bluuebunny/crossref_metadata_2025 huggingface dataset:
The Association between the Activin A Serum Level and Carotid Intima-Media Thickness in Chronic Kidney Disease Patients
Authors: Yonata Ade , Ali Zulkhair , Indrajaya Taufik , Bahar Erial , Effendi Ian , Suhaimi Novadian , Suprapti Suprapti
Published: November 2020

Introduction. Chronic kidney disease (CKD) is associated with high mortality rates, mainly as a result of cardiovascular complications. Meanwhile, recent studies have suggested a role of a homodimer protein called activin A in chronic kidney disease-mineral and bone disorder (CKD-MBD) conditions that may exist in the vascular calcification and osteolytic process. Ultrasound examination of the carotid intima-media thickness (cIMT) is a noninvasive method to assess vascular calcification. This study aimed to analyze the relationship between the activin A serum level and cIMT in patients with CKD at Mohammad Hoesin Hospital, Palembang, Indonesia. Methods. We conducted a hospital-based, cross-sectional study of consecutive CKD patients at the Department of Internal Medicine, Mohammad Hoesin Hospital, from July to November 2019. The level of activin A was measured by enzyme-linked immunosorbent assay. Meanwhile, cIMT measurements were collected by B-mode ultrasound imaging. Results. A total of 55 patients with CKD were included in this investigation. The median serum activin A level in these patients was 236.17 (116.33–283) pg/mL, while the median cIMT was 0.8 (0.6–1.45) mm. A relationship between the serum activin A level and cIMT (r  =  0.449;

p
=
0.001

) was observed. During multivariate analysis with linear regression, triglyceride

p
=
0.049

, phosphate

p
=
0.005

, and activin A

p
=
0.020

serum levels were factors associated with cIMT. Conclusion. In this study, a relationship between the activin A serum level and cIMT in patients with CKD was identified. Vascular calcification should be screened for in all CKD patients by the measurement of cIMT.
Targeting PAK4 Inhibits Ras-Mediated Signaling and Multiple Oncogenic Pathways in High-Risk Rhabdomyosarcoma
Authors: Dasgupta Atreyi , Sierra Laura , Tsang Susan V. , Kurenbekova Lyazat , Patel Tajhal , Rajapakse Kimal , Shuck Ryan L. , Rainusso Nino , Landesman Yosef , Unger Thaddeus , Coarfa Cristian , Yustein Jason T.
Published: November 2020

Rhabdomyosarcoma (RMS) is the most prevalent pediatric soft-tissue sarcoma. Multimodal treatment, including surgery and traditional chemotherapy with radiotherapy, has contributed to improvements in overall survival rates. However, patients with recurrent or metastatic disease have 5-year survival rates of less than 30%. One reason for the lack of therapeutic advancement is identification and targeting of critical signaling nodes. p21-activated kinases (PAK) are a family of serine/threonine kinases downstream of multiple critical tumorigenic receptor tyrosine kinase receptors and oncogenic regulators, including IGFR and RAS signaling, that significantly contribute to aggressive malignant phenotypes. Here, we report that RMS cell lines and tumors exhibit enhanced PAK4 expression levels and activity, which are further activated by growth factors involved in RMS development. Molecular perturbation of PAK4 in multiple RMS models in vitro and in vivo resulted in inhibition of RMS development and progression. Fusion-positive and -negative RMS models were sensitive to two PAK4 small-molecule inhibitors, PF-3758309 and KPT-9274, which elicited significant antitumor and antimetastatic potential in several primary and metastatic in vivo models, including a relapsed RMS patient-derived xenograft model. Transcriptomic analysis of PAK4-targeted tumors revealed inhibition of the RAS-GTPase, Hedgehog, and Notch pathways, along with evidence of activation of antitumor immune response signatures. This PAK4-targeting gene signature showed prognostic significance for patients with sarcoma. Overall, our results show for the first time that PAK4 is a novel and viable therapeutic target for the treatment of high-risk RMS.

Significance:

These data demonstrate a novel oncogenic role for PAK4 in rhabdomyosarcoma and show that targeting PAK4 activity is a promising viable therapeutic option for advanced rhabdomyosarcoma.
Transcriptional Activation of MYC-Induced Genes by GCN5 Promotes B-cell Lymphomagenesis
Authors: Farria Aimee T. , Plummer Joshua B. , Salinger Andrew P. , Shen Jianjun , Lin Kevin , Lu Yue , McBride Kevin M. , Koutelou Evangelia , Dent Sharon Y.R.
Published: November 2020

Overexpression of the MYC oncoprotein is an initiating step in the formation of several cancers. MYC frequently recruits chromatin-modifying complexes to DNA to amplify the expression of cancer-promoting genes, including those regulating cell cycle, proliferation, and metabolism, yet the roles of specific modifiers in different cancer types are not well defined. Here, we show that GCN5 is an essential coactivator of cell-cycle gene expression driven by MYC overexpression and that deletion of Gcn5 delays or abrogates tumorigenesis in the Eμ-Myc mouse model of B-cell lymphoma. Our results demonstrate that Gcn5 loss impacts both expression and downstream functions of Myc.

Significance:

Our results provide important proof of principle for Gcn5 functions in formation and progression of Myc-driven cancers, suggesting that GCN5 may be a viable target for development of new cancer therapies.
Cell Softness Prevents Cytolytic T-cell Killing of Tumor-Repopulating Cells
Authors: Liu Yuying , Zhang Tianzhen , Zhang Haizeng , Li Jiping , Zhou Nannan , Fiskesund Roland , Chen Junwei , Lv Jiadi , Ma Jingwei , Zhang Huafeng , Tang Ke , Cheng Feiran , Zhou Yabo , Zhang Xiaohui , Wang Ning , Huang Bo
Published: November 2020

Biomechanics is a fundamental feature of a cell. However, the manner by which actomysin tension affects tumor immune evasion remains unclear. Here we show that although cytotoxic T lymphocytes (CTL) can effectively destroy stiff differentiated tumor cells, they fail to kill soft tumor-repopulating cells (TRC). TRC softness prevented membrane pore formation caused by CTL-released perforin. Perforin interacting with nonmuscle myosin heavy-chain 9 transmitted forces to less F-actins in soft TRC, thus generating an inadequate contractile force for perforin pore formation. Stiffening TRC allowed perforin the ability to drill through the membrane, leading to CTL-mediated killing of TRC. Importantly, overcoming mechanical softness in human TRC also enhanced TRC cell death caused by human CTL, potentiating a mechanics-based immunotherapeutic strategy. These findings reveal a mechanics-mediated tumor immune evasion, thus potentially providing an alternative approach for tumor immunotherapy.

