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It has been observed that learning using visual aids is less complicated than learning using traditional methods. As they say, “Words usually cannot do a picture’s justice". Keeping the above fact in mind, we have come up with ‘Algovis’. The aim of this project is to build a website that enables a user to visualize the steps and iterations involved in Data Structures and Algorithms using custom input and various animations. The program is menu driven to fit to the convenience of the user, depending on how many inputs he wants to enter, and implement the algorithm of his/her choice. The website also aims to become a convenient pedagogical tool. Algovis helps in visualizing various Data structure algorithms using graphical animations and with 100% accuracy.

Background: While sudden cardiac arrest (CA) survivors are at risk for developing psychiatric disorders, little is known about the impact of preexisting mental health conditions on long-term survival or postacute healthcare utilization. We examined the prevalence of preexisting psychiatric conditions in CA patients who survived hospital discharge, characterized incidence and reason for inpatient psychiatry consultation during these patients' acute hospitalizations, and determined the association of pre-CA depression and anxiety with hospital readmission rates and long-term survival. We hypothesized that prior depression or anxiety would be associated with higher hospital readmission rates and lower long-term survival., Methods: We conducted a retrospective cohort study including patients resuscitated from in- and out-of-hospital CA who survived both admission and discharge from a single hospital between January 1, 2010, and December 31, 2017. We identified patients from our prospective registry, then performed a structured chart review to abstract past psychiatric history, prescription medications for psychiatric conditions, and identify inpatient psychiatric consultations. We used administrative data to identify readmissions within 1 year and vital status through December 31, 2020. We used multivariable Cox regressions controlling for patient demographics, medical comorbidities, discharge Cerebral Performance Category and disposition, depression, and anxiety history to predict long-term survival and hospital readmission., Results: We included 684 subjects. Past depression or anxiety was noted in 24% ( n  = 162) and 19% ( n  = 129) of subjects. A minority of subjects ( n  = 139, 20%) received a psychiatry consultation during the index hospitalization. Overall, 262 (39%) subjects had at least 1 readmission within 1 year. Past depression was associated with an increased hazard of hospital readmission (hazard ratio 1.50, 95% CI 1.11-2.04), while past anxiety was not associated with readmission. Neither depression nor anxiety were independently associated with long-term survival., Conclusions: Depression is an independent risk factor for hospital readmission in CA survivors., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Aim: To inform screening, referral and treatment initiatives, we tested the hypothesis that emotional distress, social support, functional dependence, and cognitive impairment within 72 hours prior to discharge predict readiness for discharge in awake and alert cardiac arrest (CA) survivors., Methods: This was a secondary analysis of a prospective single-center cohort of CA survivors enrolled between 4/2021 and 9/2022. We quantified emotional distress using the Posttraumatic Stress Disorder Checklist-5 and PROMIS Emotional Distress - Anxiety and Depression Short Forms 4a; perceived social support using the ENRICHD Social Support Inventory; functional dependence using the modified Rankin Scale; and cognitive impairment using the Telephone Interview for Cognitive Status. Our primary outcome was readiness for discharge, measured using the Readiness for Hospital Discharge Scale. We used multivariable linear regression to test the independent association of each survivorship factor and readiness for discharge., Results: We included 110 patients (64% male, 88% white, mean age 59 [standard deviation ± 13.1 years]). Emotional distress, functional dependence, and social support were independently associated with readiness for discharge (adjusted β's [absolute value]: 0.25-0.30, all p < 0.05)., Conclusions: Hospital systems should consider implementing routine in-hospital screening for emotional distress, social support, and functional dependence for CA survivors who are awake, alert and approaching hospital discharge, and prioritize brief in hospital treatment or post-discharge referrals., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Hypothermia has multiple physiological effects, including decreasing metabolic rate and oxygen consumption (VO 2 ). There are few human data about the magnitude of change in VO 2 with decreases in core temperature. We aimed to quantify to magnitude of reduction in resting VO 2 as we reduced core temperature in lightly sedated healthy individuals. After informed consent and physical screening, we cooled participants by rapidly infusing 20 mL/kg of cold (4°C) saline intravenously and placing surface cooling pads on the torso. We attempted to suppress shivering using a 1 mcg/kg intravenous bolus of dexmedetomidine followed by titrated infusion at 1.0 to 1.5 μg/(kg·h). We measured resting metabolic rate VO 2 through indirect calorimetry at baseline (37°C) and at 36°C, 35°C, 34°C, and 33°C. Nine participants had mean age 30 (standard deviation 10) years and 7 (78%) were male. Baseline VO 2 was 3.36 mL/(kg·min) (interquartile range 2.98-3.76) mL/(kg·min). VO 2 was associated with core temperature and declined with each degree decrease in core temperature, unless shivering occurred. Over the entire range from 37°C to 33°C, median VO 2 declined 0.7 mL/(kg·min) (20.8%) in the absence of shivering. The largest average decrease in VO 2 per degree Celsius was by 0.46 mL/(kg·min) (13.7%) and occurred between 37°C and 36°C in the absence of shivering. After a participant developed shivering, core body temperature did not decrease further, and VO 2 increased. In lightly sedated humans, metabolic rate decreases around 5.2% for each 1°C decrease in core temperature from 37°C to 33°C. Because the largest decrease in metabolic rate occurs between 37°C and 36°C, subclinical shivering or other homeostatic reflexes may be present at lower temperatures.

Out of hospital cardiac arrest from shockable rhythms that is refractory to standard treatment is a unique challenge. Such patients can achieve neurological recovery even with long low-flow times if perfusion can somehow be restored to the heart and brain. Extracorporeal cardiopulmonary resuscitation is an effective treatment for refractory cardiac arrest if applied early and accurately, but often cannot be directly implemented by frontline providers and has strict inclusion/exclusion criteria. We present the case of a novel treatment strategy for out of hospital cardiac arrest due to refractory ventricular fibrillation utilizing Resuscitative Endovascular Balloon Occlusion of the Aorta-assisted cardiopulmonary resuscitation and intra-arrest left stellate ganglion blockade to achieve return of spontaneous circulation and eventual good neurological outcome after 101 minutes of downtime., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Author(s).)

