Acute Cardiopulmonary Events Research Articles

O-054 COVID-19 during pregnancy, maternal immune response and neonatal cell-specific immunity

Pathogens are a major threat to maternal health and the progression of pregnancy. The immune response during normally progressing pregnancies, primarily the suppression of inflammation, likely accounts for this high susceptibility of pregnant women to infections. An increased morbidity and mortality related to influenza, COVID-19 and malaria has been reported for pregnant women, compared to non-pregnant women. Especially influenza infections during pregnancy have been well studied, as humans are severely and recurrently affected by seasonal epidemics and random pandemics. Besides severe maternal symptoms such as acute cardiopulmonary events, pneumonia, and acute respiratory distress syndrome, maternal influenza infection also causes foetal complications, such as intrauterine growth restriction, preterm birth or even foetal death. However, vertical transmission of the influenza virus across the placenta and infection of the foetus has not been observed, suggesting that the pregnancy pathologies are maternally derived.In addition to influenza-mediated adverse conditions, the recent COVID-19 pandemic has underscored that infection with the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) can also lead to severe illnesses in pregnant women, accompanied by a higher risk for foetal loss or preterm birth. Fortunately, with the ongoing pandemic, large cohort studies and meta-analyses revealed that vertical transmission and related fetal infection is a rare complication affecting only 1-3% of SARS-CoV-2 infections in pregnancy. These low risk for placental infection is likely due to the inefficient SARS-CoV-2 virus replication in placental tissues. Since understanding SARS-CoV-2-related pathogenicity during pregnancy is highly relevant, we initiated a study early in 2020, to which we have recruited more than 160 pregnant women with COVID-19. Our comprehensive placental analyses unearthed a paucity of SARS-CoV-2 viral expression ex vivo in term placentae under acute infection and in convalescent pregnant women. Furthermore, we could show inefficient SARS-CoV-2 replication in placental tissues in vitro, which provides a rationale for the low ex vivo viral expression. We detected specific SARS-CoV-2 T cell responses in mothers within a few days upon infection, which is undetectable in cord blood. Reports by others have shown that maternal SARS-CoV-2 during pregnancy may cause placental insufficiency, defined by increased perivillous fibrin deposition, histiocytic intervillositis and trophoblast necrosis. These changes can cause extensive placental damage leading to placental malperfusion and insufficiency that is incompatible with intrauterine survival. Considering that multiple SARS-CoV-2 variants of concern which emerged until today may affect pregnant women differently and bear a differential risk for pregnancy complication. This, continuous vigilance is needed in order to provide best protection of the highly vulnerable group of pregnant women and their unborn children.Trial registration number

Gender Disparities Among Adult Recipients of Layperson Bystander Cardiopulmonary Resuscitation by Location of Cardiac Arrest in Pan-Asian Communities