Significance:

Tumor-repopulating cells evade CD8+ cytolytic T-cell killing through a mechanical softness mechanism, underlying the impediment of perforin pore formation at the immune synapse site.
Functional Testing for Tranexamic Acid Duration of Action Using Modified Viscoelastometry
Authors: Kammerer Tobias , Groene Philipp , Sappel Sophia R. , Peterss Sven , Sa Paula A. , Saller Thomas , Giebl Andreas , Scheiermann Patrick , Hagl Christian , Schäfer Simon Thomas
Published: November 2020

Introduction: Tranexamic acid (TXA) is the standard medication to prevent or treat hyperfibrinolysis. However, prolonged inhibition of lysis (so-called “fibrinolytic shutdown”) correlates with increased mortality. A new viscoelastometric test enables bedside quantification of the antifibrinolytic activity of TXA using tissue plasminogen activator (TPA). Materials and Methods: Twenty-five cardiac surgery patients were included in this prospective observational study. In vivo, the viscoelastometric TPA test was used to determine lysis time (LT) and maximum lysis (ML) over 96 h after TXA bolus. Additionally, plasma concentrations of TXA and plasminogen activator inhibitor 1 (PAI-1) were measured. Moreover, dose effect curves from the blood of healthy volunteers were performed in vitro. Data are presented as median (25–75th percentile). Results: In vivo TXA plasma concentration correlated with LT (r = 0.55; p < 0.0001) and ML (r = 0.62; p < 0.0001) at all time points. Lysis was inhibited up to 96 h (LTTPA-test: baseline: 398 s [229–421 s] vs. at 96 h: 886 s [626–2,175 s]; p = 0.0013). After 24 h, some patients (n = 8) had normalized lysis, but others (n = 17) had strong lysis inhibition (ML <30%; p < 0.001). The high- and low-lysis groups differed regarding kidney function (cystatin C: 1.64 [1.42–2.02] vs. 1.28 [1.01–1.52] mg/L; p = 0.002) in a post hoc analysis. Of note, TXA plasma concentration after 24 h was significantly higher in patients with impaired renal function (9.70 [2.89–13.45] vs.1.41 [1.30–2.34] µg/mL; p < 0.0001). In vitro, TXA concentrations of 10 µg/mL effectively inhibited fibrinolysis in all blood samples. Conclusions: Determination of antifibrinolytic activity using the TPA test is feasible, and individual fibrinolytic capacity, e.g., in critically ill patients, can potentially be measured. This is of interest since TXA-induced lysis inhibition varies depending on kidney function.
Boredom in Borderline Personality Disorder: A Lost Criterion Reconsidered
Authors: Masland Sara R. , Shah Tanya V. , Choi-Kain Lois W.
Published: November 2020

Difficulty with boredom was eliminated from the formal diagnostic criteria for borderline personality disorder (BPD) in 1994 based on significantly limited, unpublished data. However, it is apparent in clinical practice that boredom remains relevant to BPD. This review synthesizes empirical research, with consideration of theoretical accounts, to critically examine the relevance of boredom to BPD. We first briefly review issues in defining and measuring boredom and offer an expanded conceptualization for BPD, which includes the notion of boredom reactivity, before turning to boredom’s differentiation from and overlap with feelings of emptiness, with which it was paired prior to its removal from the DSM. We then discuss perspectives on boredom’s significance in BPD, briefly touching on its relevance in other personality disorders. We propose a Boredom Cascade Model that articulates how boredom and boredom reactivity interact with identity disturbance and chronic emptiness to create escalating patterns of behavioral dysregulation and make recommendations for research and treatment.
EFL Students’ Attitudes and Perception towards English Language Learning and Their English Language Proficiency: A Study from Assa’adah Islamic Boarding School, Indonesia
Authors: G. Jaliyya Falita , Idrus Faizah
Published: November 2020

The English language has been given the status of Foreign Language (FL) in Indonesia, unlike the language being a second language in its neighbouring countries. However, the language has becoming quite popular and dominant in certain parts of Indonesian schools, especially private schools and colleges. Thus, this investigation sought to examine the attitudes and perceptions of selected Indonesian English language learners. It also aspired to find out how these attitudes and perceptions towards the English language affect their proficiency. A qualitative research design employing the in-depth semi-structured interview was carried out with 12 students at the As’saadah Islamic Boarding School in Banten, West Java.  Thematic analyses were also performed to analyse the data. The findings point to the direction of students’ motivation in learning English as a foreign language. Students were found to have positive attitudes  and were motivated  to learn the language although learning the language might not stem from their own willingness to learn.
Abstract 109: Aerosol Generation During Chest Compression and Defibrillation in a Swine Cardiac Arrest Model
Authors: Hsu Cindy H , Tiba Mohamad H , Boehman Andre , McCracken Brendan M , Leander Danielle C , Francalancia Stephanie C , Pickell Zachary , Sanderson Thomas H , Ward Kevin R , Neumar Robert W
Published: November 2020

Introduction:
Respiratory infections can occur through the transmission of virus-containing aerosols from infected individuals. It remains unclear whether cardiac arrest (CA) resuscitation generates aerosols that have the potential to transmit diseases including COVID-19.

Hypothesis:
In a swine CA model, chest compression and defibrillation generate aerosols (≤10 μm) that could contain respiratory viruses.

