bluuebunny/crossref_metadata_2025 huggingface dataset:
Gut Microbes and Eye Disease
Authors: Donabedian Patrick , Dawson Elizabeth , Li Qiuhong , Chen Jinghua
Published: December 2021

Microbial symbionts in the gut are increasingly recognized as having important effects on health and disease, but have only recently begun to be linked to diseases of the eye. We review current research on the intestinal microbiota’s relationship to ocular disease, focusing on autoimmune uveitis, diabetic retinopathy, age-related macular degeneration, and primary-open angle glaucoma. We discuss findings and limitations of this exciting new area of ophthalmology research and explore possible future disease-modifying treatments.
Association of Trimethylamine-N-Oxide Levels with Risk of Cardiovascular Disease and Mortality among Elderly Subjects: A Systematic Review and Meta-Analysis
Authors: Chen Guixiu , He Lin , Dou Xiaotao , Liu Tao
Published: December 2021

Background: Trimethylamine-N-Oxide (TMAO) is a microbiome-related metabolite that has been linked to cardiovascular and renal function. This study has reviewed and analyzed the relationship between TMAO and all-cause mortality and adverse cardiovascular events in elderly subjects. Methods: We determined whether this association was modified in the presence of chronic kidney disease (CKD), heart failure (HF), and diabetes. Based on the criteria, systematic review and meta-analysis were conducted and performed. Results: A total of 27 prospective cohort studies were retrieved finally to examine the associations. The high TMAO was positively associated with all-cause mortality (hazard ratio (HR): 1.38 [95% confidence interval (CI): 1.306–1.460]) as well as adverse cardiovascular events (HR: 1.032 [95% CI: 1.014–1.051]). The association remained upon subgroup analysis for patients with CKD and HF but no association found for the patients with diabetes (HR: 1.15 [95% CI, 0.81–1.64]). Conclusions: The findings of this review revealed that the TMAO level is associated with all-cause mortality and adverse cardiovascular events.
Spinal Anesthesia versus General Anesthesia in Gynecological Laparoscopic Surgery: A Systematic Review and Meta-Analysis
Authors: Della Corte Luigi , Mercorio Antonio , Morra Ilaria , Riemma Gaetano , De Franciscis Pasquale , Palumbo Mario , Viciglione Francesco , Borrelli Danilo , Laganà Antonio Simone , Vizzielli Giuseppe , Bifulco Giuseppe , Giampaolino Pierluigi
Published: December 2021

Introduction: In the last years, spinal anesthesia (SA) has been emerging as an alternative to general anesthesia (GA) for the laparoscopic treatment of gynecological diseases, for better control of postoperative pain. The aim of the review is to compare the advantages of SA compared to GA. Methods: MEDLINE, Scopus, ClinicalTrials.gov, EMBASE, Cochrane Library, and CINAHL were searched from inception until March 2021. Randomized controlled trials (RCTs) and non-randomized studies (NRSs) about women underwent SA and GA for gynecological laparoscopic surgery were analyzed. Relevant data were extracted and tabulated. Results: The primary outcomes included the evaluation of postoperative pain (described as shoulder pain), postoperative nausea and vomiting, and operative times. One hundred and eight patients were included in RCTs, 58 in NRSs. The qualitative analysis had conflicting results and for the most of parameters (hemodynamic variables, nausea, and postoperative analgesic administration) no statistically significant differences were observed: in the NRSs, contradictory results regarding the postoperative pain in SA and GA groups were reported. Regarding the quantitative analysis, in the RCTs, women who received SA had not significantly lower operative times (relative risk [RR] −4.40, 95% confidence interval [CI] −9.32–0.53) and a lower incidence of vomiting (RR 0.51, 95% CI 0.17–1.55); on the other hand, in the NRS, women who received SA had longer operative times (RR 5.05, 95% CI −0.03–10.14) and more episodes of vomiting (RR 0.56, 95% CI 0.10–2.97) compared to those with GA: anyway, the outcomes proved to be insignificant. Conclusions: Current evidence suggests no significant advantages to using SA over GA for laparoscopic treatment of gynecological diseases.
Hypogonadism in Male Infants and Adolescents: New Androgen Formulations
Authors: Chioma Laura , Cappa Marco
Published: December 2021

Background: Male hypogonadism may be associated with micropenis and cryptorchidism in newborn, absent or incomplete pubertal development when it occurs during childhood. During puberty, androgen replacement therapy plays a pivotal role in subjects with hypogonadism to induce sexual maturation, growth acceleration, anabolic effects on fat-free mass growth increasing muscle strength, directly and indirectly on the attainment of peak bone mass in young men. Moreover, in newborns with congenital hypogonadism, androgen therapy could be effective to increase genital size. Summary: Testosterone replacement therapy (TRT) represents the cornerstone of the management of hypogonadism in boys. During puberty, replacement therapy needs to be modulated with gradual dosing increase to better mimic the physiologic pubertal development. Currently, intramuscular testosterone (T) esters (in particular testosterone enanthate) and subcutaneous T pellets are the only formulations approved by the US Food and Drug Administration for delayed puberty, while no preparation is approved for long-term use in the adolescent age. Several new T formulations (as transdermal, nasal, subcutaneous, and oral formulation) are recently developed to improve the pharmacokinetic profile and to ease the administration route increasing patient compliance in adult males with hypogonadism. All these formulations are not approved for pediatric age, although some of them are used as “off-label” regimens. This special issue is aimed to illustrate new T formulations and their potential role as replacement therapy in the pediatric population, as well as to highlight investigational areas to contribute to health care improvement in these patients. Key Messages: Despite the lack of evidence-based guidelines regarding the choice of T formulation in the pediatric population, new formulations appear to have a potential role for TRT in adolescent age. They have been designed for adult age with a little flexibility of dosage, although a few formulations may be attractive for pubertal induction and penile enlargement thanks to their greater flexibility and easing of administration. On the other hand, long-acting and stable formulations could meet post-pubertal needs, increasing TRT compliance in a critical phase as the adolescent age. Further controlled, long-term safety, and efficacy studies for all these new T formulations within the pediatric population are needed.
Abstract 10475: Heat Loss Augmented by Extracorporeal Circulation is Associated with Overcooling in Cardiac Arrest Survivors Who Underwent Targeted Temperature Management
Authors: Lee Byungkook , Lee Dong Hun
Published: December 2021

