Resuscitation room management of patients with non-traumatic critical illness in the emergency department (OBSERvE-DUS-study)

BACKGROUND

Few studies address the care of critically ill non-traumatic patients in the emergency department (ED). The aim of this study was to assess the epidemiology, management, and outcome of these patients.

METHODS

In this retrospective study, we identified and analyzed data from all consecutive adult critically ill non-traumatic ED patients treated from March 2018 to February 2019. Patient characteristics, major complaint leading to admission, out-of-hospital, and in-hospital interventions and 30-day mortality were extracted from medical records of the electronic patient data management system.

RESULTS

During the study period, we analyzed 40,764 patients admitted to the ED. Of these, 621 (1.5%) critically ill non-traumatic patients were admitted for life-threatening emergencies to the resuscitation room (age: 70 ± 16 years, 52% male). Leading problem on admission was disability/unconsciousness (D), shock (C), respiratory failure (B), airway obstruction (A), and environment problems (E) in 41%, 31%, 25%, 2%, and 1%, respectively. Out-of-hospital and in-hospital measures included: intravenous access (61% vs. 99%), 12-lead ECG (55% vs. 87%), invasive airway management (21% vs. 34%) invasive ventilation (21% vs. 34%), catecholamines (9% vs. 30%), arterial access (0% vs. 52%), and cardiopulmonary resuscitation (11% vs. 6%). The underlying diagnoses were mainly neurological (29%), followed by cardiological (28%), and pulmonological (20%) emergencies. The mean length of stay (LOS) in the resuscitation room and ED was 123 ± 122 and 415 ± 479 min, respectively. The 30-day mortality was 18.5%.

CONCLUSION

The data describe the care of critically ill non-traumatic patients in the resuscitation room. Based on these data, algorithms for the structured care of critically ill non-traumatic patients need to be developed.

Identification and validation of objective triggers for initiation of resuscitation management of acutely ill non-trauma patients: the INITIATE IRON MAN study

Background

While there are clear national resuscitation room admission guidelines for major trauma patients, there are no comparable alarm criteria for critically ill nontrauma (CINT) patients in the emergency department (ED). The aim of this study was to define and validate specific trigger factor cut-offs for identification of CINT patients in need of a structured resuscitation management protocol.

Methods

All CINT patients at a German university hospital ED for whom structured resuscitation management would have been deemed desirable were prospectively enrolled over a 6-week period (derivation cohort, n = 108). The performance of different thresholds and/or combinations of trigger factors immediately available during triage were compared with the National Early Warning Score (NEWS) and Quick Sequential Organ Failure Assessment (qSOFA) score. Identified combinations were then tested in a retrospective sample of consecutive nontrauma patients presenting at the ED during a 4-week period (n = 996), and two large external datasets of CINT patients treated in two German university hospital EDs (validation cohorts 1 [n = 357] and 2 [n = 187]).

Results

The any-of-the-following trigger factor iteration with the best performance in the derivation cohort included: systolic blood pressure < 90 mmHg, oxygen saturation < 90%, and Glasgow Coma Scale score < 15 points. This set of triggers identified > 80% of patients in the derivation cohort and performed better than NEWS and qSOFA scores in the internal validation cohort (sensitivity = 98.5%, specificity = 98.6%). When applied to the external validation cohorts, need for advanced resuscitation measures and hospital mortality (6.7 vs. 28.6%, p < 0.0001 and 2.7 vs. 20.0%, p < 0.012) were significantly lower in trigger factor-negative patients.

Conclusion

Our simple, any-of-the-following decision rule can serve as an objective trigger for initiating resuscitation room management of CINT patients in the ED.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00973-4.

Abstract P3-07-03: Targeting low voltage-activated calcium channels in HER2-positive breast cancer

Under physiological conditions low voltage-activated calcium channels (LVA, also called T-type channels) occur mostly in the brain, peripheral nervous system, smooth muscles, and pacemaker of the heart. However, LVA are often aberrantly expressed in various cancers and their overexpression is inversely correlated with outcomes. Active LVA contribute to proliferation, progression and resistance to therapy in several human cancers, including breast cancer (BC). The molecular mechanism of this activity is still not fully understood, and there is a lack of pre-clinical studies that target LVA in animal models of BC.Data from the Cancer Genome Atlas (TCGA) show a positive correlation between HER2 gene amplification and LVA channel overexpression, particularly of Cav3.1 (CACNA1G) subunit. The goal of this study is to identify functional links between HER2 receptor signaling and LVA channels, and validate LVA Ca2+ channels as a potential target for BC therapy. Inhibition of LVA, by small molecule antagonist mibefradil (MIB) or shRNA, significantly decreased the activity of PI3K/mTOR/AKT pathway in HER2-positive BC cell lines, blocked cell cycle progression, and at higher concentrations induced apoptotic cell death. Furthermore, LVA antagonist, mibefradil, sensitized cells to trastuzumab, lapatinib and paclitaxel, commonly used standard treatments for HER2-positive BC. To test the effects of LVA inhibition in vivo, the MMTV-PyMT mouse model of BC was used. In this model several features of HER2-positive BC are recapitulated, such as activation of PI3K/AKT/mTOR pathway, overexpression of HER2, BIRC5 and cyclin D1, and low expression of ERα, PGR and FOXA1. In PyMT animals palpable tumors can be detected at the age of 10-12 weeks, and 100% of animals will develop high tumor burden, including lung metastases, at the age of 15-20 weeks. Expression of CACNA1G subunit was detected in breast epithelial cells of 7 week old mice, and throughout the adult life, in both wild-type and PyMT animals, but CACNA1G was not expressed in lung or skeletal muscles. In in vitro experiments, cell lines derived from PyMT tumors were sensitive to MIB. In in vivo experiment, 5 to 7 weeks-old PyMT mice were fed either control or MIB-containing diet ad lib. Analysis of mouse serum revealed stable MIB concentration of ˜1500 ng/mL achieved within one week of treatment. In MIB-fed animals tumor appearance was delayed by 2 weeks, and the tumors were smaller as compared to control, thus suggesting a supporting role for LVA channels in breast tumor development and progression. Together, our observations provide new insights into the role of Ca2+ channels in HER2 driven BC and posit a future use of LVA channel antagonists for the treatment HER2-positive breast tumors.

