Brain dynamics reflecting an intra-network brain state is associated with increased posttraumatic stress symptoms in the early aftermath of trauma

This study examines the association between brain dynamic functional network connectivity (dFNC) and current/future posttraumatic stress (PTS) symptom severity, and the impact of sex on this relationship. By analyzing 275 participants' dFNC data obtained ~2 weeks after trauma exposure, we noted that brain dynamics of an inter-network brain state link negatively with current (r=-0.179, pcorrected= 0.021) and future (r=-0.166, pcorrected= 0.029) PTS symptom severity. Also, dynamics of an intra-network brain state correlated with future symptom intensity (r = 0.192, pcorrected = 0.021). We additionally observed that the association between the network dynamics of the inter-network brain state with symptom severity is more pronounced in females (r=-0.244, pcorrected = 0.014). Our findings highlight a potential link between brain network dynamics in the aftermath of trauma with current and future PTSD outcomes, with a stronger protective effect of inter-network brain states against symptom severity in females, underscoring the importance of sex differences.

Modulation of mitochondrial function with near-infrared light reduces brain injury in a translational model of cardiac arrest

BACKGROUND

Brain injury is a leading cause of morbidity and mortality in patients resuscitated from cardiac arrest. Mitochondrial dysfunction contributes to brain injury following cardiac arrest; therefore, therapies that limit mitochondrial dysfunction have the potential to improve neurological outcomes. Generation of reactive oxygen species (ROS) during ischemia-reperfusion injury in the brain is a critical component of mitochondrial injury and is dependent on hyperactivation of mitochondria following resuscitation. Our previous studies have provided evidence that modulating mitochondrial function with specific near-infrared light (NIR) wavelengths can reduce post-ischemic mitochondrial hyperactivity, thereby reducing brain injury during reperfusion in multiple small animal models.

METHODS

Isolated porcine brain cytochrome c oxidase (COX) was used to investigate the mechanism of NIR-induced mitochondrial modulation. Cultured primary neurons from mice expressing mitoQC were utilized to explore the mitochondrial mechanisms related to protection with NIR following ischemia-reperfusion. Anesthetized pigs were used to optimize the delivery of NIR to the brain by measuring the penetration depth of NIR to deep brain structures and tissue heating. Finally, a model of out-of-hospital cardiac arrest with CPR in adult pigs was used to evaluate the translational potential of NIR as a noninvasive therapeutic approach to protect the brain after resuscitation.

RESULTS

Molecular evaluation of enzyme activity during NIR irradiation demonstrated COX function was reduced in an intensity-dependent manner with a threshold of enzyme inhibition leading to a moderate reduction in activity without complete inhibition. Mechanistic interrogation in neurons demonstrated that mitochondrial swelling and upregulation of mitophagy were reduced with NIR treatment. NIR therapy in large animals is feasible, as NIR penetrates deep into the brain without substantial tissue heating. In a translational porcine model of CA/CPR, transcranial NIR treatment for two hours at the onset of return of spontaneous circulation (ROSC) demonstrated significantly improved neurological deficit scores and reduced histologic evidence of brain injury after resuscitation from cardiac arrest.

CONCLUSIONS

NIR modulates mitochondrial function which improves mitochondrial dynamics and quality control following ischemia/reperfusion. Noninvasive modulation of mitochondria, achieved by transcranial treatment of the brain with NIR, mitigates post-cardiac arrest brain injury and improves neurologic functional outcomes.

Treatment and outcome variation in out-of-hospital cardiac arrest among four urban hospitals in Detroit

AIMS

To determine whether out-of-hospital cardiac arrest (OHCA) post-resuscitation management and outcomes differ between four Detroit hospitals.

INTRODUCTION

Significant variation exists in treatment/outcomes from OHCA. Disparities between hospitals serving a similar population is not well known.

METHODS

Retrospective OHCA data was collected from the Detroit-Cardiac Arrest Registry (DCAR) between January 2014 to December 2019. Four hospitals were compared on two treatments (angiography, do not resuscitate (DNR)) and two outcomes (cerebral performance category (CPC) ≤ 2, in-hospital death). Models for death and CPC were tested with and without coronary angiography and DNR status.