Introduction:
Extracorporeal circuit-based salvage therapy can affect targeted temperature management (TTM) in comatose out-of-hospital cardiac arrest (OHCA) survivors. We investigated the association of patients with extracorporeal device with TTM and neurological outcome.

Methods:
We performed a retrospective analysis using prospectively collected data from adult comatose OHCA survivors who underwent TTM between October 2015 and December 2020. We defined patients with ECMO and/or CRRT as the extracorporeal group. We calculated the cooling rate during the induction period; the minimum, maximum, and mean time-weighted core temperatures (TWCT), and the standard deviation (SD) of the core temperature and water temperature during the maintenance period based on the temperature measured every minute. We defined the sum of TWCT more and less than 33°C as positive and negative TWCT, respectively. The primary outcome was a poor neurological outcome, defined as cerebral performance category 3-5. We used propensity score (PS) matching to adjust the characteristics of patients who required an extracorporeal circuit device.

Results:
Of the 223 included patients, 140 (62.8%) patients had poor neurological outcome and 40 (17.9%) patients were categorized into the extracorporeal group. The extracorporeal group had a rapid cooling rate (2.08°C/h [1.13-3.73] vs. 1.24°C/h [0.77-1.79]; p < 0.001). The extracorporeal group had lower mean core temperature; higher core temperature SD; lower positive TWCT; higher negative TWCT; and higher maximum, minimum, and mean water temperature than the no-extracorporeal group. In PS matched cohort, the extracorporeal group had a lower minimum core temperature, lower mean core temperature, higher core temperature SD, higher negative TWCT, higher maximum water temperature, and higher mean water temperature. The neurological outcomes were not different between the two groups, in either the whole or PS-matched cohort.

Conclusions:
The extracorporeal group achieved the target temperature earlier. The core temperature distribution during the maintenance period was further skewed below 33°C in the extracorporeal group. The extracorporeal group had similar neurological outcomes to the no-extracorporeal group.
Abstract 10508: Variation in Community and Emergency Medical Systems Processes for Out-of-Hospital Cardiac Arrest During the COVID-19 Pandemic: A Systematic Review and Meta-Analysis
Authors: Masuda Yoshio , Teoh Seth E , Tan Darren J , Ong Marcus E , Ho Andrew F , Blewer Audrey L
Published: December 2021

Introduction:
Bystander cardiopulmonary resuscitation (B-CPR) with early defibrillation and immediate emergency medical services (EMS) care significantly increases a victim's chance of survival from out-of-hospital sudden cardiac arrest (OHCA). Few studies have assessed the overall effect of the COVID-19 pandemic on the prehospital chain of survival.

Objectives:
We sought to quantify the effect of the COVID-19 pandemic on prehospital processes including B-CPR, bystander defibrillation, community characteristics, and EMS process measures. We hypothesized that B-CPR rates would decrease and OHCA occurring in the home would increase during the pandemic.

Methods:
We conducted a systematic review and meta-analysis of studies identified through 05/03/2021. We examined 5 bibliographic databases and searched terms including cardiac arrest, OHCA, and COVID-19. Data were abstracted and independently coded. Subgroup analysis and meta-regression analysis were performed. Our primary outcome was B-CPR; our secondary outcomes were community processes and EMS characteristics.

Results:
The original search yielded 966 articles; 20 articles were included in our analysis. Studies originated from 10 different countries and were retrospective in study design. There was no difference in B-CPR rates during COVID-19 compared to Pre-COVID-19 (OR: 0.94 (0.80-1.11), p=0.46). Patients had a 1.38 (1.11-1.71) higher likelihood of having an OHCA at home during COVID-19 compared to Pre-COVID-19 (p=0.01). Receipt of bystander defibrillation was significantly lower during COVID-19 compared to Pre-COVID-19 (OR: 0.65 (0.48-0.88), p=0.01). There was a significant increase in EMS call to arrival time during COVID-19 compared to Pre-COVID-19 (Mean difference in minutes= 0.27 (0.13-0.40), p<0.01). Statistical heterogeneity was moderate-to-high; findings were robust to sensitivity analyses with no publication bias detected.

Conclusion:
B-CPR rates remained unchanged during the pandemic, while OHCA in the home increased. Bystander defibrillation decreased, while EMS response time increased during the pandemic. These findings may inform future public programing, particularly to consider interventions to improve the prehospital chain of survival.
Abstract 10707: The Impact of the COVID-19 Pandemic on Incidence and Outcomes from Out-of-Hospital Cardiac Arrest (OHCA) in Texas
Authors: Chavez Summer , Huebinger Ryan , Gill Joseph , White Lynn , Chan Hei Kit , Villa Normandy W , Jarvis Jeffrey L , Vithalani Veer D , Tannenbaum Lloyd , Bobrow Bentley
Published: December 2021

Introduction:
Nationally, the COVID-19 pandemic was associated with worse OHCA outcomes. Whether these trends persist or were consistent between states is unclear.

