NSE and S-100B are not sufficiently predictive of neurologic outcome after therapeutic hypothermia for cardiac arrest

Introduction

Prognostication of cardiac arrest survivors is challenging since therapeutic hypothermia (TH) has been introduced. We evaluated serum biomarkers and motor response.

Methods

This was a retrospective data analysis including patients in the years 2007–2012. Blood was drawn and a neurological examination was performed on admission and every morning. Outcomes were evaluated 6 months after discharge and dichotomized into good (cerebral performance category (CPC) = 1 or 2) and poor (CPC = 3, 4 or 5).

Results

123 patients (79.7% male, 63 ± 14 years) received TH; 50% had a good outcome. On admission, S-100B (P = 0.004) was significantly associated with the outcome, as well as neuron-specific enolase (NSE; P = 0.020) and S-100B (P = 0.004) on day 1 after admission. NSE on day 2, NSE progression from day 1 to 2 and motor response on day 3 also predicted the outcome (all P < 0.001).NSE > 33 μg l⁻¹ only predicted a poor outcome with a specificity of 76%. An absent motor response on day 3 was the most sensitive marker (94%). NSE > 41.1 μg l⁻¹ combined with S-100B > 0.461 μg l⁻¹ on day 1 was the most specific marker (96%).

Conclusion

Although NSE and S-100B levels are associated with the outcome, the use of previously described cut-off values was insufficiently predictive of neurologic outcome. Caution should be exercised in the use of these tests to provide neuroprognostication.     

Can early serum levels of S100B protein predict the prognosis of patients with out-of-hospital cardiac arrest?

Objective

This study aims to know if the level of S100B protein at the initiation of cardiopulmonary resuscitation (CPR) and immediately after return of spontaneous circulation (ROSC) can predict clinical outcome.

Materials and methods

A prospective observational study from December 2004 to October 2006 was conducted in an urban tertiary hospital emergency department. Clinical demographics for out-of-hospital cardiac arrest patients were collected based on the Utstein style. Outcomes collected included ROSC for 20 min, survival to admission, survival and Glasgow Outcome Scale (GOS) at 1 month. S100B protein was measured twice before starting CPR (first S100B) and immediately after ROSC (second S100B). We investigated the association between S100B protein levels and clinical outcomes using a multivariate logistic regression model.

Results

A total of 151 patients were included (age: 60.2 ± 16.8 years, male: 64.2%). Of these, 60 (39.7%) had ROSC and 46 (30.5%) survived to admission. After 1 month, 12 (8.0%) survived and only three patients showed good GOS (≥4 points). The S100B levels were not different for ROSC, survival to admission and 1-month survival between survivors and non-survivors (p > 0.05, first and second S100 B level). For the witnessed out-of-hospital cardiac arrest (OHCA) group (N = 87), only the first S100B (1.22 ± 0.85 μg l⁻¹ vs. 3.91 ± 4.25 μg l⁻¹, p < 0.001) showed significant difference for 1-month survival between survivors and non-survivors. The first S100B showed significant association with survival to emergency department (ED) but not 1-month survival (adjusted odds ratio (OR) = 0.905, 95% confidence interval = 0.821-0.998).

Conclusion

Higher levels of S100B at start of CPR were significantly associated with lower survival to admission, and not for 1-month survival.     

The effects of sleep on the relationship between brain injury severity and recovery of cognitive function: A prospective study

Background

Disturbed sleep pattern is a common symptom after head trauma and its prevalence in acute traumatic brain injury (TBI) is less discussed. Sleep has a profound impact on cognitive function recovery and the mediating effect of disturbed sleep on cognitive function recovery has not been examined after acute TBI.

Objectives

To identify the prevalence of disturbed sleep in mild, moderate, and severe acute TBI patients, and to determine the mediating effects of sleep on the relationship between brain injury severity and the recovery of cognitive function.

Design

A prospective study design.

Setting

Neurosurgical wards in a medical center in northern Taiwan.

