Potential Extracorporeal Membrane Oxygenation Use for Increased Survival of In-Hospital Cardiac Arrests

Abstract This study sought to analyze and better understand the different etiologies of in-hospital cardiac arrest (IHCA), to determine the short and long term outcomes for these patients, to review and look for trends within the “code blue” data, and to identify patients who may benefit from an advanced and aggressive cardiopulmonary support system like extracorporeal membrane oxygenation (ECMO) during the cardiopulmonary resuscitation (CPR) process. A retrospective study of 182 patient charts and resuscitation records from the years 2011-2012 was completed with patients ranging in age from 24-70 years with a median age of 58. The most significant results found were an IHCA 30 day survival rate/survival rate to discharge of 28% and that at least 44 patients may have benefitted from ECMO-CPR. Though this study includes only a very small sample size and two years of data, it is significant because it highlights places where implicating a new resuscitation process for select IHCA patients could directly save lives. It warrants further research into implementing ECMO-CPR within the Lehigh Valley Health Network and continued analysis of the current data on “code blues” and CPR protocol. Introduction In-hospital cardiac arrest (IHCA) is a relatively uncommon event but is very resource intensive and associated with a poor outcome including a low rate of survival. Cardiac arrest in the hospital setting can be the result of a variety of etiologies. The progression of cardiopulmonary resuscitation (CPR) for these arrests can vary greatly between patients. Many factors including initial cardiac rhythm, duration of CPR, quality of CPR, and cause of the arrest account for these differences and the end prognosis for the patient.1 Even when given optimal care, survival rates for IHCA are still with the majority of patients are unable to regain proper and lasting circulation to discharge. Analyzing in-hospital cardiac arrest data allows the Lehigh Valley Health Network to review their cardiopulmonary resuscitation protocols and pinpoint trends and differences within the data. This information can highlight areas of possible improvement in patient outcomes and care. As technology continues to advance, more options are slowly becoming available to improve prognoses of IHCA patients. Extracorporeal membrane oxygenation (ECMO) is a highly aggressive and advanced cardiopulmonary support system that can benefit select patients who cannot be successfully resuscitated through traditional cardiopulmonary resuscitation. Essentially, veno-arterial ECMO works similarly to the cardiopulmonary bypass machines utilized during open heart surgeries. The blood is drained from the patient and oxygenated outside of the body before it is returned to circulation. This temporarily allows for adequate bodily perfusion in patients whose hearts will not pump properly. Because ECMO is an expensive and only temporary solution for patients in refractory cardiac arrest, selection is restricted to those who have ‘reversible’ causes of cardiac arrest. ECMO offers valuable time for the pathologies behind the cardiac arrest to be evaluated and treated.2 Studies have shown that ECMO is most effective for these patients as well as patients whose arrests were witnessed and had immediate CPR intervention, which is why it is more of an option for IHCA versus out-of hospital cardiac arrests.1,3 One study found the rate of survival of ECMO-CPR for IHCA patients was 42% and out of hospital cardiac arrest only 15%.1 Patient gender, age, and body weight have not been found to be statistically significant factors in survival rates of ECMO-CPR.3 Introducing ECMO-CPR for select IHCA patients in the Lehigh Valley Health Network is a realistic way to produce positive outcomes for patients who would otherwise face grave prognoses and better the overall survival statistics for IHCA in the network. Methodology This was a retrospective study involving the 182 patients in 2011 and 2012 between the ages of 18 and 70 within the Lehigh Valley Health Network for which a “code blue” was called for a cardiac arrest. Data was examined for each patient from their medical charts, electronic medical records, and resuscitation records that are filled out for each “code blue” incidence. The overall exclusion criteria were an age 70 years or an existing do not resuscitate (DNR) before the code took place. A database was made using Microsoft Access to compile and condense relevant information for each included patient. This information included demographics, medical history, date of the cardiac arrest, cause of the cardiac arrest, initial cardiac rhythm, location within the hospital, reason the code was terminated, if there was a return of circulation (\u3e20minutes), if multiple cardiac arrests were experienced in the day, if the patient became DNR after coding, and if the patient survived to 30 days and 1 year following the arrest with or without good neurological condition. Some gender differences in IHCA within the hospital were explored, with statistics being analyzed using a Fischer’s Exact Test. All included patients were used for each analysis, except for analysis of