bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 266: Quantifying the Effect of Technological Advancements and Guidelines on Pediatric Extracorporeal Cardiopulmonary Resuscitation Survival Outcomes
Authors: Sangari Anish , Sood Nitish , Hauger Joseph
Published: November 2020

Introduction:
The 2009 H1N1 pandemic resulted in a substantial increase in the use of extracorporeal cardiopulmonary resuscitation (ECPR). The concurrent release of guidelines by the French Ministry of Health also led to the standardization of ECPR protocol. We conducted a systematic review and meta-analysis to examine if the simultaneous development of guidelines and expanded usage led to an increase in survival to hospital discharge (SHD) in pediatric ECPR and to investigate if predictors of survival have changed since 2009.

Methods:
PubMed, SCOPUS, Google Scholar, Cochrane, and EMBASE were searched to identify studies examining survival outcome and predictors of survival for pediatric ECPR. A random-effects model was applied. Additional pre-specified subgroup analysis was performed using a fixed-effects model. A univariate meta-regression analysis was conducted.

Results:
The meta-analysis included 3,454 patients from 30 studies. Total survival rates have not improved in pediatric ECPR between subgroups (Mann-Whitney U test: p > 0.05). Extracorporeal membrane oxygenation (ECMO) duration for survivors was not significantly different than nonsurvivors before 2009 RR -0.02 [95% CI: -0.19 - 0.14], but was significantly lower than nonsurvivors after 2009 RR -0.32 [-0.48 - -0.15, p < 0.05]. Meta-regression analysis revealed the ratio of ECMO duration for survivors compared to non-survivors has significantly decreased from 1998 to 2020 (p < 0.05). Patient age was a significant predictor of survival pre-2009 RR but is not correlated with survival post-2009 (p > 0.05). PaO2 was significantly higher in survivors than nonsurvivors pre-2009 RR 0.15 [0.12 - 0.18, p < 0.05] but was not significantly different post-2009 (p > 0.05). End-tidal CO2, CPR duration, pre-CPR serum lactate, and pre-CPR creatinine were not significantly different (p > 0.05) between survivors and non-survivors in either pre-2009 or post-2009.

Conclusion:
Pediatric ECPR did not see major improvement in survival rates since 2009. In addition, predictors of survival for pediatric ECPR cases have changed over the last 10 years. As such, clinicians may be advised to rely much more heavily on recent research regarding predictors of survival in pediatric ECPR cases.
Abstract 270: Combined Use of VA-ECMO and IMPELLA (ECPELLA) Can Improve Outcomes in Patients Who Underwent E-CPR
Authors: Unoki Takashi , Nakayama Tomoko , Tamura Yudai , Horio Eiji , Kametani Motoko , Takagi Daisuke , Konami Yutaka , Suzuyama Hiroto , Inoue Masayuki , Yufu Tetsuo , Kodama Kazuhisa , Yamamuro Megumi , Taguchi Eiji , Sawamura Tadashi , Nakao Koichi , Sakamoto Tomohiro
Published: November 2020

Background:
Extracorporeal CPR (E-CPR) using a veno-arterial ECMO (VA-ECMO) is effective for patients with refractory cardiac arrest. Intra-aortic balloon pumping (IABP) is often combined with VA-ECMO to increase coronary perfusion. However, this combination significantly increases left ventricular afterload. Recent studies showed VA-ECMO combined with IMPELLA pump (ECPELLA) had beneficial effect on refractory cardiogenic shock.

Objective:
Evaluate outcome of ECPELLA patients who underwent E-CPR as compared to ECMO with IABP.

Method:
We retrospectively reviewed 140 consecutive patients who underwent E-CPR from January 2012 through May 2020 in our institute. Thirty-eight patients who received ECMO alone were excluded, and 102 patients were recruited. Twenty-four patients underwent ECPELLA (ECPELLA group) and 78 patients underwent ECMO with IABP (IABP group). The 30-day survival rate and the rate of grades 1 and 2 Cerebral Performance Categories (CPC) as the neurological prognosis were assessed.

Result:
ECPELLA group showed significantly shorter time from cardiac arrest to ECMO placement compared to IABP group (24 min [IQR; 13-41] vs. 49 min [IQR; 28-75]; P=0.0003). The rate of favorable neurological prognosis were significantly higher in the ECPELLA group (38% vs. 13% ; P=0.01). The 30-day all-cause mortality of ECPELLA was significantly lower than IABP (P=0.005 by log-rank test). Multivariate cox proportional hazard analysis including the age, Out of hospital cardiac arrest, shockable rhythm, Acute coronary syndrome, Collaapse-to-ECMO under 60min, and ECPELLA revealed that the age (hazard ratio [HR], 1.34 (10 years increase), 95%CI, 1.11-1.63, P=0.002), Collapse-to-ECMO under 60 min (HR, 0.45, 95%CI, 0.23-0.87, P=0.02) and ECPELLA (HR, 0.48, 95%CI, 0.22-0.95, P=0.035) were significantly associated with 30-day mortality.

Conclusion:
ECPELLA improves mortality and favorable neurological outcome in patients who underwent E-CPR.
Abstract 273: Implications of Expanding the Utstein Case Definition for Out of Hospital Cardiac Arrest
Authors: Shin Jenny , Chocron Richard , Rea Thomas , Kudenchuk Peter , Eisenberg Mickey , McNally Bryan F
Published: November 2020

Background:
The Utstein population is defined by non-traumatic, bystander-witnessed out-of-hospital cardiac arrest (OHCA) presenting with ventricular fibrillation (VF). It is used to compare resuscitation performance across emergency medical services (EMS) systems. We hypothesized there being a system-specific survival correlation between the current Utstein and other VF populations inclusive of unwitnessed and EMS-witnessed VF OHCA that supports expanding performance metrics to this more comprehensive population that is more representative of the actual community burden of VF OHCA.