Methods:
To simulate witnessed CA with bystander-initiated CPR, 3 female non-intubated swine underwent 4 minutes of untreated ventricular fibrillation CA followed by ten 2-minute cycles of mechanical chest compression and defibrillation without ventilation. The diameter (0.3 - 10 μm) and quantity of aerosols generated during 45-second intervals of no-flow, chest compression, and after each defibrillation were collected via a nose cone by the TSI Optical Particle Sizer. Aerosol generated from the coughs of 4 healthy human subjects were also compared to the swine data.

Results:
There was no significant difference between the total aerosols generated during chest compression compared to no-flow. In contrast, defibrillation followed by chest compression generated significantly more aerosols than chest compression or no-flow alone (72.4 ± 41.6 x10
4
vs 12.3 ± 8.3 x10
4
vs 10.5 ± 11.2 x10
4
; p < 0.0001), particularly at the larger-sized aerosols. Two consecutive human coughs generated 54.7 ± 33.9 x10
4
aerosols with a size distribution much smaller than post-defibrillation CPR (Table).

Conclusion:
Chest compression generated comparable aerosols to no-flow in a swine CA model. In contrast, defibrillation followed by chest compression generated significantly more aerosols than chest compression or no-flow alone, with a distribution shift toward larger aerosols. Additional research is needed to elucidate the mechanisms by which aerosol generation during chest compression is modified by defibrillation and to assess rescuer risk during CA resuscitation.
Abstract 111: Outcomes for Patients Receiving Cardiopulmonary Resuscitation During Novel Coronavirus Outbreak in The United States
Authors: Sheth Priyanka , Kazimuddin Habeeb F , McElroy Douglas , Singh Aniruddha
Published: November 2020

Introduction:
Since the start of the novel coronavirus outbreak in the U.S., the CDC and AHA have introduced new CPR guidelines involving increased precautions for protecting healthcare providers from infection. These precautions have been widely adopted for both known and potential COVID+ patients despite debate over increased strain on CPR providers and potentially inferior outcomes. In order to bridge the knowledge gap surrounding safe, effective CPR practices in the presence of COVID-19, patient outcomes for codes performed in our medical center since March 2020 were compared to those of the same time last year.

Methods:
A total of 94 hospital codes across 80 patients were included. Age, BMI, and code duration were tested for significant differences in means between groups using ANOVA, with pairwise comparisons done using Tukey’s HSD test. Discrete variables were tested for significant differences among groups using chi-square association tests.

Results:
Groups were well matched on patient characteristics. There were no significant differences in age, comorbidities, or rhythm type among groups. COVID+ patients had significantly higher BMI than non-COVID patients. Code duration was significantly greater in the COVID+ group. However, there was no significant difference in code survival; 5 of 10 COVID+ patients (50%) survived the code event, compared to 54 of 84 (64%) non-COVID patients. Only 1 of 10 (10%) COVID+ patients was discharged alive vs. 18 of 71 non-COVID patients (25%); while not significant, this difference is perhaps worthy of further attention.

Conclusions:
Patient outcomes between 2019 and 2020 were comparable, indicating that extra precautions taken by healthcare personnel during the COVID-19 outbreak are not degrading the quality of CPR administered. However, COVID+ patients had significantly longer code durations than non-COVID patients in both years, suggesting a greater difficulty in restoring spontaneous circulation in the virus group.
Abstract 114: Effect of Body Position on Intracranial Pressure and Carotid Blood Flow During Extracorporeal Cardiopulmonary Resuscitation
Authors: Levy Yaël , Fernandez Rocio , Lidouren Fanny , Kohlhauer Matthias , Lamhaut Lionel , Hutin Alice , Leger Pierre-Louis , Debaty Guillaume P , Lurie Keith G , Ghaleh Bijan , Tissier Renaud
Published: November 2020

Introduction:
Extracorporeal cardiopulmonary resuscitation (E-CPR) using extracorporeal membrane oxygenation (ECMO) is widely proposed for the treatment of refractory cardiac arrest.

Hypothesis:
Since cerebral autoregulation is altered in such conditions, body position may modify hemodynamics during ECPR. Our goal was to determine whether a whole body tilt-up challenge (TUC) could lower intracranial pressure (ICP) as previously shown with conventional CPR, without deteriorating cerebral blood flow (CBF).

Methods:
Pigs were anesthetized and instrumented for the continuous evaluation of CBF, ICP and systemic hemodynamics. After 15 min of untreated ventricular fibrillation they were treated with 30 min of E-CPR followed by sequential defibrillation shocks until resumption of spontaneous circulation (ROSC). ECMO was continued after ROSC to target a mean arterial pressure (MAP) >60 mmHg. Animals were maintained in the flat position (FP) throughout protocol, except during a 2 min TUC of the whole body (+30°) at baseline, during E-CPR and after-ROSC.

Results:
Four animals received the entire procedure and ROSC was obtained in 3/4. After cardiac arrest, E-CPR was delivered at 29±2 ml/kg/min to maintain a MAP of 57±8 mmHg in the FP. CBF was 28% of baseline and ICP remain stable (12±1 vs 13±1 mmHg during ECPR vs baseline, respectively). Under baseline pre-arrest conditions TUC resulted in a significant decrease in ICP (-63±7%) and CBF (-21±3%) versus the FP, with no significant effect on systemic hemodynamics. During E-CPR and after ROSC, TUC markedly reduced ICP but CBF remained unchanged vs the FP (Figure).

Conclusion:
During E-CPR whole body TUC reduced ICP without lowering CBF compared with E-CPR flat. Additional investigations with prolonged TUC and selective head and thorax elevation during E-CPR are warranted.
Abstract 119: Association of Acute Exposure to Ambient Air Particulate Matter and Ozone with Risk of Out-of-hospital Cardiac Arrest
Authors: Malik Ali , Jones Philip , Brook Robert , Tran Andy T , Chan Paul S
Published: November 2020

Introduction:
Acute exposure to particulate matter < 2.5 μm in diameter (PM
2.5
) and ozone have been associated with increased all-cause mortality in the U.S. Whether these ambient air pollutants are specifically associated with a higher risk of out-of-hospital cardiac arrest (OHCA) is unknown.

