mmHg, respectively, and in OHCA patients with malignant BBB disruption 13.65±0.74, 15.72±0.67, 16.10±0.92, and 15.22±0.87 mmHg, respectively (P<0.001, P<0.001, P=0.150, and P=0.280, respectively). The P-values of changes in ICP between days 1 and 2, days 2 and 3, and days 3 and 4 of hospitalization in OHCA patients without malignant BBB disruption were P<0.001, P=0.001, and P=0.540, respectively, and in OHCA patients with malignant BBB disruption were P=0.002, P=0.550, and P=0.100, respectively.

CONCLUSION

Among OHCA patients treated with target temperature management, ICP was higher on days 1 and 2 of hospitalization and an increase in ICP occurred earlier with malignant BBB disruption than without malignant BBB disruption.

Comparison of adhesive single-lead ECG device and Holter test for atrial fibrillation monitoring

Background

There is insufficient validation of diagnostic benefits of extended monitoring with an adhesive single-lead ECG device compared to Holter test for routine medical care of AF patients.

Purpose

The study aimed to compare AF detection rates between 72-hour monitoring using an adhesive single-lead ECG device (mobiCARE MC-100, Seers Technology, Republic of Korea) and 24-hour Holter test among AF patients at outpatient clinics.

Methods

A total of 200 AF patients indicated for Holter test at cardiology outpatient clinics enrolled in the study. Study participants equipped both Holter and MC-100 for the first 24 hours (Figure 1). After then, only MC-100 continued ECG monitoring for additional 48 hours. AF detection during the first 24 hours was compared between two devices. The diagnostic benefits of extended monitoring with MC-100 were evaluated.

Results

During the first 24 hours, both monitoring methods detected AF in the same 40/200 (20.0%) patients (20 patients with paroxysmal and persistent AF each). Compared to 24-hour Holter, MC-100 increased AF detection rate by 1.5-fold (58/200; 29.0%) and 1.6-fold (64/200; 32.0%) with 48- and 72-hour monitoring, respectively (Figure 2A). With MC-100, the number of newly discovered patients with paroxysmal AF was 20/44 (45.5%), 18/44 (40.9%), and 6/44 (13.6%) for 24-, 48-, and 72-hour monitoring. Compared to 24-hour Holter, 72-hour monitoring with MC-100 increased the detection rate of paroxysmal AF by 2.2-fold (44/20). If only the episodes lasting over 30 seconds were counted as AF with MC-100, the detection rate of paroxysmal AF was decreased by 9.1% (Figure 2B).

Conclusion

Compared to Holter, AF detection rates could be improved with an adhesive single-lead device, especially for patients with paroxysmal AF. This device is expected to be useful for AF detection among patients whose conventional ECG tests were ineffective in documenting AF episodes.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Korea Medical Device Development Fund grant funded by the Korean government (the Ministry of Science and ICT, the Ministry of Trade, Industry and Energy, the Ministry of Health & Welfare, Republic of Korea, the Ministry of Food and Drug Safety)

The left atrial low-voltage area and persistent atrial fibrillation treated with pulmonary vein isolation alone

Background

There are limited data regarding the association between the burden of the left atrial low-voltage area (LVA) and the outcome of pulmonary vein isolation (PVI) alone in persistent atrial fibrillation (PeAF).

Purpose

The study aimed to investigate the impact of the burden of LVA on the patients with PeAF treated with PVI alone.

Methods

Using a retrospective cohort of PeAF patients who underwent PVI alone, both clinical and the left atrial voltage mapping data were reviewed. LVA was defined as an area of ≤0.5 mV (bipolar) when mapped during sinus rhythm and ≤0.2 mV during AF. The high burden of LVA was defined as a case when the LVA constitutes ≥10% of the total left atrial body area. The patients were categorized into either the high or low burden groups. The recurrence of any atrial tachyarrhythmia was followed up, and multivariable Cox's regression analysis was performed.

Results

A total of 50 and 25 patients were investigated for the low burden (LVA&lt;10%) and high burden (LVA≥10%) groups, respectively. Compared to the low burden group, the high burden group had a significantly less male proportion (56.0% versus 78.0%), a higher CHA2DS2-VASc score (median 3 versus 2), more chronic kidney disease (16.0% versus 2.0%), and a higher burden of LVA (20±11% versus 5±3%). During the median follow-up of 9.5 (6.2–16.2)months, there were 30.0% and 48.0% ofrecurrences for the low and high burden groups, respectively. Compared to the low burden group, the high burden group was associated with higher risks of both early and late recurrences (HR [95% CI] =2.67 [1.15–6.18] and 2.08 [1.03–4.20], respectively) (Figure 1). The best cut-off of LVA to predict 2-year recurrence was 10.1% (Figure 2).

Conclusion

The high burden of LVA was significantly associated with an increased risk of recurrence among PeAF patients treated with PVI alone. Tailored ablation in addition to PVI would be needed to improve outcomes in patients with PeAF having a high burden of LVA.

Funding Acknowledgement

Type of funding sources: None.

Protective effect of proton pump inhibitor against gastrointestinal bleeding in patients receiving oral anticoagulants: a systematic review and meta-analysis

Background

The concurrent use of proton pump inhibitor (PPI) in oral anticoagulant (OAC) treated patients may be associated with a lower risk of gastrointestinal bleeding (GIB), but evidence is still conflicting according to individual OACs.

Purpose

We conducted a meta-analysis to estimate the risk of GIB in patients with OAC and PPI co-therapy.

Methods

A systematic search of PubMed, EMBASE, and Cochrane was performed for studies reporting GIB risk in OAC and PPI co-therapy. Primary outcomes were total GIB and major GIB events. We calculated pooled estimates of GIB risk by a random-effect meta-analysis and reported as odds ratios (OR) and 95% CI. Stratified analyses according to the origin of GIB, ethnic groups, individual OACs, and the presence of underlying GIB risk factors were performed.

