The association between hemoglobin concentration and neurologic outcome after cardiac arrest.

PURPOSE: The purpose of the study is to determine the association between hemoglobin concentration (Hgb) and neurologic outcome in postarrest patients. METHODS: We conducted a retrospective cohort study using the Penn Alliance for Therapeutic Hypothermia (PATH) cardiac arrest registry. Inclusion criteria were resuscitated cardiac arrest (inhospital or out of hospital) and an Hgb value recorded within 24 hours of return of spontaneous circulation. The primary outcome was favorable neurologic status at hospital discharge. Survival to hospital discharge was a secondary outcome. RESULTS: There were 598 eligible patients from 21 hospitals. Patients with favorable neurologic outcome had significantly higher median Hgb in the first 2 hours (12.7 vs 10.5 g/dL; P \u3c .001) and 6 hours (12.6 vs 10.6 g/dL; P \u3c .001) postarrest. Controlling for age, pulseless rhythm, etiology, location of arrest, receipt of targeted temperature management, hematologic or metastatic malignancy, or preexisting renal insufficiency, there was a significant relationship between Hgb and neurologic outcome within the first 6 hours after arrest (odds ratio, 1.23; 95% confidence interval, 1.09-1.38) and survival to hospital discharge (odds ratio, 1.20; 95% confidence interval, 1.08-1.34). CONCLUSION: Higher Hgb after cardiac arrest is associated with favorable neurologic outcome, particularly within the first 6 hours. It is unclear if this effect is due to impaired oxygen delivery or if Hgb is a marker for more severe illness

Inter-rater reliability of post-arrest cerebral performance category (CPC) scores.

PURPOSE: Cerebral Performance Category (CPC) scores are often an outcome measure for post-arrest neurologic function, collected worldwide to compare performance, evaluate therapies, and formulate recommendations. At most institutions, no formal training is offered in their determination, potentially leading to misclassification. MATERIALS AND METHODS: We identified 171 patients at 2 hospitals between 5/10/2005 and 8/31/2012 with two CPC scores at hospital discharge recorded independently - in an in-house quality improvement database and as part of a national registry. Scores were abstracted retrospectively from the same electronic medical record by two separate non-clinical researchers. These scores were compared to assess inter-rater reliability and stratified based on whether the score was concordant or discordant among reviewers to determine factors related to discordance. RESULTS: Thirty-nine CPC scores (22.8%) were discordant (kappa: 0.66), indicating substantial agreement. When dichotomized into favorable neurologic outcome (CPC 1-2)/ unfavorable neurologic outcome (CPC 3-5), 20 (11.7%) scores were discordant (kappa: 0.70), also indicating substantial agreement. Patients discharged home (as opposed to nursing/other care facility) and patients with suspected cardiac etiology of arrest were statistically more likely to have concordant scores. For the quality improvement database, patients with discordant scores had a statistically higher median CPC score than those with concordant scores. The registry had statistically lower median CPC score (CPC 1) than the quality improvement database (CPC 2); p\u3c0.01 for statistical significance. CONCLUSIONS: CPC scores have substantial inter-rater reliability, which is reduced in patients who have worse outcomes, have a non-cardiac etiology of arrest, and are discharged to a location other than home

Factors associated with post-arrest withdrawal of life-sustaining therapy.