initial cardiac rhythms where nine patients had to be excluded because of unrecorded or unknown initial rhythms. When identifying patients who may have benefitted from ECMO, additional exclusion criteria used were: previous severe neurological damage, intracranial hemorrhage, cardiac arrest of traumatic origin, uncontrolled bleeding, terminal malignancy, irreversible organ failure (like hepatic failure), original unwitnessed out of hospital cardiac arrest, severe COPD, and severe PVD.2 Criteria for cardiopulmonary resuscitation with ECMO is relatively selective because ECMO-CPR is by nature much more involved, invasive, and expensive than traditional CPR. Patients recognized for possible ECMO benefit were then sorted by the etiology of their cardiac arrest. Results The results in Table 1 (see Appendix A) show that of the 182 patients suffering IHCA in 2011-2012 within the outlined age range, only 51 (28%) survived at least 30 days following their arrest despite 106 (58%) gaining some kind of return of circulation (ROC) greater than 20 minutes. 24 patients who had ROC became DNR following their first code and subsequently passed away soon after, while 35 patients who had ROC had repeat codes with only 2 surviving. The average age of all survivors to 30 days was 53 years with a range of 24-70 years, and the average duration of CPR for survivors was 15.5 minutes with a standard deviation of about 14.5 minutes and a range of About 59% of all of the IHCA patients were male and the remaining 41% female. Surprisingly, there was a difference in survival seen between male and female patients with rates of 23% and 35% respectively (Table 1). Rates of the initial cardiac rhythms at arrest between males and females were also found to be different but not significantly so (Figure 2). Survival rates varied for each initial rhythm with ventricular fibrillation or ventricular tachycardia arrests having a survival rate of almost 50%, statistically significantly (p values After reviewing comorbid conditions and causes of cardiac arrest, 44(about 34%) of the 131 patients who did not survive with traditional CPR were found to have likely benefitted from ECMO-CPR (Table 3). A variety of causes of cardiac arrest are represented within this population (Figure 3), the most common being acute coronary syndrome, pulmonary embolism, cardiomyopathy, and sepsis. Conclusion The results show a few noteworthy trends within the IHCA data for 2011-2012 including gender differences in survival, survival rates in patients who code multiple times, and patients who may have benefitted from ECMO-CPR and the causes of their arrests. The differences in survival rates between the genders in the two years have a few possible explanations. First, the small sample size and limited age range examined could have skewed the data. Secondly, there was a significantly smaller ratio of percentage of males versus females that went into ventricular fibrillation or ventricular tachycardia arrests than previous studies have found. This study found only 24% of male and 22% of female in-hospital cardiac arrests had an initial ventricular tachycardia/ventricular fibrillation rhythm, while other studies have found men to have a statistically significant larger percentage of arrests originating in this type of rhythm.4 Since an initial rhythm of ventricular fibrillation or tachycardia is well documented to have the highest rate of survival, this helps to explain the difference in survival found between the genders. This study confirmed the greater survival rate for this rhythm, with 55% of men and 43% of women surviving 30 days post arrest. From looking at the results of this study, patients who suffered repeat cardiac arrests within the same day appear to have very grave prognoses. Less than 6% of these patients survive 30 days, excluding the additional 24 patients that were DNR after their first arrest and subsequently coded. Further studies incorporating additionally years of data and data from additional hospital systems would be able to confirm if this is a consistent trend. Of the 131 patients that did not survive to 30 days post their IHCA, 44 would have been included as good candidates for ECMO-CPR per criteria listed above. Survival rates to discharge for patients undergoing ECMO-CPR for IHCA vary between studies but are most often found to be around 30-42%.1,2 Conservatively this indicates that about 13-18 patients could have been saved in 2011-2012 and increased the overall IHCA survival rate for the two years from 28% to 35-39%. This shows that introducing ECMO-CPR for select IHCA patients in the Lehigh Valley Health Network is a realistic way to produce positive outcomes for patients who would otherwise face grave prognoses and better the overall survival statistics for IHCA in the network. The study has quite a few limitations. It cannot be broadly applied due to the small sample size of only 182 total patients with only 2 years of IHCA data, limited age range of patients reviewed, and because only statistics from a single hospital system were examined. However, the findings outlined above suggest that further research of IHCA patients within the Lehigh Valley Health Network and into adopting ECMO-CPR protocols is at least warranted. Appendix