Participants

Fifty-two acute TBI patients between the ages of 18 and 65 years who had received a diagnosis of TBI for the first time, and were admitted to the neurosurgical ward.

Method

The severity of brain injury was initially determined using the Glasgow Coma Scale. Each patient wore an actigraphy instrument on a non-paralytic or non-dominated limb for 7 consecutive days. A 7-day sleep diary was used to facilitate data analysis. Cognitive function was assessed on the first and seventh day after admission based on the Rancho Los Amigos Levels of Cognitive Functioning.

Results

The mild (n = 35), moderate (n = 7) and severe (n = 10) TBI patients exhibited poorer sleep efficiency, and longer total sleep time (TST) and waking time after sleep onset, compared with the normative values for the sleep-related variables (P < .05 for all). The severe and moderate TBI patients had longer daytime TST than the mild TBI patients (P < .001), and the severe TBI patients had longer 24-h TST than the mild TBI patients (P = .001). The relationship between the severity of brain injury and the recovery of cognition function was mediated by daytime TST (t = −2.65, P = .004).

Conclusions

Poor sleep efficiency, prolonged periods of daytime sleep, and a high prevalence of hypersomnia are common symptoms in acute TBI patients. The duration of daytime sleep mediates the relationship between the severity of brain injury and the recovery of cognition function.     

Post-cardiac arrest serum levels of glial fibrillary acidic protein for predicting neurological outcome

Aim of the study

To investigate serum levels of glial fibrillary acidic protein (GFAP) for evaluation of neurological outcome in cardiac arrest (CA) patients and compare GFAP sensitivity and specificity to that of more studied biomarkers neuron-specific enolas (NSE) and S100B.

Method

A prospective observational study was performed in three hospitals in Sweden during 2008-2012. The participants were 125 CA patients treated with therapeutic hypothermia (TH) to 32-34 °C for 24 hours. Samples were collected from peripheral blood (n = 125) and the jugular bulb (n = 47) up to 108 hours post-CA. GFAP serum levels were quantified using a novel, fully automated immunochemical method. Other biomarkers investigated were NSE and S100B. Neurological outcome was assessed using the Cerebral Performance Categories scale (CPC) and dichotomized into good and poor outcome.

Results

GFAP predicted poor neurological outcome with 100% specificity and 14-23% sensitivity at 24, 48 and 72 hours post-CA. The corresponding values for NSE were 27-50% sensitivity and for S100B 21-30% sensitivity when specificity was set to 100%. A logistic regression with stepwise combination of the investigated biomarkers, GFAP, did not increase the ability to predict neurological outcome. No differences were found in GFAP, NSE and S100B levels when peripheral and jugular bulb blood samples were compared.

Conclusion

Serum GFAP increase in patients with poor outcome but did not show sufficient sensitivity to predict neurological outcome after CA. Both NSE and S100B were shown to be better predictors. The ability to predict neurological outcome did not increased when combining the three biomarkers.     

Application of Plackett–Burman and Doehlert designs for optimization of selenium analysis in plasma with electrothermal atomic absorption spectrometry

Objectives

The aim of this study was the optimization of selenium determination in plasma samples with electrothermal atomic absorption spectrometry using experimental design methodology.

Design and methods

11 variables being able to influence selenium analysis in human blood plasma by electrothermal atomic absorption spectrometry (ETAAS) were evaluated with Plackett–Burman experimental design. These factors were selected from sample preparation, furnace program and chemical modification steps. Both absorbance and background signals were chosen as responses in the screening approach. Doehlert design was used for method optimization.

Results

Results showed that only ashing temperature has a statistically significant effect on the selected responses. Optimization with Doehlert design allowed the development of a reliable method for selenium analysis with ETAAS. Samples were diluted 1/10 with 0.05% (v/v) TritonX-100 + 2.5% (v/v) HNO₃ solution. Optimized ashing and atomization temperatures for nickel modifier were 1070 °C and 2270 °C, respectively. A detection limit of 2.1 μg L^− 1 Se was obtained. Accuracy of the method was checked by the analysis of selenium in Seronorm™ Trace element quality control serum level 1. The developed procedure was applied for the analysis of total selenium in fifteen plasma samples with standard addition method. Concentrations ranged between 24.4 and 64.6 μg L^− 1, with a mean of 42.6 ± 4.9 μg L^− 1.

