Min Ji Park

Long-term survival of out-of-hospital cardiac arrest patients with malignancy

Background: The aim of this study was to investigate whether the 1‐year survival rate of out‐of‐hospital cardiac arrest (OHCA) patients with malignancy was different from that of those without malignancy. Methods: All adult OHCA patients were retrospectively analyzed in a single institution for 6 years. The primary outcome was 1‐year survival, and secondary outcomes were sustained return of spontaneous circulation (ROSC), survival to hospital admission, survival to discharge and discharge with a good neurological outcome (CPC 1 or 2). Kaplan‐Meier survival analysis and Cox proportional hazard regression analysis were performed to test the effect of malignancy. Results: Among 341 OHCA patients, 59 patients had malignancy (17.3%). Sustained ROSC, survival to admission, survival to discharge and discharge with a good CPC were not different between the two groups. The 1‐year survival rate was lower in patients with malignancy (1.7% vs 11.4%; P = 0.026). Kaplan‐Meier survival analysis revealed that patients with malignancy had a significantly lower 1‐year survival rate when including all patients (n = 341; P = 0.028), patients with survival to admission (n = 172, P = 0.002), patients with discharge CPC 1 or 2 (n = 18, P = 0.010) and patients with discharge CPC 3 or 4 (n = 57, P = 0.008). Malignancy was an independent risk factor for 1‐year mortality in the Cox proportional hazard regression analysis performed in patients with survival to admission and survival to discharge. Conclusions: Although survival to admission, survival to discharge and discharge with a good CPC rate were not different, the 1‐year survival rate was significantly lower in OHCA patients with malignancy than in those without malignancy.

Epileptiform discharge detection with the 4-channel frontal electroencephalography during post-resuscitation care

INTRODUCTION We performed this study to investigate whether the SEDline system, a 4-channel-processed electroencephalography (EEG) monitoring device in the frontal area, can detect epileptiform discharges accurately during post-resuscitation care in comatose cardiac arrest survivors. METHODS Adult comatose cardiac arrest survivors, who were admitted to the intensive care unit (ICU) for post-resuscitation care including TTM, were enrolled. Within 72h post-return of spontaneous circulation (ROSC), conventional EEG was conducted for 30min. The SEDline system data were recorded with a video camera simultaneously with conventional EEG. Data retrieved from conventional EEG were interpreted by a neurologist and data from the SEDline system were interpreted by three emergency physicians blinded to the conventional EEG data. Then, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of the SEDline system to detect epileptiform discharges were calculated. RESULTS Thirty-nine patients were enrolled in this study. Epileptiform discharges were confirmed in 6 patients (15.4%) who had the same patterns of generalized periodic epileptiform discharges in both conventional EEG and the concurrent SEDline system. The SEDline system showed 100.0% (95% confidence interval (CI), 54.1-100.0%) of sensitivity, 100.0% (95% CI, 89.4-100.0%) of specificity, 100.0% (95% CI, 54.1-100.0%) of PPV, and 100.0% (95% CI, 89.4-100.0%) of NPV. The overall classification accuracy of the SEDline system to detect epileptiform discharges was 100.0%. CONCLUSION The SEDline system detected epileptiform discharges accurately in comatose cardiac arrest survivors during post-resuscitation care.

Apocynin suppressed the nuclear factor-κB pathway and attenuated lung injury in a rat hemorrhagic shock model

BACKGROUND The aim of this study was to investigate whether a nicotinamide adenine dinucleotide phosphate (NADPH) oxidase (Nox) inhibitor, apocynin, reduces reactive oxygen species (ROS) production, suppresses the nuclear factor &kgr;B (NF-&kgr;B) pathway, attenuates lung injury, and improves survival in rat hemorrhagic shock (HS) model. METHODS Blood was drawn from male Sprague–Dawley rats (290–340 g) to maintain a mean arterial pressure of 20–25 mm Hg for 40 minutes. The rats were resuscitated with the drawn blood, and a vehicle (HS), a low dose of apocynin (20 mg/kg, LD-Apo), or a high dose of apocynin (40 mg/kg, HD-Apo) was administered intraperitoneally. The survival of the rats was observed for 72 hours. Then, a separated set of rats was euthanized at 6 hours post-HS induction. We measured gp91-phox (Nox2) expression, Nox activity, cytoplasmic phosphorylated inhibitor &kgr;B-&agr; (p-I&kgr;B-&agr;) expression, NF-&kgr;B p65 DNA-binding activity, tumor necrosis factor-&agr; (TNF-&agr;) and interleukin-6 (IL-6) gene expressions, malondialdehyde (MDA) level, myeloperoxidase (MPO) activity, and histological damage in the lung tissues. RESULTS The survival rates of the sham, HS, HS + LD-Apo, and HS + HD-Apo groups were 100% (5/5), 30% (3/10), 40% (4/10), and 70% (7/10), respectively. A high dose of apocynin decreased gp91-phox expression, Nox activity, and MDA level in the lung tissues during HS and resuscitation. It also decreased p-I&kgr;B-&agr; expression, NF-&kgr;B p65 DNA-binding activity, TNF-&agr; and IL-6 gene expressions, and MPO activity in the lung tissues and attenuated histological lung injuries. However, a low dose of apocynin failed to show these benefits. CONCLUSIONS The administration of a high dose of apocynin inhibited Nox2 expression and Nox activity, reduced lipid peroxidation, suppressed the NF-&kgr;B pathway and subsequent pro-inflammatory cytokines transcription in the lung tissues, and attenuated lung injury during HS and resuscitation in rats.