Methods:
Within the Cardiac Arrest Registry to Enhance Survival, we identified 187,047 individuals with non-traumatic OHCA during 2013-2016 that could be linked to EPA data. We estimated an individual’s exposure to PM
2.5
and ozone using data from the EPA’s Fused Air Quality Surface using a Downscaling tool, which integrates monitoring station data with atmospheric models to predict daily levels by census tract. The associations of acute exposure to PM
2.5
and ozone with OHCA were examined using a time-stratified case-crossover design. Case day was defined as the day of the OHCA. Associations were also assessed for moving average across days 0-1 (lag 1) and days 0-2 (lag 2). Control days were defined as the same weekday from the preceding 2 weeks. Associations were estimated using conditional logistic regression on PM
2.5
and ozone, stratified by patient. We also explored if associations varied by age, sex, race and OHCA rhythm.

Results:
Mean age was 62.6 ± 19.4 years, 61.1% were male, and 52.6% non-White. Mean pollutant concentrations on case day were 9.2 ± 4.9 μg/m
3
PM
2.5
and 36.9 ± 12.1 parts per billion (ppb) ozone. We found a significant effect of ozone on the case day with a 1.1% increase in odds of OHCA per +12 ppb greater ozone level. There was no association with PM
2.5
on either case or lag days, and no association with ozone on lag days

(Table). There was no interaction of age, sex, race and OHCA rhythm with PM
2.5
or ozone with risk of OHCA on either case or any lag days (p >0.2 for all).

Conclusion:
In the U.S. exposure to higher ozone levels, but not PM
2.5
, was associated with a higher risk of OHCA. Mechanisms by which acute ozone exposure increases risk need to be better defined.
Abstract 120: Artesunate Reduces the Severity of Post-Resuscitation Myocardial and Cerebral Dysfunction
Authors: Li Hui , Cheng Cheng , Liang Lian , Jin Tao , Zhang Guozhen , Bradley Jennifer , Peberdy Mary Ann A , Ornato Joseph P , Tang Wanchun
Published: November 2020

Introduction:
Artesunate (ART) possesses anti-inflammatory activity, which can mitigate the systemic inflammatory response in poor outcomes of cardiac arrest (CA). We investigated the effects of ART on myocardial and cerebral function, duration of survival, and inflammation in a rat model of CA and cardiopulmonary resuscitation (CPR).

Hypothesis:
ART reduces the severity of post resuscitation myocardial and cerebral dysfunction by alleviating inflammation in a rat model of CA and CPR.

Methods:
30 male Sprague-Dawley rats weighing between 450g-550g were randomized into 3 groups: Sham (S), Control (C), and Artesunate (A). C and A were divided into subgroups: survival and non-survival (n=6). Ventricular fibrillation (VF) was induced and untreated for 6 min. A 4J defibrillation was attempted after 8 min of CPR. Phosphate buffer (1ml/kg, pH 7.9-8.1) or ART (2.4mg/kg), was administered at return of spontaneous circulation (ROSC). Myocardial function was measured at baseline and every hour for 4h post ROSC. Plasma levels of IL-6, TNF-α and cTnI were detected at baseline and 4h after ROSC. Survival animals were observed for an additional 72h. Neurologic deficit scores were recorded daily.

Results:
ART reduced the severity of post-resuscitation myocardial dysfunction compared to C. It attenuated IL-6, TNF-α and cTnI plasma levels 4h after ROSC (p<0.05) (Fig. 1). Post-resuscitation cerebral function and survival rate also improved significantly (p<0.05) (Fig. 2).

Conclusion:
ART reduces the severity of post-resuscitation myocardial and cerebral dysfunction, improves survival rate and attenuates inflammation in a rat of model of CA and CPR.
Abstract 123: Intra-arrest Delivery of Intra-muscular Magnesium Sulfate in a Rat Model of Cardiac Arrest
Authors: Zhang Rui , Liao Jinhui , Raghunayakula Sarita , Ren Xiaodan , Maheras Kathleen , Gruley Erin , Chen Yuguo , Neumar Robert W , Sanderson Thomas H
Published: November 2020

Introduction:
Brain injury is the most common cause of death for patients resuscitated from cardiac arrest. Magnesium is an attractive neuroprotective therapy that has the potential to reduce neuronal calcium overload via NMDA receptor modulation and prevent mitochondrial permeability transition. Intramuscular (IM) delivery of MgSO4 during CPR has the potential to target these mechanisms within their presumed therapeutic window.

Hypothesis:
IM MgSO4 administrated during CPR will achieve therapeutic serum magnesium levels, which is ≥ 2 times of baseline, within 15 minutes after ROSC and improve neurologic outcomes.

Methods:
Male Long Evans rats were subjected to 8-minute asphyxial cardiac arrest. For the dose-finding study (n = 4/group), rats were block randomized to receive placebo, 107 mg/kg, 215 mg/kg, or 430 mg/kg MgSO4 IM at the onset of CPR. Serial blood samples were collected at baseline, 15 min, 30 minutes, 1 hour and 2 hours after return of spontaneous circulation (ROSC) and analyzed for serum magnesium concentration. For the long-term outcome study (n = 9/group), rats subjected to cardiac arrest were blindly block randomized to the same treatment groups with the addition of a sham-operated group. Post-cardiac arrest care included maintenance of normothermia (36.7 °C - 37.3 °C) for 72 hours. Serial blood samples were collected at baseline, 15 min and 1 hour after ROSC and neurologic function score (NFS) was performed daily for 10 days. Good neurologic function was predefined as NFS ≥ 450.

Results:
IM MgSO4 during CPR had no effect on ROSC rate (p > 0.05). The serum magnesium concentrations at 15 min after ROSC of 107 mg/kg group, 215 mg/kg group and 430 mg/kg group were 3.9 ± 0.9, 6.2 ± 1.8, and 7.6 ± 1.8 mg/dl, which were 2.0 fold, 3.1 fold and 4.2 fold of baseline respectively. IM MgSO4 had no statistically significant effect on 10-day survival or 10-day survival with good neurologic function.