Results

A total of 10 studies (1 randomized controlled study and 9 observational studies) and 1,970,931 patients who received OAC were included. OAC and PPI co-therapy were associated with a lower risk of total GIB, and major GIB; OR (95% CI) was 0.67 (0.62–0.74) for total GIB and 0.68 (0.63–0.75) for major GIB, respectively. Among total GIB, only the risk of upper GIB was lower with OAC and PPI co-therapy (OR 0.67, 95% CI 0.64–0.70). No difference in the lower risk of primary GIB outcomes of PPI co-therapy was observed between Asians and non-Asians (p-for-difference, total GIB=0.695, major GIB=0.748, respectively) and among individual OACs except for edoxaban. The protective effect of PPI on total GIB was more significant in high-risk patients, defined as those with concurrent medication of antiplatelets or non-steroidal anti-inflammatory drugs (OR 0.62, 95% CI 0.52–0.73) and presence of high bleeding risk factors such as previous GIB history, HAS-BLED score ≥3, or underlying gastrointestinal diseases. (OR 0.65, 95% CI 0.61–0.70).

Conclusion

In patients who receive OAC, the use of PPI co-therapy was associated with a lower risk of total GIB and major GIB irrespective of ethnic group and OAC type except for edoxaban. PPI co-therapy can be considered particularly in patients on concomitant NSAID and antiplatelet use or patients with high GIB risk factors.

Funding Acknowledgement

Type of funding sources: None.

Increased risk of atrial fibrillation in patients with uterine fibroids: a nationwide population-based study

Background

Uterine fibroid, the most common benign neoplasm of the uterus, is associated with an elevated risk of cardiovascular disease. The link between incident atrial fibrillation (AF) and the uterine fibroid is unclear because earlier studies focused primarily on the development of atherosclerosis and hypertension. We aimed to investigate the risk of AF in patients with uterine fibroid.

Methods

This is a retrospective cohort study using the Korean National Health Insurance Service database (NHIS). From 2009 to 2012, a total of 2,574,349 women (20 to 40 years old) who underwent general health examinations were included. Diagnosis of uterine fibroids and surgical treatment status was defined by the international classification of diseases, 10th revision codes, and procedural codes from the Korean NHIS. The primary outcome was newly diagnosed AF. The risk of AF according to the uterine fibroids and their surgical treatment status was evaluated using Cox proportional-hazard models.

Results

Of the total population, the mean age was 29.76±4.27 years, and 20,682 (0.8%) were identified to have uterine fibroid. Incident AF was identified in 3,868 patients (61 in the fibroid group, 3,807 in the control group) during a mean follow-up of 7.3±1.1 years. Patients of the uterine fibroid group showed a higher incidence of AF compared to the control group (0.41 and 0.20 per 1000 person-years, respectively, Figure 1). Multivariate Cox-regression analysis presented that uterine fibroid was an independent risk factor of AF: hazard ratio (HR) 1.50, 95% confidence interval (CI) 1.16–1.93, p=0.002. Compared to the control group, uterine fibroid patients who underwent surgical treatment tend to show a lower risk for AF (HR 1.22, 95% CI 0.79–1.90) than patients without surgical treatment (HR 1.69, 95% CI 1.24–2.30), though statistical significance was indeterminate (Figure 2). After propensity score matching, patients of the uterine fibroid group showed higher risk of AF when compared to the control group (HR 1.77, 95% CI 1.32–2.63, p&lt;0.001), which was in line with our main results. The presence of uterine fibroid was consistently associated with higher risk of AF among all subgroups except for the stroke subgroup.

Conclusion

Patients with uterine fibroids are predisposed to an increased risk of AF compared to the control group. Careful monitoring of arrhythmia development would be warranted in patients of uterine fibroid and surgical treatment as it is associated with a modest risk decrement of incident AF.

Funding Acknowledgement

Type of funding sources: None.

Paradoxical association between lipid levels and incident atrial fibrillation according to statin usage

Background

In epidemiology studies, a higher level of total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) is associated with a lower risk of atrial fibrillation (AF). Statin use might exert possible confounding effects in the paradoxical relationship; however, the inverse link between AF and cholesterol level that distinguishes statin users from non-users has not been evaluated.

Objective

We investigated the epidemiological relationships of TC–AF and LDL-C–AF in statin users and non-users, respectively.

Methods

From the Korean National Health Insurance Service database, we included 9,778,014 adults who underwent a health examination in 2009 and had no prior AF history. The levels of TC and LCL-C at the health exam were categorized in quartile (Q) and decile (D) values of the total study population. The study population was grouped into statin users and non-users, and TC–AF and LDL-C–AF relationships were evaluated.

Results

867,336 (8.9%) were on statin use among the total population. Statin users showed higher TC level (208.4±55.6 vs. 194.1±39.5 mg/dL, p&lt;0.001) and LDL-C level (123.0±102.2 vs. 121.3±226.3, p&lt;0.001) compared to non-users. Inverse associations of TC–AF and LCL-C–AF were observed; higher levels of TC and LDL-C were associated with a lower risk of AF. The hazard ratios (HR) and 95% confidence intervals (CI) were 0.797 (0.786–0.809) for the highest quartile of TC (Q4, TC ≥218) and 0.832 (0.82–0.843) for the highest quartile of LDL-C (Q4, LDL-C ≥135) when adjusted by age, sex, lifestyle behaviors, comorbidities, and low-income status. Statin users exhibited higher AF incidence rate than non-statin users, but the association in statin users generally tracked that seen among non-statin users demonstrating similar HR in Q4 of TC [0.812 (0.790–0.835) for statin users and 0.812 (0.798–0.826) for non-statin users] and LDL-C [0.842 (0.819–0.865) for statin users and 0.849 (0.835–0.863) for non-statin users].

Conclusion

The paradoxical relationship between lipid levels (TC and LDL-C) and incident AF remained consistent both in statin users and non-users. Further research is required to investigate an underlying mechanism for the cholesterol paradox of AF which still seems evident despite the pleiotropic effects of statin.

Funding Acknowledgement

Type of funding sources: None.

Fish oil supplements increase atrial fibrillation risk in healthy individuals: a population-based cohort study and Mendelian randomization analysis

Background

There is a paucity of information on the risk of atrial fibrillation (AF) in healthy individuals taking fish oil supplements.

Purpose

We aimed to investigate the epidemiologic and causal relationships between fish oil supplement intake and the long-term risk of AF.