Conclusions

The use of experimental designs allowed the development of a cheap and accurate method for selenium analysis in plasma that could be applied routinely in clinical laboratories.     

Fast ibuprofen,ketoprofen and naproxen simultaneous determination in human serum for clinical toxicology by GC–FID

Objectives

The aim of this study was to develop and validate a gas chromatographic method with flame ionization detection (GC–FID) for the measurement of ibuprofen, naproxen and ketoprofen for clinical toxicology purposes.

Design and methods

100 μL of plasma was treated with methyl chloroformate and derivatized analytes were extracted with hexane. Optimal conditions of the derivatization procedure have been found using the experimental chemometric design (face-centered central composite design). The selectivity and efficiency of the procedure was confirmed by GC–MS.

Results

The assay was linear in the concentration range of 10–400 μg mL^− 1, with adequate accuracy and precision for GC–FID (98–106.7%, CV ≤ 9.1%, respectively) and for GC–MS (99.3–105.5%, CV ≤ 9.2%, respectively).

Conclusion

The entire sample preparation procedure is completed within 5 min and the quantitative results are available within 35 min. The method was successfully applied to quantify the selected compounds in serum of patients from emergency units.     

Haemodynamic variables and functional outcome in hypothermic patients following out-of-hospital cardiac arrest

Aim of the study

To evaluate the association between haemodynamic variables during the first 24 h after intensive care unit (ICU) admission and neurological outcome in out-of-hospital cardiac arrest (OHCA) victims undergoing therapeutic hypothermia.

Methods

In a multi-disciplinary ICU, records were reviewed for comatose OHCA patients undergoing therapeutic hypothermia. The hourly variable time integral of haemodynamic variables during the first 24 h after admission was calculated. Neurologic outcome was assessed at day 28 and graded as favourable or adverse based on the Cerebral Performance Category of 1–2 and 3–5. Bi- and multivariate regression models adjusted for confounding variables were used to evaluate the association between haemodynamic variables and functional outcome.

Results

67/134 patients (50%) were classified as having favourable outcome. Patients with adverse outcome had a higher mean heart rate (73 [62–86] vs. 66 [60–78] bpm; p = 0.04) and received noradrenaline more frequently (n = 17 [25.4%] vs. n = 9 [6%]; p = 0.02) and at a higher dosage (128 [56–1004] vs. 13 [2–162] μg h⁻¹; p = 0.03) than patients with favourable outcome. The mean perfusion pressure (mean arterial blood pressure minus central venous blood pressure) (OR = 1.001, 95% CI  = 1–1.003; p = 0.04) and cardiac index time integral (OR = 1.055, 95% CI = 1.003–1.109; p = 0.04) were independently associated with adverse outcome at day 28.

Conclusion

Mean perfusion pressure and cardiac index during the first 24 h after ICU admission were weakly associated with neurological outcome in an OHCA population undergoing therapeutic hypothermia. Further studies need to elucidate whether norepinephrine-induced increases in perfusion pressure and cardiac index may contribute to adverse neurologic outcome following OHCA.     

Prolonged Emergency Department Length of Stay is Not Associated with Worse Outcomes in Traumatic Brain Injury

Background

Data suggest that prolonged Emergency Department length of stay (EDLOS) has a detrimental effect on outcomes in some critically ill patients. However, the relationship between EDLOS and outcomes in traumatic brain injury (TBI) has not been examined.

Objective

Our objective was to determine the effect of EDLOS on neurologic outcomes in TBI patients.

