Trimethylamine-N-oxide (TMAO) predicts short- and long-term mortality and poor neurological outcome in out-of-hospital cardiac arrest patients

Objectives

Prior research found the gut microbiota-dependent and pro-atherogenic molecule trimethylamine-N-oxide (TMAO) to be associated with cardiovascular events as well as all-cause mortality in different patient populations with cardiovascular disease. Our aim was to investigate the prognostic value of TMAO regarding clinical outcomes in patients after out-of-hospital cardiac arrest (OHCA).

Methods

We included consecutive OHCA patients upon intensive care unit admission into this prospective observational study between October 2012 and May 2016. We studied associations of admission serum TMAO with in-hospital mortality (primary endpoint), 90-day mortality and neurological outcome defined by the Cerebral Performance Category (CPC) scale.

Results

We included 258 OHCA patients of which 44.6% died during hospitalization. Hospital non-survivors showed significantly higher admission TMAO levels (μmol L-1) compared to hospital survivors (median interquartile range (IQR) 13.2 (6.6-34.9) vs. 6.4 (2.9-15.9), p<0.001). After multivariate adjustment for other prognostic factors, TMAO levels were significantly associated with in-hospital mortality (adjusted odds ratios (OR) 2.1, 95%CI 1.1-4.2, p=0.026). Results for secondary outcomes were similar with significant associations with 90-day mortality and neurological outcome in univariate analyses.

Conclusions

In patients after OHCA, TMAO levels were independently associated with in-hospital mortality and other adverse clinical outcomes and may help to improve prognostication for these patients in the future. Whether TMAO levels can be influenced by nutritional interventions should be addressed in future studies.

Association of Taurine with In-Hospital Mortality in Patients after Out-of-Hospital Cardiac Arrest: Results from the Prospective, Observational COMMUNICATE Study

Background: Studies have suggested that taurine may have neuro- and cardio-protective functions, but there is little research looking at taurine levels in patients after out-of-hospital cardiac arrest (OHCA). Our aim was to evaluate the association of taurine with mortality and neurological deficits in a well-defined cohort of OHCA patients. Methods: We prospectively measured serum taurine concentration in OHCA patients upon admission to the intensive care unit (ICU) of the University Hospital Basel (Switzerland). We analyzed the association of taurine levels and in-hospital mortality (primary endpoint). We further evaluated neurological outcomes assessed by the cerebral performance category scale. We calculated logistic regression analyses and report odds ratios (OR) and 95% confidence intervals (CI). We calculated different predefined multivariable regression models including demographic variables, comorbidities, initial vital signs, initial blood markers and resuscitation measures. We assessed discrimination by means of area under the receiver operating curve (ROC). Results: Of 240 included patients, 130 (54.2%) survived until hospital discharge and 110 (45.8%) had a favorable neurological outcome. Taurine levels were significantly associated with higher in-hospital mortality (adjusted OR 4.12 (95%CI 1.22 to 13.91), p = 0.02). In addition, a significant association between taurine concentration and a poor neurological outcome was observed (adjusted OR of 3.71 (95%CI 1.13 to 12.25), p = 0.03). Area under the curve (AUC) suggested only low discrimination for both endpoints (0.57 and 0.57, respectively). Conclusion: Admission taurine levels are associated with mortality and neurological outcomes in OHCA patients and may help in the risk assessment of this vulnerable population. Further studies are needed to assess whether therapeutic modulation of taurine may improve clinical outcomes after cardiac arrest.

Association of acyl carnitines and mortality in out-of-hospital-cardiac-arrest patients: Results of a prospective observational study

PURPOSE

Out-of-hospital cardiac arrest (OHCA) is a leading cause of mortality, yet the prediction of its outcome remains challenging. Serum Acyl Carnitines (ACs), a biomarker of beta-oxidation, have been associated with cardiovascular events. We evaluated the association of different AC species with mortality and neurological outcome in a cohort of OHCA patients.

MATERIAL AND METHODS

We consecutively included OHCA patients in this prospective observational study upon admission to the intensive care unit. We studied the association of thirty-nine different ACs measured at admission and 30-day mortality (primary endpoint), as well as neurological outcome at hospital discharge (secondary endpoint) using the Cerebral Performance Category scale. Multivariate models were adjusted for age, gender, comorbidities and shock markers.

RESULTS

Of 281 included patients, 137 (48.8%) died within 30 days and of the 144 survivors (51.2%), 15 (10.4%) had poor neurological outcome. While several ACs were associated with mortality, AC C2 had the highest prognostic value for mortality (fully-adjusted odds ratio 4.85 (95%CI 1.8 to 13.06, p < .01), area under curve (AUC) 0.65) and neurological outcome (fully-adjusted odds ratio 3.96 (95%CI 1.47 to 10.66, p < .01), AUC 0.63).