Background: The ThermoCool STSF catheter is used for ablation of ischemic ventricular tachycardia (VT) in routine clinical practice, although outcomes have not been studied and the catheter does not have Food and Drug Administration (FDA) approval for this indication. We used real-world health system data to evaluate its safety and effectiveness for this indication., Methods: Among patients undergoing ischemic VT ablation with the ThermoCool STSF catheter pooled across two health systems (Mercy Health and Mayo Clinic), the primary safety composite outcome of death, thromboembolic events, and procedural complications within 7 days was compared to a performance goal of 15%, which is twice the expected proportion of the primary composite safety outcome based on prior studies. The exploratory effectiveness outcome of rehospitalization for VT or heart failure or repeat VT ablation at up to 1 year was averaged across health systems among patients treated with the ThermoCool STSF vs. ST catheters., Results: Seventy total patients received ablation for ischemic VT using the ThermoCool STSF catheter. The primary safety composite outcome occurred in 3/70 (4.3%; 90% CI, 1.2-10.7%) patients, meeting the pre-specified performance goal, p = 0.0045. At 1 year, the effectiveness outcome risk difference (STSF-ST) at Mercy was - 0.4% (90% CI: - 25.2%, 24.3%) and at Mayo Clinic was 12.6% (90% CI: - 13.0%, 38.4%); the average risk difference across both institutions was 5.8% (90% CI: - 12.0, 23.7)., Conclusions: The ThermoCool STSF catheter was safe and appeared effective for ischemic VT ablation, supporting continued use of the catheter and informing possible FDA label expansion. Health system data hold promise for real-world safety and effectiveness evaluation of cardiovascular devices., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Background: There is a critical need to identify factors that can prevent emotional distress post-cardiac arrest (CA). CA survivors have previously described benefitting from utilizing positive psychology constructs (mindfulness, existential well-being, resilient coping, social support) to cope with distress. Here, we explored associations between positive psychology factors and emotional distress post-CA., Methods: We recruited CA survivors treated from 4/2021-9/2022 at a single academic medical center. We assessed positive psychology factors (mindfulness [Cognitive and Affective Mindfulness Scale-Revised], existential well-being [Meaning in Life Questionnaire Presence of Meaning subscale], resilient coping [Brief Resilient Coping Scale], perceived social support [ENRICHD Social Support Inventory]) and emotional distress (posttraumatic stress [Posttraumatic Stress Checklist-5], anxiety and depression symptoms [PROMIS Emotional Distress - Anxiety and Depression Short Forms 4a]) just before discharge from the index hospitalization. We selected covariates for inclusion in our multivariable models based on an association with any emotional distress factor (p < 0.10). For our final, multivariable regression models, we individually tested the independent association of each positive psychology factor and emotional distress factor., Results: We included 110 survivors (mean age 59 years, 64% male, 88% non-Hispanic White, 48% low income); 36.4% of survivors scored above the cut-off for at least one measure of emotional distress. In separate adjusted models, each positive psychology factor was independently associated with emotional distress (β: -0.20 to -0.42, all p < 0.05)., Conclusions: Higher levels of mindfulness, existential well-being, resilient coping, and perceived social support were each associated with less emotional distress. Future intervention development studies should consider these factors as potential treatment targets., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: SMP and JE are on the Editorial Board of Resuscitation., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Patients resuscitated from cardiac arrest have variable severity of primary hypoxic ischemic brain injury (HIBI). Signatures of primary HIBI on brain imaging and electroencephalography (EEG) include diffuse cerebral edema and burst suppression with identical bursts (BSIB). We hypothesize distinct phenotypes of primary HIBI are associated with increasing cardiopulmonary resuscitation (CPR) duration., Methods: We identified from our prospective registry of both in-and out-of-hospital CA patients treated between January 2010 to January 2020 for this cohort study. We abstracted CPR duration, neurological examination, initial brain computed tomography gray to white ratio (GWR), and initial EEG pattern. We considered four phenotypes on presentation: awake; comatose with neither BSIB nor cerebral edema (non-malignant coma); BSIB; and cerebral edema (GWR ≤ 1.20). BSIB and cerebral edema were considered as non-mutually exclusive outcomes. We generated predicted probabilities of brain injury phenotype using localized regression., Results: We included 2,440 patients, of whom 545 (23%) were awake, 1,065 (44%) had non-malignant coma, 548 (23%) had BSIB and 438 (18%) had cerebral edema. Only 92 (4%) had both BSIB and edema. Median CPR duration was 16 [IQR 8-28] minutes. Median CPR duration increased in a stepwise manner across groups: awake 6 [3-13] minutes; non-malignant coma 15 [8-25] minutes; BSIB 21 [13-31] minutes; cerebral edema 32 [22-46] minutes. Predicted probability of phenotype changes over time., Conclusions: Brain injury phenotype is related to CPR duration, which is a surrogate for severity of HIBI. The sequence of most likely primary HIBI phenotype with progressively longer CPR duration is awake, coma without BSIB or edema, BSIB, and finally cerebral edema., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier B.V.)

The COVID-19 pandemic has increased healthcare workers' (HCWs) risk for posttraumatic stress disorder (PTSD). Although subthreshold PTSD symptoms (PTSS) are common and increase vulnerability for health impairments, they have received little attention. We examined the prevalence of subthreshold PTSS and their relationship to physical health symptoms and sleep problems among HCWs during the pandemic's second wave (01/21-02/21). Participants (N = 852; 63.1% male; M age  = 38.34) completed the Short-Form PTSD Checklist (SF-PCL), the Cohen-Hoberman Inventory of Physical Symptoms, and the PROMIS Sleep-Related Impairment-Short-Form 4a. We created three groups with the SF-PCL: scores ≥11 = probable PTSD (5.5%); scores between 1 and 10 = subthreshold PTSS (55.3%); scores of 0 = no PTSS (39.2%). After controlling for demographics, occupational characteristics, and COVID-19 status, HCWs with subthreshold PTSS experienced greater physical health symptoms and sleep problems than HCWs with no PTSS. While HCWs with PTSD reported the greatest health impairment, HCWs with subthreshold PTSS reported 88% more physical health symptoms and 36% more sleep problems than HCWs with no PTSS. Subthreshold PTSS are common and increase risk for health impairment. Interventions addressing HCWs' mental health in response to the COVID-19 pandemic must include subthreshold PTSS to ensure their effectiveness., Competing Interests: Declaration of competing interest None., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

The objective of this study is to describe application of the Observational Medical Outcomes Partnership (OMOP) common data model (CDM) to support medical device real-world evaluation in a National Evaluation System for health Technology Coordinating Center (NESTcc) Test-Case involving 2 healthcare systems, Mercy Health and Mayo Clinic. CDM implementation was coordinated across 2 healthcare systems with multiple hospitals to aggregate both medical device data from supply chain databases and patient outcomes and covariates from electronic health record data. Several data quality assurance (QA) analyses were implemented on the OMOP CDM to validate the data extraction, transformation, and load (ETL) process. OMOP CDM-based data of relevant patient encounters were successfully established to support studies for FDA regulatory submissions. QA analyses verified that the data transformation was robust between data sources and OMOP CDM. Our efforts provided useful insights in real-world data integration using OMOP CDM for medical device evaluation coordinated across multiple healthcare systems., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Medical Informatics Association.)

Background: Coma is common following resuscitation from cardiac arrest. Few data describe the trajectory of recovery the first days following resuscitation. The objective of this study is to describe the evolution in neurological examination during the first 5 days after resuscitation and test if subjects who go on to awaken have different patterns of early recovery., Methods: Prospective study of adult subjects resuscitated from out-of-hospital cardiac arrest. We abstracted demographic information and trained clinicians completed daily neurologic examinations using the Glasgow Coma Scale (GCS) and Full Outline of UnResponsiveness brainstem (FOUR-B) and motor (FOUR-M) scores during daily sedation interruption. The change in scores between Day 1 and Day 5 was analyzed using the Kruskal-Wallis Test and logistic regression models. The relationship of FOUR-B, FOUR-M, and GCS with time to death was estimated by fitting cox proportional hazard models., Results: FOUR-M and GCS did not differ over time ( p  = 0.10; p  = 0.07). FOUR B increased over time ( p  < 0.01). Time to recovery of brainstem or motor function differed between those treated at 33 °C and 36 °C ( p  = 0.0023 and p  = 0.0032, respectively). FOUR-B, FOUR-M, and GCS differed between survivors and non-survivors ( p  < 0.01). Time to recovery of brainstem and motor function differed between survivors and non-survivors. FOUR-M and FOUR-B differed between those with good outcome and poor outcome., Conclusions: The brainstem clinical examination improved during the first 5 days following resuscitation. Brainstem recovery was common in entire cohort and did not differentiate between survivors and non-survivors. Recovery of motor function, however, was associated with survival., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Author(s).)