Methods

We performed a retrospective analysis of a prospectively identified cohort of patients with moderate (Glasgow Coma Scale [GCS] score 9–13) and severe (GCS ≤ 8) TBI who presented to a Level 1 trauma center (2006–2010). Inclusion criteria were transfer to the intensive care unit (ICU) or operating room (OR) from the ED. Primary outcome was Glasgow Outcome Scale (GOS) score, a measure of neurologic function, at discharge. We used a proportional odds model to control for significant predictors of GOS in univariate analysis.

Results

Two hundred and twenty-four patients were included in the analysis, 77 (34%) of which were transferred to the OR. Median EDLOS was 3.3 h and 81.2% of patients had a GOS score ≤3 (e.g., severe disability, vegetative, or deceased). In multivariable analyses, EDLOS was not associated with GOS score in either ICU bound (p = 0.57) or OR bound (p = 0.11) patients. Younger age, pupil reactivity, and absence of intubation were independent predictors of good outcomes in the ICU group. In OR patients, predictors of higher GOS score included presence of an epidural hemorrhage, absence of midline shift, and pupil reactivity.

Conclusions

Our study demonstrates that EDLOS was not associated with poor outcomes in patients with moderate to severe TBI who required intensive care or early operative intervention in an academic Level 1 trauma center.     

Prehospital neurologic deterioration is independent predictor of outcome in traumatic brain injury: analysis from National Trauma Data Bank

Background

The prevalence and impact of prehospital neurologic deterioration (PhND) in patients with traumatic brain injury (TBI) have not been investigated. We aimed to determine the prevalence of PhND during emergency medical service (EMS) transportation among patients with TBI and its impact on patient's outcome.

Methods

We used the National Trauma Data Bank, using data files from 2009 to 2010 to identify patients with TBI through International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. The initial Glasgow Coma Scale (GCS) score ascertained at the scene by EMS was compared with the subsequent GCS score evaluation in the emergency department (ED) to identify neurologic deterioration (defined as a decrease in GCS of ≥ 2 points). Patients' demographics, initial injury severity score (ISS), admission GCS score, and hospital outcome were compared between patients with PhND and patients without neurologic deterioration.

Results

A total of 257?127 patients with TBI were identified. Among patients with TBI, 22?254 patients had PhND, which comprised 9% of all patients with TBI. The mean of GCS score decrease during EMS transport was 5 points (± 3). Patients without PhND tended to have higher GCS recorded by EMS (median, 15 vs 12; P < .0001). Patients with TBI who had PhND had significantly higher hospital length of stay and intensive care unit days after adjusting for baseline characteristics and EMS GCS score, EMS transport time, type of injury, presence of intracranial hemorrhages, and ED ISS (P < .0001). These patients had higher rate of in-hospital mortality after adjusting for the same variables (odds ratio, 2.30; 95% confidence interval, 2.18-2.41).

Conclusion

Prehospital neurologic deterioration occurs in 9% of patients with TBI. It is more prevalent in men and associated with lower EMS GCS level and higher ED ISS. Prehospital neurologic deterioration is an independent predictor of worse hospital outcome and higher resource use in patients with TBI.     

Serum S100B protein is associated with depressive symptoms in patients with end-stage renal disease

Objectives

Depression is associated with a poorer prognosis in patients with end-stage renal disease (ESRD). Increasing evidence indicates that glial pathology and blood–brain-barrier (BBB) dysfunction are involved in the pathophysiology of depression. S100B, a protein expressed in astro- and oligodendroglia in the human brain is considered a biomarker of depression. Our objective was to investigate the relationship between S100B and depressive symptoms in patients undergoing hemodialysis (HD).

Design and methods

Seventy-eight Korean patients undergoing chronic HD without significant neurological issues participated in a cross-sectional observation study. Depressive symptoms were assessed with the Beck Depression Inventory-II (BDI-II), and serum S100B levels were measured using blood samples obtained prior to a mid-week HD session.