Methods:
We performed a cohort investigation of all non-traumatic, VF OHCA in the Cardiac Arrest Registry to Enhance Survival from 1/1/2013-12/31/2018 among EMS agencies that treated >=100 VF OHCA. We evaluated sample size and survival with the addition of the new VF populations. We used the Pearson coefficient to assess the correlation of agency-specific survival between the current Utstein population and unwitnessed and EMS-witnessed VF OHCA.

Results:
A total of 107 EMS agencies treated 38,836 VF arrests: 22,918 current Utstein, 11,297 unwitnessed VF, and 4621 EMS-witnessed VF OHCA. Overall, survival was 29.8% (11,567/38,836): 33.9% (7,774/22,918) among current Utstein, 17.2% (1942/11,297) among unwitnessed VF, and 40.1% (1851/4621) among EMS-witnessed VF. For agency-specific survival outcome, the Pearson correlation was 0.52 between current the Utstein population versus combined unwitnessed and EMS-witnessed groups. For survival with Cerebral Performance Category 1-2, the Pearson correlation was 0.61.

Conclusion:
Expanding the Utstein population to include unwitnessed and EMS-witnessed VF OHCA achieves a simpler, more inclusive case definition that minimizes variability in case determination and increases the number of survivors and eligible population by ~50%, while still achieving a distinguishing metric of system-specific performance.
Abstract 275: Cardiac Arrest Etiology and Associated Cognitive Impairment in Survivors
Authors: Koller Allison C , Rittenberger Jon C , Songer Thomas J , Rosso Andrea L , Salerno Jessica E , Coppler Patrick J , Callaway Clifton W
Published: November 2020

Background:
Cardiac arrest is a significant public health problem, impacting over 500,000 people in the United States annually. The four major etiologies of arrest are cardiac, respiratory, traumatic, and other. The objective was to determine the impact of etiology on cognition in cardiac arrest survivors using the Montreal Cognitive Assessment (MOCA).

Hypothesis:
Cardiac arrest etiology impacts cognitive exam score, and patient demographics and characteristics modify that relationship.

Methods:
A retrospective cohort analysis was performed on all Pittsburgh Post Cardiac Arrest Service (PCAS) patients from 2012-18. Data were acquired through medical record review. T-tests, linear and logistic regression were used to assess the relationships between exam score and modifying factors. MOCA score was analyzed as a binomial variable using a pass/fail threshold of 26/30 points (86.7%) and above for normal cognition. For statistical significance, an alpha level of 0.05 was used.

Results:
In total, 192 patients completed the MOCA: 104 with cardiac etiology, 35 with respiratory, 4 with trauma, and 49 with other. Median age for all patients was 59.3 years, and 58% were male. Mean (SE) MOCA score for all patients was 72.8 (1.1) percent. When MOCA score was converted to a binomial indicator of normal cognition, respiratory, traumatic, and other etiologies were more likely to exhibit impairment than cardiac etiology arrest when age, sex, witnessed status, length of ICU stay and coma were controlled for (OR: 2.52, 3.43, 2.18 respectively). These findings were nullified when time from arrest to MOCA administration was included. Of the MOCA subcategories, delayed recall was the most severely impacted, with patients recalling an average of 1.67 of 5 words after 5 minutes. Additionally, respiratory arrests performed significantly worse than cardiac etiology arrests in attention (4.1 vs 4.9 points, p=0.004) and language domains (1.9 vs. 2.3, p=0.04).

Conclusions:
Respiratory, traumatic, and other etiologies were more likely to exhibit abnormal cognition on the MOCA than those with a cardiac etiology. The etiological findings were nullified when time to cognitive examination was controlled for. Timing appears to influence cognitive assessments more than etiology.
Abstract 278: A Novel Resuscitative Agent, Centhaquine (Lyfaquin®), has the Potential to Treat Acute Kidney Injury Following Hemorrhagic Shock
Authors: Ranjan Amaresh , Briyal Seema , Zhang Zhong , Gulati Anil
Published: November 2020

Introduction:
Centhaquine (CQ) is being developed as a first-in-class resuscitative agent to treat hemorrhagic shock. Its safety, tolerability and efficacy have been demonstrated through pre-clinical studies and phase I, II and III clinical trials (NCT02408731, NCT04056065 and NCT04045327). Shock is often complicated with acute kidney injury (AKI).

Hypothesis:
CQ will increase renal blood flow (RBF) and attenuate hypoxia related damage after hemorrhagic shock. We investigated whether CQ improves RBF and provides protection after hemorrhagic shock.

Methods:
Rats were anesthetized, and carotid artery, femoral artery and femoral vein were catheterized. Renal arteries were clamped, hemorrhage was induced and mean arterial pressure (MAP) was maintained between 35-40 mmHg for 30 min. After 20 min of hemorrhage, renal arteries were de-clamped and hemorrhage continued for 10 more min. Resuscitation was performed with either normal saline (NS) or CQ (0.02 mg/kg) infusion for 10 min. MAP, heart rate and RBF were monitored for 120 min after which rats were sacrificed, kidneys were collected and analyzed with western blots and immunofluorescence.