Methods

From the population-based UK Biobank, we selected healthy individuals without a history of AF, other cardiac arrhythmias, or cardiovascular diseases, who were not taking lipid-lowering medications or dietary supplements other than fish oil. The 10-year risk of AF in Fish-Oil-Users vs. Non-Users was evaluated in the total population and propensity-score matched cohort. The causal relationship between n-3 polyunsaturated fatty acids (PUFA) and AF was evaluated using a two-sample summary-level Mendelian randomization analysis with fixed effects robust inverse-variance weighted method, using genetic instruments from previous studies genome-wide association studies for n-3 PUFA levels and AF, respectively.

Results

A total of 338,199 participants (aged 55.2±8.1, 44.3% men) were analysed. Of these, 35.0% (n=118,300) was taking fish oil supplements. The 10-year risk of AF was significantly higher in the Fish-Oil-Users than in the Non-Users (3.83% vs. 2.91%, adjusted hazard ratio [HR] 1.05, 95% CI [1.01–1.10], P=0.023). The result was consistent in the propensity-score matched cohort (propensity-score matched HR 1.06, 95% CI [1.00–1.12], P=0.043). The increased risk of AF by fish oil supplement was prominent in low-risk participants with healthy lifestyles. Among n-3 PUFA, the docosapentaenoic acid (DPA) showed significant causal estimates for the increased risk of AF (odds ratio [OR] 1.15, 95% CI [1.08–1.22], P&lt;0.001), while higher eicosapentaenoic acid (EPA) levels caused a decrease of AF risk (OR 0.85, 95% CI [0.80–0.90], P&lt;0.001).

Conclusion

Fish oil supplement intake significantly increased the long-term risk of AF in a healthy population. The causal effect of fish oil intake on the risk of AF may depend on the specific types of n-3 PUFA.

Funding Acknowledgement

Type of funding sources: None.

Impact of metabolic syndrome on the risk of ischemic stroke in non-anticoagulated atrial fibrillation patients having low CHA2DS2-VASc scores

Background

Metabolic syndrome (MetS) predisposes to a thromboembolic state. However, conflicting results have been reported on whether MetS confers an increased risk of ischemic stroke in atrial fibrillation (AF), especially in patients with low CHA2DS2-VASc score who are not indicated for oral anticoagulant therapy.

Purpose

We investigated the risk of ischemic stroke according to the presence of MetS, the number of MetS components (metabolic burden), and the individual metabolic components in non-anticoagulated AF patients with low CHA2DS2-VASc score.

Methods

A total of 76,015 oral anticoagulant-naïve AF patients with low CHA2DS2-VASc score (0,1 in male and 1 in female) were included from the Korean National Health Insurance Service database. The status of MetS and individual metabolic components were evaluated based on health examination data within two years of AF diagnosis. We estimated the risk of ischemic stroke according to MetS, metabolic burden, and an individual component of MetS using Cox proportional-hazards models.

Results

The mean age was 49.8±11.1 years and 52,388 (68.9%) were male. The average CHA2DS2-VASc score was 0.7±0.5 and MetS was prevalent among 21,570 (28.4%) of the study population. During a mean follow-up of 5.1 years, ischemic stroke was developed in 1,395 (1.84%) patients. MetS was associated with a higher risk of ischemic stroke after adjustment for age, sex, lifestyle behaviors, low income, and cardiovascular comorbidities: adjusted hazard ratio (aHR) 1.19, 95% confidence interval (CI) 1.06–1.33, p=0.002. A positive linear correlation was observed between metabolic burden and ischemic stroke risk. Patients with five MetS components showed the highest aHR of 1.55 (95% CI 1.14–2.11, Figure 1 and Figure 2), whereas those with a single MetS component had a marginal risk of ischemic stroke (aHR 1.18, 95% CI 0.99–1.41). Among individual metabolic components, elevated blood pressure and increased waist circumference was significantly associated with an increased risk of ischemic stroke: aHR (95% CI), 1.45 (1.30–1.62), p&lt;0.001, and 1.15 (1.03–1.30), p=0.016, respectively.

Conclusions

Among AF patients initially with CHA2DS2-VASc score 0 and 1 with no anticoagulation, the presence of MetS is associated with an increased risk of ischemic stroke. Given the linear incremental correlation between metabolic burden and ischemic stroke, special attention to the care of metabolic derangements is required in AF patients who are not indicated for anticoagulation.

Funding Acknowledgement

Type of funding sources: None.

Atrial fibrillation detection in ambulatory patients using a smart ring powered by deep learning analysis of continuous photoplethysmography monitoring

Background

Atrial fibrillation (AF) detection could be effective with photoplethysmography (PPG) signal monitoring by a wearable device.

Purpose

We aimed to validate the performance of AF detection among ambulatory patients who underwent electrical cardioversion for AF using a smart ring capable of continuous PPG monitoring and deep learning analysis.

Methods

In this prospective single-arm study, participants who underwent successful electrical cardioversion for AF were enrolled. The participants equipped a smart ring (CardioTracker, Sky Labs Inc., Seongnam, Republic of Korea) after the electrical cardioversion. The smart ring then continuously monitored PPG over 14 days to detect AF recurrence. The smart ring alarmed AF episodes based on deep learning analysis of PPG. The participants were asked to measure at least three daily ECGs using the smart ring to validate AF recurrence detected by PPG. All ECG snapshots were recorded along with lead I and saved with simultaneous PPG. ECG data were examined by the three cardiologists independently (SK, SRL, and EKC). The monitoring time, analyzable proportions of monitored signals, detection rates of AF episodes, and the diagnostic performance of PPG-based deep learning were evaluated. At the end of the monitoring, a survey on the use of the smart ring was performed.

Results

A total of 35 participants (mean age 58.9 years, male 74.3%) were enrolled. Figure 1 illustrates an example of PPG monitoring and PPG-ECG snapshots by the smart ring. The study participation period was a median of 14 days and the wearing time of the smart ring was a median of 9.2 days (IQR 7.1–11.5 days). Signal artifacts during daily activity decreased the analyzable proportions of monitored PPG by 68.5%. Irregular pulse episodes were detected by the smart ring in 29 (82.9%) participants after a median of 1 day from the cardioversion (Figure 2). A total of 2532 PPG-ECG snapshots were acquired and 1623 (64.1%) were interpretable by both the cardiologists (using ECG) and the deep learning analysis (using PPG). Comparing PPG by simultaneous ECG, the performance of AF detection by the smart ring was 98.7% for sensitivity, 97.8% for specificity, 2.2% for false positives, and 1.3% for false negatives (Figure 2). After using the smart ring, 76.9% of the participants responded that they had no discomfort in using the smart ring in daily activity and another 76.9% responded that it was helpful to monitor their disease.