RESULTS

999 patients at hospitals A - D differed (p < 0.05) before multivariable adjustment by age, race, witnessed arrest, dispatch-emergency department (ED) time, TTM, coronary angiography, DNR order, and in-hospital death. Rates of death and CPC ≤ 2 were worse in Hospital A (82.8%, 10%, respectively) compared to others (69.1%, 14.1%). After multivariable adjustment, Hospital A performed angiography less compared to B (OR = 0.17) and was more likely to initiate new DNR status than B (OR = 2.9), C (OR = 16.1), or D (OR = 3.6). CPC ≤ 2 were worse in Hospital A compared to B (OR = 0.27) and D (OR = 0.35). After sensitivity analysis, CPC ≤ 2 odds did not differ for A versus B (OR = 0.58, adjusted for angiography) or D (OR = 0.65, adjusted for DNR). Odds of death, despite angiography and DNR differences, were worse in Hospital A compared to B (OR = 1.87) and D (OR = 1.81).

CONCLUSION

Differing rates of DNR and coronary angiography was associated with observed disparities in favorable neurologic outcome, but not death, between four Detroit hospitals.

Composite Metric for Benchmarking Site Performance in Transcatheter Aortic Valve Replacement: Results From the STS/ACC TVT Registry

BACKGROUND

Transcatheter aortic valve replacement (TAVR) is a transformative therapy for aortic stenosis. Despite rapid improvements in technology and techniques, serious complications remain relatively common and are not well described by single outcome measures. The purpose of this study was to determine whether there is site-level variation in TAVR outcomes in the United States using a novel 30-day composite measure.

METHODS

We performed a retrospective cohort study using data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies Registry to develop a novel ranked composite performance measure that incorporates mortality and serious complications. The selection and rank order of the complications for the composite was determined by their adjusted association with 1-year outcomes. Sites with risk-adjusted outcomes significantly more or less frequent than the national average based on a 95% probability interval were classified as performing worse or better than expected.

RESULTS

The development cohort consisted of 52 561 patients who underwent TAVR between January 1, 2015, and December 31, 2017. Based on associations with 1-year risk-adjusted mortality and health status, we identified 4 periprocedural complications to include in the composite risk model in addition to mortality. Ranked empirically according to severity, these included stroke, major, life-threatening or disabling bleeding, stage III acute kidney injury, and moderate or severe perivalvular regurgitation. Based on these ranked outcomes, we found that there was significant site-level variation in quality of care in TAVR in the United States. Overall, better than expected site performance was observed in 25/301 (8%) sites, performance as expected was observed in 242/301 sites (80%), and worse than expected performance was observed in 34/301 (11%) sites. Thirty-day mortality; stroke; major, life-threatening, or disabling bleeding; and moderate or severe perivalvular leak were each substantially more common in sites with worse than expected performance as compared with other sites. There was good aggregate reliability of the model.

CONCLUSIONS

There are substantial variations in the quality of TAVR care received in the United States and 11% of sites were identified as providing care below the average level of performance. Further study is necessary to determine structural, process-related, and technical factors associated with high- and low-performing sites.

Dealing with existing theory: national fatality rates, vehicle standards and personal safety

In this paper we discuss some of the weaknesses in exiting theories and understandings behind road safety interventions and policy making. The paper deals with four main issues: road traffic fatality rates and per capita income of countries, vehicle crashworthiness standards, role of pedestrian and powered two-wheeler share in traffic on fatalities, and safety standards for vehicles other than cars. Recent data indicate that there may not be a strong relationship between income and road safety performance and it is possible for low and middle-income countries (LMIC) to decrease death rates at present income levels. Safer cars have had a major role in reducing fatality rates, but, gains in traffic safety in high income countries may be partly due to reducing exposure of vulnerable road users. Small lightweight vehicles (like tuk-tuks, three-wheeled scooter taxis) operating in many LMIC appear to have low fatality rates though they do not follow any crashworthiness standards. Very different crashworthiness standards need to be developed for low mass vehicles incapable of operating speeds greater than 50 km/h. LMIC may not be able to reduce fatality rates below about 7 per 100,000 population unless there are innovative developments in road design and all vehicle safety standards.