Results:
Resuscitation with CQ produced a significant improvement in RBF (at 30 min 257.03±21.2 vs 199.81±42.32, p=0.002 sustained till 120 min 211.76±27.47 vs 148.24±42.39, p=0.002 of infusion) compared to NS. A non-significant increase in MAP was observed in CQ compared to NS. Western blots showed significantly higher expression HIF1-A (1.13±0.19 vs 0.86±0.16) and lower expression of early kidney damage marker, NGAL (0.35±0.16 vs 0.82±0.31) in CQ vs NS. Immunofluorescence showed significantly higher expression of HIF1-A and lower expression of Bax in cortex (HIF1-A 11.19±0.31 vs 8.43±0.39, p=0.03689, Bax 18.09±0.47 vs 24.80±2.01, p=0.0010) of CQ than NS and similar change was observed in medulla. Expression of PHD3 and Cytochrome C was higher in the cortex (PHD3 5.38±0.38 vs 4.05±0.12, p=0.0348, Cytochrome C 24.95±0.65 vs 29.24±1.87, p=0.01429) of CQ than NS. HIF1-B expression was similar in CQ and NS groups.

Conclusions:
CQ (Lyfaquin®) is a frontline resuscitative agent with a potential to treat hemorrhagic shock related AKI by improving kidney blood flow and decreasing hypoxia related tissue damage.
Abstract 279: Multi-task Learning Improves Model Performance in Predicting Rare Catastrophic Events in Healthcare Claims Dataset
Authors: Chi ChienYu , Chen Yen-Pin , Winkler Adrian , Fu Kuan-Chun , Xu Fie , Soltani Rohollah , Huang Chien-Hua
Published: November 2020

Introduction:
Predicting rare catastrophic events is challenging due to lack of targets. Here we employed a multi-task learning method and demonstrated that substantial gains in accuracy and generalizability was achieved by sharing representations between related tasks

Methods:
Starting from Taiwan National Health Insurance Research Database, we selected adult people (>20 year) experienced in-hospital cardiac arrest but not out-of-hospital cardiac arrest during 8 years (2003-2010), and built a dataset using de-identified claims of Emergency Department (ED) and hospitalization. Final dataset had 169,287 patients, randomly split into 3 sections, train 70%, validation 15%, and test 15%.Two outcomes, 30-day readmission and 30-day mortality are chosen. We constructed the deep learning system in two steps. We first used a taxonomy mapping system Text2Node to generate a distributed representation for each concept. We then applied a multilevel hierarchical model based on long short-term memory (LSTM) architecture. Multi-task models used gradient similarity to prioritize the desired task over auxiliary tasks. Single-task models were trained for each desired task. All models share the same architecture and are trained with the same input data

Results:
Each model was optimized to maximize AUROC on the validation set with the final metrics calculated on the held-out test set. We demonstrated multi-task deep learning models outperform single task deep learning models on both tasks. While readmission had roughly 30% positives and showed miniscule improvements, the mortality task saw more improvement between models. We hypothesize that this is a result of the data imbalance, mortality occurred roughly 5% positive; the auxiliary tasks help the model interpret the data and generalize better.

Conclusion:
Multi-task deep learning models outperform single task deep learning models in predicting 30-day readmission and mortality in in-hospital cardiac arrest patients.
Abstract 283: Repolarization Heterogeneity and Torsades De Pointes: A Case Control Study
Authors: Marill Keith , Lopez Samantha , Hark David , Spahr Jennifer , Muthal Ketaki
Published: November 2020

Introduction:
Torsades de Pointes (TdP) is a potentially lethal ventricular tachydysrhythmia associated by definition with prolonged myocardial repolarization. However, prolonged myocardial repolarization is not specific for TdP. Our primary objective was to determine if heterogeneous myocardial repolarization manifested by corrected QT (QTc) and T wave variation is necessary and predictive of TdP.

Methods:
We performed an IRB approved case control study of TdP at a large urban hospital. We identified cases based on a MUSE ECG database search for tracings from 1/05 to 6/19 with QTc>500, QRS<120, and HR<60, and a subsequent natural language search of electronic health records for the terms: TdP, polymorphic ventricular tachycardia, sudden cardiac death, etc. Controls were drawn in a 2:1 ratio to cases from a similar pool of ECGs, and matching for sex, age, QTc, and heartrate. We abstracted historical, laboratory, ECG, and telemetry data using detailed written instructions and an electronic database. Groups were compared using unpaired and paired nonparametric and parametric statistics as appropriate.

Results:
We included 75 cases and 150 controls. We found no significant difference in measures of QTc or T wave repolarization heterogeneity, QTc prolonging medications, or serum electrolytes between the two groups. However, 35 cases had brief telemetry strips demonstrating TdP and a median of four beats prior to TdP onset. Ectopy was present in 25 (71%) strips prior to TdP. Heartrate in these cases was also 17 beats per minute (BPM) (95% CI 7 to 27) higher at an average 87 BPM just prior to TdP as compared to their index ECG.

Conclusions:
Repolarization heterogeneity is not greater in patients with QTc prolongation who suffer TdP. It doesn’t appear mechanistically necessary or predictive of TdP. Ventricular ectopy, possibly triggered from early after depolarizations, but not bradycardia, is common before TdP and may be usefully predictive.
Abstract 284: Looking Back to Glance Ahead: The Impact of Last Minute's Qrs Width & Frequency in Pulseless Electrical Activity
Authors: Norvik Anders , Unneland Eirik , Skjeflo Gunnar W , Buckler David , Irusta Unai , Aramendi Elisabete , Eftestol Trygve , Abella Benjamin , Bergum Daniel , Loennechen Jan P , Kvaloy Jan Terje , Skogvoll Eirik
Published: November 2020

Background:
Observed heart rate and QRS-width during CPR in Pulseless Electrical Activity (PEA) develop differently in patients who gain ROSC compared to those who do not. In this study we investigated the impact of heart rate and QRS width on the transition from PEA to ROSC.