Introduction: We compared novel methods of long-term follow-up after resuscitation from cardiac arrest to a query of the National Death Index (NDI). We hypothesized use of the electronic health record (EHR), and internet-based sources would have high sensitivity for identifying decedents identified by the NDI., Methods: We performed a retrospective study including patients treated after cardiac arrest at a single academic center from 2010 to 2018. We evaluated two novel methods to ascertain long-term survival and modified Rankin Scale (mRS): 1) a structured chart review of our health system's EHR; and 2) an internet-based search of: a) local newspapers, b) Ancestry.com, c) Facebook, d) Twitter, e) Instagram, and f) Google. If a patient was not reported deceased by any source, we considered them to be alive. We compared results of these novel methods to the NDI to calculate sensitivity. We queried the NDI for 200 in-hospital decedents to evaluate sensitivity against a true criterion standard., Results: We included 1,097 patients, 897 (82%) alive at discharge and 200 known decedents (18%). NDI identified 197/200 (99%) of known decedents. The EHR and local newspapers had highest sensitivity compared to the NDI (87% and 86% sensitivity, respectively). Online sources identified 10 likely decedents not identified by the NDI. Functional status estimated from EHR, and internet sources at follow up agreed in 38% of alive patients., Conclusions: Novel methods of outcome assessment are an alternative to NDI for determining patients' vital status. These methods are less reliable for estimating functional status., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Importance: The ThermoCool SmartTouch catheter (ablation catheter with contact force and 6-hole irrigation [CF-I6]) is approved by the US Food and Drug Administration (FDA) for paroxysmal atrial fibrillation (AF) ablation and used in routine clinical practice for persistent AF ablation, although clinical outcomes for this indication are unknown. There is a need to understand whether data from routine clinical practice can be used to conduct regulatory-grade evaluations and support label expansions., Objective: To use health system data to compare the safety and effectiveness of the CF-I6 catheter for persistent AF ablation with the ThermoCool SmartTouch SurroundFlow catheter (ablation catheter with contact force and 56-hole irrigation [CF-I56]), which is approved by the FDA for this indication., Design, Setting, and Participants: This retrospective, comparative-effectiveness cohort study included patients undergoing catheter ablation for persistent AF at Mercy Health or Mayo Clinic from January 1, 2014, to April 30, 2021, with up to a 1-year follow-up using electronic health record data., Exposures: Use of the CF-I6 or CF-I56 catheter., Main Outcomes and Measures: The primary safety outcome was a composite of death, thromboembolic events, and procedural complications within 7 to 90 days. The exploratory effectiveness outcome was a composite of AF-related hospitalization events after a 90-day blanking period. Propensity score weighting was used to balance baseline covariates. Risk differences were estimated between catheter groups and averaged across the 2 health care systems, testing for noninferiority of the CF-I6 vs the CF-I56 catheter with respect to the safety outcome using 2-sided 90% CIs., Results: Overall, 1450 patients (1034 [71.3%] male; 1397 [96.3%] White) underwent catheter ablation for persistent AF, including 949 at Mercy Health (186 CF-I6 and 763 CF-I56; mean [SD] age, 64.9 [9.2] years) and 501 at Mayo Clinic (337 CF-I6 and 164 CF-I56; mean [SD] age, 63.7 [9.5] years). A total of 798 (55.0%) had been treated with class I or III antiarrhythmic drugs before ablation. The safety outcome (CF-I6 - CF-I56) was similar at both Mercy Health (1.3%; 90% CI, -2.1% to 4.6%) and Mayo Clinic (-3.8%; 90% CI, -11.4% to 3.7%); the mean difference was noninferior, with a mean of 0.5% (90% CI, -2.6% to 3.5%; P < .001). The effectiveness was similar at 12 months between the 2 catheter groups (mean risk difference, -1.8%; 90% CI, -7.3% to 3.7%)., Conclusions and Relevance: In this cohort study, the CF-I6 catheter met the prespecified noninferiority safety criterion for persistent AF ablation compared with the CF-I56 catheter, and effectiveness was similar. This study demonstrates the ability of electronic health care system data to enable safety and effectiveness evaluations of medical devices.

We describe a case of new onset movement disorder in a patient with ventricular tachycardia storm supported with peripheral VA ECMO. The differential diagnosis of abnormal movements in a post cardiac arrest patient requiring temporary mechanical circulatory support for cardiogenic shock is explored., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Authors.)

Introduction: Out-of-hospital cardiac arrest (OHCA) is a major cause of death and disability in the United States. Cardiac arrest centers (CAC) are necessary for the management of these critically ill and complex post arrest patients due to their specialized services and provider expertise. We report the case of a patient with OHCA and the systems of care involved in his resuscitation and recovery. Case Report: Emergency medical services attended a 39-year-old male with ongoing bystander cardiopulmonary resuscitation (CPR) after a witnessed collapse. Despite receiving appropriate advanced cardiac life support, including three defibrillations, he remained in refractory ventricular fibrillation. A prehospital physician identified him as an extracorporeal cardiopulmonary resuscitation (ECPR) candidate due to his age, witnessed arrest, refractory rhythm, and functional status. He was expedited to a CAC but no longer qualified for ECPR due to the time limit. He was resuscitated by the multiple teams activated prior to his arrival. He eventually had sustained return of circulation, was taken to the catheterization lab for emergent percutaneous coronary intervention, and recovered with a good neurologic outcome. Conclusion: Cardiac arrest centers may be capable of advanced interventions including ECPR. However, the systems of care offered by these centers is itself a lifesaving intervention. As this case highlights, despite not receiving the specified intervention (ECPR) the systems of care required to offer such a resource led to this favorable outcome.

Equity in the promotion of women and underrepresented minorities (URiM) is essential for the advancement of academic emergency medicine and the specialty as a whole. Forward-thinking healthcare organizations can best position themselves to optimally care for an increasingly diverse patient population and mentor trainees by championing increased diversity in senior faculty ranks, leadership, and governance roles. This article explores several potential solutions to addressing inequities that hinder the advancement of women and URiM faculty. It is intended to complement the recently approved American College of Emergency Physicians (ACEP) policy statement aimed at overcoming barriers to promotion of women and URiM faculty in academic emergency medicine. This policy statement was jointly released and supported by the Society for Academic Emergency Medicine (SAEM), American Academy of Emergency Medicine (AAEM), and the Association of Academic Chairs of Emergency Medicine (AACEM)., Competing Interests: JF is a member of the ACEP BOD. MDL and AEP are members of the SAEM BOD. ALG is the Chair of ACEP Diversity, Inclusion, and Health Section. AAD was a prior member of the PACEP BOD., (© 2021 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Objectives: To determine the feasibility of using real-world data to assess the safety and effectiveness of two cardiac ablation catheters for the treatment of persistent atrial fibrillation and ischaemic ventricular tachycardia., Design: Retrospective cohort., Setting: Three health systems in the USA., Participants: Patients receiving ablation with the two ablation catheters of interest at any of the three health systems., Main Outcome Measures: Feasibility of identifying the medical devices and participant populations of interest as well as the duration of follow-up and positive predictive values (PPVs) for serious safety (ischaemic stroke, acute heart failure and cardiac tamponade) and effectiveness (arrhythmia-related hospitalisation) clinical outcomes of interest compared with manual chart validation by clinicians., Results: Overall, the catheter of interest for treatment of persistent atrial fibrillation was used for 4280 ablations and the catheter of interest for ischaemic ventricular tachycardia was used 1516 times across the data available within the three health systems. The duration of patient follow-up in the three health systems ranged from 91% to 97% at ≥7 days, 89% to 96% at ≥30 days, 77% to 90% at ≥6 months and 66% to 84% at ≥1 year. PPVs were 63.4% for ischaemic stroke, 96.4% for acute heart failure, 100% at one health system for cardiac tamponade and 55.7% for arrhythmia-related hospitalisation., Conclusions: It is feasible to use real-world health system data to evaluate the safety and effectiveness of cardiac ablation catheters, though evaluations must consider the implications of variation in follow-up and endpoint ascertainment among health systems., Competing Interests: Competing interests: SD receives research funding from the National Heart, Lung, and Blood Institute (NHLBI, K12HL138046) of the National Institutes of Health (NIH), from the Medical Device Innovation Consortium as part of the National Evaluation System for health Technology Coordinating Center (NESTcc), Food and Drug Administration (FDA), Greenwall Foundation, and Arnold Ventures. DJF has received educational grants from Boston Scientific, Medtronic, and Abbott; research grants from the American Heart Association, National Cardiovascular Data Registry, Boston Scientific, Abbott, Medtronic, Merit Medical, and Biosense Webster; consulting fees from Abbott and AtriCure. JGA has received consulting fees from Biosense Webster. JSR received research support through Yale University from Johnson and Johnson to develop methods of clinical trial data sharing, from the Food and Drug Administration to establish Yale-Mayo Clinic Center for Excellence in Regulatory Science and Innovation (CERSI) program (U01FD005938), from the Medical Device Innovation Consortium as part of NESTcc, from the Agency for Healthcare Research and Quality (R01HS022882), from the National Heart, Lung and Blood Institute of the National Institutes of Health (NIH) (R01HS025164, R01HL144644), and from the Laura and John Arnold Foundation to establish the Good Pharma Scorecard at Bioethics International and to establish the Collaboration for Research Integrity and Transparency (CRIT) at Yale. NDS has received research support through Mayo Clinic from the Food and Drug Administration to establish the Yale–Mayo Clinic Center for Excellence in Regulatory Science and Innovation program (U01FD005938), from the Centers of Medicare and Medicaid Innovation under the Transforming Clinical Practice Initiative, from the Agency for Healthcare Research and Quality (U19HS024075, R01HS025164, R01HS025402, R03HS025517), from the National Heart, Lung, and Blood Institute of the National Institutes of Health (R56HL130496, R01HL131535), from the National Science Foundation, and from the Patient Centered Outcomes Research Institute to develop a Clinical Data Research Network. PC is an employee of Johnson & Johnson; the manufacturer of the ThermoCool catheters, and Biosense Webster, is a Johnson & Johnson company. However, this study was a feasibility study to evaluate the suitability of the databases to conduct a study and no evaluation of the safety and effectiveness of any medical device was conducted in the study. PAN receives research funding from National Institutes of Health (NIH, including the NHLBI and the National Institute on Aging [NIA]), Agency for Healthcare Research and Quality (AHRQ), FDA, and the American Heart Association (AHA). He is a study investigator in an ablation trial sponsored by Medtronic. PAN and Mayo Clinic are involved in potential equity/royalty relationship with AliveCor. SZ is an employee of Johnson & Johnson; the manufacturer of the ThermoCool catheters and Biosense Webster, is a Johnson & Johnson company. WLS was an investigator for a research agreement, through Yale University, from the Shenzhen Center for Health Information for work to advance intelligent disease prevention and health promotion; collaborates with the National Center for Cardiovascular Diseases in Beijing; is a technical consultant to Hugo Health, a personal health information platform, and cofounder of Refactor Health, an AI-augmented data management platform for healthcare; is a consultant for Interpace Diagnostics Group, a molecular diagnostics company. In the past 36 months, JPD has received research support from Medtronic and Johnson & Johnson. His non-dependent son is an employee of Boston Scientific., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The study sought to conduct an informatics analysis on the National Evaluation System for Health Technology Coordinating Center test case of cardiac ablation catheters and to demonstrate the role of informatics approaches in the feasibility assessment of capturing real-world data using unique device identifiers (UDIs) that are fit for purpose for label extensions for 2 cardiac ablation catheters from the electronic health records and other health information technology systems in a multicenter evaluation., Materials and Methods: We focused on data capture and transformation and data quality maturity model specified in the National Evaluation System for Health Technology Coordinating Center data quality framework. The informatics analysis included 4 elements: the use of UDIs for identifying device exposure data, the use of standardized codes for defining computable phenotypes, the use of natural language processing for capturing unstructured data elements from clinical data systems, and the use of common data models for standardizing data collection and analyses., Results: We found that, with the UDI implementation at 3 health systems, the target device exposure data could be effectively identified, particularly for brand-specific devices. Computable phenotypes for study outcomes could be defined using codes; however, ablation registries, natural language processing tools, and chart reviews were required for validating data quality of the phenotypes. The common data model implementation status varied across sites. The maturity level of the key informatics technologies was highly aligned with the data quality maturity model., Conclusions: We demonstrated that the informatics approaches can be feasibly used to capture safety and effectiveness outcomes in real-world data for use in medical device studies supporting label extensions., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Medical Informatics Association.)