Purpose:
To determine the impact of COVID-19 on OHCA incidence and outcomes in Texas between 2019-2020.

Methods:
We analyzed adult OHCAs in Texas from the Cardiac Arrest Registry to Enhance Survival (CARES) during a matched period (March 11-December 31 from 2019 through 2020). We excluded cases witnessed by 9-1-1 responders and arrests occurring at healthcare facilities. Outcomes were rates of BCPR, AED use, sustained ROSC, prehospital termination of resuscitation (TOR), survival to hospital, survival to hospital discharge, good neurological outcomes and Utstein bystander survival. We created a mixed effects logistic regression model analyzing the effect of the pandemic on outcomes, using EMS agency as the random intercept. We adjusted for age, gender, race/ethnicity, witnessed arrest, initial rhythm type and location type.

Results:
There were 8,070 OHCA cases, with 4,443 (55.1%) in the pandemic period (March 11 - December 31, 2020) and 3,627 (44.5%) from March 11 - December 31 2019, a relative 18.4% increase. There was a significantly decreased odds of BCPR (46.2% v 42.2%, aOR = 0.87, 95% CI 0.79-0.95), AED use (13.0% v 7.3%, aOR = 0.53, 95% CI 0.36-0.78), and sustained ROSC (28.8% v 21.2%, aOR = 0.67, 95% CI 0.60-0.74) during the pandemic. Survival to hospital (27.1% v 20.9%, aOR = 0.72, 95% CI 0.65-0.80) and survival to hospital discharge (10.0% v 7.4%, aOR = 0.71, 95% CI 0.64-0.89) also decreased. Prehospital TOR increased (37.3% v 46.7%, aOR = 1.51, 95% CI 1.35-1.67). The pandemic was associated with a lower Utstein bystander survival rate (58.5% v 52.5%, aOR = 0.79, 95% CI 0.6-0.97).

Conclusion:
In Texas during the COVID-19 pandemic, there was a greater number of OHCA events, with lower overall survival and increased prehospital TOR.
Abstract 11119: Real-Time Nanopore Sequencing for Bacterial Pneumonia After Out-of-Hospital Cardiac Arrest, a Pilot Proof-of-Concept Study
Authors: Weissman Alexandra , Bramah Lawani Mariam , Rohan Thomas Z. , CALLAWAY Clifton W
Published: December 2021

Introduction:
Pneumonia is common after OHCA but is difficult to diagnose in the first 72 hours following ROSC, this results in early untargeted antibiotic administration based on non-specific imaging and laboratory findings. Antibiotic resistance is rising, is influenced by untargeted antibiotic administration, and can increase patient morbidity and mortality as well as healthcare costs. Precision methods of bacterial pathogen detection in OHCA patients are needed to improve patient care. This proof-of-concept pilot study aimed to assess feasibility of bacterial pathogen sequencing and comparability of sequencing results to clinical culture after OHCA.

Methods:
Blood and bronchoalveolar lavage (BAL) were obtained from residual clinical specimens collected within 12 hours of ROSC. Bacterial DNA was extracted using the Qiagen PowerLyzer PowerSoil DNA kit, sequenced using the MinION nanopore sequencer, and analyzed with Oxford Nanopore Technologies’ EPI2ME bioinformatics software. Sequencing results were compared to culture results using McNemar’s chi-square statistic. Study-defined pneumonia was based on presence of at least two characteristics within 72 hours of ROSC: fever (temperature ≥38°C); persistent leukocytosis >15,000 or leukopenia <3,500 for 48 hours; persistent chest radiography infiltrates for 48 hours per clinical radiology read; bacterial pathogen cultured.

Results:
We enrolled 38 consecutive OHCA subjects: mean age 61.8 years (18.0); 16 (42%) female; 25 (66%) White, 7 (18%) Black, 6 (16%) “Other” race; 7 subjects (18%) survived and 31 (82%) died; 16 (42%) subjects had pneumonia. Sequencing results were available in 12 hours while culture results were available in 48-72 hours after collection. There was a non-significant difference in the proportion of the same pathogens identified for each method per McNemar’s chi-square: p = 0.38, difference of 0.095 (-0.095, 0.286).

Conclusions:
Nanopore sequencing detects pathogenic bacteria comparable to clinical microbiologic culture and in less time. This technology can produce a paradigm shift in early bacterial pathogen detection in OHCA survivors, which can improve patient care. The technology is applicable to other patient populations and for viral and fungal pathogens.
Abstract 11233: A Trigger and Response System for Preventing Cardiac Arrest in the Intensive Care Unit
Authors: Moskowitz Ari , Berg Katherine , Cocchi Michael N , Grossestreuer Anne V , Balaji Lakshman , Chase Maureen , Yang Jesse L , O'Donoghue Sharon , Donnino Michael
Published: December 2021

Background:
Although patients in the ICU are closely monitored, some ICU cardiac arrest events may be preventable. In this study we sought to reduce the rate of ICU cardiac arrests.

Methods:
This was a prospective study of a novel clinical trigger and response tool deployed in the ICUs of a single, tertiary academic medical center. An interrupted time series approach was used to assess the impact of the tool on ICU cardiac arrests.

Results:
Forty-three patients experienced an ICU cardiac arrest in the pre-intervention epoch (6.79 arrests per 1000 discharges) and 59 patients experienced an ICU cardiac arrest in the intervention epoch (7.91 arrests per 1000 discharges). In the intervention epoch, the clinical trigger and response tool was activated 106 times over a 1-year period, most commonly due to unexpected new or worsening hypotension. There was no step change in arrest-rate (2.24 arrests/1000 patients, 95%CI -1.82, 6.28, p=0.28) or slope change (-0.02 slope of arrest rate, 95%CI -0.14, 0.11, p=0.79) comparing the pre-intervention and intervention time epochs (see Figure). Cardiac arrests occurring in the pre-intervention epoch were more likely to be deemed ‘potentially preventable’ than those in the intervention epoch (25.6% prior to the intervention vs. 12.3% during the intervention, OR 0.58, 95%CI 0.20, 0.88, p<0.01).