Conclusion

Despite the signal artifacts during daily activity, AF detection with PPG monitoring by a smart ring could be effective for AF screening among ambulatory patients.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): This work was supported by Sky Labs Inc, Seongnam, Republic of Korea, and by the grant No. 0320202040 from the Seoul National University Hospital Research Fund.

Development of a strategy for assessing blood-brain barrier disruption using serum S100 calcium-binding protein B and neuron-specific enolase in early stage of neuroemergencies: A preliminary study

BACKGROUND

Rapid disease progression in neuroemergencies is associated with blood-brain barrier (BBB) disruption. We investigated a less invasive strategy for assessing BBB status by evaluating S100 calcium-binding protein B (S100B) and neuron-specific enolase (NSE) at early stages of the hypoxic-ischemic brain injury (HIBI) cascade.

METHODS

This retrospective study used prospectively collected data from patients with out-of-hospital cardiac arrest (August 2019-July 2021). Albumin specimens obtained from serum and cerebrospinal fluid via arterial catheter and lumbar puncture were used to measure the albumin quotient (Qa), which is widely accepted as the gold standard method for detecting BBB disruption. Serum S100B and NSE levels were measured simultaneously following the return of spontaneous circulation. We conducted linear regression to evaluate the relationship between S100B and Qa and the predictive performance of S100B for abnormal Qa. The primary study outcome was abnormal Qa (>0.007).

RESULTS

Forty-one patients were enrolled; 30 showed an abnormal Qa suggestive of BBB disruption. S100B levels were significantly higher than in those with a normal Qa (0.244 μg/L [interquartile range [IQR], 0.146-0.823 vs 0.754 μg/L [IQR, 0.317-2.228], P = .03). We report a positive correlation between serum S100B and Qa (R2 = 0.110; P = .04). The area under the receiver operating characteristics curve (AUROC) evaluating the predictive performance of S100B with respect to abnormal Qa was 0.718 (95% confidence interval, 0.556-0.847). The cutoff value for S100B (with respect to BBB disruption) in the total cohort was 0.283 μg/L (sensitivity, 80.0%; specificity, 72.7%). Subgroup analyses in patients with serum neuron-specific enolase (NSE) levels of <40.8 ng/mL (excluding those with established neuronal cell injury) showed an improved correlation coefficient (R2 = 0.382; P < .01) and predictive performance (AUROC, 0.836 [95% confidence interval, 0.629-0.954]) compared with the total cohort.

CONCLUSIONS

Serum S100B obtained at an early stage of the HIBI cascade is associated with abnormal Qa, suggesting BBB disruption. The predictive performance of S100B and the correlation between serum S100B and Qa can be improved using a complementary strategy (i.e., evaluations of S100B and NSE levels) that combines considerations of cell damage in astrocytes and neurons.

Detection of Testicular Torsion With Preserved Intratesticular Flow By Point of Care Ultrasound in the Emergency Department: A Case Report

BACKGROUND

Ultrasonography is an effective diagnostic tool for testicular torsion (TT), which is typically characterized by the absence of blood flow in the affected testicle on color Doppler mode. However, there are a few reported cases of TT with symmetrical preserved flow. We report a case of TT with the preserved intratesticular flow on color Doppler ultrasound.

CASE REPORT

A 14-year-old boy was admitted due to sudden-onset right scrotal pain. Point-of-care ultrasound (POCUS) revealed that the right testicle was larger than the left. The intratesticular flow in both testicles was preserved. Radiology-performed ultrasound confirmed the preserved intratesticular flow observed on POCUS, but also demonstrated a whirlpool sign of the right spermatic cord. TT was confirmed surgically. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should investigate the presence of intratesticular blood flow and the whirlpool sign of the spermatic cord or other ultrasound features suggestive of TT, even if testicular blood flow is preserved. Suspicion of TT from POCUS findings warrants further evaluation to preserve the patient's fertility.

The Early Prognostic Value and Optimal Time of Measuring Serum and Cerebrospinal Fluid Tau Protein for Neurologic Outcomes in Postcardiac Arrest Patients Treated with Targeted Temperature Management

Neuroprognostication of cardiac arrest patients remains a challenge. We evaluated the early prognostic value and optimal time of measuring serum and cerebrospinal fluid (CSF) tau protein levels to predict neurologic outcome in postcardiac arrest patients treated with targeted temperature management (TTM). We also evaluated the cutoff values in predicting poor outcomes. Patients treated with TTM following cardiac arrest, from May 2018 to June 2019, were included in the study. Serum and CSF tau levels were obtained and compared immediately, at 24, 48, and 72 hours after return of spontaneous circulation (ROSC). The area under the receiver-operating characteristic curve (AUROC) and the Delong method were used to identify the cutoff values of serum and CSF tau protein levels in predicting poor outcomes at each interval. Of 38 patients enrolled, 16 experienced poor outcomes. Both serum and CSF tau levels were consistently higher in the poor outcome group than in the good outcome group. The AUROCs of serum and CSF tau protein were not significantly different at each time point. Immediately after ROSC, sensitivities of both serum and CSF tau protein levels were 31.25% at 100% specificity and increased to 86.6% and 73.3%, respectively, at 72 hours. This study demonstrates that serum and CSF tau protein levels could be used as valuable predictors of neurologic outcomes in postcardiac arrest patients treated with TTM. The early optimal time for measuring the serum and CSF tau protein levels was determined to be 72 hours after ROSC.

