Resuscitative endovascular balloon occlusion of the aorta in the patient with obesity.

BACKGROUND: Palpation of anatomic landmarks is difficult in patients with obesity, which could increase difficulty of achieving femoral access and resuscitative endovascular balloon occlusion of the aorta (REBOA) placement. The primary aim of this study was to examine the association between obesity and successful REBOA placement. We hypothesized that higher body mass index (BMI) would decrease first-attempt success and increase time to successful aortic occlusion (AO). METHODS: A review of the Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry was performed on patients who underwent REBOA placement with initiation systolic blood pressure >0 mm Hg from years 2013-2022. Patients were excluded if they received cardiopulmonary resuscitation on arrival, underwent open AO, or missing data entries for variables of interest. Body mass index categorization was as follows: non-obese (<30), class I (30-34.9), class II (35-39.9), and class III (40+) obesity. Patients were also stratified by access technique, including use of palpation or ultrasound guidance. RESULTS: Inclusion criteria were met by 410 patients. On binary analysis, no primary outcomes of interest, including rate of success, time to placement, or mortality, were significantly impacted by BMI. Among BMI subgroups, there was no statistical difference in injury severity, admission systolic blood pressure (SBP), or augmented SBP. At initiation of aortic occlusion, patients with class II and class III obesity had higher median SBP compared with non- and class I obese patients (p = 0.03). Body mass index subgroup did not impact likelihood of first-attempt success or conversion to open procedure. When stratified by access technique, there was no difference in success rates, time to success or mortality between groups. CONCLUSION: Body habitus did not impact success of REBOA placement, time to successful AO, or mortality. Further, ultrasound guidance was not superior to landmark palpation for arterial access. Following traumatic injury without hemodynamic collapse, obesity should not deter providers from considering REBOA placement. LEVEL OF EVIDENCE: Therapeutic/Care management, Observational, Cross-sectional; Level IV.

Stop the Bleed-Wait for the Ambulance or Get in the Car and Drive? A Post Hoc Analysis of an EAST Multicenter Trial.

Background: The Stop the Bleed campaign gives bystanders an active role in prehospital hemorrhage control. Whether extending bystanders' role to private vehicle transport (PVT) for urban penetrating trauma improves survival is unknown, but past research has found benefit to police and PVT. We hypothesized that for penetrating trauma in an urban environment, where prehospital procedures have been proven harmful, PVT improves outcomes compared to any EMS or advanced life support (ALS) transport.Methods: Post-hoc analysis of an EAST multicenter trial was performed on adult patients with penetrating torso/proximal extremity trauma at 25 urban trauma centers from 5/2019-5/2020. Patients were allocated to PVT and any EMS or ALS transport using nearest neighbor propensity score matching. Univariate analyses included Wilcoxon signed rank or McNemar's Test and logistic regression.Results: Of 1999 penetrating trauma patients in urban settings, 397 (19.9%) had PVT, 1433 (71.7%) ALS transport, and 169 (8.5%) basic life support (BLS) transport. Propensity matching yielded 778 patients, distributed equally into balanced groups. PVT patients were primarily male (90.5%), Black (71.2%), and sustained gunshot wounds (68.9%). ALS transport had significantly higher ED mortality (3.9% vs 1.9%, P = 0.03). There was no difference in in-hospital mortality rate, hospital LOS, or complications for all EMS or ALS only transport patients.Conclusion: Compared to PVT, ALS, which provides more prehospital procedures than BLS, provided no survival benefit for penetrating trauma patients in urban settings. Bystander education incorporating PVT for early arrival of penetrating trauma patients in urban settings to definitive care merits further investigation.

PROSPECTIVE EXAMINATION OF THE K/ICA RATIO AS A PREDICTOR FOR MORTALITY IN SEVERE HEMORRHAGE.