Method:
Defibrillator data from 293 episodes of cardiac arrest at two US and one Norwegian hospital were reviewed. The files contained ECG, impedance signal and compression depth. In total 178 episodes containing PEA intervals were included. Episodes with excessive ECG noise and signs of an active pacemaker were excluded. The files were processed in a MATLAB graphical application, and the clinical states were determined based on clinical documentation and the visual appearance of the ECG. ROSC was defined as an organized rhythm lasting longer than 1 minute without ongoing compressions. During pauses in compressions, heart rate and QRS-width was automatically measured and averaged over the preceding minute until current time and controlled and corrected manually. The results were analyzed using Aalen’s additive model for time-to-event data, using R version 3.6.3.

Results:
The average transition intensity, corresponding to the probability of gaining ROSC in one minute, was about 0.20 per min of CPR peaking at approximately 7 min. An increase in the average heart rate by 10/min increased the transition intensity by 0.03/min (p <0.01). Narrowing of the QRS in average by 100 milliseconds (ms) increased the transition intensity by 0.14/min (p <0.01). Our figure shows QRS width and heart rate for one patient with PEA approaching ROSC (gray area), with smoothed curves overlaid.

Conclusion:
Higher heart rates and narrower QRS complexes during PEA are strongly and significantly associated with a transition from PEA to ROSC. These changes could indicate whether a patient responds to ongoing CPR. In addition, there is a potential for predicting the immediate outcome based on these ECG characteristics.
Abstract 286: Factors Associated with Non-survival From In-hospital Maternal Cardiac Arrest: An Analysis of Get with the Guidelines (gwtg) Data
Authors: Zelop Carolyn M , Shaw Richard E , Edelson Dana P , Lipman Steven S , Mhyre Jill M , Jeejeebhoy Farida , Einav Sharon
Published: November 2020

Introduction:
Maternal mortality has risen in the United States during the 21
st
century. Factors influencing outcome of maternal cardiac arrest (MCA) remain largely unexplored.

Hypothesis:
We sought to further elucidate the factors affecting maternal death from in-hospital (IH) MCA.

Methods:
Our query of the American Heart Association’s GWTG
®
-Resuscitation voluntary registry from 2000-2017 revealed 561 index cases of in IH MCA with complete outcome data. Logistic regression was performed using hospital death as the primary outcome and included variables with a p value = 0.1 or less based upon univariate analysis. Age, race, year of arrest, pre-existing conditions, first documented pulseless rhythm, and location of arrest were used in the model. Sensitivity analyses and assessment of variable interaction were also performed to test model stability.

Results:
Among 561 cases of MCA, 57.2% (321/561) did not survive to hospital discharge. In-hospital death was not associated with maternal age, race and year of event. In the final model (see table), IH death was significantly associated with prearrest hypotension/hypoperfusion (p=0.009). While MCA cases with a shockable vs non-shockable first documented pulseless rhythm had similar outcomes, those with an indeterminate rhythm were less likely to die, (p=0.014). The occurrence of MCA outside of the delivery suite (referent group) or operating room was associated with a significantly higher risk of death: ICU/Recovery Room (p=0.001) and ER/other (p= 0.012). In a sensitivity analysis, removal of the indeterminate group did not alter outcomes regarding first documented pulseless rhythm or arrest location. Area under the curve for the final model was 0.715 (95% CI 0.673-0.757).

Conclusions:
Our study identified several novel factors associated with IH death of our MCA cohort. More research is required to further understand the pathophysiologic dynamics affecting outcomes of IHCA in this unique population.
Abstract 294: A Machine Learning Approach in Using Capnography to Predict Resuscitation Interventions Required in Hypoxic Pseudo-Pulseless Electrical Activity Resuscitation
Authors: Lindqwister Alexander L , Ivanov Alexander , Hu Yiyuan D , Klein Samuel B , Moodie Karen L , Paradis Norman A
Published: November 2020

Introduction:
Pseudo-Pulseless Electrical Activity (p-PEA) is a lifeless form of profound cardiac shock characterized by measurable cardiac mechanical activity without clinically detectable pulses. Patients in pseudo-PEA carry different prognoses than those in true PEA and may require different therapies. End-tidal carbon dioxide (ET-CO
2
) has been studied in ventricular fibrillation and true PEA, but not in p-PEA. We evaluated the ability of capnography to predict the need for CPR in p-PEA.

Methods:
Female swine (N = 14) under intravenous anesthesia were instrumented with aortic and central venous micromanometer pressure catheters. ECG and ET-CO
2
were measured continuously. p-PEA was induced by ventilation with 6% oxygen in 94% nitrogen and was defined as a systolic aortic pressure less than 40 mmHg. Pigs were grouped into cohorts based on the interventions required to achieve ROSC: 100% O
2
, 100% O
2
+ CPR, 100% O
2
+ CPR + epinephrine. One hundred 4 sec. snippets of ET-CO
2
data were randomly sampled during the p-PEA state, and the mean, maximum, slope, and r-value of each epoch was used to train 7 machine learning algorithms to predict which intervention cohort they belonged to. Data was split randomly into 60% training and 40% testing sets.

Results:
Ensemble approaches were highly successful, with the gradient boosting model achieving an AUC of 0.91 on ROC curves (Figure 1), with an accuracy 0.83, sensitivity 0.86, specificity 0.78.