Background: Bystander cardiopulmonary resuscitation (BCPR) is a critical component of the ‘chain of survival’ in reducing mortality among out-of-hospital cardiac arrest (OHCA) victims. Inconsistent findings on gender disparities among adult recipients of layperson BCPR have been reported in the literature. We aimed to fill this knowledge gap by investigating the extent of gender disparities in a cross-national setting within Pan-Asian communities. Methods: We utilized data collected from the Pan-Asian Resuscitation Outcomes Study (PAROS), an international, multicenter, prospective study conducted between 2009 and 2018. We included all OHCA cases with non-traumatic arrest etiology transported by emergency medical services and excluded study sites that did not consistently collect information about the location of cardiac arrest. Logistic regression was used to analyze the association between gender and BCPR, stratified by location. Findings: We analyzed a cohort of 56,192 OHCA cases with an overall BCPR rate of 36.2% (20,329/56,192). At public locations, BCPR rate was 31.2% (631/2022) for female and 36.4% (3235/8892) for male OHCA victims; while at home, the rate was 38.3% (6838/17,842) for females and 35.1% (9625/27,436) for males. Controlling for country differences and several factors in multivariable logistic regression, we found females less likely to receive BCPR than males in public locations (odds ratio [OR]=0.89, 95% confidence interval [CI]: 0.70–0.99), but more likely to receive BCPR at home (OR=1.16, 95% CI: 1.11–1.21). Interpretation: In Pan-Asian communities, gender differences exist in adult recipients of BCPR and differ between home and public locations. Funding Statement: The study is supported by grants from the National Medical Research Council (NMRC/CSA/0049/2013) and Laerdal Foundation (20040). Declaration of Interests: MEH Ong reports funding from the ZOLL Medical Corporation for a study involving mechanical cardiopulmonary resuscitation devices; grants from the Laerdal Foundation, Laerdal Medical, and Ramsey Social Justice Foundation for funding of the Pan-Asian Resuscitation Outcomes Study; an advisory relationship with Global Healthcare SG, a commercial entity that manufactures cooling devices; and funding from Laerdal Medical on an observation program to their Community CPR raining Centre Research Program in Norway. MEH Ong has a licensing agreement and patent filed (Application no: 13/047,348) with ZOLL Medical Corporation for a study titled “Method of predicting acute cardiopulmonary events and survivability of a patient. NL and MEH Ong are the co-founders and scientific advisors of TIIM Healthcare, a commercial entity which develops real-time prediction and risk stratification solutions at triage. All other authors have no conflict of interest to declare. Ethics Approval Statement: The study was granted approval from SingHealth Centralised Institutional Review Board and Domain Specific Review Board with waiver of patient informed consent.

Euthyroid sick syndrome in hip fractures: Valuation of vitamin D and parathyroid hormone axis

IntroductionFemur fracture is an acute event with a high incidence and mortality worldwide. Euthyroid sick syndrome (ESS) is a disease characterized by an alteration of fT3 in the absence of a primary thyroid pathology. The aim of the study is evaluating the association between femur fracture and ESS and post-operative fluctuations of the parathyroid hormone (PTH) and vitamin D and their physio-pathological implications. Materials and MethodsAll patients older than 65 years, admitted in our emergency care unit with a diagnosis of proximal femur fracture were recruited. Exclusion criteria were acute cardio-pulmonary events, neoplastic diseases, any thyroid or endocrine pathology and use of drugs with thyroidal interactions. All patients underwent surgery within 48 h from the injury. The outcome of the study is the presence of ESS, moreover, post-operative fluctuations of the PTH and vitamin D are also evaluated. Result45 patients (13 men and 32 females) were enrolled. 20 patients had a normal thyroidal function, while 23 had a diagnosis of ESS. Mean age was 81.9. BMI was lower in the ESS group than the controls (25,3 vs 22,7; p < 0.02). In the ESS group a significantly higher decrease in Vitamin D levels was observed, compared to controls (3.96 ng/ml, p<0.001). Values of PTH were significantly different between the two groups, with a level 44.29 pg/ml lower among the ESS group compared to controls (p = 0.002). In the ESS group a significant decrease of serum calcium on the first post-surgery day was observed, compared to controls (8,7 vs 8,3; p < 0,01). There were no differences in the CCI, serum electrolytes and other variables collected between the two groups. ConclusionPart of the geriatric population suffering from fractures of the proximal femur are affected by ESS. This population displays anomalies of the Vitamin d-PTH axis and a lower BMI.

Machine Learning Approach To Estimate Hourly Exposure to Fine Particulate Matter for Urban, Rural, and Remote Populations during Wildfire Seasons.

Exposure to wildfire smoke averaged over 24-hour periods has been associated with a wide range of acute cardiopulmonary events, but little is known about the effects of sub-daily exposures immediately preceding these events. One challenge for studying sub-daily effects is the lack of spatially and temporally resolved estimates of smoke exposures. Inexpensive and globally applicable tools to reliably estimate exposure are needed. Here we describe a Random Forests machine learning approach to estimate 1-hour average population exposure to fine particulate matter during wildfire seasons from 2010 to 2015 in British Columbia, Canada, at a 5 km × 5 km resolution. The model uses remotely sensed fire activity, meteorology assimilated from multiple data sources, and geographic/ecological information. Compared with observations, model predictions had a correlation of 0.93, root mean squared error of 3.2 μg/m3, mean fractional bias of 15.1%, and mean fractional error of 44.7%. Spatial cross-validation indicated an overall correlation of 0.60, with an interquartile range from 0.48 to 0.70 across monitors. This model can be adapted for global use, even in locations without air quality monitoring. It is useful for epidemiologic studies on sub-daily exposure to wildfire smoke and for informing public health actions if operationalized in near-real-time.