Different Stratification of Physiological Factors Affecting Cerebral Perfusion Pressure in Hypoxic-Ischemic Brain Injury after Cardiac Arrest According to Visible or Non-Visible Primary Brain Injury: A Retrospective Observational Study

We aimed to explore the stratification of physiological factors affecting cerebral perfusion pressure, including arterial oxygen tension, arterial carbon dioxide tension, mean arterial pressure, intracranial pressure (ICP), and blood-brain barrier (BBB) status, with respect to primary or secondary brain injury (PBI or SBI) after out-of-hospital cardiac arrest (OHCA). Among the retrospectively enrolled 97 comatose OHCA survivors undergoing post-cardiac arrest (PCA) care, 46 (47.4%) with already established PBI (high signal intensity (HSI) on diffusion-weighted imaging (DWI) had higher ICP (p = 0.02) and poorer BBB status (p < 0.01) than the non-HSI group. On subgroup analysis within the non-HSI group to exclude the confounding effect of already established PBI, 40 (78.4%) patients with good neurological outcomes had lower ICP at 24 h (11.0 vs. 16.0 mmHg, p < 0.01) and more stable BBB status (p = 0.17 in pairwise comparison) compared to those with poor neurological outcomes, despite the non-significant differences in other physiological factors. OHCA survivors with HSI on DWI showed significantly higher ICP and poorer BBB status at baseline before PCA care than those without HSI. Despite the negative DWI findings before PCA care, OHCA survivors have a cerebral penumbra at risk for potentially leading the poor neurological outcome from unsuppressed SBI, which may be associated with increased ICP and BBB permeability.

Risk of atrial fibrillation in young adults aged 20 to 39 years with isolated diastolic, isolated systolic, and systolic-diastolic hypertension: a nationwide population-based study

Background

There is limited evidence regarding the comparative risks of incident atrial fibrillation (AF) associated with stage 1 isolated systolic hypertension (ISH), isolated diastolic hypertension (IDH), and systolic-diastolic hypertension (SDH), especially amongst young adults aged 20–39 years.

Purpose

To evaluate the association between early-stage of hypertension and AF in young adults aged 20–39 years.

Methods

From the Korean nationwide health screening database, 2,958,544 subjects aged 20–39 years who were not prescribed antihypertensive medication at the index examination in 2009 were included. Subjects were categorized into eight groups according to the 2017 American College of Cardiology/American Heart Association blood pressure (BP) guidelines: normal BP, elevated BP, stage 1 IDH, stage 1 ISH, stage 1 SDH, stage 2 IDH, stage 2 ISH, and stage 2 SDH. The primary outcome was new-onset AF during follow-up.

Results

During a median follow-up of 8.3 years, 7,347 subjects had incident AF (incidence rate, 0.3 per 1,000 person-years). Compared to the normal BP group, stage 1 IDH (adjusted hazard ratio [aHR], 1.160; 95% confidence interval [CI], 1.086–1.240) and stage 1 SDH (1.250; 1.165–1.341) were associated with higher risks of incident AF, but not stage 1 ISH. Stage 2 IDH, ISH, and SDH were associated with higher risks of incident AF by 24%, 37%, and 61%, respectively (Figure).

Conclusion

Among young adults, stage 1 IDH and SDH were associated with higher risks of incident AF compared to normal BP. The risk of incident AF with stage 2 IDH was similar to that of stage 1 SDH. Optimal BP control including diastolic BP is crucial for preventing new-onset AF, even amongst young adults.

Funding Acknowledgement

Type of funding sources: None.

Association between body mass index and the risk of atrial fibrillation and ischemic stroke according to age: a nationwide population-based cohort study

Background

Atrial fibrillation (AF) and ischemic stroke (IS) are two significant cardiovascular diseases that confer an enormous healthcare burden. A limited study comprehensively evaluated the association between full ranges of body mass index (BMI), including underweight, and AF or IS risks, especially in the different age subgroups.

Purpose

We investigated the association between BMI and AF and IS incidence according to the Korean population's age groups.

Methods

This was a nationwide population-based cohort study using data from the Korea National Health Insurance Service, including 9 194 477 healthy adults who underwent a medical examination in 2009. We stratified the study population into three age subgroups: age 20–39 (young, 33.1%), age 40–64 (middle-aged, 56.3%), and age over 65 years (elderly, 10.6%). In each age group, the individuals were categorized based on BMI (kg/m2) into underweight (&lt;18.5), normal (18.5 to &lt;23), overweight (23 to &lt;25), obese I (25 to &lt;30), and obese II (≥30). The first occurrences of AF and IS were followed up until December 31, 2018. According to BMI in each age group, the risks of AF and IS were analyzed by Cox proportional hazards regression with 95% confidence intervals (CI) by adjusting age, sex, lifestyle behaviors, and comorbidities.

Results

Overall, both underweight and higher BMI were associated with an increased risk of AF and stroke across all age groups. The increased risk of AF for patients with obese II was slightly accentuated compared to patients with normal BMI in the young population than elderly population (hazard ratio [HR] 1.78, 95% CI 1.63–1.94 for age 20–39 years; HR 1.55, 95% CI 1.48–1.61 for age ≥65 years, respectively). For underweight individuals, however, the increased risk of AF became more prominent in the elderly: HR and 95% CI was 1.12 (1.07–1.17) in the age over 65 years old, and 1.05 (0.94–1.16) in the age 20–39. Regarding IS, the young group presented a considerable increment in the magnitude of HRs in both underweight and higher BMI groups. However, the association between the BMI and stroke risk became attenuated in the elderly: HRs and 95% CI in underweight and obese II individuals were 1.10 (0.93–1.30) and 2.223 (1.99–2.49) in the age 20–39 group, whereas 0.97 (0.93–1.01) and 1.03 (0.98–1.08) in the age over 65 years old.

Conclusions

Underweight as well as obesity was associated with increased risks of AF and IS in the general population. In both AF and IS, the gradient of risks according to BMI was apparent at young ages; thus, maintaining normal body weight should be warranted in early life. An interplay of several factors other than BMI may contribute to ischemic stroke in the old ages, requiring integrated risk management in older patients.

Funding Acknowledgement

Type of funding sources: None.