CONCLUSIONS

ACs are interesting surrogate biomarkers that are associated with mortality and poor neurological outcome in patients after OHCA and may help to improve the understanding of pathophysiological mechanisms and risk stratification.

Code status discussions in medical inpatients: results of a survey of patients and physicians

INTRODUCTION

Code status discussions are useful for understanding patients&rsquo; preferences in the case of a cardiac/pulmonary arrest. These discussions can also provide patients with a basis for informed decision-making regarding life-sustaining treatment. We conducted a survey to understand current practices and perceptions of code status discussions in a tertiary-care Swiss hospital.

METHODS

We performed systematic interviews across different departments of the University Hospital of Basel. We interviewed 258 physicians and 145 patients who were hospitalised between May and July 2018 using a questionnaire designed to assess the use of code status discussions and to gauge patients&rsquo; individual experiences and opinions.

RESULTS

A total of 61.4% of patients did not recall having had a code status discussion during the hospital stay. However, a higher proportion of medical patients compared to surgical patients recalled having had a discussion (43.6 vs 22.4%, p = 0.03). For 9 out of 38 (23.7%) patients who did recall the discussion, there was a lack of agreement between the preference given in the interview regarding resuscitation measures and the documented code status in the medical electronic chart. Furthermore, a majority of physicians (72.4%) recalled defining a do-not-resuscitate (DNR) status for a patient without prior discussion with the patient. Physicians who recalled determining the DNR status without patient consultation reported conflicts with patients and relatives regarding code status at a higher rate compared to physicians who did not define DNR status without consultation (62.4 vs 39.4%, p &lt;0.001).

CONCLUSION

A majority of patients do not report having discussed code status during their hospital stay and physicians frequently omit such discussions, thereby potentially failing to attend to patients&rsquo; preferences for care. Physician training regarding code status discussions may improve the quality of informed decision-making and patient-centred care.

[Practical approach of insomnia in the elderly]

Elderly people often suffer from insomnia which is responsible for high comorbidity and lower quality of life in this population. Somatic and psychiatric pathologies must be screened as primary sleep disorders. Chronic sleep disorders and benzodiazepine abuse might be avoided by an early treatment of causal factors. We wished to propose here a practical approach of the insomnia in the elderly going from the diagnosis to the treatment by advancing the not pharmacological approaches, while specifying at best the place of different drugs available and their limits.

Gait abnormalities in obstructive sleep apnea and impact of continuous positive airway pressure

We aimed to determine the effect of continuous positive airway pressure (CPAP) on gait in obstructive sleep apnea (OSA) patients. Gait during single and dual tasks was recorded in 15 OSA patients at baseline and after 8 weeks of CPAP therapy. Step and stance time improved after CPAP. We showed a specific dual-task effect in the condition of verbal fluency. Eight weeks of CPAP seems to improve gait of OSA patients that are specifically disturbed by the dual task of verbal fluency.

[Sleep disorder and pain: the good hypnotic]

Chronic pain and sleep disorder can put the patient in a vicious circle (bidirectional relation between those two morbid entities). Clinical management must be global. The physiopathology includes chronic sleep deficit, mainly in deep sleep (the "restoring" sleep) generated principally by the prefrontal regions. These areas are also implicated in the modulation of pain. To break this "loops", we advocate an approach based on three main components: hygiene principles, cognitive and behavioral therapy, medications with analgesic and hypnotic proprieties.

[Status epilepticus and neuronal degeneration: of circuitries and vicious circles]

The relationship between status epilepticus (SE) and neuronal degeneration is quite complex and difficult to investigate. Animal studies suggest that SE induces a progressive neuronal death; however, clinical observations on humans are less uniform: generalized SE may precede the development of hippocampal sclerosis, but other forms (such as simple-partial or complex-partial) seem less ominous. On the other side, SE can be encountered in many patients with neurodegenerative disorders, particularly those with severe forms. It is thus likely that SE represents a sign, rather than an aetiology, of clinical gravity. Therefore, while it is ancillary to treat rapidly any SE form, the therapeutic approach, especially the use of aggressive treatments, should be tailored according to the underlying medical conditions.