Conclusions:
A trigger-and-response tool did not reduce the incidence of ICU cardiac arrest. Arrests occurring after introduction of the tool were less likely to be rated as ‘potentially preventable.’
Abstract 11312: Activation of Citizen Responders to Out-of-Hospital Cardiac Arrest: Temporal Changes During the COVID-19 Outbreak in Denmark 2020
Authors: Gregers Mads Christian Tofte , Andelius Linn , Hansen Carolina Malta , Kragh Astrid Rolin , Torp-Pedersen Christian , Christensen Helle Collatz , Kjoelbye Julie , Væggemose Ulla , Christensen Erika Frischknecht , Folke Fredrik
Published: December 2021

Introduction:
Multiple citizen responder (CR) programs worldwide which dispatch laypersons to out-of-hospital cardiac arrest (OHCA) to perform cardiopulmonary resuscitation (CPR) and use of automated external defibrillators (AEDs) were affected by the COVID-19 outbreak in 2020, but little is known about how the pandemic affected CR activation and initiation of bystander CPR and defibrillation. In Denmark, the CR program continued to run during lockdown but with the recommendation to perform chest-compression-only CPR in contrast to standard CPR including ventilations. We hypothesized that bystander interventions as CPR and AED usage decreased during the first COVID-19 lockdown in two regions of Denmark in the spring of 2020.

Methods:
All OHCAs from January 1, 2020 to June 30, 2020 with CR activation from the Danish Cardiac Arrest Registry and the National Citizen Responder database. Bystander CPR, AED usage, and CRs’ alarm acceptance rate during the national lockdown from March 11, 2020 to April 20, 2020 were compared with the non-lockdown period from January 1, 2020 to March 10, 2020 and from April 21 to June 30, 2020.

Results:
A total of 6,120 CRs were alerted in 443 (23/100.000 inhabitants) cases of presumed OHCA of which 256 (58%) were confirmed cardiac arrests. Bystander CPR remained equally high in the lockdown period compared with non-lockdown period (99% vs. 92%, p=0.07). Likewise, there was no change in bystander defibrillation (9% vs. 14%, p=0.4). There was a slight increase in the number of CRs who accepted an alarm (7 per alarm, IQR 4) during lockdown compared with non-lockdown period (6 per alarm, IQR 4), p=0.0001. The proportion of patients achieving return of spontaneous circulation at hospital arrival was also unchanged (lockdown 23% vs non-lockdown 23%, p=1.0) (Table 1).

Conclusion:
Bystander initiated resuscitation rates did not change during the first COVID-19 lockdown in Denmark for OHCAs where CRs were activated through a smartphone app.
Abstract 11340: Increasing Mean Arterial Pressure or Cardiac Output in Comatose Out-of-Hospital Cardiac Arrest Patients Undergoing Targeted Temperature Management: Effects on Cerebral Tissue Oxygenation
Authors: Grand Johannes , Wiberg Sebastian , Kjaergaard Jesper , Hassager Christian
Published: December 2021

Introduction:
There are few data regarding the effects of norepinephrine-uptitration on global and regional hemodynamics in cardiac intensive care patients.

Methods:
We prospectively studied 10 OHCA patients at our cardiac intensive care unit. The trial consisted of 5 phases. The first 4 phases were achieved by titrating norepinephrine to reach targets of mean arterial pressure (MAP). First a MAP of 65 mmHg, second 75 mmHg, third 85 mmHg, fourth 65 mmHg again. The fifth phase was with a constant MAP of 65 mmHg but aiming at an increased PaCO2 from 6.5-7.3 kPa to increase cardiac output. During each phase, 20 minutes steady state was achieved before measurements. We measured hemodynamic variables with a Swan-Ganz catheter, arterial and mixed venous blood gases, and near-infrared spectroscopy at the forehead (cerebral oxygen saturation).

Results:
To obtain a MAP at 85 mmHg, norepinephrine was increased from 0.11±0.02 to 0.18±0.02 μg · kg–1 · min–1 (P < 0.001). Norepinephrine uptitration significantly increased MAP, systemic vascular resistance and pulmonary artery pressure, without affecting cardiac output or heart rate. After phase 3, norepinephrine was decreased to basal values, and all variables returned to baseline. Increasing pCO2, resulted in a significant increase in cardiac output and cerebral oxygen saturation, while decreasing systemic vascular resistance. MAP (and NE dose) was unaffected by increasing pCO2.

Conclusions:
A short-term increase in MAP with norepinephrine in resuscitated OHCA-patients is associated with increased SVR and PVR without affecting cardiac output or NIRS of the brain. An increase in CO caused by an increase in pCO2 and thereby a decreased SVR increased NIRS potentially improving brain oxygenation.
Abstract 11597: Characterization of Epinephrine Use During Extracorporeal Cardiopulmonary Resuscitation
Authors: Kucher Nicholas , Marquez Alexandra , Guerguerian Anne M , Moga Michael-Alice , Vargas-Gutierrez Mariella , Todd Mark , Honjo Osami , Haller Christoph , Goco Geraldine , Floh Alejandro
Published: December 2021

Introduction:
Guidelines recommend dosing Epinephrine (Epi) at regular intervals during pediatric cardiac arrest, including patients requiring extracorporeal membrane oxygenation (ECMO). The impact of Epi-induced vasoconstriction on systemic afterload and veno-arterial ECMO support is poorly understood.