Improvement in Non-Traumatic, Out-Of-Hospital Cardiac Arrest Survival in Detroit From 2014 to 2016

Background In 2002, the out-of-hospital cardiac arrest ( OHCA ) survival rate in Detroit was the lowest in the nation. Concerted efforts sought to improve the city's chain of survival with a focus on emergency medical services ( EMS ). This study assesses the impact on OHCA survival rates and describe factors associated with survival. Methods and Results Data for non-traumatic OHCA cases in Detroit from 2014 to 2016 were extracted from CARES (Cardiac Arrest Registry to Enhance Survival). Chi-squared tests, non-parametric tests, and a multivariable logistic regression analysis were employed to examine the associations between overall survival and its covariates. A total of 2359 non-traumatic OHCA cases were examined. The overall survival rate increased from 3.7% in 2014 to 5.4% in 2015, and 6.4% in 2016 ( P<0.01), reflecting a 73% improvement in survival over the 3-year period. EMS median on-scene time decreased over the study period, while the rate at which EMS initiated cardiopulmonary resuscitation and applied an automated external defibrillator (AED) greatly increased ( P<0.001). The factors significantly associated with survival were female sex (odds ratio=1.70, P<0.05), a public setting (odds ratio=2.31, P<0.01), an EMS witness (odds ratio=6.18, P<0.01), and the presence of an initial shockable rhythm (odds ratio=1.88, P<0.05). Conclusions From 2014 to 2016, the overall survival rate for OHCA patients in Detroit, MI significantly improved. Our results suggest that an improved chain of survival may explain this progress. This study is an example of how OHCA data analysis and EMS improvement can improve end OHCA outcomes in a resource-limited urban setting.

Gender Differences in Pain Experience and Treatment after Motor Vehicle Collisions: A Secondary Analysis of the CRASH Injury Study

PURPOSE

Little is known about gender differences in the treatment of pain after motor vehicle collisions (MVCs) in an emergency department (ED). We aimed to describe gender differences in pain experiences and treatment, specifically the use of opioids and benzodiazepines after ED discharge, for MVC-related pain.

METHODS

This was a secondary analysis of previously collected data from the CRASH Injury studies. We included patients who were seen and discharged from an ED after an MVC and who were enrolled in 1 of 2 multicenter longitudinal prospective cohort studies (1 black/non-Hispanic and 1 white/non-Hispanic). First, we compared the experience of pain as defined by self-reported moderate-to-severe axial pain, widespread pain, number of somatic symptoms, pain catastrophizing, and peritraumatic distress between women and men using bivariate analyses. We then determined whether there were gender differences in the receipt of prescription medications for post-MVC pain symptoms (opioids and benzodiazepines) using multivariate logistic regression adjusting for demographic characteristics, pain, and collision characteristics.

FINDINGS

In total, 1878 patients were included: 61.4% were women. More women reported severe symptoms on the pain catastrophizing scale (36.8% vs 31.0%; P = 0.032) and peritraumatic distress following the MVC (59.7% vs 42.5%; P < 0.001), and women reported more somatic symptoms than men (median, 3.9; interquartile range, 3.7-4.0 vs median, 3.3; interquartile range, 3.1-3.5; P < 0.001). Unadjusted, similar proportions of women and men were given opioids (29.2% vs 29.7%; P = 0.84). After adjusting for covariates, women and men remained equally likely to receive a prescription for opioids (relative risk = 0.83; 95% confidence interval, 0.58-1.19). Women were less likely than men to receive a benzodiazepine at discharge from an ED (relative risk = 0.53; 95% confidence interval, 0.32-0.88).

IMPLICATIONS

In a large, multicenter study of ED patients treated for MVC, there were gender differences in the acute psychological response to MVC with women reporting more psychological and somatic symptoms. Women and men were equally likely to receive opioid prescriptions at discharge. Future research should investigate potential gender-specific interventions to reduce both posttraumatic distress and the risk of developing negative long-term outcomes like chronic pain.

A Brain Electrical Activity Electroencephalographic-Based Biomarker of Functional Impairment in Traumatic Brain Injury: A Multi-Site Validation Trial

The potential clinical utility of a novel quantitative electroencephalographic (EEG)-based Brain Function Index (BFI) as a measure of the presence and severity of functional brain injury was studied as part of an independent prospective validation trial. The BFI was derived using quantitative EEG (QEEG) features associated with functional brain impairment reflecting current consensus on the physiology of concussive injury. Seven hundred and twenty adult patients (18-85 years of age) evaluated within 72 h of sustaining a closed head injury were enrolled at 11 U.S. emergency departments (EDs). Glasgow Coma Scale (GCS) score was 15 in 97%. Standard clinical evaluations were conducted and 5 to 10 min of EEG acquired from frontal locations. Clinical utility of the BFI was assessed for raw scores and percentile values. A multinomial logistic regression analysis demonstrated that the odds ratios (computed against controls) of the mild and moderate functionally impaired groups were significantly different from the odds ratio of the computed tomography (CT) postive (CT+, structural injury visible on CT) group (p = 0.0009 and p = 0.0026, respectively). However, no significant differences were observed between the odds ratios of the mild and moderately functionally impaired groups. Analysis of variance (ANOVA) demonstrated significant differences in BFI among normal (16.8%), mild TBI (mTBI)/concussed with mild or moderate functional impairment, (61.3%), and CT+ (21.9%) patients (p < 0.0001). Regression slopes of the odds ratios for likelihood of group membership suggest a relationship between the BFI and severity of impairment. Findings support the BFI as a quantitative marker of brain function impairment, which scaled with severity of functional impairment in mTBI patients. When integrated into the clinical assessment, the BFI has the potential to aid in early diagnosis and thereby potential to impact the sequelae of TBI by providing an objective marker that is available at the point of care, hand-held, non-invasive, and rapid to obtain.