Prognostic role of serum neutrophil gelatinase-associated lipocalin in cardiac arrest patients: A prospective observational study

Accurate neurological prognostication is of the utmost importance to avoid futile treatments in patients treated with targeted temperature management (TTM) after out-of-hospital cardiac arrest (OHCA). This study aimed to investigate the prognostic value of serum neutrophil gelatinase-associated lipocalin (NGAL) by comparing with neuron-specific enolase (NSE), which is currently recommended by international guidelines in patients treated with TTM after OHCA.The study included 85 comatose adult patients with OHCA who underwent TTM between May 2018 and December 2020. Serum NGAL and NSE were measured at 24-hour intervals until 72 hours after return of spontaneous circulation (ROSC). The primary outcome was their prognostic performance for poor neurological outcome at 3 months after OHCA.Forty-nine patients (57.6%) had a poor neurological outcome; NGAL levels at all time points measured were significantly higher in these patients than in those with a good outcome (P < .01). NGAL showed lower maximal sensitivity (95% confidence interval [CI]) under a false-positive rate of 0% for the primary outcome compared with NSE (18.2% [95% CI 8.2-32.7] vs 66.7% [95% CI 50.5-80.4]). The combination of NGAL with NSE at 48 h showed the highest sensitivity (69.1% [95% CI 52.9-82.4]) and had the highest area under the curve (0.91 [95% CI 0.81-0.96]) for a poor outcome. The prognostic performance of NGAL alone was inadequate at all time points. However, NGAL combined with NSE at 24 and 28 hours after ROSC showed improved sensitivity compared to NGAL alone.NGAL should be considered a supplementary biomarker in combination with NSE for prognostication in patients with OHCA treated with TTM.

Relationships between serum levels of lactate dehydrogenase and neurological outcomes of patients who underwent targeted temperature management after out-of-hospital cardiac arrest

This study aimed to evaluate times for measuring serum lactate dehydrogenase levels (SLLs) to predict neurological prognosis among out-of-hospital cardiac arrest (OHCA) survivors.This retrospective study examined patients who experienced OHCA treated with targeted temperature management (TTM). The SLLs were evaluated at the return of spontaneous circulation (ROSC) and at 24, 48, and 72 hours later. Neurological outcomes after 3 months were evaluated for relationships with the SLL measurement times.A total of 95 comatose patients with OHCA were treated using TTM. Seventy three patients were considered eligible, including 31 patients (42%) who experienced good neurological outcomes. There were significant differences between the good and poor outcome groups at most time points (P < .001), except for ROSC (P = .06). The ROSC measurement had a lower area under the receiver operating characteristic curve (AUC: 0.631, 95% confidence interval [CI]: 0.502-0.761) than at 48 hours (AUC: 0.830, 95% CI: 0.736-0.924), at 24 hours (AUC: 0.786, 95% CI: 0.681-0.892), and at 72 hours (AUC: 0.821, 95% CI: 0.724-0.919).A higher SLL seemingly predicted poor neurological outcomes, with good prognostic values at 48 hours and 72 hours. Prospective studies should be conducted to confirm these results.

Hypertension burden and the risk of new-onset atrial fibrillation: a nationwide population-based study

Funding Acknowledgements

Type of funding sources: None.

Background

The association between the cumulative hypertension burden and the development of atrial fibrillation (AF) is unclear.

Purpose

We aimed to investigate the relationship between hypertension burden and the development of incident AF.

Methods and Results: Using the Korean National Health Insurance Service database, we identified 3,726,172 subjects who underwent four consecutive annual health checkups between 2009 and 2013, with no history of AF. During the median follow-up of 5.2 years, AF was newly diagnosed in 22,012 patients (0.59% of the total study population, 1.168 per 1,000 person-years). Using the BP values at each health checkup, we determined the burden of hypertension (systolic blood pressure [SBP] ≥130 mmHg or diastolic blood pressure [DBP] ≥80 mmHg), stratified as 0 to 4 per the hypertension criteria. The subjects were grouped according to hypertension burden scale 1 to 4: 20% (n = 742,806), 19% (n = 704,623), 19% (n = 713,258), 21% (n = 766,204), and 21% (n = 799,281). Compared to normal people, subjects with hypertension burdens of 1, 2, 3, and 4 were associated with an 8%, 18%, 26%, and 27% increased risk of incident AF, respectively. On semi-quantitative analyses with further stratification of stage 1 (SBP 130-139 mmHg or DBP 80-89 mmHg) and stage 2 (SBP ≥140 mmHg or DBP ≥90 mmHg) hypertension, the risk of AF increased with the hypertension burden by up to 71%.

Conclusions

Both a sustained exposure and the degree of increased blood pressure were associated with an increased risk of incident AF. Tailored blood pressure management should be emphasized to reduce the risk of AF. Abstract Figure.

Comparison of Prognostic Performance between Neuron-Specific Enolase and S100 Calcium-Binding Protein B Obtained from the Cerebrospinal Fluid of Out-of-Hospital Cardiac Arrest Survivors Who Underwent Targeted Temperature Management

We compared the prognostic performances of serum neuron-specific enolase (sNSE), cerebrospinal fluid (CSF) NSE (cNSE), and CSF S100 calcium-binding protein B (cS100B) in out-of-hospital cardiac arrest (OHCA) survivors. This prospective observational study enrolled 45 patients. All samples were obtained immediately and at 24 h intervals until 72 h after the return of spontaneous circulation. The inter- and intragroup differences in biomarker levels, categorized by 3 month neurological outcome, were analyzed. The prognostic performances were evaluated with receiver operating characteristic curves. Twenty-two patients (48.9%) showed poor outcome. At all-time points, sNSE, cNSE, and cS100B were significantly higher in the poor outcome group than in the good outcome group. cNSE and cS100B significantly increased over time (baseline vs. 24, 48, and 72 h) in the poor outcome group than in the good outcome group. sNSE at 24, 48, and 72 h showed significantly lower sensitivity than cNSE or cS100B. The sensitivities associated with 0 false-positive rate (FPR) for cNSE and cS100B were 66.6% vs. 45.5% at baseline, 80.0% vs. 80.0% at 24 h, 84.2% vs. 94.7% at 48 h, and 88.2% (FPR, 5.0%) vs. 94.1% at 72 h. High cNSE and cS100B are strong predictors of poor neurological outcome in OHCA survivors. Multicenter prospective studies may determine the generalizability of these results.