Conclusions:
In porcine hypoxic p-PEA, machine learning derived models of ET-CO2 appeared able to predict the degree of interventions needed for ROSC. If confirmed clinically, such an approach may be useful in guiding treatment of this increasingly common type of cardiac arrest.
Abstract 296: Adult Swine Model of Ventricular Fibrillation Arrest for Resuscitation with Perfluorocarbon Emulsions
Authors: Murphy Travis W , Zhu Jiepei , Parsons Travis , Spiess Bruce D , Becker Torben K
Published: November 2020

Background:
The purpose of this study was to develop a model of ventricular fibrillation arrest with reliable outcomes and minimally invasive methods to study the use of perfluorocarbon emulsions (PFC) as agents to prevent ischemia-reperfusion injury after cardiac arrest as quantified by known biomarkers.

Methods:
Female Yorkshire swine underwent anesthesia and minimally invasive instrumentation for monitoring under ultrasound. Cardiac arrest was induced with spinal needle insertion at the apex and right parasternal space. Ventricular fibrillation was reliably obtained in all animals on initial attempts. A three-minute circulatory arrest state was observed. Administration of PFC was concurrent with resuscitation including closed chest compressions, epinephrine, amiodarone, and defibrillation at 1J/kg. Primary endpoint was induction of cardiac arrest and tolerance of PFC with return of spontaneous circulation. Blood levels of glial fibrillary acidic protein (GFAP) and ubiquitin C-Terminal Hydrolase-L1 (UCLH1) were secondary end points for three animals.

Results:
Six of six animals were induced into ventricular fibrillation on initial attempt and two of three survival experiments were able to obtain spontaneous circulation. PFC with pretreatment was tolerated well and no signs of increased pulmonary pressures. GFAP, UCHL1 were significantly lower in intervention animals compared to controls.

Conclusions:
The results obtained from this preliminary study and technical refinements via additional donated animals have allowed us to make modifications in the choice of PFC, vascular access, and anticoagulation plan. This model provides a consistent method for inducing ventricular fibrillation with minimally invasive techniques. The PFC tested was well tolerated. More robust evaluation of PFC as resuscitative agents is needed with appropriately powered studies.
Abstract 303: Optic Nerve Sheath Diameter Differences by Sex, Rhythm, and Neurological Outcome After Out-of-hospital Cardiac Arrest
Authors: Kotini-Shah Pavitra , Gordon Richard , Karfunkle Benjamin , Li Jing , Kim Hajwa , Yen Pei-Shan , Granado Misha , Doshi Pratik B , Wang Henry E , Vanden Hoek Terry L
Published: November 2020

Introduction:
Neurologically guided resuscitation after out-of-hospital cardiac arrest (OHCA) to improve survival has been limited due to knowledge gaps in cerebral edema changes. Point-of-care ultrasound (POCUS) for the assessment of optic nerve sheath diameter (ONSD) is an established modality to characterize the extent of cerebral edema. We aimed to describe ONSD differences by sex, rhythm type, neurological outcome using cerebral performance category (CPC), and overall survival status.

Methods:
We studied adult OHCA treated at an urban academic ED with return of spontaneous circulation (ROSC) from May 2018 to May 2020. After ROSC, trained emergency physicians obtained bilateral ONSD measurements at 1, 6, 24, 48, and 72 hours, in the transverse, oblique, and sagittal planes for each eye. All the ONSD measurements were averaged for each time point and comparisons were made between each predictor’s categories. To compare the mean at each time point between groups, t-test or ANOVA was used. The trend comparison was done using generalized estimating equations. Statistical analysis was performed using SAS 9.4 under the significance level of 0.05.

Results:
Out of 62 eligible patients, 35 (56%) were male and 27 (44%) were female, 33 (59%) had a shockable rhythm and 23 (41%) had non-shockable rhythm. At 72 hr, 6 (10%) had a CPC of 1-2 and 57 (90%) had CPC of 3-5. Overall, there were 37 (61%) survivors and 24 (39%) non-survivors. There was a notable sex difference in the mean ONSD across all time points between males and females (p = 0.031), with males showing higher ONSD, and between shockable and non-shockable (p= 0.035), with the shockable group having relatively lower ONSD. There is a statistically significant difference of mean ONSD between CPC 1-2 and CPC 3-5 groups at 6hr, 48hr, and at 72hr, with higher means in the CPC 3-5 group. Across all times, the trend line was statistically significant between non-survivors and survivors (p= 0.015), with non-survivors having higher ONSD.

Conclusion:
Males, patients with non-shockable rhythm, CPC 3-5 at 72 hr, and non-survivors had higher ONSD. Understanding cerebral edema dynamics during resuscitation will allow for future work to potentially tailor interventions to individual patient cerebral injury patterns.
Abstract 307: Epidemiology, Outcomes and Factors Associated with Survival Following Out of Hospital Cardiac Arrests in Vietnam
Authors: Do Son N , Luong Chinh Q , Pham Dung T , Nguyen Chi V , Ton Tra T , Pham Thao T , Hoang Quoc T , Hoang Hanh T , Nguyen Dat T , Khuong Dai Q , Nguyen Quan H , Nguyen Tuan A , Pham Hanh T , Nguyen My H , McNally Bryan F , Ong Marcus E , Nguyen Anh D
Published: November 2020

Introduction:
Pre-hospital capabilities are minimally developed in Vietnam; therefore, the prognosis of OHCA might differ from that of other countries. The aim of this study was to investigate survival rate from OHCA and potential determinants of the chain of survival following an OHCA in a developing country.

Hypothesis:
Understanding the country-specific etiologies and the disease risk and prognosis of OHCA are crucial for reducing mortality in Vietnam, as well as in other countries that face challenges in clinical practice owing to limited medical resources.