Results

The mean age of patients was 59.0 years, and the mean dialysis duration was 51.7 months. About 45% of patients undergoing HD met criteria for depression (BDI-II ≥ 20). Serum S100B levels were significantly higher in patients with depression compared with patients without depression (115.1 ± 45.4 vs. 66.1 ± 35.3 pg/mL, p < 0.001). S100B (r = 0.556, p < 0.001) and high-sensitivity C-reactive protein (hs-CRP; r = 0.422, p < 0.001) and β2-microglobulin (r = 0.391, p < 0.001) levels were positively correlated with BDI-II scores. A multivariate regression analysis showed that both S100B and hs-CRP were significantly associated with BDI-II scores.

Conclusions

The results showed a close association between S100B and depressive symptoms in patients undergoing HD. However, the mechanisms underlying this relationship are currently unknown and warrant further investigation.     

Serum glial fibrillary acidic protein as a predictive biomarker of neurological outcome after cardiac arrest

Aim of the study

Serum glial fibrillary acidic protein (GFAP) has recently been identified as a specific predictor of brain damage and neurological outcome in patients with head trauma. In this study, serum GFAP was assessed as a predictor of neurological outcome in post-cardiac-arrest (PCA) patients.

Methods

This study was a retrospective, single-medical-center analysis, conducted in the intensive care unit of a university hospital. Forty-four sequential PCA patients with cardiogenic or non-cardiogenic arrest were included. The patients were treated with or without therapeutic hypothermia (TH). Serum samples were collected from the patients at 12, 24, and 48 h after the return of spontaneous circulation (ROSC). Serum GFAP concentrations were measured by enzyme-linked immunosorbent assay and compared in patients with good and poor neurological outcomes, evaluated over a period of 6 months using Glasgow Outcome Scale.

Results

Serum GFAP was significantly higher in patients with a poor outcome at 12 and 24 h without TH and at 48 h with TH (P < 0.05). GFAP (>0.1 ng dL⁻¹) was a specific predictor of poor neurological outcome at 6 months with or without TH treatment.

Conclusions

Although this study is preliminary, serum GFAP after ROSC reflected a poor neurological outcome in PCA patients.     

Determinants of renal function at hospital discharge of patients treated with renal replacement therapy in the intensive care unit

Purpose

Identification of risk factors for impaired renal function at hospital discharge in critically ill patients with acute kidney injury (AKI) requiring renal replacement therapy (RRT).

Methods

A single-center retrospective cohort study was performed evaluating demographic and clinical parameters as potential risk factors for a modest to severely impaired renal function at hospital discharge in patients with AKI requiring RRT in the intensive care unit.

Results

Of the 353 patients in our cohort, 90 (25.5%) patients had pre-existing chronic kidney disease (CKD). An estimated glomerular filtration rate (eGFR) ≤ 60 mL min^− 1 1.73 m^− 2 at hospital discharge occurred in 64.0% of which 63.7% without known renal impairment before hospital admission and 8.2% of all cases left the hospital dialysis-dependent. Multivariable logistic regression showed that age (OR = 1.051, P < .001), serum creatinine concentration at start of RRT (OR = 1.004, P < .001) and administration of iodine-containing contrast fluid (OR = 0.830, P = .045) were associated with an eGFR ≤ 60 mL min^− 1 1.73 m^− 2. Furthermore, a medical history of CKD (OR = 5.865, P < .001) was associated with dialysis dependence.

Conclusions

Elderly and patients with pre-existing CKD are at a high risk for modest to severely impaired renal function at hospital discharge after AKI requiring RRT.     

Reference intervals for whole blood viscosity using the analytical performance-evaluated scanning capillary tube viscometer

Objectives

This study was performed to establish the reference intervals for whole blood viscosity (WBV) using the analytical performance-evaluated scanning capillary tube viscometer (SCTV).

Design and methods

The analytical performance of the SCTV was evaluated using three different levels of QC materials and sixty human EDTA-blood samples. To establish the reference intervals for WBV, 297 healthy individuals (123 men and 174 women) were selected from 1083 subjects.