Conclusion:
Single dose IM MgSO4 during CPR achieves up to 4-fold baseline magnesium levels within 15 min after ROSC in a rat model of asphyxia cardiac arrest. This treatment strategy did not improve survival or recovery of neurologic function. Future studies with repeated dosing or in combination with hypothermic targeted temperature management may be indicated.
Abstract 129: Gasping During Cardiac Arrest Before Cardiopulmonary Resuscitation Increases Cerebral Oximetry in a Swine Model
Authors: Rojas-Salvador Nelly , Salverda Bayert , Moore Johanna C , Lick Michael , Debaty Guillaume P , Lurie Keith G
Published: November 2020

Introduction:
Spontaneous gasping (SG) during cardiac arrest is associated with favorable neurological outcomes. SG lowers intrathoracic pressure (ITP), enhancing flow of respiratory gases to the lungs and venous blood to the heart, while simultaneously lowering intracranial pressure (ICP). The impact of SG on regional cerebral oximetry (rSO2) is unknown.

Hypothesis:
During untreated ventricular fibrillation (VF), SG will increase rSO2 until the gasping effort declines.

Methods:
Swine (~40 kg) were intubated and anesthetized with isoflurane. After 8 min of untreated VF, conventional mechanical CPR at 100 compressions/min was performed. Intrathoracic pressure (ITP), mean aortic pressure (MAP), ICP, right atrial pressure (RAP) and calculated cerebral perfusion pressure (CerPP) were measured continuously. rSO2 was measured continuously with near-infrared spectroscopy (Equanox 7600, Nonin Medical). These parameters were assessed before and during SG, and during CPR. Data are expressed as mean ± SD. A paired Student’s
t-
test was used.

Results:
SG occurred in 19/22 pigs during untreated VF, with 9.2 ± 4.3 gasps/pig. For pigs that gasped, the individual gasp duration was 1.74 ± 0.52 sec and the maximum negative ITP (mmHg) was -3.24 ± 1.93 mmHg. rSO2 increased in 9/19 (47%) pigs from 54.7% ± 4.1 to 57.8% ± 4.8 during SG (p<0.001). Figure 1 shows rSO2 from 2 representative pigs, A) with and B) without SG. SG also decreased ITP (p<0.001), RAP (p=0.02) and ICP (p<0.001), and increased MAP (p<0.001) and CerPP (p<0.001). After 8 min of untreated VF, rSO2 for all 22 pigs was 49.3% ± 3.7. After 30 and 60 sec of CPR, rSO2 values were 54.6% ± 3.8 and 57.8% ± 3.8, respectively.

Conclusions:
rSO2 values increased in nearly half of animals with SG. This increase in rSO2 with SG was equal to the level of rSO2 achieved after 1 minute of CPR. Further study is warranted to determine potential prognostic and therapeutic implications of SG-induced increases rSO2 during cardiac arrest.
Abstract 133: Association of End Tidal Carbon Dioxide >20mmhg with Pediatric In-hospital Cardiac Arrest Quality of Cpr and Survival
Authors: Yu Priscilla , Sutton Robert M , Hanna Richard , Zhang Xuemei , Griffis Heather M , Niles Dana E , Berg Robert A , Christoff Andrea , del Castillo Jimena , Ikeyama Takanari , Gilleland Jonathan , Abulebda Kamal , Raymond Tia T , Nadkarni Vinay M
Published: November 2020

Introduction:
AHA recommends titrating chest compressions (CC) to achieve end-tidal carbon dioxide (ETCO2)>20mmHg, based on laboratory, adult, and very limited pediatric IHCA data.

Hypothesis:
ETCO2>20mmHg averaged during the first 10 min of recorded CPR is associated with 1) compliance with AHA CC depth quality targets, and 2) survival to hospital discharge.

Methods:
All pediatric 2015-2019 IHCA events reported by 4 pediRES-Q sites with simultaneous ETCO2 and CC metrics (ZOLL R-Series defibrillator) measured. Analysis included the first 10 min of CPR with CC data recorded using dual sensor accelerometers that compensate for mattress deflection. Compliance with 2015 AHA guidelines CC depth quality target defined as ∼1/3 estimated AP diameter: ≥3.4 cm for infants <1yr, ≥4.4cm for 1 to < 8yrs, and 4.5-6.6cm for 8 to ≤ 18yrs. Primary analysis for
ETCO2>20mmHg cutoff
association with CC depth and survival by modified Poisson regression models, accounting for age. Secondary analysis for
mean ETCO2 (no a priori cutoff)
association with CC depth and survival, adjusting for age.

Results:
Of 44 events (24 index): median 10-min averaged ETCO2 was 23 [IQR 13, 37] mmHg, CPR duration was 23 [IQR 10, 53] min, return of spontaneous circulation (ROSC) was 70% (31/44), and survival to hospital discharge was 33% (8/24). ETCO2>20 mmHg cutoff

was

associated with CC depth [RR 1.55 (95%CI: 1.20,2.00) p=0.0007], and age-specific AHA depth quality target compliance [RR 1.01 (95%CI: 1.00,1.02) p=0.02. However, ETCO2 > 20mmHg cutoff

was not

significantly associated with survival: ROSC [RR 1.08 (95%CI: 0.71, 1.65), p=0.72)] nor survival to hospital discharge [RR 1.10 (95%CI: 0.33, 3.65), p=0.87]. Mean 10-min averaged ETCO2 (no cutoff)

was not

significantly associated with CC depth (p=0.09), age-specific AHA depth quality target compliance (p=0.07), ROSC (p=0.57) , nor survival to hospital discharge (26 [IQR 14, 43] mmHg vs. 16 [IQR 13,34] mmHg non-survival to hospital discharge, p=0.28).