ABSTRACT: Background: Patients receiving massive transfusion protocol (MTP) are at risk for posttransfusion hypocalcemia and hyperkalemia. Previous retrospective analysis has suggested the potassium/ionized calcium (K/iCa) ratio as a prognostic indicator of mortality. This prospective study sought to validate the value of the K/iCa ratio as a predictor for mortality in patients receiving MTP. Methods: This was a prospective analysis of adult trauma patients who underwent MTP activation from May 2019 to March 2021 at an urban level 1 trauma center. Serum potassium and iCa levels within 0 to 1 h of MTP initiation were used to obtain K/iCa. Receiver operator characteristic curve analysis assessed predictive capacity of K/iCa on mortality. Kaplan-Meier survival analysis and Cox regression examined the effect of K/iCa ratio on survival. Results: A total of 110 of 300 MTP activation patients met inclusion criteria. Overall mortality rate was 31.8%. No significant differences between the elevated K/iCa and lower K/iCa groups were found for prehospital or emergency department initial vitals, shock index, or injury severity. However, nonsurvivors had a significantly higher median K/iCa ratio compared with those who survived ( P < 0.01). Multivariable logistic regression revealed the total number of blood products to be significantly associated with elevated K/iCa (odds ratio, 1.02; 95% CI, 1.01-1.04; P = 0.01). The Kaplan Meier survival curve demonstrated a significantly increased rate of survival for those with an elevated K/iCa ratio ( P < 0.01). Multivariable Cox regression adjusted for confounders showed a significant association between K/iCa and mortality (Hazard Ratio, 4.12; 95% CI, 1.89-8.96; P < 0.001). Conclusion: This evidence further highlights the importance of the K/iCa ratio in predicting mortality among trauma patients receiving MTP. Furthermore, it demonstrates that posttransfusion K levels along with iCa levels should be carefully monitored in the MTP setting. Level of Evidence: Level II. Study Type: Prognostic/epidemiological.

Traumatic Injury in Pregnancy: A Propensity Score-Matched Analysis.

INTRODUCTION: Trauma represents the leading cause of nonobstetrical maternal death. How in-hospital outcomes of acutely injured pregnant patients (PP) compares to that of similarly aged nonpregnant control groups (CGs) has not been described. We hypothesized that PPs suffering acute traumatic injuries would have worse outcomes compared to a matched CG. MATERIALS AND METHODS: The American College of Surgeons Trauma Quality Improvement Program (TQIP) was used to identify traumatically injured females between 2017 and 2019. Propensity score matching on age, race, injury severity score , and type of trauma (blunt, penetrating, or other) was used to compare PPs and the CG. Primary outcomes were mortality, disposition, length of stay (LOS), and complications. RESULTS: A total of 1078 traumatically injured pregnant females were identified. Propensity score matching resulted in 990 patients in the PP and CG cohorts. After matching, PPs were more likely to be assault victims (11% versus 6%, P < 0.001), had longer length of stay (LOS) (5 versus 3 d, P < 0.001), and were more likely to require mechanical ventilation (26% versus 16%, P < 0.001) or intensive care unit (ICU) admission (44% versus 32%, P < 0.001). PPs were more likely to proceed directly to the operating room (OR)(34% versus 15%, P < 0.001) and less likely to be discharged home from the emergency department (ED) (1% versus 12%, P < 0.001). Complications and mortality rates were similar among PPs. CONCLUSIONS: After acute trauma, PPs did not have increased mortality or complications when compared to matched controls, although they were more likely to be victims of assault, directly proceed to the OR, require mechanical ventilation or ICU admission, and have longer LOSs.

A CIRCULATION-FIRST APPROACH FOR RESUSCITATION OF TRAUMA PATIENTS WITH HEMORRHAGIC SHOCK.

ABSTRACT: The original guidelines of cardiopulmonary resuscitation focused on the establishment of an airway and rescue breathing before restoration of circulation through cardiopulmonary resuscitation. As a result, the airway-breathing-circulation approach became the central guiding principle of resuscitation. Despite new guidelines by the American Heart Association for a circulation-first approach, Advanced Trauma Life Support guidelines continue to advocate for the airway-breathing-circulation sequence. Although definitive airway management is often necessary for severely injured patients, endotracheal intubation (ETI) before resuscitation in patients with hemorrhagic shock may worsen hypotension and precipitate cardiac arrest. In severely injured patients, a paradigm shift should be considered, which prioritizes restoration of circulation before ETI and positive pressure ventilation while maintaining a focus on basic airway assessment and noninvasive airway interventions. For this patient population, the most reasonable current strategy may be to target a simultaneous resuscitation approach, with immediate efforts to control hemorrhage and provide basic airway interventions while prioritizing volume resuscitation with blood products and deferring ETI until adequate systemic perfusion has been attained. We believe that a circulation-first sequence will improve both survival and neurologic outcomes for a traumatically injured patient and will continue to advocate this approach, as additional clinical evidence is generated to inform how to best tailor circulation-first resuscitation for varied injury patterns and patient populations.

IMPACT OF TIME TO EMERGENCY DEPARTMENT RESUSCITATIVE AORTIC OCCLUSION AFTER NONCOMPRESSIBLE TORSO HEMORRHAGE.

