St George's Hospital is a teaching hospital in Tooting, London. Founded in 1733, it is one of the UK's largest teaching hospitals and one of the largest hospitals in Europe. It is run by the St George's University Hospitals NHS Foundation Trust. It shares its main hospital site in Tooting in the London Borough of Wandsworth, with St George's, University of London, which trains NHS staff and carries out advanced medical research.The hospital has around 1,300 beds and most general tertiary care such as accident and emergency, maternity services and care for older people and children. However, as a major acute hospital, St George's Hospital also offers specialist care for the more complex injuries and illnesses, including trauma, neurology, cardiac care, renal transplantation, cancer care and stroke. It is also home to one of four major trauma centres and one of eight hyper-acute stroke units for London.St George's Hospital also provides care for patients from a larger catchment area in the South East of England, for specialities such as complex pelvic trauma. Other services treat patients from all over the country, such as family HIV care and bone marrow transplantation for non-cancer diseases. The trust also provides a nationwide endoscopy training service.
AIMS:The ARREST trial demonstrated that in adult patients, transfer to a cardiac catheter laboratory in a cardiac arrest centre (CAC) following resuscitated out-of-hospital cardiac arrest (OHCA) without ST-elevation did not reduce deaths at 30 days compared with delivery to the geographically closest emergency department (standard care). More than half of the CACs had a co-located emergency department to which patients were delivered as part of the standard care arm, which may have influenced outcomes. AIMS:We performed a pre-specified as-treated analysis to determine if a CAC and the location patients were delivered to, either emergency department or cardiac catheter laboratory, reduced deaths. METHODS AND RESULTS:Patients (aged ≥18 years) with resuscitated OHCA without ST elevation who were enrolled in the ARREST trial were grouped according to the location they were to delivered to- either an emergency department with or without a co-located CAC or a cardiac catheter laboratory within a CAC-at one of 35 hospitals in London, UK-by London Ambulance Service irrespective of randomized allocation. The as-treated population was therefore analysed as one of three groups: 1) emergency department in a CAC, 2) direct to a cardiac catheter laboratory in a CAC, and 3) emergency department in a non-CAC. The primary outcome of the trial was all-cause mortality at 30 days. Secondary outcomes included all-cause mortality at 3 months and neurological outcome at discharge and 3 months. A pre-specified analysis adjusting for age, sex, initial shockable rhythm, witnessed cardiac arrest, bystander CPR, the time from cardiac arrest until ROSC, and location of cardiac arrest was performed in the as-treated groups. Between 15 January 2018 and 1 December 2022, a total of 862 participants were enrolled into the trial. Data for the primary outcome for this analysis were available in 818/862 (94.9%). Patients delivered to an ED in a CAC had fewer deaths at 30 days compared with the ED in a non-CAC group (83/182, 45.6% vs. 178/233, 76.4%; adjusted OR 0.43, 95% CI 0.24 to 0.76; P = 0.0039). Patients delivered to a cardiac catheter laboratory in a CAC also had fewer deaths compared with the ED in a non-CAC group, but there was no statistical difference (250/403, 62.0%: adjusted OR 0.72, 95% CI 0.44 to 1.18; P = 0.19). Survival with a favourable neurological outcome at hospital discharge occurred in 88/177 (49.7%) of the ED in a CAC group, 130/406 (32%) of the catheter laboratory in a CAC group, and 42/228 (18.4%) of the ED in a non-CAC group. CONCLUSION:In this as-treated analysis of the ARREST trial, in adult patients with resuscitated OHCA without ST-elevation, we observed a lower 30-day mortality and favourable neurological outcomes following delivery to an ED in a CAC and cardiac catheter laboratory in CAC, when compared with delivery to ED in a non-CAC.
Children with chronic kidney disease (CKD) are at risk of hypertension and increased arterial stiffness. We examined the roles of blood pressure (BP) and kidney function in development of arterial stiffening in children with early CKD, compared to healthy children. Children who attended for two measurements (mean interval 3.1 ± 1.4 years) of carotid-femoral pulse wave velocity (PWV) as part of the HOT-KID study were included. Annual progression of PWV (PWVAP) was compared for children with CKD (n = 106) versus healthy controls (n = 45), adjusting for mean arterial pressure (MAP) and other risk factors at baseline and follow-up. Multivariable linear regression analyses identified variables significantly associated with PWVAP for each group. There was no significant difference in PWVAP between children with CKD and those without, when adjusted for key covariates at baseline and follow-up (0.12 ± 0.03 m/s/year and 0.12 ± 0.05 m/s/year respectively, P = 0.977). In healthy controls, PWVAP was independently associated with annual progression of MAP (MAPAP, β = 0.49, P = 0.006), whereas in children with CKD, PWVAP was strongly associated with both baseline MAP and MAPAP (β = 0.26, P = 0.007 and β = 0.53, P < 0.001, respectively) but not baseline or change in estimated glomerular filtration rate. These results indicate that there is no demonstrable difference in arterial stiffness between children with early CKD and those without. Renal function in early CKD does not appear to affect arterial stiffening, independent of the BP. The strong association between arterial stiffening and MAP suggests a need for careful BP control in children with CKD. A higher resolution version of the Graphical abstract is available as Supplementary information.