Syndrome of Acute Anxiety Among Marines After Recent Arrival at High Altitude

Management of mental health is critical for maintenance of readiness in austere military environments. Emerging evidence implicates hypoxia as an environmental trigger of anxiety spectrum symptomatology. One thousand thirty-six unacclimatized infantry Marines ascended from sea level to the Marine Corps Mountain Warfare Training Center (2,061-3,383 m) for a 30-day exercise. Within the first 6 days of training, 7 servicemen presented with severe, acute anxiety/panic with typical accompanying signs of sympathetic activation and no classic symptoms of acute mountain sickness (including headache). Four had a history of well-controlled psychiatric diagnoses. Invariably, cardiopulmonary and neurological evaluations were unrevealing, and acute cardiopulmonary events were excluded within limits of expeditionary diagnostic capabilities. All patients responded clinically to oxygen, rest, and benzodiazepines, returning to baseline function the same day. The unexpected onset of 7 cases of acute anxiety symptomatology coincident with recent arrival at moderate-to-high altitudes represents a highly unusual incidence and temporal distribution, suggestive of hypobaric hypoxemia as the proximal cause. We propose acute hypoxic physiological anxiety (AHPA) as a unique member of the spectrum of altitude-associated neurological disorders. Recognition of AHPA is particularly relevant in a military population; warfighters with anxiety spectrum diagnoses may have a recognizable and possibly preventable vulnerability.

Electrocardiographic impacts of lung resection

IntroductionElectrocardiographic (ECG) changes accompanying lung resection have not been well investigated previously in a large controlled series of human adults. Thus, our current investigation was undertaken for a better understanding of the ECG changes associated with lung resection. Materials and MethodsMedical records of 117 patients who underwent lung resection (segmentectomy, lobectomy, or pneumonectomy) were reviewed. Their clinical course and ECGs were compared during early, intermediate and late postoperative course (<1month, 1month to 1year and >1year post-op respectively). ResultsPatients in the acute postoperative phase had higher heart rate, increased maximum P-duration and P-dispersion, increased incidence of atrial arrhythmias and frequent ST-T changes. P-vector and QRS-vector were significantly affected after the lung resections; the correlation being most consistent between the anatomical displacements and the QRS-vector in the majority of patients. The axial shifts also demonstrated a characteristic temporal relationship after left pneumonectomy (a leftward deviation in the acute, normal or slight rightward deviation in the intermediate and a rightward deviation in the late postoperative course). The precordial R/S transition is often affected due to the mediastinal shifts and the ECGs in patients after left lung resection may simulate acute anteroseptal myocardial infarction due to a delayed R/S transition. ConclusionThe understanding and recognition of the expected ECG findings after lung resection are imperative to avoid confusing these changes with other acute cardiopulmonary events which would prevent unnecessary further investigational work-up. These ECG changes are often dynamic and may bear a temporal relationship to the dynamic post-surgical changes in the thoracic anatomy.

Acute Anxiety Among Marines After Recent Arrival at High Altitude: High Altitude Anxiety as a Distinct Diagnostic Entity