Results

Within-day precisions with QC materials and human whole blood and between-day precisions with QC materials were below 5.0%, 6.6% and 8.0% in CVs at all shear rates, respectively. Comparison tests between the SCTV and the Brookfield viscometer showed a significant correlation (R² = 0.972, p < 0.001). The reference intervals for WBV in healthy men were 3.66–5.41 cP at 300 s^− 1 and 23.15–36.45 cP at 1 s^− 1 while those in women were 3.27–4.32 cP at 300 s^− 1 and 18.20–27.36 cP at 1 s^− 1, respectively.

Conclusions

Using the analytical performance-evaluated SCTV, the reference intervals for WBV were established in healthy adults, which could be beneficial to the clinical utility of WBV in the aspect of appropriate modalities for the improvement of blood viscosity.     

Blood ammonia and lactate levels on hospital arrival as a predictive biomarker in patients with out-of-hospital cardiac arrest

Introduction

No reliable predictor for the prognosis of out-of-hospital cardiac arrest (OHCA) on arrival at hospital has been identified so far. We speculate that ammonia and lactate may predict patient outcome.

Methods

This is a prospective observational study. Non-traumatic OHCA patients who gained sustained return of spontaneous circulation and were admitted to acute care unit were included. Blood ammonia and lactate levels were measured on arrival at hospital. The patients were classified into two groups: ‘favourable outcome’ group (Cerebral Performance Category CPC1-2 at 6-months’ follow-up) and ‘poor outcome’ group (CPC3-5). Basal characteristics obtained from the Utstein template and biomarker levels were compared between these two outcome groups. Independent predictors were selected from all candidates using logistic regression analysis.

Results

A total of 98 patients were included. Ammonia and lactate levels in the favourable outcome group (n = 10) were significantly lower than those in poor outcome group (n = 88) (p < 0.05, respectively). On receiver operating characteristic analysis, the optimal cut-off value for predicting favourable outcome was determined as 170 μg dl⁻¹ of ammonia and 12.0 mmol l⁻¹ of lactate (area under the curve; 0.714 and 0.735, respectively). Logistic regression analysis identified ammonia (≤170 μg dl⁻¹), therapeutic hypothermia and witnessed by emergency medical service personnel as independent predictors of favourable outcome. When both these biomarker levels were over threshold, positive predictive value (PPV) for poor outcome was calculated as 100%.

Conclusions

Blood ammonia and lactate levels on arrival are independent prognostic factors for OHCA. PPV with the combination of these biomarkers predicting poor outcome is high enough to be useful in clinical settings.     

Low-dose nitroglycerine improves outcome after cardiac arrest in rats

Objective

The aim of this study was to evaluate the outcome of intravenously applied nitroglycerine (NTG, 1 μg kg⁻¹ min⁻¹ for 1 h) after resuscitation from an asphyxia cardiac arrest (ACA) insult. We hypothesized that NTG infused for 1 h after the return of spontaneous circulation (ROSC) would improve functional and neuro-morphological outcomes.

Methods

Adult rats were subjected to 8 min of ACA followed by resuscitation. There were three treatment groups: ACA, ACA + NTG and sham operated. Vital and blood parameters were monitored during the 1 h post-resuscitation intensive care phase. After survival times of 3, 6, 12, 24, 72 h and 7 days, the neurological deficit score (NDS) was measured. Histological evaluation of the hippocampus, cortex, the thalamic reticular nucleus and the caudate-putamen was performed 7 days post insult.

Results

We found that NTG (i) induced significantly higher initial MAP peaks; (ii) resulted in a less-pronounced elevation of heart rates after ROSC with significantly faster normalization to baseline levels; and (iii) influenced glucose metabolism, temporarily elevating blood glucose to non-physiological levels. Even so, NTG (iv) improved the neurological outcome and (v) reduced neurodegeneration, mainly in the hippocampal CA1 region. A significant NTG-associated decrease in blood pressure did not occur.