Diffusion-weighted MRI in cortical ischaemia

We carried out MRI on 16 male and three female comatose patients, aged 2 days to 79 years, with suspected cortical ischaemia referred from our intensive care units. Using a head coil, and following standard imaging, including coronal fluid-attenuated inversion-recovery images, we performed diffusion-weighted imaging (DWI) using a whole-brain multislice single-shot echo-planar sequence with b 0 and 1000 s/mm2: 5-mm slices covering the whole brain, TR 7000 TE 106 ms, 128 x 128 pixels, field of view 250 mm, one excitation. Maps of apparent diffusion coefficients (ADC) were generated automatically. DWI showed cortical, basal ganglia and watershed-area high signal in all cases, associated with a decrease in ADC to 60- 80% of normal. DWI showed lesions not seen (40%) or underestimated (40%) on conventional T2-weighted imaging. Within 24 h of the onset of symptoms, DWI showed changes not readily detectable on T2-weighted images. The cortical high signal on DWI and the ADC changes, suggesting severe ischaemia rather than oedema, was found in areas known to be affected by cortical laminar necrosis. Extension to the brain stem and white matter was associated with a higher likelihood of death.

Kinematics of a coordinated goal-directed bimanual task

The experiments address the problem of bimanual coordination in a familiar task of everyday life. A goal-directed drawer-pulling task, with asymmetrical assignments among hands, was analyzed with the objective to detect discrete kinematic events ('anchors') that potentially could serve in proper goal synchronization. The left hand reached out for the drawer and opened it while the right hand performed a prehension movement to pick up a peg from the drawer. The task was smoothly performed, independently of vision. Typically, trajectories and velocity profiles of the leading pull-hand were more stereotypical than the more variable ones of the pick-hand. The pull-hand had a large velocity peak during reaching, followed by a small peak during pulling. Velocity profiles of the pick-hand were not bell-shaped and exhibited one or two broad waves, often with an irregular and probing evolution. Velocity profiles of both hands were aligned with the first or the second velocity peak of the leading pull-hand. In the majority of cases, temporal associations of events in the kinematics of the two limbs could thus be identified, which could serve to synchronize the hands at the goal. The nearly straight biphasic reach-and-pull trajectory of the leading hand contrasted with the more curved trajectory of the right pick-hand whereas, in the same unimanual action, the latter trajectories were quasi-rectilinear. Changing constraints (no vision, cutaneous anesthesia of pulling fingers) could change the coordination pattern. We argue that bimanual coordination relies on two interacting mechanisms: (1) feedforward control on the basis of sensorimotor memory; (2) temporal adjustments during the evolving bimanual synergy. Multiple strategies, imposed by the leading pull-hand, appeared to be responsible for feedback-induced corrections in the pick-hand and were found to contribute to the goal-invariance and to the principle of motor equivalence.

Simple and complex vestibular responses induced by electrical cortical stimulation of the parietal cortex in humans

The present study reports on a patient undergoing invasive monitoring for intractable epilepsy who experienced different vestibular sensations after electrical cortical stimulation of the inferior parietal lobule at the anterior part of the intraparietal sulcus. Types of vestibular response ranged from simple to complex sensations and depended on stimulation site and applied current. The findings suggest vestibular topography and hierarchical processing within the parietal vestibular cortex of humans.

EEG-triggered functional MRI in patients with pharmacoresistant epilepsy

Functional magnetic resonance imaging (fMRI) triggered by scalp electroencephalography (EEG) recordings has become a promising new tool for noninvasive epileptic focus localization. Studies to date have shown that it can be used safely and that highly localized information can be obtained. So far, no reports using comprehensive clinical information and/or long-term follow-up after epilepsy surgery in a larger patient group have been given that would allow a valuable judgment of the utility of this technique. Here, the results of 11 patients with EEG-triggered fMRI exams who also underwent presurgical evaluation of their epilepsy are given. In most patients we were able to record good quality EEG inside the magnet, allowing us to trigger fMRI acquisition by interictal discharges. The fMRI consisted of echoplanar multislice acquisition permitting a large anatomical coverage of the patient's brain. In 8 of the 11 patients the exam confirmed clinical diagnosis, either by the presence (n = 7) or absence (n = 1) of focal signal enhancement. In six patients, intracranial recordings were carried out, and in five of them, the epileptogenic zone as determined by fMRI was confirmed. Limitations were encountered a) when the focus was too close to air cavities; b) if an active epileptogenic focus was absent; and c) if only reduced cooperation with respect to body movements was provided by the patient. We conclude that EEG-triggered fMRI is a safe and powerful noninvasive tool that improves the diagnostic value of MRI by localizing the epileptic focus precisely.

Location of the human frontal eye field as defined by electrical cortical stimulation: anatomical, functional and electrophysiological characteristics

Electrical cortical stimulation of the human frontal gyri and the precentral gyrus has been shown to induce eye movements and it has classically been assumed that these stimulation-induced eye movements result from electrical interference with the human homologue of the monkey frontal eye field (FEF). However, amplitude of electrical current and induced type of eye movement, which are essential for the determination of eye fields in the monkey, have not been investigated systematically in man. We applied electrical cortical stimulation in the lateral frontal cortex in six epileptic patients. Sites whose stimulation resulted in eye movements were determined with respect to gyral and sulcal patterns, Talairach coordinates and neighboring functions as found by electrical cortical stimulation. Based on this approach, a restricted location of the electrically defined FEF is proposed within a larger oculomotor region on the posterior part of the middle frontal gyrus.