ABSTRACT: Introduction: Time is an essential element in outcomes of trauma patients. The relationship of time to treatment in management of noncompressible torso hemorrhage (NCTH) with resuscitative endovascular balloon occlusion of the aorta (REBOA) or resuscitative thoracotomy (RT) has not been previously described. We hypothesized that shorter times to intervention would reduce mortality. Methods: A review of the Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery registry from 2013 to 2022 was performed to identify patients who underwent emergency department aortic occlusion (AO). Multivariate logistic regression was used to examine the impact of time to treatment on mortality. Results: A total of 1,853 patients (1,245 [67%] RT, 608 [33%] REBOA) were included. Most patients were male (82%) with a median age of 34 years (interquartile range, 30). Median time from injury to admission and admission to successful AO were 31 versus 11 minutes, respectively. Patients who died had shorter median times from injury to successful AO (44 vs. 72 minutes, P < 0.001) and admission to successful AO (10 vs. 22 minutes, P < 0.001). Multivariate logistic regression demonstrated that receiving RT was the strongest predictor of mortality (odds ratio [OR], 6.6; 95% confidence interval [CI], 4.4-9.9; P < 0.001). Time from injury to admission and admission to successful AO were not significant. This finding was consistent in subgroup analysis of RT-only and REBOA-only populations. Conclusions: Despite expedited interventions, time to aortic occlusion did not significantly impact mortality. This may suggest that rapid in-hospital intervention was often insufficient to compensate for severe exsanguination and hypovolemia that had already occurred before emergency department presentation. Selective prehospital advanced resuscitative care closer to the point of injury with "scoop and control" efforts including hemostatic resuscitation warrants special consideration.

Trends and Burden of Firearm-Related Injuries Among Children and Adolescents: A National Perspective.

INTRODUCTION: Firearm-related injuries in America have been under increasing scrutiny over the last several years. Few studies have examined the burden of these injuries in the pediatric population. The objective of this study was to describe the incidence of firearm-related injuries in hospitalized pediatric patients in the United States and identify the risk factors associated with readmission in this young population. METHODS: The Nationwide Readmission Database was examined from 2010 to 2017. Pediatric patients (aged ≤18 y) who survived their index hospitalization for any firearm injury were analyzed to determine incidence rate, case fatality rate, risk factors for 30-d readmission, and financial health care burden. RESULTS: There were 35,753 pediatric firearm injuries (86.8% male) with an overall incidence rate of 10.49 (95% confidence interval [CI]: 9.26-11.71) per 100,000 pediatric hospitalizations. Adolescents aged >12 y had the highest incidence rate (60.51, 95% CI: 55.19-65.84). In-hospital mortality occurred in 1948 cases (5.5%), with higher case fatality rates in males. There were 1616 (5.7%) unplanned 30-d readmissions. Multivariate analysis showed abdominal firearm injuries (hazard ratio: 1.13, 95% CI: 1.03-1.24; P = 0.006) and longer length of stay (hazard ratio: 1.27, 95% CI: 1.04-1.55; P = 0.016) were associated with a greater risk of 30-d readmission. The median health care cost for firearm-related injuries was $36,535 (interquartile range: $19,802-$66,443), 22% of which was due to readmissions. Cost associated with 30-d readmissions was $7978 (interquartile range: $4305-$15,202). CONCLUSIONS: Firearm-related injury is a major contributor to pediatric morbidity, mortality, and health care costs. Males are disproportionately affected by firearm injury, but females are more likely to require unplanned 30-d readmissions. Interventions should target female sex, injuries of suicidal intent, psychiatric comorbidities, prolonged index hospitalization, and abdominal injuries.

State Gun Law Grades and Impact on Mass Shooting Event Incidence: An 8-Year Analysis.