Cardiopulmonary Resuscitation in Adults and Children With Mechanical Circulatory Support: A Scientific Statement From the American Heart Association

Cardiac arrest in patients on mechanical support is a new phenomenon brought about by the increased use of this therapy in patients with end-stage heart failure. This American Heart Association scientific statement highlights the recognition and treatment of cardiovascular collapse or cardiopulmonary arrest in an adult or pediatric patient who has a ventricular assist device or total artificial heart. Specific, expert consensus recommendations are provided for the role of external chest compressions in such patients.

Emergency Department Triage of Traumatic Head Injury Using a Brain Electrical Activity Biomarker: A Multisite Prospective Observational Validation Trial

OBJECTIVES

A brain electrical activity biomarker for identifying traumatic brain injury (TBI) in emergency department (ED) patients presenting with high Glasgow Coma Scale (GCS) after sustaining a head injury has shown promise for objective, rapid triage. The main objective of this study was to prospectively evaluate the efficacy of an automated classification algorithm to determine the likelihood of being computed tomography (CT) positive, in high-functioning TBI patients in the acute state.

METHODS

Adult patients admitted to the ED for evaluation within 72 hours of sustaining a closed head injury with GCS 12 to 15 were candidates for study. A total of 720 patients (18-85 years) meeting inclusion/exclusion criteria were enrolled in this observational, prospective validation trial, at 11 U.S. EDs. GCS was 15 in 97%, with the first and third quartiles being 15 (interquartile range = 0) in the study population at the time of the evaluation. Standard clinical evaluations were conducted and 5 to 10 minutes of electroencephalogram (EEG) was acquired from frontal and frontal-temporal scalp locations. Using an a priori derived EEG-based classification algorithm developed on an independent population and applied to this validation population prospectively, the likelihood of each subject being CT+ was determined, and performance metrics were computed relative to adjudicated CT findings.

RESULTS

Sensitivity of the binary classifier (likely CT+ or CT-) was 92.3% (95% confidence interval [CI] = 87.8%-95.5%) for detection of any intracranial injury visible on CT (CT+), with specificity of 51.6% (95% CI = 48.1%-55.1%) and negative predictive value (NPV) of 96.0% (95% CI = 93.2%-97.9%). Using ternary classification (likely CT+, equivocal, likely CT-) demonstrated enhanced sensitivity to traumatic hematomas (≥1 mL of blood), 98.6% (95% CI = 92.6%-100.0%), and NPV of 98.2% (95% CI = 95.5%-99.5%).

CONCLUSION

Using an EEG-based biomarker high accuracy of predicting the likelihood of being CT+ was obtained, with high NPV and sensitivity to any traumatic bleeding and to hematomas. Specificity was significantly higher than standard CT decision rules. The short time to acquire results and the ease of use in the ED environment suggests that EEG-based classifier algorithms have potential to impact triage and clinical management of head-injured patients.

Abstract OT3-04-01: BRE12-158: A phase II randomized controlled trial of genomically directed therapy after preoperative chemotherapy in patients with triple negative breast cancer (TNBC)

Background: About 1/3 of patients with TNBC who receive preoperative therapy will experience a pathological complete response (pCR). Patients with residual disease have a markedly inferior overall survival (OS) compared to those who experience pCR. Recently, the CREATE-X trial demonstrated an improvement in disease free survival (DFS) and OS for post-neoadjuvant capecitebine; although the addition of capecitebine to standard therapy has not previously improved outcome across other non-selected adjuvant or neo-adjuvant trials. Prior data have also demonstrated that the residual tumors are genomically diverse and that these genetic changes are reflected at time of relapse.