Hypothesis:
Higher total dose of Epi and shorter interval between Epi dose and ECMO flow during cardiac arrest will increase systemic afterload and interfere with ECMO support.

Methods:
This is an ancillary study to a single-center, retrospective observational study of patients 0-18 years old who required ECMO cannulation during resuscitation over a six-year period. Patients were excluded if ECMO was initiated prior to arrest or if the resuscitation record was incomplete. The primary exposure was time from last dose of Epi to initiation of ECMO flows; secondary exposures included cumulative Epi dose delivered and indexed to arrest time. Mean arterial pressure (MAP) and systemic vasodilator therapy were used as surrogates for systemic afterload; ECMO pump speed and vasoactive-inotrope score (VIS) were used as measures of ECMO support.

Results:
A total 92 events in 87 patients analyzed. The patient cohort was 53% female with median (IQR) age of 122 (30-478) days, weight 4.4 (3.3 - 8.7) kg, and 43% single ventricle physiology. On average, Epi was given 7 (4 - 10) times during a 35 (27 - 44) min arrest, for a total dose of 65 (37 - 101) mcg/kg; the last dose was given 6 (2 -16) min prior to the initiation of ECMO flows. In the 6 hours following initiation of ECMO, MAP increased from 42 (36 - 56) mmHg to 57 (47 - 70) mmHg, (p<0.0001). Shorter interval between last Epi dose and ECMO initiation trended with higher MAP after 1 hour of support (estimate -0.43, p=0.06) and associated with increased of vasodilators within 6 hours of ECMO (vasodilators used (1 - 6) vs not used 9 (3 - 16) min, p=0.05). No other associations were found between Epi delivery, MAP, vasodilator use, pump speed or VIS.

Conclusion:
There is limited evidence to support that regular dosing of Epi throughout a cardiac arrest is associated with clinically significant increases in afterload after ECMO cannulation. Additional studies are needed to validate findings against ECMO flows and clinically relevant outcomes.
Abstract 11964: Citizen Responders Provide Emotional Support for Relatives to Out-of-Hospital Cardiac Arrest Patients
Authors: Kragh Astrid Rolin , Andelius Linn , Gregers Mads Christian Tofte , Kjoelbye Julie , Zinckernagel Line , Torp-Pedersen Christian , Folke Fredrik , Hansen Carolina M
Published: December 2021

Introduction:
A citizen responder (CR) system to activate volunteer citizens by a smartphone application (HeartRunner) to nearby cardiac arrests was implemented in 2017 in the Capital Region of Denmark. Participating in resuscitation may not only involve provision of cardio-pulmonary resuscitation (CPR) but also include provision of emotional support for relatives to the cardiac arrest patient. We examined the proportion of CR who reported provision of support to relatives to out-of-hospital cardiac arrest (OHCA) patients during resuscitation attempt.

Hypothesis:
We hypothesized that CR not only deliver CPR but also provide emotional support to relatives of OHCA patients.

Methods:
All CR activated by the HeartRunner app received a follow-up questionnaire 90 minutes after the alarm including questions about how CRs participated in resuscitation and whether they provided emotional support to relatives present during the resuscitation attempt. All surveys from March 12, 2020 to June 1, 2021, from CR who accepted an alarm and arrived at the cardiac arrest location were included.

Results:
A total of 1,868 CR responded to the survey (median age 37 years (IQR 28-37). Half (54.4%) were male and 23.9% health care professionals. CRs arrived before the emergency medical services (EMS) in almost 1/3 (28.9%) of OHCA cases with CR activation, with 227 CRs (41.9%) performing CPR and 139 (25.7%) attaching an automated external defibrillator. In total, more than 433 CRs (23.2%) reported provision of support for relatives at the OHCA location. Even though a higher proportion of support was observed among CR who arrived before the EMS, almost 12% reported provision of support to relatives even when arriving after EMS (Figure).

Conclusions:
Citizen responders provide not only resuscitative efforts but offer emotional support to relatives to OHCA patients. Citizen responders may be an important resource for both EMS personnel and relatives who are present at the cardiac arrest scene.
Abstract 11972: Ivabradine Attenuates Hypoxia/Reoxygenation-Induced Excessive Autophagy in H9c2 Cardiomyocyte by Modulation of the PI3K/Akt/mTOR Pathway
Authors: yang min , Li Hui , Jiatian Wu , Tianfeng Hua
Published: December 2021

Introduction:
Despite recent advances in resuscitation techniques, the mortality associated with survival from cardiac arrest (CA) still remains low. Cardiovascular ischemia/reperfusion injury (IRI) is one of the primary pathophysiology involved.

Hypothesis:
We assessed the hypothesis that ivabradine could attenuate hypoxia/reoxygenation injury of H9c2 cardiomyocytes by inhibiting excessive autophagy through PI3K/Akt/mTOR Pathway.

Methods:
Cultured H9c2 were randomly divided into 3 groups: CON (normoxia), H/R (hypoxia reoxygenation) and IVA. The IVA was divided into 4 subgroups, in which H9c2 were treated with or without ivabradine(20μM or 100μM) or PI3-kinase inhibitor LY294002(10μM) for 12 hours and then subjected to 12 hours of hypoxia and 24 hours of reoxygenation. Hypoxia was achieved by a hypoxia chamber filled with 5%CO
2
and 95% N
2
at 37°C. Cell viability were measured with CCK-8 assay kits. Cell autophagy was assessed by transmission electron microscopy (TEM). The expressions of autophagy marker protein (LC3, Beclin-1), PI3K, Akt and mTOR were determined by Western-blot assay.