Background: Hypothermia improves outcomes following ischemia-reperfusion injury. Shivering is common and can be mediated by agents such as dexmedetomidine. The combination of dexmedetomidine and hypothermia results in bradycardia. We hypothesized that glycopyrrolate would prevent bradycardia during dexmedetomidine-mediated hypothermia., Methods: We randomly assigned eight healthy subjects to premedication with a single 0.4 mg glycopyrrolate intravenous (IV) bolus, titrated glycopyrrolate (0.01 mg IV every 3 min as needed for heart rate <50), or no glycopyrrolate during three separate sessions of 3 h cooling. Following 1 mg/kg IV dexmedetomidine bolus, subjects received 20 ml/kg IV 4 °C saline and surface cooling (EM COOLS, Weinerdorf, Austria). We titrated dexmedetomidine infusion to suppress shivering but permit arousal to verbal stimuli. After 3 h of cooling, we allowed subjects to passively rewarm. We compared heart rate, core temperature, mean arterial blood pressure, perceived comfort and thermal sensation between groups using Kruskal-Wallis test and ANOVA., Results: Mean age was 27 (SD 6) years and most (N = 6, 75%) were male. Neither heart rate nor core temperature differed between the groups during maintenance of hypothermia (p > 0.05). Mean arterial blood pressure was higher in the glycopyrrolate bolus condition (p < 0.048). Thermal sensation was higher in the control condition than the glycopyrrolate bolus condition (p = 0.01). Bolus glycopyrrolate resulted in less discomfort than titrated glycopyrrolate (p = 0.04)., Conclusions: Glycopyrrolate did not prevent the bradycardic response to hypothermia and dexmedetomidine. Mean arterial blood pressure was higher in subjects receiving a bolus of glycopyrrolate before induction of hypothermia. Bolus glycopyrrolate was associated with less intense thermal sensation and less discomfort during cooling., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Rationale: During the coronavirus disease (COVID-19) pandemic, many intensive care units (ICUs) have shifted communication with patients' families toward chiefly telehealth methods (phone and video) to reduce COVID-19 transmission. Family and clinician perspectives about phone and video communication in the ICU during the COVID-19 pandemic are not yet well understood. Increased knowledge about clinicians' and families' experiences with telehealth may help to improve the quality of remote interactions with families during periods of hospital visitor restrictions during COVID-19. Objectives: To explore experiences, perspectives, and attitudes of family members and ICU clinicians about phone and video interactions during COVID-19 hospital visitor restrictions. Methods: We conducted a qualitative interviewing study with an intentional sample of 21 family members and 14 treating clinicians of cardiothoracic and neurologic ICU patients at an academic medical center in April 2020. Semistructured qualitative interviews were conducted with each participant. We used content analysis to develop a codebook and analyze interview transcripts. We specifically explored themes of effectiveness, benefits and limitations, communication strategies, and discordant perspectives between families and clinicians related to remote discussions. Results: Respondents viewed phone and video communication as somewhat effective but inferior to in-person communication. Both clinicians and families believed phone calls were useful for information sharing and brief updates, whereas video calls were preferable for aligning clinician and family perspectives. Clinicians and families expressed discordant views on multiple topics-for example, clinicians worried they were unsuccessful in conveying empathy remotely, whereas families believed empathy was conveyed successfully via phone and video. Communication strategies suggested by families and clinicians for remote interactions include identifying a family point person to receive updates, frequently checking family understanding, positioning the camera on video calls to help family see the patient and their clinical setting, and offering time for the family and patient to interact without clinicians participating. Conclusions: Telehealth communication between families and clinicians of ICU patients appears to be a somewhat effective alternative when in-person communication is not possible. Use of communication strategies specific to phone and video can improve clinician and family experiences with telehealth.

Background Many patients are subject to potential risks and filter-related morbidity when standard retrieval methods fail. We evaluated the safety and efficacy of the laser sheath technique for removing embedded inferior vena cava filters. Methods and Results Over an 8.5-year period, 500 patients were prospectively enrolled in an institutional review board-approved study. There were 225 men and 275 women (mean age, 49 years; range, 15-90 years). Indications for retrieval included symptomatic acute inferior vena cava thrombosis, chronic inferior vena cava occlusion, and/or pain from filter penetration. Retrieval was also offered to prevent risks from prolonged implantation and potentially to eliminate need for lifelong anticoagulation. After retrieval failed using 3X standard retrieval force (6-7 lb via digital gauge), treatment escalation was attempted using laser sheath powered by 308-nm XeCl excimer laser system (CVX-300; Spectranetics). We hypothesized that the laser-assisted technique would allow retrieval of >95% of embedded filters with <5% risk of major complications and with lower force. Primary outcome was successful retrieval. Primary safety outcome was any major procedure-related complication. Laser-assisted retrieval was successful in 99.4% of cases (497/500) (95% CI, 98.3%-99.9%) and significantly >95% ( P <0.0001). The mean filter dwell time was 1528 days (range, 37-10 047; >27.5 years]), among retrievable-type (n=414) and permanent-type (n=86) filters. The average force during failed attempts without laser was 6.4 versus 3.6 lb during laser-assisted retrievals ( P <0.0001). The major complication rate was 2.0% (10/500) (95% CI, 1.0%-3.6%), significantly <5% ( P <0.0005), 0.6% (3/500) (95% CI, 0%-1.3%) from laser, and all were successfully treated. Successful retrieval allowed cessation of anticoagulation in 98.7% (77/78) (95% CI, 93.1%-100.0%) and alleviated filter-related morbidity in 98.5% (138/140) (95% CI, 96.5%-100.0%). Conclusions The excimer laser sheath technique is safe and effective for removing embedded inferior vena cava filters refractory to high-force retrieval. This technique may allow cessation of filter-related anticoagulation and can be used to prevent and alleviate filter-related morbidity. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01158482.