Politics, hospital behaviour and health care spending

This paper examines the link between legislative politics, hospital behaviour, and health care spending. When trying to pass sweeping legislation, congressional leaders can attract votes by adding targeted provisions that steer money toward the districts of reluctant legislators. This targeted spending provides tangible local benefits that legislators can highlight when fundraising or running for re-election. We study a provision - Section 508 – that was added to the 2003 Medicare Modernization Act (MMA). Section 508 created a pathway for hospitals to apply to get their Medicare payment rates increased. We find that hospitals represented by members of the House of Representatives who voted ‘Yea’ on the MMA were significantly more likely to receive a 508 waiver than hospitals represented by members who voted ‘Nay.’ Following the payment increase generated by the 508 program, recipient hospitals treated more patients, increased payroll, hired nurses, added new technology, raised CEO pay, and ultimately increased their spending by over $100 million annually. Section 508 recipient hospitals formed the Section 508 Hospital Coalition, which spent millions of dollars lobbying Congress to extend the program. After the vote on the MMA and before the vote to reauthorize the 508 program, members of Congress with a 508 hospital in their district received a 22% increase in total campaign contributions and a 65% increase in contributions from individuals working in the health care industry in the members’ home states. Our work demonstrates a pathway through which the link between politics and Medicare policy can dramatically affect US health spending

Variable Classifications of Glycemic Index Determined by Glucose Meters

The study evaluated and compared the differences of glucose responses, incremental area under curve (IAUC), glycemic index (GI) and the classification of GI values between measured by biochemical analyzer (Fuji automatic biochemistry analyzer (FAA)) and three glucose meters: Accue Chek Advantage (AGM), BREEZE 2 (BGM), and Optimum Xceed (OGM). Ten healthy subjects were recruited for the study. The results showed OGM yield highest postprandial glucose responses of 119.6 ± 1.5, followed by FAA, 118.4 ± 1.2, BGM, 117.4 ± 1.4 and AGM, 112.6 ± 1.3 mg/dl respectively. FAA reached highest mean IAUC of 4156 ± 208 mg × min/dl, followed by OGM (3835 ± 270 mg × min/dl), BGM (3730 ± 241 mg × min/dl) and AGM (3394 ± 253 mg × min/dl). Among four methods, OGM produced highest mean GI value than FAA (87 ± 5) than FAA, followed by BGM and AGM (77 ± 1, 68 ± 4 and 63 ± 5, p<0.05). The results suggested that the AGM, BGM and OGM are more variable methods to determine IAUC, GI and rank GI value of food than FAA. The present result does not necessarily apply to other glucose meters. The performance of glucose meter to determine GI value of food should be evaluated and calibrated before use

Depletion of B-cells with rituximab improves endothelial function and reduces inflammation among individuals with rheumatoid arthritis.

BackgroundIndividuals with rheumatoid arthritis (RA) are at increased risk for cardiovascular disease, partly due to systemic inflammation and endothelial dysfunction. B-cells play an important pathogenic role in the inflammatory process that drives RA disease activity. Rituximab, a chimeric murine/human monoclonal antibody that depletes B-cells, is an effective therapy for RA. The purpose of this study was to determine whether B-cell depletion with rituximab reduces systemic inflammation and improves macrovascular (brachial artery flow-mediated dilation, FMD) and microvascular (reactive hyperemia) endothelial function in RA patients.Methods and resultsRA patients received a single course of rituximab (1000 mg IV infusion at baseline and on day 15). FMD, reactive hyperemia, inflammatory markers, and clinical assessments were performed at baseline, week 12, and week 24. Twenty patients (95% female, median age 54 years) completed the study. Following treatment, FMD improved from a baseline of 4.5±0.4% to 6.4±0.6% at 12 weeks (mean±SE; P&lt;0.0001), followed by a decline at week 24; a similar pattern was observed for hyperemic velocity. Significant decreases in RA disease scores, high-sensitivity C-reactive protein, erythrocyte sedimentation rate, and circulating CD19+ B-cells were sustained through week 24. Cholesterol and triglycerides became significantly although modestly elevated during the study.ConclusionsDepletion of B-cells with rituximab improved macrovascular and microvascular endothelial function and reduced systemic inflammation, despite modest elevation in lipids. Given these results, rituximab should be evaluated in the future for its possible role in reducing excess cardiovascular risk in RA.Clinical trial registrationURL http://ClinicalTrials.gov. Unique identifier: NCT00844714