Results:
A decrease of cell viability and an increase formulation of autophagosomes /autophagy lysozymes occurred after H/R. Significant improvement was noted in cells treated with ivabradine compared to H/R(Figure 1). Ivabradine promoted pmTOR/mTOR expression and lower expressions of LC3II/LC3I and Beclin 1. LY294002 antagonized the effects of ivabradine on antophagy (Figure 2).

Conclusions:
Ivabradine could protect H9c2 against H/R injury via inhibiting excessive autophagy through PI3K/Akt/mTOR pathway.
Abstract 12052: A Comprehensive Simulation-Based Training for E-CPR Improves the Neurological Outcome of Patients With Refractory Cardiac Arrest
Authors: Toyofuku Takaaki , Unoki Takashi , Matsuura Junya , Konami Yutaka , Suzuyama Hiroto , Inoue Masayuki , Horio Eiji , Yufu Tetsuo , Kodama Kazuhisa , Yamamuro Megumi , Taguchi Eiji , Sawamura Tadashi , Nakao Koichi , Sakamoto Tomohiro
Published: December 2021

Background:
Extracorporeal cardiopulmonary resuscitation (E-CPR) has been utilized as a rescue strategy for patients with refractory cardiac arrest (CA). To improve the outcome of E-CPR, we developed a comprehensive simulation-based E-CPR training program. In the present study we assessed whether the E-CPR training improved the mortality and the neurological outcome.

Methods:
We have implemented the comprehensive E-CPR simulation training program twice a year to the medical team, which consists of emergency physicians, cardiologists, nurses, clinical engineers, and radiographers using a mock vascular model for E-CPR (ECMO cannulation). We assessed collapse to ECMO time, cumulative 30-day survival and good neurological outcome at hospital discharge defined as the cerebral performance categories (CPC) of 1 or 2.

Results:
Fifty-three consecutive patients received E-CPR for OHCA from January 2012 to December 2020 in which 31 patients were prior to (until September 2017) and 22 were after (from October 2017) the initiation of the E-CPR training. No differences were found in age, rates of witnessed and bystander-CPR, shockable rhythms, or acute coronary syndrome (ACS). Intra-aortic balloon pump was used in 87% patients prior to and 27% patients after the training (p<0.001), and a microaxial Impella pump was used in 55% after the training. Collapse to ECMO time was significantly shorter after the training (p<0.001). Cumulative 30-day survival and the rate of favorable neurological outcome were significantly higher after the training (p<0.05). Multivariate cox proportional hazard analysis revealed that age (hazard ratio [HR], 1.38 (10 years increase), 95% confidence interval [CI], 1.12-1.73, p=0.002), Collapse to ECMO time (HR, 1.14, 95%CI, 1.04-1.23, p=0.006), and additional Impella use (HR, 0.23, 95% CI, 0.08-0.69, p=0.0009) were significantly associated with the 30-day survival.

Conclusions:
The E-CPR training significantly improved the collapse to ECMO time. The faster deployment of ECMO improves the neurological outcome and 30-day survival in patients with refractory CA. Additional use of Impella may improve the survival.
Abstract 13013: Survival After In-Hospital Cardiopulmonary Resuscitation for Cardiac Arrest in Patients With COVID-19: An Updated Meta-Analysis
Authors: Pattupara Archana , Aggarwal Devika , Bhatia Kirtipal S , Gomez-Rojas Olga , jain vardhmaan , Ho Kam , Singh Avinash , Fox Arieh , Qamar Arman , Mathew Joseph
Published: December 2021

Introduction:
Several small studies have reported variable outcomes following in-hospital cardiac arrest (IHCA) in patients with COVID-19. A clear estimate is important in prognostication and guiding resuscitation efforts and policies for these patients.

Methods:
A search of PubMed, Embase, and Scopus databases was conducted to identify studies reporting outcomes after IHCA in adult patients with confirmed COVID-19. The cumulative characteristics of the patients were described. The primary outcome studied was survival at 30 days or at hospital discharge (short term survival). Additional outcomes of interest were proportional prevalence of the initial rhythm at arrest, return of spontaneous circulation (ROSC), and neurological recovery (defined as Cerebral Performance Category Score of 1-2 ). Metanalysis of proportions was performed utilizing the Metaprop command. A random effects model was chosen to account for interstudy variance.

Results:
A total of 13 eligible studies were identified and included in the analyses. Out of all the hospitalized patients with COVID-19, 1,618 underwent advanced cardiac resuscitation after an IHCA. Patients who had a cardiac arrest had a median age between 50-69 years. IHCA occurred predominantly in men, and in the ICU setting. Shockable rhythms were identified in 8% (95% CI 5-10%, I2; 56%) and non-shockable rhythms in 89% (95% CI 85-94% I2; 84%) of patients (Fig. 1a). ROSC was achieved in 40% (95% CI 31-48% I2; 90%) (Fig. 1b). Only 7 % ( 95% CI 3-12% I2; 86%) of patients survived at 30 days/hospital discharge (Fig. 1c). Neurological recovery was seen in 5% (95% CI 3-9% I2; 67%) of patients who suffered a IHCA (Fig. 1d).

Conclusions:
Our meta-analysis demonstrates the majority of the cardiac arrests in patients with COVID-19 have non-shockable rhythms. Survival rate in these patients is low, and neurological recovery is unfavorable. This study provides further insight in guiding resuscitation efforts in these patients.
Abstract 13027: Investigating the Airway Opening Index During Cardiopulmonary Resuscitation
Authors: Bhandari Shiv , Coult Jason , Bulger Natalie , Counts Catherine , Kwok Heemun , Latimer Andrew , Sayre Michael , Rea Thomas , Johnson Nicholas
Published: December 2021

Introduction:
In 40-70% of out-of-hospital cardiac arrest (OHCA) cases, chest compressions (CCs) during CPR induce measurable oscillations in capnography (E
T
CO
2
). Recent studies suggest the magnitude and frequency of oscillations are due to intrathoracic airflow dependent on airway patency. These oscillations can be quantified by the Airway Opening Index (AOI), ranging from 0-100%. We sought to develop, automate, and evaluate multiple methods of computing AOI throughout CPR.