Conclusions:
In this multicenter pediatric In-hospital CPR cohort, ETCO2>20mmHg cutoff averaged during the first 10-min of recorded CPR was significantly associated with CC depth and age-specific AHA depth quality target compliance, but not with ROSC or survival to hospital discharge.
Abstract 137: Lack of Racial Diversity in Cardiopulmonary Resuscitation Training Films: A Cross-sectional Analysis
Authors: Blount Courtland , Lynes Carlos , Richie Jamaal , Narvaez Brittiany , Green Danielle B , Herrera Crystal M , Sella Sarah F , Jara Christian H , Ogburn Tim , Nguyen Eric B , Toft Lorrel E
Published: November 2020

Introduction:
Minorities are less likely to be CPR-trained, and less likely to receive bystander CPR compared to whites.

Hypothesis:
We hypothesized that modern CPR training films demonstrate poor racial diversity and therefore poor relevance to minority communities.

Methods:
Using the query “how to do CPR” in Google and YouTube, 350 and 500 films were reviewed. Exclusion criteria included: pre-2015, non-English, non-instructional, pediatric or animal victims, duplicates, parity, or in-hospital cardiac arrest. For each film, 4 racially-diverse evaluators identified the race of the instructor, rescuer, victim, and manikin as “white” or “non-white.” Films were scored on 6 aspects of CPR instruction: scene safety, check responsiveness, activate Emergency Medical Services, proper hand position, accurate rate, and appropriate depth of compressions. Similarly, the race of characters in CPR training films from the American Heart Association (AHA) and American Red Cross (ARC) were analyzed by one self-identified non-white evaluator.

Results:
Of 72 online films meeting the criteria, 50 used a human instructor (76% white); 19 showed a human victim (84% white); 70 depicted a human rescuer (74% white); and 58 featured a manikin (95% white) (p<0.0001 for all, white v. non-white). Only 10 of 72 films (14%) taught hands-only CPR, featured AT LEAST ONE non-white character, and were of high-quality (
>
5 aspects of CPR instruction). Inter-rater reliability was high (>0.775). We also reviewed 7 ARC and 7 AHA adult CPR training films (2015 or later). Four of 7 AHA films (57%) and 2 of 7 ARC films (29%) featured at least one non-white character (Figure 1).

Conclusion:
We identified only 10 online high-quality films teaching hands-only CPR which feature at least one non-white character. CPR instructional films from the AHA and ARC showed greater racial diversity. Improved racial representation in CPR training films is important to increase relevance to under-trained minority communities.
Abstract 143: The Modified Shock Index Separates Survivors from Non-Survivors in a Swine Model of Hemorrhagic Shock and Traumatic Brain Injury
Authors: Mendelson Jenna , Maggio Matt , Aiello Salvatore , Radhakrishnan Jeejabai , Baetiong Alvin , Gazmuri Raul J
Published: November 2020

The ratio between heart rate and arterial blood pressure during hemorrhagic shock has been shown useful to identify individuals at risk of death. We herein compared the index using the systolic arterial pressure (SI) and using the mean arterial pressure (MSI) along with other measurements including cardiac index and lactate in a swine model of hemorrhagic shock and traumatic brain injury developed to model injury in the battlefield. The parent study was designed to compare three different types of vasopressin agonists with control solution while practicing fluid-restricted resuscitation. The present analysis included 60 experiments focused on the initial 240 minutes with induction of hemorrhagic shock by liver laceration removing approximately 1,000 ml of blood in 30 minutes. Eight animals died during the acute phase and compare to 52 survivors, they had higher (median, IQR) MSI (4.6; 3.3 - 5.4 vs 2.5; 2.0 - 3.1; p < 0.001), SI (2.7; 2.1 - 3.1 vs 1.8; 1.6 - 2.2; p < 0.001), lower cardiac index (2.8; 2.3 - 3.4 vs 3.7; 3.2 - 4.2; p < 0.001), but no differences in lactate levels. Three of the eight non-survivors (37.5%) and 42 of the 52 survivors (80.1%) received a vasopressin analog (p = 0.019). Compared to other measurements of hemodynamic stability, monitoring the ratio between the heart rate and mean arterial pressure is a feasible and practical approach to deploy in various out of hospital settings including the battlefield as well as in civilian trauma. This approach could also guide interventions including the use of vasopressor agents, which our studies demonstrate having a survival effect during acute bleeding caused by hemorrhagic shock.
Abstract 146: Association of Epinephrine Prior to Defibrillation with Survival in Patients with In-hospital Cardiac Arrest
Authors: Evans Erin , Swanson Morgan B , Mohr Nicholas , Nassar Boulos , Chan Paul S , Girotra Saket
Published: November 2020

Background:
Prompt defibrillation is a first line treatment for in-hospital cardiac arrest (IHCA) due to a shockable rhythm, with epinephrine recommended only when defibrillation is ineffective. However, empirical data regarding epinephrine prior to first defibrillation for shockable IHCA and its association with survival are unavailable.

Methods:
Using 2000-2018 Get with the Guidelines Resuscitation data, we identified adults (
>
18 years) with an index IHCA due to an initial shockable rhythm. We conducted a time-dependent propensity-matched analysis to evaluate the association of epinephrine prior to first defibrillation with survival to discharge and acute resuscitation survival (i.e., return of spontaneous circulation for
>
20 minutes).

Results:
Among 34,688 subjects, 10,057 (29.0%) received epinephrine before defibrillation. Median age was 67 years in both groups. Compared to defibrillation first, patients in the epinephrine first group were less likely to have myocardial infarction or heart failure, but more likely to have renal failure, sepsis and pneumonia, be located in an intensive care unit, and already receiving mechanical ventilation (P <0.001 for all). Treatment with epinephrine first was strongly associated with a delay in first defibrillation (median 3 min vs. 0 min; P <0.001). In propensity-matched analysis, epinephrine prior to defibrillation was associated with lower odds of survival to discharge (OR: 0.81, 95% CI 0.76 - 0.86) and acute resuscitation survival (OR: 0.79, 95% CI 0.74 - 0.84). Early epinephrine was associated with lower survival (OR: 0.87, 95% CI 0.78-0.97) and acute resuscitation survival (OR for acute resuscitation survival: 0.83, 95% CI 0.74-0.93) even in patients who received defibrillation within 2 minutes.