Trial Design: This trial is a randomized phase II trial to determine whether a genomically guided therapy in the setting of incomplete response to standard neoadjuvant therapy will improve outcomes compared to standard of care. DNA from archived tumor samples collected at the time of surgery will be extracted and sequenced. The sequencing data will be interrogated for known genomic drivers of sensitivity or resistance to existing FDA approved agents. A cancer genomic tumor board (CGTB) will consider the genomic data along with the patient's prior treatment history, toxicities, and comorbidities and select the optimal therapy. Participants with a CGTB recommendation will be randomized to Experimental Arm A (genomically directed monotherapy) or Control Arm B (standard of care). Participants may have no CGTB recommendation either because sequencing did not identify a matched drug or because the drug was contraindicated and will be assigned to Control Arm B.

Eligibility criteria: Patients must have histologically confirmed TNBC with completion of all definitive local therapy and no evidence of metastatic disease. There must be significant residual disease characterized by &gt;2cm primary tumor, or lymph node positivity or RCB classification II or III. An FFPE tumor block with tumor cellularity &gt;20% is required. All patients must have completed preoperative chemotherapy including a taxane or anthracycline or both.

Specific aims: The Primary Aim is to compare 2-year DFS with a genomically directed therapy vs. standard of care. Secondary Aims include 1-year DFS, 5-year OS, collection of archival specimens for correlative studies, and to describe toxicities. Exploratory Aims are to describe the evolution of genomically directed therapies during the course of the study and to evaluate the drug specific effect on efficacy and toxicity.

Statistical methods: In order to detect an improvement in the fraction of patients free from disease at 2-year from 40% in the control Arm B to 63.2% in the genomically directed Experimental Arm A (corresponding to an HR=0.5), 136 participants will have 80% power to detect a difference in DFS using a two-side log-rank test with 0.05 level of significance.

Present accrual/target accrual: 38 accrued of 136 to be randomized.

Citation Format: Schneider B, Miller KD, Badve S, O'Neil B, Helft P, Chitambar C, Falkson C, Nanda R, McCormick M, Danso M, Blaya M, Langdon R, Lippman M, Paplomata E, Walling R, Thompson M, Robin E, Aggarwal L, Shalaby I, Canfield V, Adesunloye B, Lee T, Daily K, Ma C, Erban J, Radhakrishnan N, Bruetman D, Graham M, Reddy NA, Lynce FC, Radovich M. BRE12-158: A phase II randomized controlled trial of genomically directed therapy after preoperative chemotherapy in patients with triple negative breast cancer (TNBC) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT3-04-01.

CT positive brain injury in mild TBI patients presenting with normal SAC scores

INTRODUCTION

Traumatic brain injury accounts for over 1 million U.S. emergency department visits annually. A significant percentage of patients undergo CT scans to exclude intracranial bleeds. The Standardized Assessment of Concussion (SAC) is designed to rapidly determine whether a concussion has occurred, (0-30 scale, where ≥25 is considered normal). Although not intended to be used in isolation, results in the normal range are considered an indication of low suspicion of brain injury. This study evaluated the relationship between CT findings of structural injury (CT+) and performance on the SAC.

METHODS

We performed a prospective observational study on mild head-injured patients presenting to the emergency department who underwent CT scans and had SAC evaluations.

RESULTS

We enrolled 368 patients, of which 66 were read by a neuroradiologist as positive (CT+), with an average age of 46.7, and an average Glasgow Coma Scale of 14.85. 38.2% of these CT+ patients had a SAC score ≥25. There were no significant differences between time of injury and CT scan or SAC for those with high or low SAC scores. Both high and low SAC groups contained similar CT+ abnormalities (e.g., hematomas).

CONCLUSIONS

These results indicate that a normal SAC score alone does not exclude intracranial injury.

Low-Dose (10%) Computed Tomography May Be Inferior to Standard-Dose CT in the Evaluation of Acute Renal Colic in the Emergency Room Setting

Introduction: Noncontrast CT is the standard of care to evaluate nephrolithiasis. We evaluated the performance of low-dose CT (LDCT) scan for evaluation of renal colic in the emergency room (ER).

Materials and Methods: Patients visiting the ER with suspected nephrolithiasis received a standard-dose CT (SDCT) and an LDCT. Two urologists read the LDCTs and later they read SDCTs. Stone information was recorded on a diagram of the renal system. Findings on SDCTs and LDCTs were correlated through side-by-side comparison of the diagrams. Later, the two urologists adjudicated all nonconcordance between SDCTs and LDCTs in an unblinded manner.