Methods:
We conducted a retrospective study of all OHCA cases in Seattle, WA during 2019. E
T
CO
2
and impedance waveforms from LifePak 15 defibrillators were annotated for the presence of intubation and CPR, and imported into MATLAB for analysis. Four proposed methods for computing AOI were developed (Fig. 1) using peak E
T
CO
2
in conjunction with ΔE
T
CO
2
(oscillations in E
T
CO
2
from CCs). We examined the feasibility of automating ΔE
T
CO
2
and AOI calculation during CCs throughout OHCA resuscitation and evaluated differences in mean AOI using each method. Statistical significance was assessed with ANOVA (alpha = 0.05).

Results:
AOI was measurable in 312 of 465 cases. Mean [95% confidence interval] AOI across all cases was 34.3% [32.0-36.5%] for method 1, 27.6% [25.5-29.7%] for method 2, 22.7% [21.1-24.3%] for method 3, and 28.8% [26.6-31.0%] for method 4. Mean AOI was significantly different across the four methods (p<0.001), with the greatest difference between method 1 and 3 (11.6%, p<0.001), but no significant difference between methods 2 and 4 (p=0.44). Mean ΔE
T
CO
2
was 7.76 [7.08-8.44] mmHg.

Conclusion:
We implemented four proposed methods of automatically calculating AOI during OHCA. Each method produced a different average AOI. Consistent, automated methods to measure AOI provide the foundation to evaluate if, and how, AOI may change with treatment or predict outcomes. These four approaches require additional investigation to understand which may be best suited to improve OHCA care.
Abstract 13082: Region-Specific Diffusion-Weighted Imaging Predicts Neurological Outcome in Comatose Post-Cardiac Arrest Patients
Authors: Chan Wang Pong , Gallerani Troy , Keenan Caitlyn , Musatova Darya , Dam Katie , Sheng Heping , Jamil Taylor , Gross Hana , Stafford Rebecca , Greer David
Published: December 2021

Introduction & Hypothesis:
Diffusion-weighted imaging (DWI), a technique sensitive to acute brain ischemia, may hold utility in predicting neurological outcome in comatose post-cardiac arrest patients. Outcome studies are biased by early withdrawal of life sustaining therapy (WLST), leading to a self-fulfilling prophecy. This creates a need to reassess the use of DWI as a neuroprognostic tool in patients who have not undergone WLST. We hypothesize that DWI abnormalities is a robust predictor of poor neurological outcome in our WLST - controlled cohort.

Methods:
We leveraged the MOCHA database, a registry of over 300 comatose post-cardiac arrest patients, to retrospectively examine neurological outcomes in a cohort of patients who did not undergo WLST. A good outcome was defined by a cerebral performance category (CPC) score at discharge of 1 - 3, while a poor outcome CPC 4 - 5 (n=43). We first examined the relationship between the number of brain regions with DWI abnormalities and CPC score using a linear regression. We then examined how DWI abnormalities in specific brain regions correlated with CPC score outcome groups using a fisher exact test. DWI abnormalities were qualitatively determined by two vascular neurologists.

Results:
We found a positive correlation between the number of brain regions with DWI abnormalities and CPC score (
linear regression
, R
2
=0.572, p=2.670x10
-9
). Interestingly, the association between DWI abnormalities and CPC score exhibited brain region-specific variability. DWI abnormalities exhibited the strongest association with poor neurological outcome in the occipital lobe (
fisher exact test
, p=7.413x10
-10
), parietal lobe (p=9.125x10
-9
), frontal lobe (p=5.385x10
-9
), temporal lobe (p=3.904x10
-8
) and basal ganglia (p=2.342x10
-7
); and the weakest association in the white matter (p=1.000) and brain stem (p=6.612x10
-2
).

Conclusion:
Our preliminary results suggest that the region of ischemia is an important factor to consider in predicting neurological outcome. This warrants a larger scale WLST-controlled study examining region-specific DWI abnormalities and neurological outcome - the findings of which would improve our neuroprognostication capabilities in comatose post-cardiac arrest patients.
Abstract 13163: Use of a QR Code Accessed Debrief Tool is Associated With Higher Rates of Debrief After In-Hospital Cardiac Arrest
Authors: Mitchell Oscar J , Drus Karsten , Yuriditsky Eugene , Parnia Sam , Mukhopadhyay Amrita , Horowitz James
Published: December 2021

Introduction:
In-hospital cardiac arrest (IHCA) affects over 200 000 patients in the US annually. Approximately 20% will survive to hospital discharge, although outcomes vary between hospitals. Debriefing has been shown to improve resuscitation quality and teamwork and has been associated with improved IHCA outcomes. All IHCA at NYU Langone Health are attended by the ALERT team, a dedicated team of critical care nurses who perform active patient surveillance and respond to acute in-hospital emergencies. IHCA debriefs at NYU Langone Health have historically been performed on paper forms but were limited by low rates of compliance. As part of an ongoing quality improvement (QI) initiative, we designed and implemented an electronic debriefing tool for use after IHCA (eDebrief).