Conclusions:
Despite a strong emphasis on prompt defibrillation in current guidelines, nearly 1 in 3 patients with IHCA due to a shockable rhythm received epinephrine prior to first defibrillation. Epinephrine before defibrillation was associated with worse survival outcomes. Although delays in defibrillation were more common in the early epinephrine group, early epinephrine remained associated with worse outcomes even in patients who received prompt defibrillation.
Abstract 147: Rapid Responder Operating Times for Out-of-hospital Cardiac Arrest Using Three Automated External Defibrillator Models
Authors: Gao Mengqi , Liu Chenguang , Jorgenson Dawn
Published: November 2020

Background:
Early defibrillation with an automated external defibrillator (AED) is crucial for improving the survival rate in out-of-hospital resuscitation from sudden cardiac arrest (SCA). Chance of survival decreases by 7% to 10% for every minute that defibrillation is delayed. While simulation studies have been used to assess AED usability factors, our objective was to report the actual operating time for three Philips AED models used in SCA responses.

Methods:
A convenience dataset recorded by Philips AEDs (HS1, FRx, or FR3) was obtained from Europe and the United States from 2007 - 2018. The HS1 is intended for minimally trained or untrained individuals, the FRx is for Basic Life Support (BLS), and the FR3 is for both BLS and Advanced Life Support (ALS) responders. A retrospective analysis was conducted to report the operating time intervals for cases where a shock was delivered after initial rhythm analysis. The study analyzed 90 HS1, 46 FRx and 32 FR3 cases.

Results:
Compared with HS1, both FRx (p < 0.001) and FR3 (p = 0.001) responders spent less time in placing pads on the patient after powering on the AED (Figure 1) as expected. Similarly, time intervals from the start of shock advised prompt to first shock delivery for FRx (p = 0.02) and FR3 (p < 0.01) are shorter than for HS1. Time from AED power-on to first shock was within 90 seconds in 74.4% (67 of 90) HS1 cases, 97.8% (45 of 46) FRx cases, and 100% (32 of 32) FR3 cases. On average, the FR3 and FRx responders were able to deliver the first shock within 48 seconds.

Conclusions:
The analysis shows that responders were able to quickly apply the AEDs and respond to the shock advisory prompt for all three AED models despite different training levels. This real-world performance is better than most reported simulation studies, however, this analysis cannot convey variety of activities that account for the differences in timing (e.g. pads applied before power-on, or compressions began before applying pads, etc.).
Abstract 148: A Machine Learning-based Dispatch Rule for Drone-delivered Defibrillators
Authors: Chu Jamal , Leung K.H. Benjamin , Cheskes Sheldon , Snobelen Paul , Nevils Gordon , Drennan Ian , Chan Timothy
Published: November 2020

Introduction:
Drone-delivered defibrillators may reduce response time for out-of-hospital cardiac arrest (OHCA). However, an optimal dispatch rule is not yet known.

Methods:
We identified all suspected OHCAs in Peel Region, Ontario, Canada from Jan. 2014 to Dec. 2019. We trained a neural network model to predict emergency medical services (EMS) response times using OHCA location, distance from responding ambulance, day of week and time of day. Instead of least-squares loss, our model optimized a loss function that penalized weighted errors in the dispatch decision (type I/II error). Assuming drones were deployed from three bases in the region, we calculated drone response time to each suspected OHCA using real drone specifications. Our dispatch rule dispatched a drone when its calculated response time was shorter than the predicted EMS response time. Response time was calculated as the minimum of the drone and EMS response times. The performance of our dispatch rule was compared on out-of-sample OHCAs using 5-fold cross validation to the baseline cases of (1) no drones, and (2) drone dispatch to every suspected OHCA. Statistical analysis on the median response times was performed using a right-tailed sign test.

Results:
We identified 4774 suspected OHCAs with a median historical EMS response time of 6.0 minutes. Using our dispatch rule, median response time was significantly shorter at 3.9 minutes (P<0.001). Drones were dispatched to 3803 cases (79.7%) and of those, drone response was faster than EMS in 3076 cases (80.9%). When the drone was not dispatched, it would have been slower than EMS in 856 cases (88.1%). Sending a drone to every suspected OHCA resulted in an identical median response time of 3.9 minutes (P<0.001), with drones arriving before EMS in 3191 cases (66.8%).

Conclusion:
A machine learning-based dispatch rule can achieve similar response times as a policy that dispatches a drone to all suspected OHCAs, while dispatching drones less frequently.
Abstract 152: Cerebral Oximetry During Pediatric In-hospital Cardiac Arrest
Authors: Esangbedo Ivie D , Rajapreyar Prakadeshwari , Kirschen Matthew , Hanna Richard , Niles Dana E , Zhang Xuemei , Griffis Heather M , Francoeur Conall , Wakeham Martin K , Petersen Tara , Topjian Alexis A , Nadkarni Vinay M , Raymond Tia T
Published: November 2020

Introduction:
Cerebral near-infrared spectroscopy (NIRS) measuring regional oxygen saturation (rSO
2
) during cardiopulmonary resuscitation (CPR) is associated with return of spontaneous circulation (ROSC) and survival to hospital discharge (SHD) in adults, with limited data in children. We hypothesized mean cerebral rSO
2
during pediatric in-hospital cardiac arrest (IHCA) would be associated with return of spontaneous circulation (ROSC).

Methods:
Consecutive case series of pediatric IHCA events with rSO
2
data reported between 2016-2020 by 3 sites to the Pediatric Resuscitation Quality (pediRES-Q) collaborative. We excluded patients with CPR duration ≤2 minutes or who had return of circulation via extracorporeal membrane oxygenation. We calculated mean rSO
2
for duration of CPR and the primary outcome measure was ROSC. Exploratory sensitivity analyses were performed for cutoffs of mean rSO
2
>25, >30, >35, >40 and >50%. Analysis was done using independent samples t test, Exact logistic regression and Fisher’s exact test.