Negative pressure wound therapy for skin necrosis prevention after snakebite in the emergency department: A retrospective cohort study

This retrospective cohort study aimed to compare the effectiveness of conventional treatment and ultra-early application of negative pressure wound therapy (NPWT) in patients with snakebites.Patients who visited the emergency department within 24 hours after a snakebite were assigned to the non- NPWT or NPWT group. Swelling resolution time and rates of necrosis, infection, and operations were compared between the 2 groups. The Stony Brook Scar Evaluation Scale was used to measure short- and long-term wound healing results.Among the included 61 patients, the swelling resolution time was significantly shorter in the NPWT group than in non- NPWT group (P = .010). The NPWT group showed lower necrosis (4.3% versus 36.8%; P = .003) and infection (13.2% and 4.3%; P = .258) rates than the non- NPWT group. The median Stony Brook Scar Evaluation Scale scores were higher in the NPWT group than in the non- NPWT group (P< .001).These findings suggest that ultra-early application of NPWT reduces edema, promotes wound healing, and prevents necrosis in patients with snakebites.

Cerebrospinal Fluid Lactate Levels, Brain Lactate Metabolism and Neurologic Outcome in Patients with Out-of-Hospital Cardiac Arrest

BACKGROUND/OBJECTIVE

Cerebrospinal fluid (CSF) and serum lactate levels were assessed to predict poor neurologic outcome 3 months after return of spontaneous circulation (ROSC). We compared arterio-CSF differences in the lactate (ACDL) levels between two neurologic outcome groups.

METHODS

This retrospective observational study involved out-of-hospital cardiac arrest (OHCA) survivors who had undergone target temperature management. CSF and serum samples were obtained immediately (lactate₀), and at 24 (lactate₂₄), 48 (lactate₄₈), and 72 (lactate₇₂) h after ROSC, and ACDL was calculated at each time point. The primary outcome was poor 3-month neurologic outcome (cerebral performance categories 3-5).

RESULTS

Of 45 patients, 27 (60.0%) showed poor neurologic outcome. At each time point, CSF lactate levels were significantly higher in the poor neurologic outcome group than in the good neurologic outcome group (6.97 vs. 3.37, 4.20 vs. 2.10, 3.50 vs. 2.00, and 2.79 vs. 2.06, respectively; all P < 0.05). CSF lactate's prognostic performance was higher than serum lactate at each time point, and lactate₂₄ showed the highest AUC values (0.89, 95% confidence interval, 0.75-0.97). Over time, ACDL decreased from - 1.30 (- 2.70-0.77) to - 1.70 (- 3.2 to - 0.57) in the poor neurologic outcome group and increased from - 1.22 (- 2.42-0.32) to - 0.64 (- 2.31-0.15) in the good neurologic outcome group.

CONCLUSIONS

At each time point, CSF lactate showed better prognostic performance than serum lactate. CSF lactate₂₄ showed the highest prognostic performance for 3-month poor neurologic outcome. Over time, ACDL decreased in the poor neurologic outcome group and increased in the good neurologic outcome group.

Measuring global impairment of cerebral perfusion using dynamic susceptibility contrast perfusion-weighted imaging in out-of-hospital cardiac arrest survivors: A prospective preliminary study

BACKGROUND AND PURPOSE

This study aimed to assess the global impairment and prognostic performance of cerebral perfusions (CP) measured by dynamic susceptibility contrast perfusion-weighted imaging (DSC-PWI) in out-of-hospital cardiac arrest (OHCA) patients after sustained restoration of spontaneous circulation (ROSC).

MATERIALS AND METHODS

This is a single-centre, prospective observational study. OHCA patients performed DSC-PWI within 8 h after ROSC were enrolled. We quantified the CP parameters, such as cerebral blood volume (CBV), cerebral blood flow (CBF), mean transit time (MTT), time to peak (TTP), and time to maximum of the residue function (Tmax) either by normalization or arterial input function (AIF). The primary and secondary outcomes were survival to discharge and comparison of prognostic performance between CP parameters and serum neuron-specific enolase (NSE) using area under the receiver operating characteristic (AUROC) and sensitivity values.

RESULTS

Thirty-one patients were included in this study. CBV and TTP quantified by normalization, and MTT and Tmax quantified by AIF showed significantly higher CP values in the non-survival group (p = 0.02, 0.03, 0.02, and <0.01, respectively). Their AUROCs and 100% specific sensitivities were 0.74/25.0%, 0.60/33.3%, 0.75/56.3%, and 0.79/43.8%, respectively. MTT quantified by AIF showed sensitivity in predicting mortality at an early stage of PCA care, comparable with NSE.

CONCLUSION

Hyperaemia and delayed CP were generally observed in OHCA patients regardless of outcomes. MTT and Tmax quantified by AIF have prognostic performance in predicting mortality, comparable with NSE. Further prospective multicentre studies are required to confirm our results.

Clinical relationship between blood concentration and clinical symptoms in aconitine intoxication

BACKGROUND

Aconitine is well-known for its potential analgesic, anti-inflammatory, and circulation promoting effects and has been widely used as a folk medicine in South Korea. Owing to its extremely toxic nature and relatively low safety margin, intoxication is sometimes fatal. The toxic compound mainly affects the central nervous system, heart, and muscle, resulting in cardiovascular complications.

PURPOSE

To determine the exact relationship between blood concentration of aconitine and clinical manifestation.

BASIC PROCEDURES

The National Forensic Service (NFS) was commissioned to assist in a quantitative analysis of highly toxic aconitine and corresponding blood concentrations by analyzing the body fluids of three patients who were suspected of aconitine poisoning.

MAIN FINDINGS

Aconitine blood values tested by the NFS showed that patients with a blood concentration below a certain level developed symptoms slowly and showed a high severity of clinical manifestation. There was no correlation between blood concentration and symptoms or ECG results.

CONCLUSIONS

In case of suspected aconitine poisoning, an emergency care department should be visited, even with symptomatic improvement, and the patient should be monitored for at least 24 h, depending on the level of recovery and changes in ECG results.

Interleukin-6 as a Potential Predictor of Neurologic Outcomes in Cardiac Arrest Survivors Who Underwent Target Temperature Management

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.