Citation Format: Dziegielewska B, Dunlap-Brown ME, Warnock WT, Dillon PM, Bouton AH, Dziegielewski J. Targeting low voltage-activated calcium channels in HER2-positive breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-07-03.

Enzymatic activation of a new antitumour drug, 5-diethylaminoethylamino-8-hydroxyimidazoacridinone, C-1311, observed after its intercalation into DNA

The imidazoacridinone derivative, C-1311, is a new antitumour agent that exhibits strong antitumour activity against experimental colorectal cancer and has been selected for entry into clinical trial. The compound has previously been shown to have DNA non-covalent binding properties in vitro and to bind irreversibly to DNA of tumour cells. The latter effect has also been observed in a cell-free system, but only in the presence of activated enzymes. The present studies were aimed at finding out whether and in what way the enzymatic activation of C-1311 and its non-covalent binding to DNA influence or depend on each other. Enzymatic activation was performed with a model system containing horseradish peroxidase (HRP) and hydrogen peroxide (H2O2) and was followed by UV-VIS spectroscopy and by HPLC with UV-VIS and electrospray ionisation mass spectrometry detection. DNA non-covalent binding was studied in the cell-free system by means of an unwinding assay and UV-VIS spectroscopy. It was shown that C-1311 was oxidised by the HRP/H2O2 system in a manner dependent on the drug:H2O2 ratio. In the case of ratios of 1:3 and 1:5, the reaction gave highly reactive species that were quickly transformed into the further products p2 and p3 that were unable to intercalate into DNA. In the presence of DNA, C-1311 first intercalated into DNA and the intercalated compound was then oxidised. This oxidation was directed to only one product. Therefore, DNA seems to play the role of a "scavenger" of the reactive oxidation product(s) yielded from the intercalated drug and prevents its further deactivation. We conclude that, under the conditions studied, intercalation of C-1311 into DNA is followed by its HRP-mediated activation, giving rise to the intercalated species that might irreversibly bind to DNA. Since peroxidase-type enzymes are present in the cell nucleus, the proposed sequence of events may also be expected to take place in the cellular environment in vivo.

Bleomycin-induced alterations in DNA replication: relationship to DNA damage

Bleomycin (BLM), a well-known DNA scission agent, is assumed to inhibit intracellular DNA replication by damaging the DNA template (cis-acting mechanism), although other DNA damaging compounds can alter DNA replication through modulation of crucial replication factor(s) (trans-acting mechanism). The present study examines the relationship between DNA damage and inhibition of replication caused by BLM in the well-defined simian virus 40 (SV40) intracellular and cell-free in vitro systems. Treatment of SV40-infected BSC-1 cells for 2 h with BLM at 50 microg/mL, induced 0.3 break/viral genome. Under the same treatment conditions, analysis of replication intermediates on two-dimensional gels showed a decrease in both mass of SV40 replication intermediates and replication activity. The mass of SV40 intermediates was decreased to about 30%, whereas replication activity was reduced to less than 5%. These results suggest that BLM inhibits both initiation and elongation phases of SV40 replication. In a cell-free DNA replication system, extracts from BLM-treated cells (50 micro/mL) were able to support SV40 DNA replication by only 50%. In this study, non-drug-treated DNA template was used, implying that BLM can induce a trans-acting effect. Finally, the drug-induced effects on SV40 DNA replication in cell-free and intracellular viral systems were compared to the effects on genomic DNA replication in BSC-1 cells. Overall, the results support the concept that BLM-induced inhibition of DNA replication occurs by both trans- (inhibition of replication of nondamaged template) and cis-acting mechanisms (template damage).

QSAR of acridines, III. Structure-activity relationship for antitumour imidazoacridinones and intercorrelations between in vivo and in vitro tests

A study on quantitative relationships between the biological activity and physicochemical properties of antitumour 5-alkylaminoimidazoacridinone derivatives was carried out. The activity was based on the results of several in vitro tests as well as experimental antileukaemic therapy. The capacity factor, log k', determined by the reverse-phase HPLC method, was a measure of lipophilic properties. UV and NMR spectra of the compounds were employed to describe electronic parameters. Values of steric descriptors were calculated as topological indexes. Results obtained by means of principal component analysis (PCA) allow us to group biological tests into two subsets: the lipophilicity-dependent and lipophilicity-independent test groups. The highest intercorrelation, R = 0.92, was shown between the optimal dose, pOD, determined in leukaemia P388-bearing mice and cytotoxicity expressed as pEC50 in leukaemia cells. The equation describing this relationship could be applied to predict the therapeutic doses of imidazoacridinone derivatives which would be effective in experimental antileukaemic therapy. The quantitative structure-activity relationship (QSAR) study showed that lipophilic properties significantly influence cytotoxicity, pEC50, and antileukaemic potency, pOD, only in the case of 8-hydroxy analogues of imidazoacridinones, whereas the activity of the remaining derivatives is very low and does not depend on lipophilicity. Electronic resonance properties seem to influence this specific impact of lipophilicity on the biological activity of 8-hydroxy derivatives. Hence, it may be possible to improve the antitumour activity of 8-hydroxyimidazoacridinones by obtaining more hydrophilic derivatives, up to the optimal value of the lipophilic parameter.