As United States and allied armed forces maintain a presence in high altitude regions such as eastern Afghanistan, a better understanding of the prevention, diagnosis, and treatment of altitude illness has become increasingly important. This preventable form of disease/nonbattle injury presents a significant issue to readiness for warfighter performance in the field. At the Marine Corps Mountain Warfare Training Center in Bridgeport, California (operational altitudes: 2061 to 3383 m), 1036 unacclimatized Marines participated in battalion-level mountain warfare exercises in July 2010. Several unexpected, clear-cut cases of severe anxiety were observed at the Battalion Aid Station (BAS), located at 2061 m, over the first 6 days after training proceeded above 2000 m. These cases occurred among otherwise healthy Marines, some having had no prior history of psychiatric illness, and others having had a history of well-controlled panic disorders or combat stress-related psychiatric illness. All patients presented with similar symptoms of mild to moderate tachycardia, tachypnea, and diaphoresis; some presented with extremity numbness and tingling. Acute cardiopulmonary events could not be decisively ruled out by electrocardiogram, chest radiograph, or lab studies (given the equipment limitation of the BAS); however, patients were monitored clinically with vital signs, pulse oximetry, and chest auscultation/palpation. All patients responded clinically to oxygen, rest, and benzodiazepine management; all returned to baseline psychiatric function within the same day. The near-simultaneous and unexpected onset of 7 cases of acute anxiety, coincident with new arrival at moderate to high altitude, represents a highly unusual incidence, prevalence, and temporal distribution suggestive of hypobaric hypoxemia as the proximal cause. Based upon the authors' extensive combined clinical experience and review of emerging peer-reviewed literature, High Altitude Anxiety is proposed as a diagnostic entity for consideration in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Further research is indicated.

Contrasting actions of diesel exhaust particles on the pulmonary and cardiovascular systems and the effects of thymoquinone

Acute exposure to particulate air pollution has been linked to acute cardiopulmonary events, but the underlying mechanisms are uncertain. EXPERIMENTAL APPROACH We investigated the acute (at 4 and 18 h) effects of diesel exhaust particles (DEP) on cardiopulmonary parameters in mice and the protective effect of thymoquinone, a constituent of Nigella sativa. Mice were given, intratracheally, either saline (control) or DEP (30 µg·per mouse). KEY RESULTS At 18 h (but not 4 h) after giving DEP, there was lung inflammation and loss of lung function. At both 4 and 18 h, DEP caused systemic inflammation characterized by leucocytosis, increased IL-6 concentrations and reduced systolic blood pressure (SBP). Superoxide dismutase (SOD) activity was decreased only at 18 h. DEP reduced platelet numbers and aggravated in vivo thrombosis in pial arterioles. In vitro, addition of DEP (0.1-1 µg·mL(-1)) to untreated blood-induced platelet aggregation. Pretreatment of mice with thymoquinone prevented DEP-induced decrease of SBP and leucocytosis, increased IL-6 concentration and decreased plasma SOD activity. Thymoquinone also prevented the decrease in platelet numbers and the prothrombotic events but not platelet aggregation in vitro. At 4 h after DEP exposure, the cardiovascular changes did not appear to result from pulmonary inflammation but possibly from the entry of DEP and/or their associated components into blood. However, at 18 h, DEP induced significant changes in pulmonary and cardiovascular functions along with lung inflammation. Pretreatment with thymoquinone prevented DEP-induced cardiovascular changes.

Acute decreases in proteasome pathway activity after inhalation of fresh diesel exhaust or secondary organic aerosol.

BackgroundEpidemiologic studies consistently demonstrate an association between acute cardiopulmonary events and changes in air pollution; however, the mechanisms that underlie these associations are not completely understood. Oxidative stress and inflammation have been suggested to play a role in human responses to air pollution. The proteasome is an intracellular protein degradation system linked to both of these processes and may help mediate air pollution effects.ObjectivesIn these studies, we determined whether acute experimental exposure to two different aerosols altered white blood cell (WBC) or red blood cell (RBC) proteasome activity in human subjects. One aerosol was fresh diesel exhaust (DE), and the other freshly generated secondary organic aerosol (SOA).MethodsThirty-eight healthy subjects underwent 2-hr resting inhalation exposures to DE and separate exposures to clean air (CA); 26 subjects were exposed to DE, CA, and SOA. CA responses were subtracted from DE or SOA responses, and mixed linear models with F-tests were used to test the effect of exposure to each aerosol on WBC and RBC proteasome activity.ResultsWBC proteasome activity was reduced 8% (p = 0.04) after exposure to either DE or SOA and decreased by 11.5% (p = 0.03) when SOA was analyzed alone. RBCs showed similar 8–10% declines in proteasome activity (p = 0.05 for DE alone).ConclusionsAir pollution produces oxidative stress and inflammation in many experimental models, including humans. Two experimental aerosols caused rapid declines in proteasome activity in peripheral blood cells, supporting a key role for the proteasome in acute human responses to air pollution.