Results: Twenty-seven patients were included. SDCTs revealed 27 stones in 18 patients. Mean stone size was 3.81 mm. LDCTs revealed 27 stones in 18 patients with a mean stone size of 4.7 mm (p = 0.23). Overall sensitivity and specificity of LDCTs were 70% and 39%, respectively. There were eight false-positive and eight false-negative stones. All the false-positive stones on LDCTs were placed in the ureter, in which all of the corresponding SDCTs were visible calcifications outside the ureter. Of the eight false-negative stones on LDCTs, seven were visible calcifications on the SDCTs and the eighth stone was 1 mm and was not visible.

Conclusion: LDCT may not perform well in the evaluation of suspected nephrolithiasis in the acute setting. LDCT scan accurately demonstrates calcifications; however, accurate placement of calcifications in or out of the urinary tract may be diminished due to impaired resolution of soft tissue structures.

Quantitative brain electrical activity in the initial screening of mild traumatic brain injuries

Introduction:

The incidence of emergency department (ED) visits for Traumatic Brain Injury (TBI) in the United States exceeds 1,000,000 cases/year with the vast majority classified as mild (mTBI). Using existing computed tomography (CT) decision rules for selecting patients to be referred for CT, such as the New Orleans Criteria (NOC), approximately 70% of those scanned are found to have a negative CT. This study investigates the use of quantified brain electrical activity to assess its possible role in the initial screening of ED mTBI patients as compared to NOC.

Methods:

We studied 119 patients who reported to the ED with mTBI and received a CT. Using a hand-held electroencephalogram (EEG) acquisition device, we collected data from frontal leads to determine the likelihood of a positive CT. The brain electrical activity was processed off-line to generate an index (TBI-Index, biomarker). This index was previously derived using an independent population, and the value found to be sensitive for significant brain dysfunction in TBI patients. We compared this performance of the TBI-Index to the NOC for accuracy in prediction of positive CT findings.

Results:

Both the brain electrical activity TBI-Index and the NOC had sensitivities, at 94.7% and 92.1% respectively. The specificity of the TBI-Index was more than twice that of NOC, 49.4% and 23.5% respectively. The positive predictive value, negative predictive value and the positive likelihood ratio were better with the TBI-Index. When either the TBI-Index or the NOC are positive (combining both indices) the sensitivity to detect a positive CT increases to 97%.

Conclusion:

The hand-held EEG device with a limited frontal montage is applicable to the ED environment and its performance was superior to that obtained using the New Orleans criteria. This study suggests a possible role for an index of brain function based on EEG to aid in the acute assessment of mTBI patients.

Predictors of 30-day cardiovascular events in patients with prior percutaneous coronary intervention or coronary artery bypass grafting

OBJECTIVES

Risk stratification of patients with potential acute coronary syndrome (ACS) is difficult. Patients with prior revascularization are considered higher risk, but they can also have symptoms from noncardiac causes. This study evaluated whether the presenting clinical characteristics were predictive of an increased risk of 30-day cardiovascular events in patients with prior revascularization presenting to the emergency department (ED) with symptoms of potential ACS.

METHODS

This was a secondary analysis of the DISPO-ACS study, a 2000-patient, four-site, randomized controlled trial of patients presenting with potential ACS. Process outcomes were evaluated using point-of-care cardiac markers compared to standard laboratory-based markers. Data included demographics, history, presenting symptoms, laboratory and electrocardiogram (ECG) results, hospital course, and 30-day cardiovascular events (death, acute myocardial infarction [AMI], revascularization). The association between presenting characteristics and 30-day cardiovascular events was assessed using univariable analysis and logistic regression; odds ratios (ORs) with 95% confidence intervals (CIs) are given.

RESULTS

Of 2,000 patients enrolled, 611 had prior revascularization (538 percutaneous coronary intervention [PCI], 232 coronary artery bypass graft [CABG], 159 both). The mean (±SD) age was 66 (±14) years, 44% were female, and 22% were black. By 30 days, 101 patients (17%) had cardiovascular events (81 during the index visit, 20 during follow-up). There were four deaths, 28 AMIs, and 67 revascularizations within 30 days; 20 patients had multiple endpoints. Being male (OR = 1.67, 95% CI = 1.07 to 2.62) or nonblack (OR = 1.95, 95% CI = 1.07 to 3.56) or having a family history of coronary artery disease (CAD; OR = 2.09, 95% CI = 1.32 to 3.3), elevated lipids (OR = 1.71, 95% CI = 1.04 to 2.82), prior AMI (OR = 1.79, 95% CI = 1.16 to 2.76), abnormal ECG on arrival (OR = 2.1, 95% CI = 1.33 to 3.34), and a positive initial troponin (OR = 14.7, 95% CI = 6.8 to 32.2) were predictive of cardiovascular events. The multivariable model found family history of CAD (OR = 2.06, 95% CI = 1.26 to 3.36), abnormal initial ECG (OR = 1.89, 95% CI = 1.16 to 3.09), and positive initial troponin (OR = 13.3, 95% CI = 5.9 to 29.6) remained predictive of 30-day cardiovascular events.