INTRODUCTION: Most successfully resuscitated cardiac arrest patients do not survive to hospital discharge. Many have withdrawal of life sustaining therapy (WLST) as a result of the perception of poor neurologic prognosis. The characteristics of these patients and differences in their post-arrest care are largely unknown. METHODS: Utilizing the Penn Alliance for Therapeutic Hypothermia Registry, we identified a cohort of 1311 post-arrest patients from 26 hospitals from 2010 to 2014 who remained comatose after return of spontaneous circulation. We stratified patients by whether they had WLST post-arrest and analyzed demographic, arrest, and post-arrest variables. RESULTS: In our cohort, 565 (43%) patients had WLST. In multivariate regression, patients who had WLST were less likely to go to the cardiac catheterization lab (OR 0.40; 95% CI: 0.26-0.62) and had shorter hospital stays (OR 0.93; 95% CI: 0.91-0.95). When multivariate regression was limited to patient demographics and arrest characteristics, patients with WLST were older (OR 1.18; 95% CI: 1.07-1.31 by decade), had a longer arrest duration (OR 1.14; 95% CI: 1.05-1.25 per 10min), more likely to be female (OR: 1.41; 95% CI: 1.01-1.96), and less likely to have a witnessed arrest (OR 0.65; 95% CI: 0.42-0.98). CONCLUSION: Patients with WLST differ in terms of demographic, arrest, and post-arrest characteristics and treatments from those who did not have WLST. Failure to account for this variability could affect both clinical practice and the interpretation of research

Right ventricular dysfunction after resuscitation predicts poor outcomes in cardiac arrest patients independent of left ventricular function.

OBJECTIVE: Determination of clinical outcomes following resuscitation from cardiac arrest remains elusive in the immediate post-arrest period. Echocardiographic assessment shortly after resuscitation has largely focused on left ventricular (LV) function. We aimed to determine whether post-arrest right ventricular (RV) dysfunction predicts worse survival and poor neurologic outcome in cardiac arrest patients, independent of LV dysfunction. METHODS: A single-center, retrospective cohort study at a tertiary care university hospital participating in the Penn Alliance for Therapeutic Hypothermia (PATH) Registry between 2000 and 2012. PATIENTS: 291 in- and out-of-hospital adult cardiac arrest patients at the University of Pennsylvania who had return of spontaneous circulation (ROSC) and post-arrest echocardiograms. MEASUREMENTS AND MAIN RESULTS: Of the 291 patients, 57% were male, with a mean age of 59 ± 16 years. 179 (63%) patients had LV dysfunction, 173 (59%) had RV dysfunction, and 124 (44%) had biventricular dysfunction on the initial post-arrest echocardiogram. Independent of LV function, RV dysfunction was predictive of worse survival (mild or moderate: OR 0.51, CI 0.26-0.99, p CONCLUSIONS: Echocardiographic findings of post-arrest RV dysfunction were equally prevalent as LV dysfunction. RV dysfunction was significantly predictive of worse outcomes in post-arrest patients after accounting for LV dysfunction. Post-arrest RV dysfunction may be useful for risk stratification and management in this high-mortality population

Magnesium Depletion in Patients Treated with Therapeutic Hypothermia After Cardiac Arrest

Magnesium (Mg2+) depletion can have detrimental effects in postcardiac arrest patients through multiple potential mechanisms. Therapeutic hypothermia (TH) produces a Mg2+ diuresis, but the effects of postcardiac arrest TH on serum Mg2+ levels in patients with postcardiac arrest syndrome (PCAS) are yet to be systematically quantified. We conducted a retrospective chart review of 119 consecutive comatose PCAS patients treated with TH between 2005 and 2010 and compared them to 33 matched historic controls (HCs) seen at the same institution between 2002 and 2005 who were not treated with TH. We abstracted data from the first 96 hours postarrest, including date, time, and value of serum Mg2+ levels and date, time, and amount of Mg2+ repletion, along with outcomes at discharge. The median Mg2+ level of TH patients was 2.0?mg/dL [interquartile range (IQR), 1.9?2.2?mg/dL] (0.82 mmol/L [IQR, 0.78?0.90 mmol/L]) versus 2.2?mg/dL [IQR, 1.9?2.4?mg/dL] (0.90 mmol/L [IQR, 0.82?0.99 mmol/L]) (p=0.2) in HCs. In addition, 42.9% (520/1214) of Mg2+ levels in TH patients versus 31.9% (43/135) (p=0.014) in HC patients were below 2.0?mg/dL [0.82 mmol/L]. The average number of times the Mg2+ level was checked in TH patients was 10.2 (range 1?18) versus 4.1 (range 1?10) in HCs. The TH patients were more likely to receive supplemental Mg2+ than HCs (81.5% [97/119] vs. 27.3% [9/33] [p<0.01]). The mean supplemental Mg2+ dose was 1.9?g for TH patients versus 0.5?g for HC patients. Mortality in patients treated with TH was 53.1% (60/113) versus 78.6% (22/28) (p=0.014) in HCs. Low serum Mg2+ levels with subsequent Mg2+ supplementation were more common in comatose patients with PCAS treated with TH compared to normothermic HC patients. The effect of untreated hypomagnesemia on postcardiac arrest outcomes remains to be determined.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140255/1/ther.2014.0012.pd