BACKGROUND: Gun violence, particularly in the form of mass shooting events (MSE), is a growing, significant public health crisis in the US. Whether stricter gun laws decrease MSE is not known. We hypothesized that stronger state gun laws would be associated with lower MSE incidence. STUDY DESIGN: Mass shooting events, defined as at least 4 people injured in a single event, and state gun law grade data for years 2014 through 2021 were obtained from the Gun Violence Archive and Giffords Law Center, respectively. An A grade indicated strictest gun control laws, and F indicated the weakest. US 2020 Census data were used to estimate MSE per million per state. The number of MSE per million was examined for association with gun law grades. RESULTS: From 2014 through 2020, there were a total of 2,736 recorded MSE, with at least a 2-fold increase in incidence from 272 in 2014 to 626 in 2020. Concomitantly, the number of F grade states decreased from 27 to 21 (22%). The MSE mean (SD) per F state increased from 4.0 (5.1) in 2014 to 9.7 (10.3) in 2020 (p = 0.03). No differences were found in unadjusted number of MSE per year by gun law grade for any study year examined (p = 0.67). After adjusting for population, this finding of no difference persisted. CONCLUSIONS: Strength of state gun law grades does not affect MSE incidence, even after correction for population size. This suggests that legislation by itself is not an effective prevention measure and other broader and meaningful primary gun violence interventions are needed.

Structural confirmation of sulconazole sulfoxide as the primary degradation product of sulconazole nitrate.

Sulconazole has been reported to degrade into sulconazole sulfoxide via sulfur oxidation; however, structural characterization data was lacking and the potential formation of an N-oxide or sulfone could not be excluded. To clarify the degradation pathways and incorporate the impurity profile of sulconazole into the United States Pharmacopeia-National Formulary (USP-NF) monographs, a multifaceted approach was utilized to confirm the identity of the degradant. The approach combines stress testing of sulconazole nitrate, chemical synthesis of the degradant via a hydrogen peroxide-mediated oxidation reaction, semi-preparative HPLC purification, and structural elucidation by LC-MS/MS and NMR spectroscopy. Structural determination was primarily based on the comparison of spectroscopic data of sulconazole and the oxidative degradant. The mass spectrometric data have revealed a McLafferty-type rearrangement as the characteristic fragmentation pathway for alkyl sulfoxides with a ß-hydrogen atom, and was used to distinguish the sulfoxide from N-oxide or sulfone derivatives. Moreover, the generated sulconazole sulfoxide was utilized as reference material for compendial procedure development and validation, which provides support for USP monograph modernization.

A Method for Mapping Glycosylation Sites in Proteins.

The analysis of protein glycosylation by mass spectrometry (MS) has been a challenging technical problem. Quantification by HPLC of N-linked glycans can be executed by the use of peptide-N-glycosidase F to release them from the protein, followed by attachment of a fluorescent label and subsequent fluorescence detection. Similar quantification of O-linked glycans is not possible, as a result of the lack of a universal deglycosylation enzyme. Site-specific analyses by MS, such as the use of proteases to digest the glycoprotein, are difficult to use for quantification of glycans, as a result of the presence of miscleavages. Here, we present a new application of a digestion method for native proteins using resin-bound, thermally stabilized proteases. The use of this enzymatic treatment eliminates miscleavages around the site of glycosylation, thereby allowing site-specific relative quantification of glycans on glycoproteins. A native, intact human mAb was digested using a thermally stable, resin-bound trypsin to produce glycopeptides from the Fc region using a single-step protocol. A 1 mg sample was treated with 60 µg trypsin for 3 h at 70°C. After digestion, acetonitrile was added, and the mixture was centrifuged to remove the resin before analysis. Liquid chromatography (LC)/MS with hydrophilic interaction chromatography was used to analyze the glycopeptides produced. All of the glycopeptides found resulted from a single peptide (EEQYNSTYR). The LC/MS analysis of the glycopeptides is compared with that of fluorescently labeled glycans. Quantitative analysis produced a correlation coefficient of 0.87 for the linear fit between the glycopeptide and released glycan methods.

Superhydrophobic materials and coatings: a review.

Over the past few years, the scientific community, as well as the world's coatings industry has seen the introduction of oxide/polymer-based superhydrophobic surfaces and coatings with exceptional water repellency. Online videos have caught the public's imagination by showing people walking through mud puddles without getting their tennis shoes wet or muddy, and water literally flying off coated surfaces. This article attempts to explain the basics of this behavior and to discuss and explain the latest superhydrophobic technological breakthroughs. Since superhydrophobic surfaces and coatings can fundamentally change how water interacts with surfaces, and the fact that earth is a water world, it can legitimately be said that this technology has the potential to literally change the world.

Superhydrophobic ceramic coatings enabled by phase-separated nanostructured composite TiO2-Cu2O thin films.