Politics, Hospital Behavior, and Health Care Spending

This paper examines the link between legislative politics, hospital behavior, and health care spending. When trying to pass sweeping legislation, congressional leaders can attract votes by adding targeted provisions that steer money toward the districts of reluctant legislators. This targeted spending provides tangible local benefits that legislators can highlight when fundraising or running for reelection. We study a provision - Section 508 – that was added to the 2003 Medicare Modernization Act (MMA). Section 508 created a pathway for hospitals to apply to get their Medicare payment rates increased. We find that hospitals represented by members of the House of Representatives who voted ‘Yea’ on the MMA were significantly more likely to receive a 508 waiver than hospitals represented by members who voted ‘Nay.’ Following the payment increase generated by the 508 program, recipient hospitals treated more patients, increased payroll, hired nurses, added new technology, raised CEO pay, and ultimately increased their spending by over $100 million annually. Section 508 recipient hospitals formed the Section 508 Hospital Coalition, which spent millions of dollars lobbying Congress to extend the program. After the vote on the MMA and before the vote to reauthorize the 508 program, members of Congress with a 508 hospital in their district received a 22% increase in total campaign contributions and a 65% increase in contributions from individuals working in the health care industry in the members’ home states. Our work demonstrates a pathway through which the link between politics and Medicare policy can dramatically affect US health spending