CONCLUSIONS

In patients with prior revascularization, the initial ECG and early cardiac marker elevations, but not clinical presentation, predict odds of 30-day death, AMI, or revascularization.

Capturing the pathophysiology of acute coronary syndromes with circulating biomarkers

There have been considerable advances in the evaluation of suspected acute coronary syndromes (ACS): sophistication of the clinical examination, electrocardiography, risk prediction scores, multiple blood biomarkers, and rapid cardiovascular imaging. Integration of information remains a formidable challenge for the physician in the setting of time-sensitive clinical decision making. In addition to conventional panels of biomarkers, there are novel entities that may be able to signal different stages of the acute event, including plaque disruption, atherothrombosis, ischemic damage, tissue hypoxia, and oxidative stress. The natriuretic peptides are normal myocyte products that reflect myocardial tissue response to neurohormonal and mechanical forces that rapidly change during an ACS event. This article summarizes major advancements in the integrative use of multiple blood biomarkers and cardiovascular imaging in the diagnosis, prognosis, and management of ACS.

An evidence-based algorithm for the use of B-type natriuretic testing in acute coronary syndromes

Measurable B-type natriuretic peptides (BNPs), which are largely produced by the left ventricle, include BNP and N-terminal prohormone BNP (NT-proBNP). These proteins are released by cardiomyocytes in response to wall tension and neurohumoral signals, and are established tools in the diagnosis and prognosis of heart failure (HF). We identified 32 articles for entry into evidence tables that presented original data on BNP and/or NT-proBNP in more than 100 patients with acute coronary syndromes (ACS) presenting with chest discomfort with or without dyspnea. Natriuretic peptide (NP) elevation was associated with older age, female sex, hypertension, diabetes, prior HF, prior ischemic heart disease, and reduced renal function. Clinical correlates of elevated blood NP levels included left main or 3-vessel coronary disease, lipid-rich plaques with large necrotic cores in proximal locations, large zones of myocardial ischemia or infarction, no-reflow and impaired perfusion after percutaneous intervention, reduced left ventricular ejection fraction, higher Killip classification, and the development of cardiogenic shock. All studies indicated that after adjustment for baseline predictors and clinical risk scores, elevated NP concentrations were independently predictive of the development of HF and all-cause mortality. In contrast, studies did not consistently demonstrate that NPs were predictive of myocardial infarction and rehospitalization for ACS. In addition to baseline measurement, there is consensus that repeat testing at 4 to 12 weeks and 6 to 12 months in follow-up is helpful in the anticipation of late cardiac sequelae and may assist in assessing prognosis and guiding management.

The diagnostic accuracy of 64-slice computed tomography coronary angiography compared with stress nuclear imaging in emergency department low-risk chest pain patients

STUDY OBJECTIVE

We compared the accuracy of multidetector computed tomography (CT) coronary angiography with stress nuclear imaging for the detection of an acute coronary syndrome or 30-day major adverse cardiac events in low-risk chest pain patients.

METHODS

This was a prospective study of the diagnostic accuracy of myocardial perfusion imaging and multidetector CT in low-risk chest pain patients. The target condition was an acute coronary syndrome (confirmed >70% coronary stenosis on coronary artery catheterization) or major adverse cardiac events within 30 days. Patients were low risk by Reilly/Goldman criteria and had negative serial ECGs and cardiac markers. All had both rest/stress sestamibi nuclear imaging and multidetector CT. Patients with abnormal stress nuclear imaging results (reversible perfusion defects) or multidetector CT results (stenosis >50% or calcium score >400) were considered for cardiac catheterization, and those with discordant results had a greater than 30-day reevaluation (including ECG) by a cardiologist. All were followed up for evidence of major adverse cardiac events within 30 days by review of hospital records and structured telephone interview. Primary outcomes were the accuracy of multidetector CT and myocardial perfusion imaging for the detection of an acute coronary syndrome and 30-day major adverse cardiac events.