Results:
Of 36 events (26 index), median age was 3 [IQR 1,7.8] months; 29 (80.5%) had congenital heart disease and 15 (41.7%) had single ventricle (SV) physiology. Median CPR duration was 7.5 [IQR 3.8, 32.2] minutes and 28/36 (77.8%) had ROSC. Mean intra-arrest cerebral rSO
2
was 44.2% (±19.5) for ROSC vs. 37.4% (±15) for non-ROSC group (
p
=0.267). Using Exact logistic regression, there was no association found between rSO
2
and ROSC, even after controlling for age, presence of congenital heart disease, and SV physiology. Using mean rSO
2
cutoffs >25, >30, >35, >40, and >50%, we found no significant association with ROSC. We found same result in the SV subgroup.

Conclusion:
In this small pediatric cohort of predominantly cardiac patients, there was no significant association between cerebral rSO
2
during pediatric cardiac arrest and ROSC, even after controlling for important confounders of age and SV physiology. More extensive studies using larger populations, and evaluating intra-arrest change in cerebral rSO
2
from baseline, are warranted to provide more insight into the possibilities of using rSO
2
to guide CPR.
Abstract 200: Discordance Between Monitor-measured and EMS Documented Respiratory Rates in Major Traumatic Brain Injury: Implications for Injury Scoring Systems
Authors: Barnhart Bruce J , Spaite Daniel W , Helfenbein Eric , Jorgenson Dawn , Babaeizadeh Saeed , Gaither Joshua B , Rice Amber D , Keim Samuel M , Bradley Gail , Hu Chengcheng
Published: November 2020

Background:
Respiratory rate (RR) is a key component in commonly-used trauma scoring systems [e.g., Revised Trauma Score (RTS), TRISS]. Imprecise documentation of RR introduces misclassification when these tools are used in trauma research. By identifying each waveform, nasal cannula end tidal CO2 (NCCO2) accurately measures RR in non-intubated patients.

Objective:
Evaluate the relationship between EMS-documented RR measurements in patient care records (PCRs) vs. true RR recorded by non-invasive NCCO2 monitoring in major TBI patients who were never actively ventilated.

Methods:
Among spontaneously-breathing, major TBI cases (moderate/severe/critical), continuous NCCO2 data (Philips MRx™) were evaluated from the EPIC Prehospital TBI Study (NIH 1R01NS071049). RR classifications for RTS/TRISS were then established for each case using both PCR-documentation and monitor data. Routine monitor data (including RR) were available to EMS providers on the display at all times during care.

Results:
Included: 158 cases from 7 Arizona EMS agencies [(7/13-7/17; median age 55 (range 18-94); 65% male]. The Table shows RTS/TRISS case classification by PCR and monitor RR. PCR-documented RR frequently failed to correctly classify cases: RR <6 (0/10; 0%); 6-9 (3/21; 14.3%; >29: (11/34, 32.4%), normal (67/93, 72.0%; Table). In total, PCR documentation misclassified 48.7% of cases (77/158).

Conclusion:
These findings identify a major contributor to inaccurate trauma scoring. Since RTS and TRISS are used widely in research, this has important implications for study enrollment, case ascertainment, confounding, and risk-adjustment in injury studies. Whenever possible, QI and research studies should utilize monitor data to identify and evaluate RR and other vitals rather than relying on PCR documentation. Future development of monitor-based, real-time feedback technology might improve trauma scoring precision and provider identification of RR abnormalities.
Abstract 201: Bougie-Assisted Endotracheal Intubation in the Pragmatic Airway Resuscitation Trial
Authors: Bonette Austin , Aufderheide Tom P , Nichol Graham , Jarvis Jeffrey , Hansen Matthew L , Colella Riccardo , Lesnick Jason , Carlson Jestin N , Stephens Shannon W , Wang Henry E
Published: November 2020

Objective:
Paramedics often perform endotracheal intubation (ETI) in the management of out-of-hospital cardiac arrest (OHCA). While ETI assisted by use of the gum elastic Bougie has been associated with improved first-pass intubation success in the emergency department, its influence upon out-of-hospital cardiac arrest (OHCA) ETI is unknown. We compared success rates and outcomes between Bougie-assisted and standard ETI in the Pragmatic Airway Resuscitation Trial (PART).

Methods:
We conducted a secondary analysis of PART, a clinical trial comparing initial-ETI vs. initial-laryngeal tube airway management strategies in adult OHCA. We included only patients receiving initial ETI attempts. The primary exposure was Bougie-assisted vs. standard ETI. The primary outcome was first-pass ETI success. Secondary outcomes included overall ETI success, time to successful ETI, 72-hour survival, hospital survival and hospital survival with favorable neurologic status. We assessed the associations between Bougie-assistance and ETI outcomes using Generalized Estimating Equations and Cox Regression, adjusting for for age, sex, race, witnessed arrest, bystander CPR and initial rhythm.

Results:
Of the 3,004 patients enrolled in PART, 1,227 received initial ETI, including 440 Bougie-assisted and 787 standard ETI. First-pass ETI success did not differ between Bougie-assisted and standard ETI (53.1% vs. 42.8%; adjusted OR 1.12, 95% CI: 0.97 to 1.39). Overall ETI success was slightly higher for Bougie-assisted ETI (56.2% vs. 49.1%; adjusted OR 1.19, 95% CI: 1.01 to 1.32). Time to ETI was longer for Bougie-assisted than standard ETI (median 13 vs. 11 min; adjusted HR 0.63, 95% CI: 0.45 to 0.90). While survival to hospital discharge was lower for Bougie-assisted than standard ETI (3.6% vs. 7.5%; adjusted OR 0.94, 95% CI: 0.92 to 0.96), there were no differences in 72-hour survival or hospital survival with favorable neurologic status.

Conclusion:
In the PART trial, Bougie assistance resulted in slightly higher overall ETI success but with longer airway placement time. Bougie assistance was not associated with first-pass ETI success. The association between Bougie-assisted ETI and OHCA survival was unclear. The role of Bougie-assisted ETI in OHCA is uncertain.