Methods:
The eDebrief tool was developed by the NYU Interdisciplinary Resuscitation Committee. The tool captures cardiopulmonary resuscitation (CPR) quality metrics, teamwork and leadership, use of resuscitation equipment (mechanical CPR, advanced airway adjuncts, and ultrasound), and outcomes. ALERT team nurses received an educational session and
ad hoc
refresher sessions if required. Data were collected at the conclusion of the event using an electronic device (iPhone, Apple, Cupertino CA). The tool is accessible using a QR code located on every code cart. Rates of IHCA debrief post-implementation (2/13/20-06/10/21) were compared to prior years (01/01/19 - 12/31/19 and 01/01/18-12/31/19).

Results:
The eDebrief tool was implemented on 2/13/20. During the post-implementation phase, there were 254 IHCA at NYU Langone Health. The eDebrief form was used in 175 events (69%). The debrief rate from previous calendar years were 38% and 42% for 2019 and 2018 respectively. Use of the eDebrief form has identified three targets for ongoing quality improvement and research projects: room overcrowding (identified in 64/175 IHCAs, 37%); ultrasound use (39/175 IHCAs, 22%); and optimization of mechanical CPR.

Conclusions:
Use of electronic debriefing is feasible at a large academic medical center and has been associated with increased uptake of IHCA debrief. Regular debriefs at our center have identified several targets for further quality improvement and research initiatives.
Abstract 13358: Pediatric Defibrillation; Safety and Efficacy of Shocks in Both Ventricular Fibrillation and Sinus Rhythm in a Porcine Model
Authors: McCartney Ben , Harvey Adam , Kernaghan Amy , Morais Sara , McAlister Olibhear , Torney Hannah , Crawford Paul , Biglarbeigi Pardis , Bond Raymond , Finlay Dewar , McEneaney David
Published: December 2021

Introduction:
Pediatric sudden cardiac arrest may require the delivery of a defibrillating shock to promote return of spontaneous circulation (ROSC). Fear of harm is a barrier for the use of automated external defibrillators by lay personnel, particularly when the patient is a child. The aim of this study was to observe the effects of delivering pediatric defibrillation shocks to pediatric weight swine who are in a perfusing rhythm or ventricular fibrillation (VF).

Methods:
Eight swine (10.3-26.8 kg) were studied under anesthesia. Up to 30 shocks were applied using modified samaritan AEDs (HeartSine, UK) to animals either in sinus rhythm or after 30 seconds of VF. Shocks delivered in sinus rhythm were unsynchronized. Four different shock types were applied, utilizing two different waveforms (Waveform-A at 50 J, Waveform-A at 75 J, Waveform-A at 90J and Waveform-B at 50 J). Left ventricular (LV) pressures were recorded invasively (Millar, USA). If the shock was successful, the animal entered a rest period of approximately 5 minutes, after which the next shock was applied.

Results:
Data presented in Table 1. Out of a total of 77 shocks delivered in sinus rhythm, 2 (2.6%) resulted in conversion to a cardiac arrest rhythm. Analysis of LV pressures demonstrated no significant differences in the change of LV dP/dt from baseline at 1, 10 and 60 seconds post-shock. There was no significant difference in shock success or ROSC between the shock types for defibrillation of VF. Analysis of LV pressures demonstrated no significant differences in the change of LV dP/dt from baseline at at 1, 10 and 60 seconds post-shock between the groups.

Conclusions:
The results of this study indicate defibrillation shocks applied to swine in sinus rhythm rarely result in conversion to an arrhythmia. Additionally, the variety of shock types demonstrated similar levels of safety and efficacy in this porcine model.
Abstract 13678: Validation of the Termination of Resuscitation Rules in Detroit
Authors: Chalek Adam D , Husain Arqam , Dunne Robert B
Published: December 2021

Introduction:
326,000 patients suffer from an out of hospital cardiac arrest (OHCA) each year. The Termination of Resuscitation (TOR) criteria, which recommends termination when the arrest is unwitnessed by EMS, no shocks are administered, and no ROSC occurs, guides physicians in determining the futility of continuing CPR and transporting patients to the hospital. We examined compliance with current BLS TOR rules as well as assessed an alternate set of rules, with the goal of retrospectively deriving improved TOR guidelines for OHCAs in Detroit.

Methods:
This is a retrospective study utilizing non-traumatic OHCA cases in Detroit from January 1, 2017 to December 31, 2019, which includes time before and after BLS TOR guidelines were officially implemented (June 1, 2018). Data is extracted from the Detroit Cardiac Arrest Registry (DCAR). Patients younger than 18 years of age and arrests of traumatic origin or those with no resuscitation attempted were excluded.

Results:
BLS TOR criteria was applied to the pre-TOR implementation data with resulting specificity of 79% (95% CI: 50.7-80.8) and PPV of 97.3% (95% CI: 95.5-98.6). Survival to hospital discharge when termination was recommended was projected at 2.9% (13/444). Overall transportation rate was 85% (559/656). Post-TOR implementation, specificity was 88.9% (95% CI: 78.6-99.1) and PPV was 99.1% (95% CI: 98.3-99.9). Survival to hospital discharge was 0.88% (4/453) with a 69% (451/650) overall transportation rate. Post-hoc addition of age or EMS time to patient side increased transportation rates to 81% (529/650) and 88% (571/650), respectively, and decreased false positive terminations to 0.84% (2/237) and 0% (0/148), respectively.

Conclusion:
Overall survival when TOR was recommended as well as futile transportation rates decreased since the implementation of the BLS TOR guidelines in Detroit. Addition of EMS time to patient side or patient age to the current TOR guidelines suggested improved performance. Although the additional criteria resulted in higher transportation rates, these factors may be useful for physicians to consider when deciding to transport patients who meet the current TOR criteria. However, further derivation and validation are needed to create optimal TOR guidelines.