Time structure of a goal-directed bimanual skill and its dependence on task constraints

The aim of the study was to elucidate the underlying principles of bimanual coordination and to establish quantitative coordination criteria. Healthy human subjects were instructed to open a loaded drawer with the left hand and to grasp, lift and reinsert with the right hand a small peg in the drawer recess. This bimanual goal-oriented task was executed promptly and consistently after a few trials. The temporal structure of the individual limb actions was assessed for computing interlimb synchronization and temporal correlation. In all subjects, both hands were well synchronized at the goal with high intermanual correlation in reaching the goal (event times of drawer opening and grasping the peg). This temporal goal-invariance was independent of movement speed and of the highly variable timing of the individual hands and persisted when subjects were blindfolded. Unilateral loading of the pulling hand and cutaneous anesthesia of the left index finger and thumb used for grasping the drawer handle significantly increased the pull-phase. This slowing of the left hand was matched by an adaptive delay of the right non-disturbed hand, thus preserving goal invariance. As a working hypothesis, we propose that multimodal sensory signals generated in the leading arm be transmitted centrally to re-parameterize the non-disturbed arm.

To see better to the left when looking more to the right: effects of gaze direction and frames of spatial coordinates in unilateral neglect

Unilateral spatial neglect entails a failure to detect or respond to stimuli in the space opposite to a brain lesion. However, the contralesional hemispace can be determined by different frames of spatial coordinates, such as eyes-, head-, body-, or environment-centered coordinates. We observed 2 patients with a right hemisphere stroke whose left spatial neglect was modulated by distinct coordinates systems depending on the task. Four tasks were given in different conditions of central gaze and either the eyes or the head rotated 30 degrees to the right or 30 degrees to the left. While the 2 patients had a retinotopic defect in 1 visual field quadrant that remained the same irrespective of gaze direction (upper or lower quadrant in 1 case each), the other quadranopic field defect improved with eyes rotation to the right but not with head rotation, suggesting a head-centered spatiotopic deficit. Performance on line bisection was influenced both by eyes and head rotation, as well as by the position of the lines with respect to the trunk midline, suggesting the involvement of both head-centered and body-centered coordinates. Visual imagery and auditory extinction were not modified by changing the eyes or head position. These findings suggest that distinct spatial coordinates are brought into play depending on the tasks demands.

Effects of lesions in the mesial frontal cortex on bimanual co-ordination in monkeys

The hypothesis was tested that the mesial frontal cortex, including the supplementary motor area, is engaged in bimanual co-ordination. Three monkeys, trained in a well-co-ordinated bimanual pull-and-grasp task, were subjected to unilateral or bilateral lesions of the mesial frontal cortex. With unilateral lesions, the deficit consisted in a delay in movement initiation of the contralateral arm. With a bilateral lesion, the deficit was more pronounced with marked bilateral delays in movement onset and slowing in reaching. However, in the three monkeys bimanual co-ordination at the moment of goal achievement remained intact with an excellent temporal co-variation of the two limbs. In the two unilateral cases, an adaptive strategy developed after a few sessions, either by catching up during reaching with the limb contralateral to the lesion (monkey M1) or by delaying movement initiation of the limb ipsilateral to the lesion (monkey M2). This outcome is discussed in terms of Lashley's principle of motor equivalence, i.e. invariant goal achievement with variable means. Bilateral lesions led to a transient and near-total impairment in movement self-initiation when all external cues were absent. It is concluded that in monkeys the mesial frontal cortex does not play a crucial role in bimanual co-ordination but rather in movement initiation, especially when sensory cues are absent.

Temporal coordination in bimanual actions

The issue of bimanual temporal coordination in human subjects is discussed for three selected movement paradigms: (i) simple, symmetric, bimanual finger movements, (ii) bimanual unloading, and (iii) a complex bimanual pull and grasp task. Temporal synchronization was found for all three experiments and was least variable for the first experiment. In the second experiment, synchronization concerned unloading with the index finger of one hand (electromyographic activation of the first dorsal interosseus muscle) and the postural adjustment of the load-bearing index finger of the other hand (electromyographic deactivation of the first dorsal interosseus muscle). In the third experiment, a goal-related temporal invariance was observed, even in the absence of visual guidance. Possible neural mechanisms for the observed temporal coordination of the three types of bimanual movements are discussed, as well as the concepts of goal invariance and motor equivalence.