Methods:
This is a multi-center prospective observational study of OHCA patients (age>18 years) presenting to the ED of three tertiary hospitals from February 2014 to December 2018. Factors associated with survival following OHCA were collected and compared among types of pre-hospital care transportation and between survival and non-survival to admission. Factors for survival to admission were assessed using logistic regression analysis.

Results:
Among 590 OHCA patients (male, 74.6%; age, 56.1±17.2 years), we observed low rates of survival to admission (24.2%) and discharge (14.1%). Of total patients, 67.8% occurred at home, 79.4% witnessed by bystanders, 124/555 (22.3%) received bystander CPR, a minority of patients (8.64%) was conveyed by EMS, and 49/152 (32.2%) received pre-hospital defibrillation. Multivariate analysis revealed that past medical history (PMH) of respiratory disease (OR, 3.128; 95% CI, 1.197-8.173), pre-hospital defibrillation (OR, 3.904; 95% CI, 1.540-9.898), pre-hospital advanced airway (OR, 3.441; 95% CI, 1.203-9.844) and ROSC at ED (OR, 2.891; 95% CI, 1.030-8.115) were independent factors for survival to admission. Following OHCA with cardiac etiology, EMS use (OR, 0.203; 95% CI, 0.044-0.935) was also an independent factor for survival to admission.

Conclusions:
This was a highly selected cohort of OHCA patients presenting to the ED. Many OHCA victims in Vietnam do not come to the ED. PMH of respiratory disease, pre-hospital defibrillation and advanced airway, and ROSC at ED were independent factors predicting survival to admission. EMS use was also an inverse and independent predictor of survival to admission among patients following OHCA with cardiac etiology.
Abstract 309: Prediction Chart for Neurological Outcomes of Elderly Patients with Out-of-hospital Cardiac Arrest and the Corresponding Time to Termination of Resuscitation: Evidence from a Japanese Nationwide Population-based Cohort Study
Authors: Funada Akira , Goto Yoshikazu , Takamura Masayuki
Published: November 2020

Introduction:
Neurological outcomes and the appropriate duration from call receipt to termination of resuscitation (TOR) in patients with out-of-hospital cardiac arrest (OHCA) could differ according to patient characteristics.

Hypothesis:
We hypothesized that a prediction chart comprising prehospital variables, including age, could be useful for predicting neurological outcomes and determining the time to TOR in the field or at the emergency department.

Methods:
We evaluated 19,829 elderly patients with OHCA (age ≥65 years) of cardiac origin who achieved prehospital return of spontaneous circulation (ROSC). Data were obtained from the prospectively recorded All-Japan Utstein Registry between 2011 and 2016. Patients with OHCA witnessed by emergency medical service providers were excluded. The primary outcome was 1-month neurologically intact survival, defined as a cerebral performance category (CPC) score of 1-2. Patients with OHCA were divided into 12 groups according to shockable rhythm (YES/NO), witness status (YES/NO), and age (65-74, 75-89, or ≥90 years). The time from call receipt to ROSC was calculated and categorized by 5-min intervals. The time from call receipt to ROSC at which the probability of 1-month CPC 1-2 decreased to <1% was defined as the call to TOR duration.

Results:
The overall 1-month CPC 1-2 rate was 18.9% (n = 3,756). When stratified by patient characteristics, the 1-month CPC 1-2 rates ranged from 52.3% in patients aged 65-74 years with shockable rhythm and witnessed OHCA (best-case scenario) to 1.6% in patients aged ≥90 years with non-shockable rhythm and un-witnessed OHCA (worst-case scenario). The corresponding call to TOR duration ranged from 35 to 10 min (Table).

Conclusions:
Neurological outcomes and the appropriate call to TOR duration differed according to patient characteristics, including age. Our prediction chart for elderly patients with OHCA could be useful for determining TOR in the field or at the emergency department.
Abstract 311: One-year Outcomes of DPP-4 Inhibitor Treatment in Diabetic Patients After Contemporary Percutaneous Coronary Intervention - Ps Matching from Data of Multicenter Registry -
Authors: Hata Takehiro , Hagiwara Nobuhisa , Jujo Kentaro
Published: November 2020

Introduction:
Clinical prognosis in diabetic patients comorbid with coronary artery disease (CAD) remained poor, even in the current drug-eluting stent (DES) era. However, there has been a limited evidence about the prognosis in diabetic patients with CAD who were treated with dipeptidyl peptidase-4 inhibitors (DPP4i).

Methods:
This study is a subanalysis from the TWINCRE registry that is a multicentral prospective cohort including patients who underwent percutaneous coronary intervention (PCI) at 12 hospitals in Japan between 2017 and 2019. Among 1,905 registered patients who were followed up, we ultimately evaluated 615 diabetic patients. They were divided into two groups depending on the prescription of DPP4i at the hospital discharge after the index PCI; DPP4i group (n=287) and Non-DPP4i group (n=328). For the two groups, we performed propensity-score (PS) matching using variables as follows: age, sex, acute coronary syndrome, left ventricular ejection fraction, serum creatinine, insulin use, prescriptions of statin, beta blocker, aspirin, and ACE inhibitor/ARB. The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCE) including death, acute coronary syndrome, stent thrombosis, hospitalization due to heart failure and ischemic stroke.

Results:
Overall MACCE was observed in 70 patients (11.4%) during 364 days of median observation period. In unmatched patients, Kaplan-Meier analysis showed that patients in the DPP4i group showed a significantly lower MACCE rate than those in the Non-DPP4i group (Log-rank test, p=0.009, Figure A). In 284 PS-matched patients, patients in the DPP4i group still had lower MACCE rate than those in the non-DPP4i group (hazard ratio 0.39, 95% confidence interval 0.16-0.96, p=0.034, Figure B).