Conclusion

The effect of low-dosed NTG applied post-resuscitation appears to be neuroprotective, demonstrated by reduced hippocampal damage and a better NDS, even with temporarily elevated blood glucose to non-physiological levels. Thus, additional studies are needed to evaluate NTG-triggered mechanisms and optimized dosages before clinical translation should be considered.Animal study institutional protocol number: 42502-2-2-947-Uni-MD.     

Neuron specific enolase and S-100B as predictors of outcome after cardiac arrest and induced hypothermia

Aim

To assess the prognostic value of repetitive serum samples of neuron specific enolase (NSE) and S-100B in cardiac arrest patients treated with hypothermia.

Methods

In a three-centre study, comatose patients after cardiac arrest were treated with hypothermia at 33 °C for 24 h, regardless of cause or the initial rhythm. Serum samples were collected at 2, 24, 48 and 72 h after the arrest and analysed for NSE and S-100B in a non-blinded way. The cerebral performance categories scale (CPC) was used as the outcome measure; a best CPC of 1–2 during 6 months was regarded as a good outcome, a best CPC of 3–5 a poor outcome.

Results

One centre was omitted in the NSE analysis due to missing 24 and 48 h samples. Two partially overlapping groups were studied, the NSE group (n = 102) and the S-100B group (n = 107). NSE at 48 h >28 μg/l (specificity 100%, sensitivity 67%) and S-100B >0.51 μg/l at 24 h (specificity 96%, sensitivity 62%) correlated with a poor outcome, and so did a rise in NSE of >2 μg/l between 24 and 48 h (odds ratio 9.8, CI 3.5–27.7). A majority of missing samples (n = 123) were from the 2 h sampling time (n = 56) due to referral from other hospitals or inter-hospital transfer.

Conclusion

NSE was a better marker than S-100B for predicting outcome after cardiac arrest and induced hypothermia. NSE above 28 μg/l at 48 h and a rise in NSE of more than 2 μg/l between 24 and 48 h were markers for a poor outcome.     

The Glasgow coma score is a predictor of good outcome in cardiac arrest patients treated with therapeutic hypothermia

Background

With the recent introduction of therapeutic hypothermia the application of sedation becomes necessary in cardiac arrest patients. We therefore analysed the usefulness of the Glasgow coma score (GCS) for outcome prediction in survivors of cardiac arrest treated with therapeutic hypothermia.

Patients and methods

In a prospective observational study we identified 72 comatose patients admitted to our intensive care unit after cardiac arrest. All patients were treated with therapeutic hypothermia. After sedation stop the Glasgow coma scale (GCS) was recorded until day 4. Neurological outcome was assessed using the Pittsburgh cerebral performance category (CPC) score.

Results

Forty-four of 72 patients (61%) were discharged with a favourable neurological outcome (CPC 1 + 2). GCS was significantly higher in patients with good outcome compared to patients with unfavourable outcome at every point in time after sedation stop (p < 0.001). The value for prediction of good outcome with the highest accuracy was a GCS > 4 at the first day after sedation stop (sensitivity 61%, PPV 90% and AUC 0.808) and GCS > 6 in the following days (sensitivity 84%, PPV 92.5% and AUC 0.921 at day 4). In particular a score of >3 on the motor component of the GCS predicted good outcome with a specificity of 100% (sensitivity 43%) at the first day.

Conclusions

Our results indicate that monitoring of the GCS is a simple and reliable method for clinical outcome assessment in patients treated with therapeutic hypothermia. Thus, GCS monitoring remains a powerful tool to predict outcome of patients treated with therapeutic hypothermia.     

C-reactive protein levels after cardiac arrest in patients treated with therapeutic hypothermia

Aim

Prognostication of outcome after cardiac arrest (CA) is challenging. We assessed the prognostic value of daily blood levels of C-reactive protein (CRP), a cheap and widely available inflammatory biomarker, after CA.