The crystal structures of EAP domains from Staphylococcus aureus reveal an unexpected homology to bacterial superantigens

Abstract The Eap (extracellular adherence protein) of Staphylococcus aureus functions as a secreted virulence factor by mediating interactions between the bacterial cell surface and several extracellular host proteins. Eap proteins from different Staphylococcal strains consist of four to six tandem repeats of a structurally uncharacterized domain (EAP domain). We have determined the three-dimensional structures of three different EAP domains to 1.8, 2.2, and 1.35 Å resolution, respectively. These structures reveal a core fold that is comprised of an -helix lying diagonally across a five-stranded, mixedsheet. Comparison of EAP domains with known structures reveals an unexpected homology with the C-terminal domain of bacterial superantigens. Examination of the structure of the superantigen SEC2 bound to the -chain of a T-cell receptor suggests a possible ligand-binding site within the EAP domain (Fields, B. A., Malchiodi, E. L., Li, H., Ysern, X., Stauffacher, C. V., Schlievert, P. M., Karjalainen, K., and Mariuzza, R. (1996) Nature 384, 188-192). These results provide the first structural characterization of EAP domains, relate EAP domains to a large class of bacterial toxins, and will guide the design of future experiments to analyze EAP domain structure/function relationships

The Crystal Structures of EAP Domains from Staphylococcus aureus Reveal an Unexpected Homology to Bacterial Superantigens

The Eap (extracellular adherence protein) of Staphylococcus aureus functions as a secreted virulence factor by mediating interactions between the bacterial cell surface and several extracellular host proteins. Eap proteins from different Staphylococcal strains consist of four to six tandem repeats of a structurally uncharacterized domain (EAP domain). We have determined the three-dimensional structures of three different EAP domains to 1.8, 2.2, and 1.35 {angstrom} resolution, respectively. These structures reveal a core fold that is comprised of an {alpha}-helix lying diagonally across a five-stranded, mixed {beta}-sheet. Comparison of EAP domains with known structures reveals an unexpected homology with the C-terminal domain of bacterial superantigens. Examination of the structure of the superantigen SEC2 bound to the {beta}-chain of a T-cell receptor suggests a possible ligand-binding site within the EAP domain (Fields, B. A., Malchiodi, E. L., Li, H., Ysern, X., Stauffacher, C. V., Schlievert, P. M., Karjalainen, K., and Mariuzza, R. (1996) Nature 384, 188-192). These results provide the first structural characterization of EAP domains, relate EAP domains to a large class of bacterial toxins, and will guide the design of future experiments to analyze EAP domain structure/function relationships

On Combining Stated Preferences and Revealed Preferences Approaches to Evaluate Environmental Resources Having a Recreational Use

This work aims at analysing the value of recreational water uses for the Idro Lake (Lombardy, Northern Italy), which has been experiencing dramatic fluctuations in its levels in recent years, due to excessive productive withdrawal that affected recreational uses. It estimates the economic benefits deriving from recreational uses, by considering the current recreational demand and the hypothetical one obtained by considering an “improved quality” scenario. Through an on-site survey, we built a panel dataset. Following Whitehead et al. (2000) and Hanley et al. (2003) we get welfare estimates by combining SP and RP responses. The present CS is estimated in €134 per individual, whilst the increase in CS is estimated in €173 per individual. These figures can be confronted with the economic value of competitive uses and with the clean up costs, respectively, to infer some policy indications