Conclusion:
Propensity-matching analysis showed that hyperglycemia control by DPP4i was associated with better 1-year clinical outcomes in diabetic patients after PCI in the contemporary DES era.
Abstract 313: Neuron-specific Enolase and S-100B Protein in Crebrospinal Fluid: A Study of Sequential Analysis in Cardiac Arrest Patients Who Underwent Target Temperature Management
Authors: Kang Changshin
Published: November 2020

Background:
Neuron-specific enolase (NSE) and S-100B protein have been reported that they are associated with neurological outcome in out-of-hospital cardiac arrest (OHCA) survivors. However, comparing the prognostic performance between NSE and S-100B obtained from cerebrospinal fluid (CSF) has not been assessed yet. Therefore, this study aimed to investigate the prognostic performance of NSE and S-100B obtained from CSF for poor neurological outcomes in OHCA survivors.

Methods:
This was a prospective single-centre observational study, conducted from November 2018 to February 2019. The CSF samples of NSE and S-100B were serially obtained until 72 h from immediate as possible from return of spontaneous circulation (ROSC), at 24 h interval (NSE
i
,
24,48,72
and S-100B
i
,
24,48,72
). The area under curves (AUCs) were used to identify the sensitivities of two biomarkers for predicting poor neurologic outcomes. The primary outcome was the 3-months neurological outcomes.

Results:
We enrolled 35 patients (males, 28), and 16 subjects had a poor neurologic outcome. NSE and S-100B levels were significantly higher in the poor outcome group compared to the good outcome group at each time point. The AUCs of NSE and S-100B for poor neurological outcomes were 0.87 versus 0.95 at immediately, 0.96 versus 0.92 at 24 h, 0.99 versus 0.97, and 0.98 versus 0.97 at 72 h after ROSC, respectively. The sensitivities with 100% specificity of NSE and S-100B for poor neurological outcomes were 62.5 versus 33.3 at immediate, 73.3 versus 71.4 at 24 h, 92.9 versus 92.3 at 48 h, and 91.7 versus 88.9 at 72 h after ROSC, respectively.

Conclusions:
S-100B can be useful for early predicting the neurological outcomes of comatose OHCA patients within 24 hours from ROSC in spite of low sensitivity, whereas NSE need 24 hours at least for prognostication. Further prospective with large sample size in multicenter studies are needed to confirm out results.
Abstract 316: Younger Age Increases Risk of Self-reported Affective and Cognitive Sequelae Six Months Post Cardiac Arrest
Authors: Evald Lars , Bronnick Kolbjorn , Duez Christophe Henri Valdemar , Jeppesen Anni , Grejs Anders Morten , Søreide Eldar , Kirkegaard Hans , Feldbæk Nielsen Jørgen
Published: November 2020

Introduction:
Self-reported affective and cognitive sequelae are frequently reported in cardiac arrest survivors; however, little is known about the risk factors.

Hypothesis:
We assessed the hypothesis that self-reported (subjective) affective and cognitive outcomes six months after OHCA may be associated with demography, acute care and cerebral outcome.

Methods:
This is a sub study of the multicenter “Target Temperature Management for 48 vs. 24 hours and Neurologic Outcome after Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial” (the TTH48 trial) investigating the effect of prolonged TTM (24h vs 48h) at 33±1°C. Patients with good outcome on the Cerebral Performances Categories (CPC score≤2) were invited to answer questionnaires on anxiety, depression, emotional distress, perceived stress and cognitive failures six months after OHCA. Multivariate regression analyses were used to test the possible predictors of self-reported outcomes six months follow-up added successively in three blocks: [1] demography (age and gender), [2] acute care (time to ROSC and allocated treatment (24h vs 48h TTM)) and [3] cerebral outcome (objective cognitive impairment and CPC score).

Results:
A total of 79 out of 107 eligible patients were included in the analysis. There were no significant differences in baseline characteristics between the included group and the group lost to follow-up. [1] Younger age was a significant predictor across all self-reported outcomes, even when controlling for gender, ROSC time, treatment allocation, cognitive impairment and global outcome (CPC). Female gender was a predictor of anxiety, though this should be interpreted cautiously as only eight women participated. [2] ROSC time predicted self-reported cognitive failures, when not controlling for block 3. Treatment allocation had no predictive value. [3] Objective cognitive impairment was not a predictor of self-reported affective or cognitive sequelae. The CPC score was a significant predictor of self-reported affective outcomes, albeit not for self-reported cognitive failures.

Conclusion:
Younger age was a significant risk factor for self-reported affective and cognitive sequelae six months post OHCA. The CPC score may be a proxy for self-reported affective outcomes.
Abstract 317: Outcome Predictors in Substance - Related Cardiac Arrests
Authors: Kulpanowski Annelise , Hancock Brandon , Rosenthal Eric , Edlow Brian L , Kimberly William , Westover Michael B , Amorim Edilberto , Ning Mingming , Copen William A , Schaefer Pamela , Malhotra Rajeev , Giacino Joseph T , Greer David M , Wu Ona
Published: November 2020

Introduction:
The incidence of substance-related cardiac arrests (SRCA) has increased due to the opioid epidemic. Previous studies have shown that SRCA present differently than non-SRCA. Weinvestigated differences in the clinical courses between the two groups for patients who were initially comatose post-resuscitation.