Background: End-of-shift assessments (ESA) can provide representative data on medical trainee performance but do not occur routinely and are not documented systematically., Objective: To evaluate the implementation of a web-based tool with text message prompts to assist mobile ESA (mESA) in an emergency medicine (EM) residency program., Methods: mESA used timed text messages to prompt faculty/trainees to expect in-person qualitative ESA in a milestone content area and for the faculty to record descriptive performance data through a web-based platform. We assessed implementation between January 2018 and November 2019 using the RE-AIM framework (reach, effectiveness, adoption, implementation, and maintenance)., Results: Reach : 96 faculty and 79 trainees participated in the mESA program. Effectiveness : From surveys, approximately 72% of faculty and 58% of trainees reported increases in providing and receiving ESA feedback after program implementation. From ESA submissions, trainees reported receiving in-person feedback on 90% of shifts. Residency leadership confirmed perceived utility of the mESA program. Adoption : mESA prompts were sent on 7792 unique shifts across 4 EDs, all days of week, and different times of day. Faculty electronically submitted ESA feedback on 45% of shifts. Implementation quality : No technological errors occurred. Maintenance : Completion of in-person ESA feedback and electronic submission of feedback by faculty was stable over time., Conclusions: We found mixed evidence in support of using a web-based tool with text message prompts for mESA for EM trainees., Competing Interests: Conflict of interest: The authors declare they have no competing interests., (© 2020.)

Importance: It is uncertain what the optimal target temperature is for targeted temperature management (TTM) in patients who are comatose following cardiac arrest., Objective: To examine whether illness severity is associated with changes in the association between target temperature and patient outcome., Design, Setting, and Participants: This cohort study compared outcomes for 1319 patients who were comatose after cardiac arrest at a single center in Pittsburgh, Pennsylvania, from January 2010 to December 2018. Initial illness severity was based on coma and organ failure scores, presence of severe cerebral edema, and presence of highly malignant electroencephalogram (EEG) after resuscitation., Exposure: TTM at 36 °C or 33 °C., Main Outcomes and Measures: Primary outcome was survival to hospital discharge, and secondary outcomes were modified Rankin Scale and cerebral performance category., Results: Among 1319 patients, 728 (55.2%) had TTM at 33 °C (451 [62.0%] men; median [interquartile range] age, 61 [50-72] years) and 591 (44.8%) had TTM at 36 °C (353 [59.7%] men; median [interquartile range] age, 59 [48-69] years). Overall, 184 of 187 patients (98.4%) with severe cerebral edema died and 234 of 243 patients (96.3%) with highly malignant EEG died regardless of TTM strategy. Comparing TTM at 33 °C with TTM at 36 °C in 911 patients (69.1%) with neither severe cerebral edema nor highly malignant EEG, survival was lower in patients with mild to moderate coma and no shock (risk difference, -13.8%; 95% CI, -24.4% to -3.2%) but higher in patients with mild to moderate coma and cardiopulmonary failure (risk difference, 21.8%; 95% CI, 5.4% to 38.2%) or with severe coma (risk difference, 9.7%; 95% CI, 4.0% to 15.3%). Interactions were similar for functional outcomes. Most deaths (633 of 968 [65.4%]) resulted after withdrawal of life-sustaining therapies., Conclusions and Relevance: In this study, TTM at 33 °C was associated with better survival than TTM at 36 °C among patients with the most severe post-cardiac arrest illness but without severe cerebral edema or malignant EEG. However, TTM at 36 °C was associated with better survival among patients with mild- to moderate-severity illness.

Objective: Abnormal electroencephalography (EEG) patterns are common after resuscitation from cardiac arrest and have clinical and prognostic importance. Bedside continuous EEGs are not available in many institutions. We tested the feasibility of using a point-of-care system for EEG acquisition., Methods: We prospectively enrolled a convenience sample of post-cardiac arrest patients between 9/2015-1/2017. Upon hospital arrival, a limited EEG montage was applied. We tested both continuous EEG (cEEG) and this point-of-care EEG (eEEG). A board-certified epileptologist and a board-certified neurointensivist jointly reviewed all EEGs. Cohen's kappa coefficient evaluated agreement between eEEG and cEEG and Fisher's exact test evaluated their associations with survival to hospital discharge and proximate cause of death., Results: We studied 95 comatose post-cardiac arrest patients. Mean age was 59 (SD17) years. Most (61%) were male, few (N = 22; 23%) demonstrated shockable rhythms, and PCAC IV illness severity was present in 58 (61%). eEEG was interpretable in 57 (60%) subjects. The most common eEEG interpretations were: continuous (21%), generalized suppression (14%), burst-suppression (12%) and burst-suppression with identical bursts (10%). Seizures were detected in 2 eEEG subjects (2%). No patient with seizure or burst-suppression with identical bursts survived. cEEG demonstrated generalized suppression (31%), burst-suppression with identical bursts (27%), continuous (18%) and seizure (4%). The eEEG and cEEG demonstrated fair agreement (kappa = 0.27). Neither eEEG nor cEEG was associated with survival (p = 0.19; p = 0.11) or proximate cause of death (p = 0.14; p = 0.8) CONCLUSIONS: eEEG is feasible, although artifact often precludes interpretation. eEEG is fairly associated with cEEG and may facilitate post-cardiac arrest care., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Introduction: Cardiac arrest etiology is often assigned according to the Utstein template, which differentiates medical (formerly "presumed cardiac") from other causes. These categories are poorly defined, contain within them many clinically distinct etiologies, and are rarely based on diagnostic testing. Optimal clinical care and research require more rigorous characterization of arrest etiology., Methods: We developed a novel system to classify arrest etiology using a structured chart review of consecutive patients treated at a single center after in- or out-of-hospital cardiac arrest over four years. Two reviewers independently reviewed a random subset of 20% of cases to calculate inter-rater reliability. We used X 2 and Kruskal-Wallis tests to compare baseline clinical characteristics and outcomes across etiologies., Results: We identified 14 principal arrest etiologies, and developed objective diagnostic criteria for each. Inter-rater reliability was high (kappa = 0.80). Median age of 986 included patients was 60 years, 43% were female and 71% arrested out-of-hospital. The most common etiology was respiratory failure (148 (15%)). A minority (255 (26%)) arrested due to cardiac causes. Only nine (1%) underwent a diagnostic workup that was unrevealing of etiology. Rates of awakening and survival to hospital discharge both differed across arrest etiologies, with survival ranging from 6% to 60% (both P < 0.001), and rates of favorable outcome ranging from 0% to 40% (P < 0.001). Timing and mechanism of death (e.g. multisystem organ failure or brain death) also differed significantly across etiologies., Conclusions: Arrest etiology was identifiable in the majority cases via systematic chart review. "Cardiac" etiologies may be less common than previously thought. Substantial clinical heterogeneity exists across etiologies, suggesting previous classification systems may be insufficient., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objectives: Cardiac arrest etiology may be an important source of between-patient heterogeneity, but the impact of etiology on organ injury is unknown. We tested the hypothesis that asphyxial cardiac arrest results in greater neurologic injury than cardiac etiology cardiac arrest (ventricular fibrillation cardiac arrest), whereas ventricular fibrillation cardiac arrest results in greater cardiovascular dysfunction after return of spontaneous circulation., Design: Prospective observational human and randomized animal study., Setting: University laboratory and ICUs., Patients: Five-hundred forty-three cardiac arrest patients admitted to ICU., Subjects: Seventy-five male Sprague-Dawley rats., Interventions: We examined neurologic and cardiovascular injury in Isoflurane-anesthetized rat cardiac arrest models matched by ischemic time. Hemodynamic and neurologic outcomes were assessed after 5 minutes no flow asphyxial cardiac arrest or ventricular fibrillation cardiac arrest. Comparison was made to injury patterns observed after human asphyxial cardiac arrest or ventricular fibrillation cardiac arrest., Measurements and Main Results: In rats, cardiac output (20 ± 10 vs 45 ± 9 mL/min) and pH were lower and lactate higher (9.5 ± 1.0 vs 6.4 ± 1.3 mmol/L) after return of spontaneous circulation from ventricular fibrillation cardiac arrest versus asphyxial cardiac arrest (all p < 0.01). Asphyxial cardiac arrest resulted in greater early neurologic deficits, 7-day neuronal loss, and reduced freezing time (memory) after conditioned fear (all p < 0.05). Brain antioxidant reserves were more depleted following asphyxial cardiac arrest. In adjusted analyses, human ventricular fibrillation cardiac arrest was associated with greater cardiovascular injury based on peak troponin (7.8 ng/mL [0.8-57 ng/mL] vs 0.3 ng/mL [0.0-1.5 ng/mL]) and ejection fraction by echocardiography (20% vs 55%; all p < 0.0001), whereas asphyxial cardiac arrest was associated with worse early neurologic injury and poor functional outcome at hospital discharge (n = 46 [18%] vs 102 [44%]; p < 0.0001). Most ventricular fibrillation cardiac arrest deaths (54%) were the result of cardiovascular instability, whereas most asphyxial cardiac arrest deaths (75%) resulted from neurologic injury (p < 0.0001)., Conclusions: In transcending rat and human studies, we find a consistent phenotype of heart and brain injury after cardiac arrest based on etiology: ventricular fibrillation cardiac arrest produces worse cardiovascular dysfunction, whereas asphyxial cardiac arrest produces worsened neurologic injury associated with greater oxidative stress.