The cut-off value of a qualitative brain diffusion-weighted image (DWI) scoring system to predict poor neurologic outcome in out-of-hospital cardiac arrest (OHCA) patients after target temperature management

AIM

We presented the cut-off value of a diffusion-weighted image (DWI) scoring system to predict poor neurologic outcome using DWI taken 72-96 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 72-96 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 72-96 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 96 h after ROSC were valuable tools to predict poor neurologic outcome in post-OHCA patients treated with TTM.

Cultural dance significantly improves hypertension management

Hypertension (HT), uncontrolled blood pressure (&gt;140/90 mmHg), is the leading preventable cause of premature death globally and a major risk factor for coronary heart disease, stroke, and other conditions. European and African regions have the highest prevalence rates at about 40% of adults. The U.S. has comparable rates and disturbing disparities in non-White minority groups. Native Hawaiians (NH), an indigenous U.S. population, are 70% more likely to have HT; 4 times more likely to have coronary heart disease or stroke than Whites. Hula, the cultural dance of NH, offers promise of a culturally responsive strategy for HT control.

We conducted a randomized clinical trial with a waitlist control to test the impact of a hula-based cultural dance intervention (CDI) on systolic blood pressure (SBP) in 263 NH with HT. All participants received HT education (e.g. diet, exercise, medication) during 3 1-hr sessions over 2 weeks, then randomly assigned to CDI (n = 131) or waitlist control (WC; n = 132). The CDI received 6 months of hula (2 1-hr sessions/week x 3 months, then 1 lesson/mth x 3 months with self-directed practice), with group activities to reinforce HT education. WC only received the initial HT education, then offered hula after the study. Assessments were done at 0-, 3- and 6-month, with 12-month for CDI only.

Baseline characteristics were balanced between groups, except for weight. Adjusting for weight and baseline SBP in intent-to-treat analysis, CDI achieved significant reductions (p &lt; .05) in SBP (-15.3 mmHg; SE = 1.6) compared to WC (-11.8 mmHg, SE = 1.7). From 6 to 12 months, CDI maintained their SBP (mean change: 1.47 mmHg, SE = 1.26; p = .16) improvements at 12 months. CDI were more likely to achieve SBP reduction ≥ 10 mmHg than WC, 60% vs 48% (p = .03), respectively.

A CDI based on the NH cultural dance significantly improved HTN management in NH with uncontrolled SBP. Improvements were comparable to the best proven non-medication treatment of HT.

Key messages

Improving elevated blood pressure control with at-risk populations can be effectively and innovatively achieved by utilizing culturally responsive strategies, such as cultural dance interventions. Leveraging and aligning community strengths and health objectives leads to innovation and empowerment.

Cerebrospinal Fluid Volume Proportion Using Magnetic Resonance Imaging as a Predictor of Poor Neurological Outcome in Survivors of Out-of-Hospital Cardiac Arrest

We aimed to investigate the prognostic performance of the proportion of cerebrospinal fluid volume (pCSV) using brain apparent diffusion coefficient-magnetic resonance imaging (ADC-MRI) in cardiac arrest (CA) survivors. This retrospective single-cohort study comprised adult comatose CA survivors who underwent brain MRI and targeted temperature management (TTM) from March 2018 to October 2019. We calculated pCSV (pCSV0 and pCSV72 within 6 and 72 hours after return of spontaneous circulation, respectively) using an automated quantitative analysis program. The difference between pCSV0 and pCSV72 was defined as the pCSVd. Neurologic outcome 3 months after CA was assessed with the Cerebral Performance Category scale and dichotomized as good (1 or 2) or poor (3-5). Of the 73 patients included, 44 (60.3%) had a poor neurological outcome. Patients with poor outcome had significantly lower pCSV at baseline and at 72 hours, and a negative change in pCSV over time. The prognostic performance of pCSV72 and pCSVd was significantly higher compared with pCSV0 (all p < 0.001). The pCSVd showed excellent area under the curve values (0.96; 95% confidence interval 0.85-0.99) and highest sensitivity (95%) at 100% specificity. pCSV on brain ADC-MRI was associated with 3-month neurologic outcome in CA survivors. The pCSVd is a highly predictive and sensitive marker of 3-month poor neurological outcome in CA survivors treated with TTM. Multicenter prospective studies are required to determine the generalizability of these results.

Does Combining Biomarkers and Brain Images Provide Improved Prognostic Predictive Performance for Out-Of-Hospital Cardiac Arrest Survivors before Target Temperature Management?

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.

Utility of the blood urea nitrogen to serum albumin ratio as a prognostic factor of mortality in aspiration pneumonia patients

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.

Changes in peak inspiratory flow rate and peak airway pressure with endotracheal tube size during chest compression

BACKGROUND

Adequate airway management plays an important role in high-quality cardiopulmonary resuscitation (CPR). Airway management is usually performed using an endotracheal tube (ETT) during CPR. However, no study has assessed the effect of ETT size on the flow rate and airway pressure during CPR.

METHODS

We measured changes in peak inspiratory flow rate (PIFR), peak airway pressure (P_peak), and mean airway pressure (P_mean) according to changes in ETT size (internal diameter 6.0, 7.0, and 8.0 mm) and with or without CPR. A tidal volume of 500 mL was supplied at a rate of 10 times per minute using a mechanical ventilator. Chest compressions were maintained at a constant compression depth and speed using a mechanical chest compression device (LUCAS2, mode: active continuous, chest compression rate: 102±2/minute, chest compression depth 2-2.5 inches).

RESULTS

The median of several respiratory physiological parameters during CPR was significantly different according to the diameter of each ETT (6.0 vs. 8.0 mm): PIFR (32.1 L/min [30.5-35.3] vs. 28.9 L/min [27.5-30.8], P<0.001), P_peak (48.84 cmH₂O [27.46-52.11] vs. 27.45 cmH₂O [22.53-52.57], P<0.001), and P_mean (18.34 cmH₂O [14.61-21.66] vs.13.66 cmH₂O [8.41-19.24], P<0.001).

CONCLUSION

The changes in PIFR, P_peak, and P_mean were related to the internal diameter of ETT, and these values tended to decrease with an increase in ETT size. Higher airway pressures were measured in the CPR group than in the no CPR group.

Cerebrospinal fluid lactate dehydrogenase as a potential predictor of neurologic outcomes in cardiac arrest survivors who underwent target temperature management

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.