RESULTS

Of the 92 patients, 7 (8%) were excluded because of uninterpretable multidetector CT scans. Of the remaining 85 study patients (49+/-11 years, 53% men), 7 (8%) were found to have the target condition, with all having significant coronary stenosis (88%+/-9%) and none having myocardial infarction or major adverse cardiac events during 30 days. Stress nuclear imaging results were negative in 72 (85%) patients, and multidetector CT results were negative in 73 (86%) patients. The sensitivity of stress nuclear imaging was 71% (95% confidence interval [CI] 36% to 92%), and multidetector CT was 86% (95% CI 49% to 97%), and the specificity was 90% (95% CI 81% to 95%) and 92% (95% CI 84% to 96%), respectively. The negative predictive value of stress nuclear imaging and multidetector CT was 97% (95% CI 90% to 99%) and 99% (95% CI 93% to 100%), respectively, and the positive predictive value was 38% (95% CI 18% to 64%) and 50% (95% CI 25% to 75%), respectively.

CONCLUSION

The accuracy of multidetector CT is at least as good as that of stress nuclear imaging for the detection and exclusion of an acute coronary syndrome in low-risk chest pain patients.

The relationship between the hospital setting and perceptions of family-witnessed resuscitation in the emergency department

OBJECTIVE

To compare the support for, and perceptions of, family-witnessed resuscitation (FWR) in urban and suburban emergency departments (ED).

METHODS

A convenience sample of ED personnel from two urban and two suburban midwestern hospitals in the United States were surveyed. Survey questions assessed respondents' opinions and experiences regarding the presence of family members during a resuscitation attempt. Data analysis was conducted using descriptive statistics, 95% confidence intervals (CI), and chi2 tests.

RESULTS

There were 218 respondents to the survey (108 urban, 110 suburban) of which the majority (63.3%) were female, and a mean (S.D.) age of 36.9 (10.2). The majority [131 (60.1%)] were health care providers (i.e. physicians, nurses, and physician assistants) while the remainder included support staff (i.e. security, pastoral care, and social workers). Half (50.9%; 95% CI: 44.3-57.6) of all ED personnel felt it was appropriate for an escorted family member to be allowed to be present during a resuscitation attempt. However, ED personnel of urban settings were less likely to support FWR (38.9% urban versus 62.7% suburban; p < 0.001). Likewise, fewer urban than suburban personnel thought that the psychological impact of witnessing a failed resuscitation attempt would be beneficial for a family member (37.6% versus 61.7%; respectively, p = 0.001). Of note, a minority, yet substantial percentage of all ED personnel believed that the practice would increase the potential for malpractice litigation (28.7% urban versus 21.8% suburban; p = 0.242).

CONCLUSION

Overall, there is divided support among ED personnel for FWR. The hospital setting appears to influence this support strongly, as well as the perceived benefit of FWR.

Open-chest CPR improves survival and neurologic outcome following cardiac arrest

STUDY OBJECTIVE

To determine if 15 min of open-chest cardiac massage (OC-CPR) versus closed-chest compressions (CC-CPR) improves 72-h survival and neurologic outcome (behavioral and histologic) after 5 min of untreated cardiac arrest.

METHODS

Mongrel dogs were anesthetized and instrumented. Cardiac arrest was induced by KCl injection and after a 5-min period of non-intervention, dogs were randomized to receive either CC-CPR (N = 7) or OC-CPR (N = 5) performed for 15 min. The dogs were then resuscitated and physiologic data was recorded. Surviving dogs were scored at 72 h using canine neurodeficit score of Safar et al. (NDS; 0 = behaviorally normal, 500 = brain death). Dogs that could not be resuscitated or died before 72 h were assigned a score of 500. Brain histology was performed on all survivors.

RESULTS

All OC-CPR dogs were successfully resuscitated and were behaviorally normal at 72 h (NDS = 0). Histology in OC-CPR dogs showed little to no injury. Only three out of the seven CC-CPR dogs survived to 72 h. Of the survivors, one dog exhibited minor ataxia (NDS = 15), and two had incapacitating deficits (both NDS = 180). Two dogs died within 24 h after extubation, and one could not be resuscitated and the other could not be weaned from the ventilator (each NDS = 500). Histology of the CC-CPR survivors revealed moderate to severe lesions. NDS between groups was statistically significant (p < 0.0079).

CONCLUSION

In our canine model of cardiac arrest, OC-CPR significantly improved 72-h survival and neurologic outcome when compared to CC-CPR.