Background: The Resuscitation Science Symposium (ReSS) is the dedicated international forum for resuscitation science at the American Heart Association's Scientific Sessions. In an attempt to increase curated content and social media presence during ReSS 2017, the Journal of the American Heart Association (JAHA) coordinated an inaugural social media campaign., Methods and Results: Before ReSS, 8 resuscitation science professionals were recruited from a convenience sample of attendees at ReSS 2017. Each blogger was assigned to either a morning or an afternoon session, responsible for "live tweeting" with the associated hashtags #ReSS17 and #AHA17. Twitter analytics from the 8 bloggers were collected from November 10 to 13, 2017. The primary outcome was Twitter impressions. Secondary outcomes included Twitter engagement and Twitter engagement rate. In total, 8 bloggers (63% male) generated 591 tweets that garnered 261 050 impressions, 8013 engagements, 928 retweets, 1653 likes, 292 hashtag clicks, and a median engagement rate of 2.4%. Total engagement, likes, and hashtag clicks were highest on day 2; total impressions were highest on day 3, and retweets were highest on day 4. Total impressions were highly correlated with the total number of tweets ( r =0.87; P =0.005) and baseline number of Twitter followers for each blogger ( r =0.78; P =0.02)., Conclusion: In this inaugural social media campaign for the 2017 American Heart Association ReSS, the degree of online engagement with this content by end users was quite good when evaluated by social media standards. Benchmarks for end-user interactions in the scientific community are undefined and will require further study., (© 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Objective: End-of-life interventions should be predicated on consensus understanding of patient wishes. Written documents are not always understood; adding a video testimonial/message (VM) might improve clarity. Goals of this study were to (1) determine baseline rates of consensus in assigning code status and resuscitation decisions in critically ill scenarios and (2) determine whether adding a VM increases consensus., Methods: We randomly assigned 2 web-based survey links to 1366 faculty and resident physicians at institutions with graduate medical education programs in emergency medicine, family practice, and internal medicine. Each survey asked for code status interpretation of stand-alone Physician Orders for Life-Sustaining Treatment (POLST) and living will (LW) documents in 9 scenarios. Respondents assigned code status and resuscitation decisions to each scenario. For 1 of 2 surveys, a VM was included to help clarify patient wishes., Results: Response rate was 54%, and most were male emergency physicians who lacked formal advanced planning document interpretation training. Consensus was not achievable for stand-alone POLST or LW documents (68%-78% noted "DNR"). Two of 9 scenarios attained consensus for code status (97%-98% responses) and treatment decisions (96%-99%). Adding a VM significantly changed code status responses by 9% to 62% (P ≤ 0.026) in 7 of 9 scenarios with 4 achieving consensus. Resuscitation responses changed by 7% to 57% (P ≤ 0.005) with 4 of 9 achieving consensus with VMs., Conclusions: For most scenarios, consensus was not attained for code status and resuscitation decisions with stand-alone LW and POLST documents. Adding VMs produced significant impacts toward achieving interpretive consensus.

