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Introduction In response to the COVID-19 pandemic in Detroit, an earlier termination of resuscitation protocol was initiated in March 2020. To characterize pre-hospital cardiac arrest careduring COVID-19 in Detroit, we analyzed out-of-hospital cardiac arrest (OHCA) rate of ROSC (return of spontaneous circulation) and patient characteristics before and during the COVID-19 pandemic. Methods OHCA data was analyzed between March 10th, 2020 – April 30th, 2020 and March 10th, 2019 – April 30th, 2019. ROSC, patient demographics, arrest location, initial rhythms, bystander CPR and field termination were compared before and during the pandemic. Descriptive statistics were utilized to compare arrest characteristics between years, and the odds of achieving vs. not achieving ROSC. 2020 vs. 2019 as a predictor for ROSC was assessed with logistic regression. Results 471 patients were included. Arrests increased to 291 during the pandemic vs. 180 in 2019 (62% increase). Age (mean difference + 6; 95% CI: +2.4 to +9.5), arrest location (nursing home OR = 2.42; 95% CI: 1.42–4.31; public place OR = 0.47; 95% CI: 0.25–0.88), BLS response (OR = 0.68; 95% CI: 0.47–0.99), and field termination of resuscitation (OR = 2.36; 95% CI: 1.36–4.07) differed significantly in 2020 compared to 2019. No significant difference was found in the confounder-adjusted odds of ROSC in 2020 vs 2019 (OR = 0.61; 95% CI: 0.34–1.11). Conclusion OHCA increased by 62% during COVID-19 in Detroit, without a significant change in prehospital ROSC. The rate of ROSC remained similar despite the implementation of an early termination of resuscitation protocol in response to COVID-19.

Angiotensin-converting enzyme inhibitors (ACEi) are part of the indicated treatment in hypertensive African Americans. ACEi have blood pressure-independent effects that may make them preferred for certain patients. We aimed to evaluate the impact of ACEi on anti-fibrotic biomarkers in African American hypertensive patients with left ventricular hypertrophy (LVH). We conducted a post hoc analysis of a randomized controlled trial in which hypertensive African American patients with LVH and vitamin D deficiency were randomized to receive intensive antihypertensive therapy plus vitamin D supplementation or placebo. We selected patients who had detectable lisinopril (lisinopril group) in plasma using liquid-chromatography/mass spectrometry analysis and compared them to subjects who did not (comparison group) at the one-year follow-up. The pro-fibrotic marker type 1 procollagen C-terminal propeptide (PICP) and the anti-fibrotic markers matrix metalloproteinase-1 (MMP-1), tissue inhibitor of metalloproteinases 1 (TIMP-1), telopeptide of collagen type I (CITP), and N-acetyl-seryl-aspartyl-lysyl-proline (Ac-SDKP) peptide were measured. Sixty-six patients were included, and the mean age was 46.2 ± 8 years. No difference was observed in the number and intensity of antihypertensive medications prescribed in each group. Patients with detectable lisinopril had lower blood pressure than those in the comparison group. The anti-fibrotic markers Ac-SDKP, MMP-1, and MMP-1/TIMP-1 ratio were higher in patients with detectable ACEi (all p < .05). In a model adjusted for systolic blood pressure, MMP-1/TIMP-1 (p = .02) and Ac-SDKP (p < .001) levels were associated with lisinopril. We conclude that ACEi increase anti-fibrotic biomarkers in hypertensive African Americans with LVH, suggesting that they may offer added benefit over other agents in such patients.

Background: Left heart catheterization (LHC) and TTM are proven beneficial after OHCA. Detroit CARES data found a strong, though insignificant, trend for LHC rate and survival (p = 0.1). In 2018, the rate of patients with LHC and good CPC nearly doubled, despite an overall decrease in LHC rate. Therefore, we hypothesize LHC is performed later (after second day of hospitalization) nationwide and a good CPC is likely associated with selection of patients expected to survive. Methods: We analyzed the national CARES registry (2013 - 2018) to investigate whether delayed LHC after OHCA was occurring nationally. Included were patients 18 or older, non-skilled care facility patients and surviving to admission. The primary outcome was the CPC dichotomized into good (1 or 2) and poor (3 - 5). A propensity score was derived to predict early LHC that incorporated factors associated with LHC and outcome. A multi-level logistic regression analyses was fit using inverse weighted propensity scores. The primary predictor of interest was early LHC relative to no or late LHC. Also examined were TTM, year of cardiac arrest, and other predictors. Results reported are odds ratios (OR) and the corresponding 95% confidence intervals (95% CI). Results: 62,195 individual cases were identified; the median age was 61, (IQR-16), 62% male, 32% unwitnessed, 37% bystander CPR, and 35% initial shockable rhythm. 29% had good outcome and 22% received early LHC, 6% late LHC and 72% no LHC. 13% of patients receiving early LHC and 23% with no or late LHC had a good outcome. OR and 95% CI for good outcome were: 2.4 (2.2-2.7) for early LHC, 3.6 (3.3-3.8) for shockable rhythm, 1.9 (1.7-2.0) for public location and 2.0 (1.8-2.2) for witnessed arrest. Over the five-year period, no change in the total LHC occurred and a slight decrease in early LHC, (25%-23%), (Fig 1). Conclusion: Early LHC was associated with good outcome (CPC) at hospital discharge. The overall LHC rate is unchanged from 2013-18 with a slight decrease in early LHC.