Prognostic value of pneumococcal urinary antigen test in community-acquired pneumonia

Background The pneumococcal urinary antigen test (UAT) has been known to improve sensitivity and specificity for the diagnosis of pneumococcal pneumonia. Associations of UAT results with prognosis in community acquired pneumonia (CAP) are not known. We hypothesized that positive UAT is associated with a good prognosis, and incorporation of UAT into CRB65 would improve its prognostic performance. Methods In this registry-based retrospective study, we analyzed CAP patients over a 10-year period beginning in April 2008. Patients who had UAT results were included in multivariable extended Cox-regression analyses to determine the association between UAT positivity and 30-day mortality. UAT results were incorporated for patients with a CRB65 score of 1 by subtracting 1 from the scoring system if the test was positive. The performance of the modified scoring systems was assessed with area under the receiver operating characteristic (AUROC) curves. Results Among 5145 CAP patients, total 2280 patients had UAT results and were included in analyses. A positive UAT result was associated with a good prognosis after a week of hospitalization (aHR, 0.14; p = 0.007). After modification of CRB65 using UAT results, positive and negative predictive values for 30-day mortality were increased from 7.7 to 8.3 (p<0.001) and 98.9 to 99.1 (p = 0.010). The AUROC increased from 0.73 to 0.75 (p<0.001). Conclusions Positive results on UAT could be considered as a good prognostic factor in CAP. UAT could be used as a useful tool in deciding whether to refer patients to the hospital, especially in moderate CAP with a CRB score of 1.

Early detection of cerebral infarction with middle cerebral artery occlusion with functional near-infrared spectroscopy: a pilot study

Background: NIRSIT, a functional near-infrared spectroscopy (fNIRS) device with 204 channels, can measure oxyhemoglobin (HbO2) and deoxyhemoglobin (HbR) in non-pulsatile blood flow non-invasively using the absorption difference between HbO2 and HbR at a wavelength of 700–1,000 nm and can display the perfusion status in real time. Objective: We applied NIRSIT to patients with stroke to evaluate the usefulness of NIRSIT as an fNIRS device for the early detection of stroke. Methods: We performed a prospective pilot study in an emergency department (ED). Adult patients who had suspected symptoms and signs of stroke within 12 h of the first abnormal time and who underwent intravenous thrombolysis (IVT) or intra-arterial thrombectomy with acute middle cerebral artery (MCA) or internal carotid artery (ICA) infarction were enrolled. NIRSIT was applied to the patients before the imaging study, and the perfusion status of the brain was displayed in real time at the bedside. We compared the NIRSIT results with the mean transit time (MTT) map from perfusion computed tomography (PCT) and the time-to-peak (TTP) map from perfusion-weighted magnetic resonance imaging (PWI). Results: Six male and three female patients were enrolled, and the median age was 74 years. The most common symptom was unilateral extremity weakness (77.8%), followed by dysarthria (33.3%) and aphasia (11.1%). The median National Institutes of Health Stroke Scale (NIHSS) score was 17. All cases of MCA infarction showed different cerebral oxygen saturation values between bilateral lobes of the brain in fNIRS imaging, and these values matched the PCT and PWI results. Conclusions: The brain hemisphere with low oxygen saturation on fNIRS showed hypoperfusion on PCT or PWI. The fNIRS device could be useful in assessing the perfusion status of the brain and detecting MCA or ICA infarction in real time at the bedside.

Admission levels of high-density lipoprotein and apolipoprotein A-1 are associated with the neurologic outcome in patients with out-of-hospital cardiac arrest

Objective To investigate whether serum levels of high-density lipoprotein (HDL) and apolipoprotein A-1 (ApoA1), after the return of spontaneous circulation, can predict the neurologic outcome in patients with out-of-hospital cardiac arrest (OHCA). Methods This was a retrospective observational study conducted in a single tertiary hospital intensive care unit. All adult OHCA survivors with admission lipid profiles were enrolled from March 2013 to December 2015. Good neurologic outcome was defined as discharge cerebral performance categories 1 and 2. Results Among 59 patients enrolled, 13 (22.0%) had a good neurologic outcome. Serum levels of HDL (56.7 vs. 40 mg/dL) and ApoA1 (117 vs. 91.6 mg/dL) were significantly higher in patients with a good outcome. Areas under the HDL and ApoA1 receiver operating curves to predict good outcomes were 0.799 and 0.759, respectively. The proportion of good outcome was significantly higher in patients in higher tertiles of HDL and ApoA1 (test for trend, both P=0.003). HDL (P=0.018) was an independent predictor in the multivariate logistic regression model. Conclusion Admission levels of HDL and ApoA1 are associated with neurologic outcome in patients with OHCA. Prognostic and potential therapeutic values of HDL and ApoA1 merit further evaluation in the post-cardiac arrest state, as in other systemic inflammatory conditions such as sepsis.

Six-hour central venous oxygen saturation has no prognostic value in patients with septic shock

Methods We have retrospectively identified septic shock patients who received protocolized treatment in two tertiary academic EDs. All patients were treated using the early goaldirected protocol. The data with respect to demographics, predisposing factors, site of infection, and the admission APACHE II score were collected. Hemodynamic (mean arterial pressure and central venous pressure) and laboratory (arterial blood gas analysis, Scv02, and lactate level) parameters at baseline and 6-hour were also recorded. To test the prognostic value of 6-hour Scv02, the area under receiver operating characteristics curve (AUROC) to predict 1-month mortality was calculated and compared with that of 6-hour lactate level. Pearson correlation coefficient between 6-hour Scv02 or lactate level and the admission APACHE II score were also analyzed.