Introduction: The Institute of Medicine and American Heart Association have called for tiered accreditation standards and regionalization of post-cardiac arrest care, but there is little data to support that regionalization has a durable effect on patient outcomes. We tested the effect of treatment at a high-volume center on long-term outcome after sudden cardiac arrest (SCA)., Methods: We included patients hospitalized at one of 7 medical centers in Southwestern Pennsylvania after SCA from 2005 to 2013. Centers were one regional referral center with an organized systems for post-SCA care, two moderate volume tertiary care centers and 4 low-volume centers. We abstracted clinical characteristics and outcomes at hospital discharge, and for survivors to discharge we queried the National Death Index for long-term survival data. We used Cox regression to determine the unadjusted associations of baseline predictors and survival, and built an adjusted model controlling for baseline predictors., Results: Overall, 987 patients survived to discharge. During 2196 person-years of follow-up, median survival was 5.3 years and there were 396 deaths. In unadjusted analysis, treating center, age, arrest location, Charlson Comorbidity Index, initial rhythm, cardiac catheterization, defibrillator placement, discharge disposition, and neurological status at discharge were associated with long-term outcome. In adjusted analysis, treatment at the high-volume cardiac arrest center was associated with improved survival compared to treatment at other centers (hazards ratio 1.49, 95% confidence interval 1.19-1.86)., Conclusion: Treatment at a high-volume cardiac arrest center with organized systems for post-arrest care is associated with a substantial long-term survival benefit after hospital discharge., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Cardiac arrest afflicts more than 300,000 persons annually in North America alone. Advances in systematic, regimented postresuscitation care have lowered mortality and improved neurologic outcomes in select cohorts of patients over the last decade. Postcardiac arrest care now comprises its own link in the chain of survival. For most patients, high-quality postcardiac arrest care begins in the Emergency Department. This article reviews the evidence and offers treatment strategies for the key components of postcardiac arrest care., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction: Cardiac arrest commonly results in varying degrees of cognitive injury. Standard outcome measures used in the cardiac arrest cohort do not rigorously evaluate for these injury patterns. We examined the utility of the Computerized Assessment for Mild Cognitive Injury (CAMCI) in cardiac arrest (CA) survivors. We hypothesized that cognitive deficits would be more severe in patients who were comatose on hospital arrival., Methods: Prospective cohort of CA survivors at a single tertiary care facility where participants received neurocognitive testing using CAMCI. CAMCI results were subdivided into memory, attention, and executive functions. Scores between subjects who were initially comatose and were not comatose following resuscitation were compared using the Mann-Whitney test., Results: Of 72 subjects included, the majority (N=44) were initially comatose following resuscitation with mean age of 54 (±14) years. The majority experienced a good neurologic outcome based on Cerebral Performance Category (N=47; 66%) and Modified Rankin Scale (N=38; 53%). Time from resuscitation to CAMCI testing was not associated with total CAMCI score in this cohort (Pearson's r(2) value -0.1941, p=0.20). Initially comatose and not comatose subjects did not differ in their CAMCI overall scores (p=0.33), or in any subtest areas. The not comatose cohort had 1 subtest for which there was a Moderate Risk for mild cognitive impairment (Nonverbal Accuracy), and 2 for which there was a Moderately Low Risk (Verbal Accuracy and Executive Accuracy). The Comatose cohort had 4 subtests, which were deemed Moderately Low Risk for cognitive impairment (Verbal Accuracy, Attention Accuracy, Executive Accuracy and Nonverbal Accuracy)., Conclusions: In-hospital CAMCI testing suggests memory, attention and executive impairment are commonly in patients following resuscitation from cardiac arrest. Outcome evaluations should test for deficits in memory, attention, and executive function., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: The purpose of this study was to validate the ability of an early post-cardiac arrest illness severity classification to predict patient outcomes., Methods: The Pittsburgh Cardiac Arrest Category (PCAC) is a 4-level illness severity score that was found to be strongly predictive of outcomes in the initial derivation study. We assigned PCAC scores to consecutive in and out-of-hospital cardiac arrest subjects treated at two tertiary care centers between January 2011 and September 2013. We made assignments prospectively at Site 1 and retrospectively at Site 2. Our primary outcome was survival to hospital discharge. Inter-rater reliability of retrospective PCAC assessments was assessed. Secondary outcomes were favorable discharge disposition (home or acute rehabilitation), Cerebral Performance Category (CPC) and modified Rankin Scale (mRS) at hospital discharge. We tested the association of PCAC with each outcome using unadjusted and multivariable logistic regression., Results: We included 607 cardiac arrest patients during the study (393 at Site 1 and 214 at Site 2). Site populations differed in age, arrest location, rhythm, use of hypothermia and distribution of PCAC. Inter-rater reliability of retrospective PCAC assignments was excellent (κ=0.81). PCAC was associated with survival (unadjusted odds ratio (OR) for Site 1: 0.33 (95% confidence interval (CI) 0.27-0.41)) Site 2: 0.32 (95% CI 0.24-0.43) even after adjustment for other clinical variables (adjusted OR Site 1: 0.32 (95% CI 0.25-0.41) Site 2: 0.31 (95% CI 0.22-0.44)). PCAC was predictive of secondary outcomes., Conclusions: Our results confirm that PCAC is strongly predictive of survival and good functional outcome after cardiac arrest., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Introduction: Post-cardiac arrest patients are often exposed to 100% oxygen during cardiopulmonary resuscitation and the early post-arrest period. It is unclear whether this contributes to development of pulmonary dysfunction or other patient outcomes., Methods: We performed a retrospective cohort study including post-arrest patients who survived and were mechanically ventilated at least 24 hours after return of spontaneous circulation. Our primary exposure of interest was inspired oxygen, which we operationalized by calculating the area under the curve of the fraction of inspired oxygen (FiO₂AUC) for each patient over 24 hours. We collected baseline demographic, cardiovascular, pulmonary and cardiac arrest-specific covariates. Our main outcomes were change in the respiratory subscale of the Sequential Organ Failure Assessment score (SOFA-R) and change in dynamic pulmonary compliance from baseline to 48 hours. Secondary outcomes were survival to hospital discharge and Cerebral Performance Category at discharge., Results: We included 170 patients. The first partial pressure of arterial oxygen (PaO₂):FiO₂ ratio was 241 ± 137, and 85% of patients had pulmonary failure and 55% had cardiovascular failure at presentation. Higher FiO₂AUC was not associated with change in SOFA-R score or dynamic pulmonary compliance from baseline to 48 hours. However, higher FiO₂AUC was associated with decreased survival to hospital discharge and worse neurological outcomes. This was driven by a 50% decrease in survival in the highest quartile of FiO₂AUC compared to other quartiles (odds ratio for survival in the highest quartile compared to the lowest three quartiles 0.32 (95% confidence interval 0.13 to 0.79), P = 0.003)., Conclusions: Higher exposure to inhaled oxygen in the first 24 hours after cardiac arrest was not associated with deterioration in gas exchange or pulmonary compliance after cardiac arrest, but was associated with decreased survival and worse neurological outcomes.

Background: Physician Orders for Life-Sustaining Treatment (POLST) documents are active medical orders to be followed with intention to bridge treatment across health care systems. We hypothesized that these forms can be confusing and jeopardize patient safety., Objectives: The aim of this study was to determine whether POLST documents are confusing in the emergency department setting and how confusion impacts the provision or withholding of lifesaving interventions., Methods: Members of the Pennsylvania chapter of the American College of Emergency Physicians were surveyed between September and October 2013. Respondents were to determine code status and treatment decisions in scenarios of critically ill patients with POLST documents who emergently arrest. Combinations of resuscitations (do not resuscitate [DNR], cardiopulmonary resuscitation) and levels of treatment (full, limited, comfort measures) were represented. Responses were summarized as percentages and analyzed by subgroup using the Fisher exact test. P = 0.05 was considered significant. We defined confusion in response as absence of consensus (supermajority of 95%)., Results: Our response rate was 26% (223/855). For scenarios specifying DNR and either full or limited treatment, most chose DNR (59%-84%) and 25% to 75% chose resuscitation. When the POLST specified DNR with comfort measures, 90% selected DNR and withheld resuscitation. When cardiopulmonary resuscitation/full treatment was presented, 95% selected "full code" and resuscitation. Physician age and experience significantly affected response rates; prior POLST education had no impact. In most scenarios depicted, responses reflected confusion over its interpretation., Conclusions: Significant confusion exists among members of the Pennsylvania chapter of the American College of Emergency Physicians regarding the use of POLST in critically ill patients. This confusion poses risk to patient safety. Additional training and/or safeguards are needed to allow patient choice as well as protect their safety.