Methods:
Data from out-of-hospital arrest patients seen between 2007-2019 were retrospectively analyzed. Arrests were classified as SRCA if the patient had a positive toxicology screen, witnesses testified to substance use, or drug paraphernalia was present at the scene. Arrest types were categorized as shockable or non-shockable. Cerebral edema classifications were based on MRI or CT radiology reports. Poor outcomes were defined as Cerebral Performance Category (CPC) > 3 at discharge. Differences in demographics, presentation and outcomes were compared (Fisher’s Exact Test or Exact Wilcoxon-Mann-Whitney). Multivariable backward stepwise logistic regression was performed.

Results:
SRCA patients (N=90) were younger (p<.001), more likely to be non-shockable (p<.001) and have worse Glasgow Coma Scale (GCS) scores (p=.041) and higher Incidence (p<.001) and earlier development of cerebral edema (p=.04) than non-SRCA patients (N=339) (see Table). Adjusting for age and sex, SRCA was a significant predictor of GCS (p=0.02), shockable rhythm (p<.001), edema (p=.004) and poor outcomes (p=.016). SRCA (p<.001) remained an independent predictor of shockable rhythm in multivariable regression including sex (p<.001) and GCS (p=.006). Multivariable analyses showed younger age (p=.001) and non-shockable rhythm (p=.002) to be predictors of edema development. Older age (p=.002) and edema (p<.001) remained significant predictors of poor outcomes.

Discussion:
SRCA patients are more likely to have non-shockable arrests which in turn leads to cerebral edema development and potentially worse outcomes.
Abstract 319: A Multi-faceted Programmatic Approach Associated with Over 50% Reduction in In-hospital Mortality
Authors: Mukhopadhyay Amrita , Cheung Wai Sha (Sally) , Yuriditsky Eugene , Drus Karsten , Wong Quyen , Horowitz James , Radford Martha J
Published: November 2020

Introduction:
In the United States, the chance of dying in the hospital widely varies by hospital, with bottom-decile hospitals having twice the rates of risk-adjusted mortality when compared to top-decile hospitals. This suggests a need for improvement in health systems nationwide. Here, we describe the implementation of, and associated outcomes for a multi-faceted, evidence-based approach to reducing in-hospital mortality.

Methods:
This is a retrospective interrupted time-series conducted at a large, urban, academic health system. Specifically, we describe the implementation of the following evidence-based methods: 1) escalation of communication guidelines, 2) proactive rounding with nurse response teams, and 3) rapid response teams with dedicated staff. We then quantify the associated observed-to-expected (O:E) in-hospital mortality over a 12-year period at our main hospital, and subsequently over a 3-year period at an affiliated hospital where the same interventions were later implemented.

Results:
Over 12 years, 445,308 patients were discharged from our main hospital, with 3,948 (0.9%) being discharged to an acute care facility, 4,558 (1.0%) discharged to hospice, and 4,648 (1.0%) expiring in the hospital. Patients had an average age of 53.1 years (std.dev 22.8 years), with the majority being female (59.0%), non-Hispanic white (66.1%), and admitted from the outpatient setting (93.3%). From the years 2010 to 2013, there was decline in O:E mortality by 59.0% (Figure 1A). This effect was sustained from 2014-2018. At the affiliate hospital, there was a similar decline in O:E mortality after implementation of the same interventions (60.5%, Figure 1B).

Conclusion:
Our multi-faceted, programmatic approach was associated with over 50% reductions in in-hospital mortality that were sustained for several years after implementation, and were reproduced at an affiliated hospital.
Abstract 320: Posttraumatic Stress Symptoms Are Associated with Quality of Life in Both Cardiac Arrest Survivors with Good Neurologic Recovery and Caregivers
Authors: Presciutti Alex , Newman Mary M , Vranceanu Ana-maria , Shaffer Jonathan , Perman Sarah M
Published: November 2020

Introduction:
Improvements in cardiac arrest (CA) survival have led to increased attention to quality of life (QoL) of survivors and their caregivers. In survivors, posttraumatic stress symptoms (PTS) are predictive of poor clinical outcome and subjective recovery. This study tested the hypothesis that PTS is associated with QoL in survivors and caregivers.

Method:
We distributed an online survey to CA survivors and caregivers who were members of the Sudden Cardiac Arrest Foundation. This analysis examined the following items: participant characteristics, PTSD Checklist-5 (PCL-5), Lawton Instrumental Activities of Daily Living scale, and physical, psychological, and social QoL subscales of the WHOQOL-BREF. We followed an identical analytic plan for survivors and caregivers. We identified potential covariates through a bivariate correlation matrix. We then ran three multiple regression models examining associations between PCL-5 scores with each QoL subscale, adjusted for covariates identified from the correlation matrix.

Results:
A total of 163 survivors (mean age: 50.1 years, 50.3% women, 95.5% white, mean months since arrest: 63.9) and 52 caregivers (mean age: 51.8 years, 86.5% women, 88.5% white, mean months since arrest: 43.2) provided full data. For survivors, the following variables showed significant bivariate associations with any QoL subscale: Lawton scores, self-reported memory problems, male sex, low income, months since CA, age, and CA location; for caregivers, months since CA, age, and low income. In survivors and caregivers, PCL-5 scores were associated with each QoL subscale (β: -.33 - -.54, p < .05) after adjusting for respective covariate sets. Further, in survivors, Lawton scores (β: .23, p <.01), presence of memory problems (β: -.24, p < .01), and male sex (β: .14, p <.05) were associated with physical QoL; presence of memory problems (β: -.26, p < .01) was associated with psychological QoL; and low income (β: -.16, p < .05) was associated with social QoL. In caregivers, months since CA was associated with social QoL (β: .27, p <.05).

Conclusion:
PTS was associated with QoL in CA survivors and caregivers. Future study should examine the feasibility of in-hospital assessment of PTS in dyads of CA survivors and their caregivers.