Drug Abuse Paradox Seen in Out-of-Hospital Cardiac Arrest Data

Drug Abuse Paradox Seen in Out-of-Hospital Cardiac Arrest Data Alexandra Maryashina1, Amanda Broderick1 and Jordan Williams1 James Wu, MD1,2 1Department of Surgery, Division of Cardiothoracic Surgery, Lehigh Valley Health Network 2Research Scholar Program Mentor Abstract This study aimed to determine OHCA baseline characteristics, cardiopulmonary resuscitation variables and survival-to-discharge rates for drug abusers and then compare them to those for patients without drug abuse disorders. It was a retrospective study involving 250 patients aged 18 to 70 years treated for OHCA of non-traumatic origin at the Lehigh Valley Health Network between January 2012 and May 2015. Although more drug abusers presented with unwitnessed OHCA and PEA/asystole initial rhythms, their survival-to-discharge rate was higher than that of non-drug abusers. This difference in outcomes between drug abusers and non-drug abusers may be due to a shorter CPR duration, a younger average age and lower rates of prior cardiac history among drug abusers. This study warrants further research into implementing more aggressive treatments for OHCA patients with drug abuse disorder at the Lehigh Valley Health Network. Introduction Out-of-hospital cardiac arrest (OHCA) is the largest cause of natural death in the U.S1. It is responsible for more than 350,000 deaths in the country per year — about one every minute, and many of the affected individuals are in their productive years2. As a result, OHCA remains a major public health burden. Despite numerous important improvements in cardiopulmonary resuscitation (CPR) over the past decades, survival-to-discharge rates after OHCA remain low, and are often reported to be between 5% and 10%3-4. Many factors including age, initial cardiac rhythm, duration of resuscitation, the time interval from collapse to resuscitation, and cause of the arrest may be related to the outcome3. Illicit drug use is often considered in defining cardiac arrest risk5. However, limited research has been undertaken to examine the baseline characteristics and cardiopulmonary resuscitation variables for drug abusers with OHCA. We therefore wished to determine OHCA baseline characteristics and cardiopulmonary resuscitation variables for drug abusers and compare them to those for patients without drug abuse disorders. To accomplish this, we conducted a retrospective chart review of patients who presented at the Lehigh Valley Health Network from January 2012 to May 2015 with OHCA. We also compared survival-to-discharge rates after OHCA for drug abusers and non-drug abusers. This analysis can highlight areas of potential improvements in quality of patient care at the Lehigh Valley Health Network. Methods This was a retrospective study involving 250 patients aged 18 to 70 years treated for OHCA at the Lehigh Valley Health Network between January 2012 and May 2015. This study was approved by the Lehigh Valley Health Network Institutional Review Board. Patients with OHCA were eligible for the study if the following criteria were met: (a) aged 18–70 years; (b) non-traumatic origin of the arrest; (c) arrest in the absence of a written do-not-resuscitate (DNR) order. All OHCA patients were identified from preexisting cardiac arrest database at the Lehigh Valley Health Network, which contained date of the cardiac arrest, patients’ age, gender and arrest outcomes data. Missing clinical and demographic data were obtained by reviewing individual electronic medical records and cardiopulmonary resuscitation protocols. We abstracted the following information from patient charts: demographics, prior medical history, social history, prior surgeries, cause of the cardiac arrest, whether the arrest was witnessed or not, initial cardiac rhythm, whether there was a return of spontaneous circulation (ROSC) for greater than 20 minutes or not, and a total CPR duration, which was calculated by the summation of pre-hospital CPR and in-hospital CPR durations. In addition, we reviewed admission notes for prior history of drug abuse disorders and positive urine drug screen (UDS) indicating higher likelihood of active drug abuse. Prior medical history obtained from individual electronic medical records included preexisting hypertension, hyperlipidemia, coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), prior myocardial infarctions, diabetes mellitus, obesity and prior cerebrovascular accidents. We calculated body mass index (BMI) from height and weight data obtained from the admission notes. Ultimately, all the data were entered into the database (Microsoft Excel) to compile and condense relevant information for each patient in our study. All included patients were used for each analysis. Results and Discussion Of the 250 OHCA patients that were eligible for the study only 28 (11%) survived at least 30 days following their arrest. Of the 50 drug abusers 6 survived (12%), while of the 200 non-drug abusers 22 survived (11%). Thus, the survival-to-discharge rate for drug abusers was higher than that for non-drug abusers. The difference in outcomes between the two sets of patients may be due to a shorter CPR duration, a younger average age and lower rates of prior cardiac history among drug abusers. Indeed, the average age of drug abusers was 42 years, while the average age of non-drug abusers was 58 years. Previous studies have reported that the survival-to-discharge rate decreases when CPR duration exceeds 10–15 min6. Our results show that 11% of drug abusers underwent CPR for less than 15 minutes. In contrast, only 6% of non-drug abusers underwent CPR for less than 15 minutes. Moreover, 36% of drug abusers underwent CPR for more than 45 minutes, while among non-drug abusers this proportion was 46%. Analysis of prior medical history has shown that on average drug abusers were healthier. Only 29% of drug abusers had had preexisting cardiac diseases before OHCA, while among non-drug abusers 49% had had preexisting cardiac diseases. Specifically, 21% of non-drug abusers had had previously experienced a myocardial infarction, while only 10% of drug abusers had had experienced it. 39% of non-drug abusers and only 15% of drug abusers had had a prior history of coronary artery disease (CAD). 