Potential Health Risks of Air Pollution Beyond Triggering Acute Cardiopulmonary Events

Andrea Baccarelli, MD; Ida Martinelli, MD; Antonella Zanobetti, PhD; Paolo Grillo, MD; Li-Fang Hou, PhD; Pier A. Bertazzi, MD; Pier Mannuccio Mannucci, MD; Joel Schwartz, PhD Background Particulate air pollution has been linked to heart disease and stroke, possibly resulting from enhanced coagulation and arterial thrombosis. Whether particulate air pollution exposure is related to venous thrombosis is unknown. Methods We examined the association of exposure to particulate matter of less than 10 μm in aerodynamic diameter (PM10) with deep vein thrombosis (DVT) risk in 870 patients and 1210 controls from the Lombardy region in Italy, who were examined between 1995 and 2005. We estimated exposure to PM10 in the year before DVT diagnosis (cases) or examination (controls) through area-specific mean levels obtained from ambient monitors. Results Higher mean PM10 level in the year before the examination was associated with shortened prothrombin time (PT) in DVT cases (standardized regression coefficient [β] = −0.12; 95% confidence interval [CI], −0.23 to 0.00) (P = .04) and controls (β = −0.06; 95% CI, −0.11 to 0.00) (P = .04). Each increase of 10 μg/m3 in PM10 was associated with a 70% increase in DVT risk (odds ratio [OR], 1.70; 95% CI, 1.30 to 2.23) (P < .001) in models adjusting for clinical and environmental covariates. The exposure-response relationship was approximately linear over the observed PM10 range. The association between PM10 level and DVT risk was weaker in women (OR, 1.40; 95% CI, 1.02 to 1.92) (P = .02 for the interaction between PM10 and sex), particularly in those using oral contraceptives or hormone therapy (OR, 0.97; 95% CI, 0.58 to 1.61) (P = .048 for the interaction between PM10 level and hormone use). Conclusions Long-term exposure to particulate air pollution is associated with altered coagulation function and DVT risk. Other risk factors for DVT may modulate the effect of particulate air pollution.

Influenza-associated morbidity and mortality in young and middle-aged women.

Data are limited on rates of influenza-associated hospitalizations and deaths among adults younger than 65 years. To quantify serious morbidity and mortality from influenza for women younger than 65 years with and without certain chronic medical conditions, including human immunodeficiency virus infection. Retrospective cohort study. Women aged 15 to 64 years enrolled in the Tennessee Medicaid program from 1974 to 1993. All hospitalizations for and deaths from pneumonia, influenza, and other selected acute cardiopulmonary conditions for women with and without selected chronic medical conditions during 19 consecutive years. Influenza-attributable risk was calculated by subtracting event rates during peri-influenza season (November through April of each year when influenza virus was not circulating) from adjusted rates during influenza season (November through April when influenza virus was circulating). During the 19 years of the study, we identified 53607 acute cardiopulmonary hospitalizations and deaths. Rates of such events were consistently higher during influenza seasons than peri-influenza seasons. Among high-risk women, the estimated annual excess was 23 hospitalizations and deaths per 10000 women aged 15 to 44 years and 58 such events per 10000 women aged 45 to 64 years. The estimated annual excess mortality due to influenza was 2 deaths per 10000 high-risk women for both age groups combined. Among women with no identified high-risk conditions, estimated annual excess hospitalizations and deaths were 4 and 6 per 10000 women aged 15 to 44 and 45 to 64 years, respectively. Women younger than 65 years with certain chronic medical conditions experience substantial morbidity and mortality from acute cardiopulmonary events during influenza season. More effective targeting of these populations for annual influenza immunization is warranted.