Methods

We reviewed the data of all patients admitted to our intensive care unit (ICU) after CA between January 2009 and December 2011 and who survived for at least 24 h. We collected demographic data, CA characteristics (initial rhythm; location of arrest; time to return of spontaneous circulation [ROSC]), occurrence of infection, ICU survival and neurological outcome at three months (good = cerebral performance category [CPC] 1–2; poor = CPC 3–5). CRP levels were measured daily from admission to day 3.

Results

A total of 130 patients were admitted after successful resuscitation from CA and survived more than 24 h; 76 patients (58%) developed an infection and overall mortality was 56%. CRP levels increased from admission to day 3. CRP levels were higher in in-hospital than in out-of-hospital CA, especially on admission and day 1 (44.1 vs. 2.1 mg L⁻¹ and 74.5 vs. 29.5 mg L⁻¹, respectively; p < 0.001), and in patients with non-shockable than in those with shockable rhythms. In a logistic regression model, high CRP levels on admission were independently associated with poor neurological outcome at 3 months.

Conclusion

CRP levels increase in the days following successful resuscitation of CA. Higher CRP levels in patients with in-hospital CA, non-shockable rhythms and infection, suggest a greater inflammatory response in these patients. High CRP levels on admission may identify patients at high-risk of poor outcome and could be a target for future therapies.     

Effects of kinesiotaping on foot posture in participants with pronated foot: A quasi-randomised,double-blind study

Objective

To investigate whether kinesiotaping improves excessive foot pronation compared with sham kinesiotaping.

Design

Quasi-randomised, double-blind study.

Setting

One primary care centre.

Participants

One hundred and thirty participants were screened for inclusion. Sixty-eight participants with pronated feet [Foot Posture Index (FPI) ≥ 6] were enrolled, and the follow-up rate was 100%.

Interventions

Participants were allocated into one of two groups: an experimental kinesiotaping group (KT1) and a sham taping group (KT2). Measures were collected by a blinded assessor at baseline, and 1 minute, 10 minutes, 60 minutes and 24 hours after taping.

Main outcome measures

The primary outcome was total FPI score, and the secondary outcome was rear-foot FPI score.

Results

There were no significant differences in total FPI score between kinesiotaping and sham taping at any time point. Similarly, there were no significant differences in rear-foot FPI score, apart from at 60-minute follow-up when the difference between groups was significant (P = 0.04) but the effect size was very small (0.85 points on the rear-foot FPI score between −6 and +6).

Conclusions

Kinesiotaping does not correct foot pronation compared with sham kinesiotaping in people with pronated feet.     

Genetic predisposition to acute kidney injury induced by severe sepsis

Purpose

The aim of this study was to demonstrate that candidate gene polymorphisms are associated with an increased risk of acute kidney injury (AKI).

Materials and Methods

Patients admitted to the intensive care unit with the diagnosis of severe sepsis and an expected intensive care unit length of stay more than 48 hours were included. Genetic polymorphisms studied included angiotensin-converting enzyme insertion/deletion (polymerase chain reaction); tumor necrosis factor α − 376, − 308, and − 238; interleukin-8 − 251; vascular endothelial growth factor (VEGF) + 405 and + 936; and pre–B-cell colony-enhancing factor − 1001 (TaqMan SNP genotyping assay, Life Technologies, Grand Island, NY). Acute kidney injury was defined as the risk, injury, and failure categories, as per the RIFLE (risk, injury, failure, loss, end-stage kidney disease) classification.

Results

One hundred thirty-nine patients were included, 65 of whom developed AKI. In univariate analysis, the VEGF + 936 CC and the pre–B-cell colony-enhancing factor − 1001 GG genotypes were associated with AKI. In multivariate analysis, Simplified Acute Physiology Score II score (odds ratio [95% confidence interval], 1.06 [1.03-1.09]), chronic arterial hypertension (3.15 [1.39-7.15]), and the presence of the VEGF + 936 CC genotype (3.41 [1.19-9.79]) were associated with AKI.

Conclusion

This is the first study demonstrating an association between the VEGF + 936 CC genotype and the risk to develop AKI in patients with severe sepsis.