75% of non-drug abusers and 40% of drug abusers had had a prior history of hypertension. 38% of non-drug abusers and 21% of drug abusers had had a prior history of hyperlipidemia. Ultimately, 15% of non-drug abusers and only 8% of drug abusers had had a prior history of chronic obstructive pulmonary disease (COPD). Only 10% of drug abusers had had previously undergone cardiac surgeries, and, in contrast, 30% of non-drug abusers had had previously undergone cardiac surgeries. Moreover, less drug abusers had diabetes mellitus (21%) than non-drug abusers (41%) and less drug abusers had had previously experienced cerebrovascular accident (CVA) (4%) than non-drug abusers (12%). Finally, less drug abusers were obese at admission (47%) than non-drug abusers (61%). Gender ratios were found to be similar among drug abusers (68% of males) and non-drug abusers (66% of males) and gender did not seem to correlate with survival-to-discharge rates. In previous studies the initial rhythm at arrest was consistently reported as an important factor for survival. Specifically, ventricular fibrillation (V-fib) and ventricular tachycardia (V-tach) as the initial cardiac rhythms were often associated with higher survival-to-discharge rates7. In our study the rate of pulseless electrical activity (PEA) as the initial cardiac rhythm at arrest between drug abusers and non-drug abusers was found to be similar (26% for both sets of patients). However, there was a significant difference in the rates of asystole and ventricular fibrillation (V-fib) or ventricular tachycardia (V-tach) as the initial cardiac rhythms at arrest between drug abusers and non-drug abusers. More non-drug abusers (30%) than drug abusers (16%) had ventricular fibrillation (V-fib) or ventricular tachycardia (V-tach) as the initial cardiac rhythm. In addition, non-drug abusers were less likely to have unwitnessed cardiac arrest (29%) than drug abusers (58%). Conclusion Although more drug abusers presented with unwitnessed OHCA and PEA/asystole initial rhythms, their survival-to-discharge rate was higher than that of non-drug abusers. This difference in survival-to-discharge rates between drug abusers and non-drug abusers may be due to a shorter CPR duration, a younger average age and lower rates of prior cardiac history among drug abusers. Introducing more aggressive treatments such as extracorporeal membrane oxygenation (ECMO) in the Lehigh Valley Health Network for patients with drug abuse history may be a promising way to increase the overall survival to discharge rates for OHCA. The study has several data limitations. This report is a single center experience and the number of patients is relatively small. Nevertheless, the results of the study indicate that further research on more aggressive treatments for OHCA patients with drug abuse disorder is warranted. References 1. Wilson PW, D\u27Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation. 1998; 97:1837-1847 2. Fishman GI, Chugh SS, DiMarco JP, Albert CM, Anderson ME, Bonow RO, Buxton AE, ChenPS, Estes M, Jouven X, Kwong R, Lathrop DA, Mascette AM, Nerbonne JM, O’Rouke B,Page RL, Roden DM, Rosenbaum, DS, Sotoodehnia N, Trayanova NA, Zheng ZJ. Sudden cardiac death prediction and prevention – Report from a National, Lung, and Blood Institute and Heart Rhythm Society Workshop. Circulation. 2010; 122:2335-2348 3. Peberdy MA, Kaye W, Ornato JP, et al. Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation. 2003; 58:297–308. 4. Sasson C, Rogers M, Dahl J, Kellermann A. Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis. Circulation. 2010; 3:63–81. 5. Lange RA, Hillis LD. Cardiovascular complications of cocaine use. N Engl J Med. 2001; 345:351-358. 6. Chen YS, Yu HY, Huang SC, et al. Extracorporeal membrane oxygenation support can extend the duration of cardiopulmonary resuscitation. Crit Care Med. 2008; 36:2529–35. 7. Wang CH, Chou NK, Becker LB, Lin JW, Yu HY, Chi NH, et al. Improved outcome of extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest–a comparison with that for extracorporeal rescue for in-hospital cardiac arrest. Resuscitation. 2014; 85:1219–24

Screen Correspondence: Mapping Interchangeable Elements between UIs

Understanding user interface (UI) functionality is a useful yet challenging task for both machines and people. In this paper, we investigate a machine learning approach for screen correspondence, which allows reasoning about UIs by mapping their elements onto previously encountered examples with known functionality and properties. We describe and implement a model that incorporates element semantics, appearance, and text to support correspondence computation without requiring any labeled examples. Through a comprehensive performance evaluation, we show that our approach improves upon baselines by incorporating multi-modal properties of UIs. Finally, we show three example applications where screen correspondence facilitates better UI understanding for humans and machines: (i) instructional overlay generation, (ii) semantic UI element search, and (iii) automated interface testing