Background: Neuron specific enolase (NSE) and astroglial protein S100B are associated with outcome following resuscitation from cardiac arrest. We tested whether NSE and S100B levels are associated with illness severity on hospital arrival, and whether levels are independently associated with survival to hospital discharge after adjusting for initial illness severity., Methods: Levels of NSE and S100B were obtained at arrival, 6, 12, 24, 48, and 72h after successful resuscitation from cardiac arrest. Clinical data included demographics, Pittsburgh Cardiac Arrest Category (PCAC I-IV) and survival to hospital discharge. Univariable and multivariable predictive models including NSE and S-100B were created to predict survival. ROC analyses were performed to determine sensitivity and specificity of NSE and S-100B at each time interval., Results: Of 77 comatose subjects, 5 did not receive therapeutic hypothermia and were excluded. Mean age was 59 (SD 16) years, with 58% male (N=42), 72% out-of-hospital arrest (N=52), and 43% VF/VT. Survival was 36% (N=26). PCAC IV was associated with higher levels of NSE at 24h (p=0.001) and S100B at 24h (p=0.005). In the multivariate analysis, survival was associated with initial S100B level (OR 0.24; 95% CI 0.07-0.86). NSE values>49.5ng/mL at 48h and NSE values>10.59ng/mL at 72h predicted mortality. S100B levels>0.414ng/mL at 72h predicted mortality., Conclusions: More severe neurologic injury on initial examination is associated with higher levels of NSE and S100B. Elevated levels of S100B immediately following resuscitation were associated with death. Persistently elevated levels of NSE and S100B at 48 and 72h were associated with death., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Background: Cardiac arrest patients often suffer from dysfunction of multiple organ systems after return of spontaneous circulation (ROSC). The incidence of renal dysfunction in patients with out-of-hospital cardiac arrest (OHCA) is not well described. Renal dysfunction has been associated with worse outcomes in critical illness., Hypothesis: Renal dysfunction is common after OHCA, and renal dysfunction is independently associated with survival., Methods: We performed a retrospective review of consecutive adult patients admitted to an intensive care unit after successful resuscitation from OHCA between 01/01/2005 and 12/31/2010. Patients were excluded for death or withdrawal of care within 24h, preexisting end-stage renal disease, or OHCA due to hyperkalemia. The RIFLE criteria were used to classify subjects with renal dysfunction into one of three categories - risk, injury, or failure - based on trending of serum creatinine concentration or glomerular filtration rate. Data were analyzed using descriptive statistics., Results: Of 364 patients, 38 were excluded due to death or withdrawal of care within 24h, 11 due to end-stage renal disease, and 4 due to OHCA from hyperkalemia, leaving 311 patients in the final analysis. The mean age was 58 (SD 16) years; 174 (59%) were male, VF/VT was the primary rhythm in 156 (50%), and 236 (80%) were comatose at hospital arrival. Among 311 patients, 32 (10.3%) developed acute renal failure (ARF), 27 (8.7%) developed acute kidney injury (AKI), and 56 (18.0%) developed risk of renal dysfunction. Of the 32 subjects that developed ARF, renal replacement therapy (RRT) was initiated on 13 (40.6%). Development of ARF was not associated with survival (OR 0.73; 95% CI 0.26, 2.05) after adjusting for initial rhythm or illness severity., Conclusions: More than one-third of patients resuscitated from OHCA developed evidence of renal dysfunction, and 19% of patients meeting criteria for AKI or ARF. In this study, development of renal failure was not independently associated with survival., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Background: Following successful resuscitation from cardiac arrest, a prothrombotic state may contribute to end-organ dysfunction. We examined whether the level of serum thrombin-antithrombin (TAT) in patients hospitalized after cardiac arrest was associated with survival or the development of multiple organ failure (MOF)., Methodology: A prospective cohort study of subjects with in-hospital cardiac arrest (IHCA) or out-of-hospital cardiac arrest (OHCA) treated between 1/1/2007 and 5/30/2010 at a single tertiary care referral center. TAT levels were measured at hospital arrival and 24h after cardiac arrest. Logistic regression was used to determine associations between TAT levels and survival and development of MOF., Results: Data were available for 86 subjects. TAT levels decreased over time. Initial TAT levels (OR 0.03; 95%CI 0.001, 0.62) and category of illness severity (OR 0.39; 95% CI 0.21, 0.73) were associated with survival. Male gender (OR 3.86; 95% CI 1.17, 12.75) and category of illness severity (OR 1.86; 95% CI 1.09, 3.20), but not TAT levels were associated with development of MOF. Neither the 24-h TAT level, nor the change in TAT from initial to 24h was associated with survival when adjusted for category of illness severity., Conclusions: Initial serum TAT levels and category of illness severity are associated with survival. TAT levels are not associated with development of MOF. Initial TAT levels may be a useful prognostic adjunct in the post arrest population., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objective: Evaluate the prevalence of fever in the first 48 h after cardiac arrest and its effect on outcomes., Methods: Review of patients treated between 1/1/2005 and 6/30/2010. Fever was defined as T ≥ 38.0°C. We classified categories of post-cardiac arrest illness severity as (I) awake, (II) coma+mild cardiopulmonary dysfunction (SOFA cardiac+respiratory score <4), (III) coma+moderate-severe cardiopulmonary dysfunction, and (IV) deep coma. Associations between fever and survival or good neurologic outcome were examined between hypothermia (TH) and non-TH groups., Results: In 336 patients, mean age was 60 years (SD 16), 63% experienced out-of-hospital cardiac arrest and 65% received TH. A shockable rhythm was present in 40%. Post arrest illness severity was category II in 38%, category III in 20%, and category IV in 42%. Fever was present in 42% of subjects, with a post-arrest median onset of 15 h in the non-TH cohort and 36 h in TH cohort. Fever was not associated with survival within the whole cohort (OR 0.32, CI 0.15, 0.68) or TH cohort (OR 1.21, CI 0.69, 2.14), but was associated with survival in non-TH cohort (OR 0.47, CI 0.20, 1.10). Fever was not associated with good outcomes in the whole cohort (OR 0.83, CI 0.49, 1.40), TH cohort (OR 1.09, CI 0.56, 2.12) or non-TH cohort (OR 0.34, CI 0.11, 1.06)., Conclusions: The development of fever within the first 48 h after ROSC is common. Fever is associated with death in non-TH patients. TH treatment appears to mitigate this effect, perhaps by delaying fever onset., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Background: Alterations of endothelial nitric oxide synthase (eNOS) enzyme activity via eNOS gene polymorphisms have been associated with significant cardiovascular morbidity and mortality. Both the thymidine to cytosine transition mutation (T(-786)-->C) in the promoter region and the missense mutation in the exon 7 coding region of the eNOS gene (G(894)-->T) have been associated with several cardiovascular disease states. We hypothesized that heart transplant recipients who carried at least 1 allele of either of the polymorphisms would have reduced myocardial tissue expression of eNOS measured in the explanted heart., Methods and Results: Genomic DNA was isolated from myocardial tissue samples obtained from 43 explanted human hearts using standard methods. Regions of the eNOS gene were amplified from genomic DNA with a polymerase chain reaction using specific primers. Protein expression of eNOS was measured by Western blot analysis. There was a statistically significant decrease in mean eNOS expression in samples containing at least one allele for the T(-786)-->C promoter polymorphism (P=.04) compared with patients homozygous for the T allele. There was no change in eNOS expression associated with the G(894)-->T exonic polymorphisms., Conclusions: Our data show in failing human myocardium that the T(-786)-->C promoter polymorphism is associated with reduced eNOS expression, whereas the G(894)-->T polymorphism of exon 7 is not associated with change in either eNOS mRNA or protein expression. Reduced eNOS expression associated with the promoter polymorphism may contribute to the vascular, contractile, and autonomic responses to ventricular failure., ((c) 2010 Elsevier Inc. All rights reserved.)

Dextrocardia with situs inversus totalis is a rare disorder but is frequently associated with anomalous venous return. Pacemaker/Internal Cardioverter Defibrillator implantation in this population can be difficult given the difficult venous anatomy. This case illustrates how beforehand knowledge of the venous anatomy by cardiac MRI can facilitate device implantation.

Claudin-5 is a transmembrane cell junction protein that is a component of tight junctions in endothelial cell layers. We have previously shown that claudin-5 also localizes to lateral membranes of murine cardiomyocytes at their junction with the extracellular matrix. Claudin-5 levels are specifically reduced in myocytes from a mouse model of muscular dystrophy with cardiomyopathy. To establish whether claudin-5 is similarly specifically reduced in human cardiomyopathy, we compared the levels of claudin-5 with other cell junction proteins in 62 cardiomyopathic end-stage explant samples. We show that claudin-5 levels are reduced in at least 60% of patient samples compared with non-failing controls. Importantly, claudin-5 reductions can be independent of connexin-43, a gap junction protein previously reported to be reduced in failing heart samples. Other cell junction proteins including alpha-catenin, beta-catenin, gamma-catenin, desmoplakin, and N-cadherin are reduced in only a small number of failing samples and only in combination with reduced claudin-5 or connexin-43 levels. We also show that reduced claudin-5 levels can be present independently from dystrophin alterations, which are known to be capable of causing and resulting from cardiomyopathy. These data are the first to show alterations of a tight junction protein in human cardiomyopathy samples and suggest that claudin-5 may participate in novel mechanisms in the pathway to end-stage heart failure.

Pheochromocytoma is a rare cause of secondary hypertension. It may present atypically as cardiogenic shock with significant morbidity and mortality. We present a patient in cardiogenic shock dependent on an intra-aortic balloon pump and vasopressor support who completely recovered cardiac function within 96 h of hospitalization.

Vasopressin administration has been suggested during cardiopulmonary resuscitation, and a previous clinical trial has suggested that vasopressin is most effective when administered with epinephrine. Adult subjects (n = 325) who received > or =1 dose of intravenous epinephrine during cardiopulmonary resuscitation for nontraumatic, out-of-hospital cardiac arrest were randomly assigned to receive 40 IU of vasopressin (n = 167) or placebo (n = 158) as soon as possible after the first dose of epinephrine. The rate of return of pulses was similar between the vasopressin and placebo groups (31% vs 30%), as was the presence of pulses at the emergency department (19% vs 23%). No subgroup appeared to be differentially affected, and no effect of vasopressin was evident after adjustment for other clinical variables. Additional open-label vasopressin was administered by a physician after the study drug for 19 subjects in the placebo group and 27 subjects in the vasopressin group. Results were similar if these subjects were excluded or were assigned to an actual drug received. Survival duration for subjects admitted to the hospital did not differ between groups. In conclusion, vasopressin administered with epinephrine does not increase the rate of return of spontaneous circulation.

Twenty-five heart transplant recipients underwent 45 coronary interventions at a mean of 7.8 +/- 2.2 years from time of transplant. Periprocedural success was high, and there was a trend toward better outcomes in the group that underwent stent deployment compared with conventional balloon angioplasty.