Introduction: March 10 th , 2020 marked the first positive case of SARS-CoV-2 in Detroit. EMS protocol changes were implemented by March 25 th , 2020 in response to the virus. These modifications restricted intubation and allowed medical control to terminate resuscitation in cases of suspected COVID-19 after 10 minutes of CPR without ROSC. Due to global changes in pre-hospital cardiac arrest care caused by COVID-19, we conducted an analysis to determine OHCA characteristics of patients and fatality rates in the COVID-19 era. Methods: CARES data was analyzed between March 10 th , 2019 - April 30 th , 2019 and March 10 th , 2020 - April 30 th, 2020 for comparison before and during the pandemic. Patient demographics, location of arrest, initial rhythms, bystander CPR, EMS interventions and field termination were compared between the two time points. No major factors occurred in 2019 that would potentially skew that data. Descriptive statistics were utilized. Results: A total of 475 CARES patients were included during the study period. Total arrests surged in the COVID-19 era from 180 to 295. OHCA for individuals greater than 50 increased from 130 to 243. An initial rhythm of PEA tripled (10 to 30) during COVID-19, possibly due to hypoxia. The percentage of patients with a shockable rhythm declined (7.8 to 5.1). Bystander CPR decreased from 28.9% (52) to 18.3% (54), secondary to an increase of arrests being in non-public places and concern about disease transmission. Nursing home cardiac arrests increased during COVID from 19 to 73, from the previous year. Placement of an endotracheal tube or supraglottic airway by a basic or advanced unit decreased from 68.3% (123) in pre-COVID-19 era to 37.0% (109) in the current state of the pandemic. Termination of resuscitation in the field occurred over 3-fold from the previous year, an absolute increase from 64 to 204. Conclusion: There was a 61% increase in cardiac arrests during COVID-19 in Detroit. The pandemic and subsequent protocol changes greatly altered practice. COVID-19 has likely directly and indirectly, due to fear of going to the hospital, affected the number of out-of-hospital cardiac arrests. Additional review is being conducted to further delineate arrest etiologies.

Isolated hyperglycinuria is a rare disorder that is associated with osteoporosis and renal calculi. We report findings in a middle-aged, black woman who presented for renal function evaluation with a history of transient hypobicarbonataemia associated with topiramate therapy. She displayed the full triad of high urinary glycine, early-onset osteopenia despite normal reproductive hormones, and renal calculus with high urinary oxalate, phosphate and uric acid. Parathyroid hormone and fibroblast growth factor 23 were both normal. Formal genetic testing did not reveal mutations in SLC6A20, SLC6A18, SLC6A19, SLC36A2, the known genes associated with glycinuria; however, black individuals are poorly represented in the genetic databases. It may well be that otherwise unidentified mutations may be present or that topiramate may result in a lingering proximal tubule defect even after cessation of the drug.

Introduction: Survival with good neurologic outcome following out-of-hospital cardiac arrest (OHCA) requires intensive post-ROSC care. In response to a recent decline in OHCA survival rates in Detroit, we conducted an analysis to identify factors contributing to this regression. Methods: CARES data from Detroit EMS transports were analyzed, including adult non-traumatic OHCA patients treated from 2014-2018 at four hospitals. Patient demographics, conditions of the arrest, and post-ROSC interventions including left heart catheterization, (LHC) and targeted temperature management, (TTM), were correlated to survival to hospital discharge and discharge with CPC 1 or 2. We calculated crude and adjusted survival rates across sites. Survival rates were adjusted for Utstein criteria using multilevel multi-variable regression analyses. Results: A total of 5,175 CARES patients were included. There was no difference in Utstein criteria between years, other than a small increase in the rate of witnessed arrest. We noted a steady decrease in LHC, and steady increase in TTM rate over the 5 years. There was a system-wide decrease in survival to hospital discharge during 2018, though the percentage of patients discharged with CPC 1 or 2 was similar. We found a strong, though insignificant, trend for LHC rate and survival: 0.72 (p = 0.1057), R 2 : 0.88, Adjusted R 2 : 0.76; and for survival with CPC 1 or 2: 0.59 (p = 0.5172), R 2 : 0.72, Adjusted R 2 : 0.44. In 2018, the rate of patients with LHC and good CPC nearly doubled. Conclusion: During the study period, we found a steady increase in TTM rate and concomitant decrease in LHC rate. The rate of LHC correlated best with survival to hospital discharge. In 2018, an increase in the proportion of patients with CPC 1 or 2 receiving LHC occurred, despite a decline in the overall rate of LHC.

ACEi are first line treatment in hypertension; however, there is controversy regarding the benefit over other antihypertensive drugs. ACEi have pressure independent effects that may make them preferable for certain patients. We aimed to evaluate the impact of ACEi on antifibrotic biomarkers in hypertensive patients with left ventricular hypertrophy (LVH). We conducted a post hoc analysis of a randomized controlled trial where hypertensive African American patients with LVH and vitamin D (VTD) deficiency were randomized to receive standard antihypertensive therapy plus VTD supplementation or placebo. We selected patients who had detectable lisinopril in plasma at one year follow-up and compared them to subjects who did not. The profibrotic marker propeptide of procollagen type I (CPIP) and the antifibrotic markers: matrix metalloproteinase-1 (MMP-1), tissue inhibitor of MMP1 (TIMP-1), the MMP-1/TIMP-1 ratio, telopeptide of collagen type I (CITP) and Ac-SDKP peptide were measured. Sixty six patients were included. Table 1 shows patients characteristics. Patients with lisinopril had lower blood pressure at one-year but no differences were observed in left ventricular mass index (LVMI). The antifibrotic markers Ac-SDKP (3.9±2.6 vs 6.3±2.8; p