By exploiting phase-separation in oxide materials, we present a simple and potentially low-cost approach to create exceptional superhydrophobicity in thin-film based coatings. By selecting the TiO2-Cu2O system and depositing through magnetron sputtering onto single crystal and metal templates, we demonstrate growth of nanostructured, chemically phase-segregated composite films. These coatings, after appropriate chemical surface modification, demonstrate a robust, non-wetting Cassie-Baxter state and yield an exceptional superhydrophobic performance, with water droplet contact angles reaching to ~172° and sliding angles <1°. As an added benefit, despite the photo-active nature of TiO2, the chemically coated composite film surfaces display UV stability and retain superhydrophobic attributes even after exposure to UV (275 nm) radiation for an extended period of time. The present approach could benefit a variety of outdoor applications of superhydrophobic coatings, especially for those where exposure to extreme atmospheric conditions is required.

Optically transparent, mechanically durable, nanostructured superhydrophobic surfaces enabled by spinodally phase-separated glass thin films.

We describe the formation and properties of atomically bonded, optical quality, nanostructured thin glass film coatings on glass plates, utilizing phase separation by spinodal decomposition in a sodium borosilicate glass system. Following deposition via magnetron sputtering, thermal processing and differential etching, these coatings are structurally superhydrophilic (i.e., display anti-fogging functionality) and demonstrate robust mechanical properties and superior abrasion resistance. After appropriate chemical surface modification, the surfaces display a stable, non-wetting Cassie-Baxter state and exhibit exceptional superhydrophobic performance, with water droplet contact angles as large as 172°. As an added benefit, in both superhydrophobic and superhydrophilic states these nanostructured surfaces can block ultraviolet radiation and can be engineered to be anti-reflective with broadband and omnidirectional transparency. Thus, the present approach could be tailored toward distinct coatings for numerous markets, such as residential windows, windshields, specialty optics, goggles, electronic and photovoltaic cover glasses, and optical components used throughout the US military.

Matrix-assisted laser desorption/ionization mass spectrometry reveals decreased calcylcin expression in small cell lung cancer.

To date, most of the proteomic analyses on lung cancer tissue samples have been performed using surgical specimens, which are obtained after a diagnosis is made. To determine if a proteomic signature obtained from bronchoscopic biopsy samples could be found to assist with diagnosis, 50 lung cancer bronchoscopic biopsy samples and 13 adjacent normal lung tissue samples were analyzed using histology-directed, matrix-assisted laser desorption/ionization (MALDI) mass spectrometry (MS). Lung tissue samples were cryosectioned, and sinapinic acid was robotically deposited on areas of each tissue section enriched in epithelial cells, either tumor or normal. Mass spectra were acquired using a MALDI-time of flight instrument. Small cell lung cancers (SCLCs) demonstrated clearly different protein profiles from normal lung tissue and from non-small cell lung cancers (NSCLCs). Calcyclin (m/z= 10,094.7) was identified to be underexpressed in small cell lung cancers, as compared with non-small cell lung cancers and normal lung tissue. An immunohistochemistry study using 152 NSCLCs and 21 SCLCs confirmed significantly reduced calcyclin stain in SCLCs. Thus, protein profiles obtained from bronchoscopic biopsy samples via MALDI MS distinguish cancerous epithelium from normal lung tissue and between NSCLCs and SCLCs.

Quantitative analysis of phospholipids using nanostructured laser desorption ionization targets.

Since its introduction as an ionization technique in mass spectrometry, matrix-assisted laser desorption ionization (MALDI) has been applied to a wide range of applications. Quantitative small molecule analysis by MALDI, however, is limited due to the presence of intense signals from the matrix coupled with non-homogeneous surfaces. The surface used in nano-structured laser desorption ionization (NALDI) eliminates the need for a matrix and the resulting interferences, and allows for quantitative analysis of small molecules. This study was designed to analyze and quantitate phospholipid components of liposomes. Here we have developed an assay to quantitate the DPPC and DC(8,9)PC in liposomes by NALDI following various treatments. To test our method we chose to analyze a liposome system composed of DPPC (1,2-dipalmitoyl-sn-glycero-3-phosphocholine) and DC(8,9)PC (1,2-bis(tricosa-10,12-diynoyl)-sn-glycero-3-phosphocholine), as DC(8,9)PC is known to undergo cross-linking upon treatment with UV (254 nm) and this reaction converts the monomer into a polymer. First, calibration curves for pure lipids (DPPC and DC(8,9)PC) were created using DMPC (1,2-dimyristoyl-sn-glycero-3-phosphocholine) as an internal standard. The calibration curve for both DPPC and DC(8,9)PC showed an R(2) of 0.992, obtained using the intensity ratio of analyte and internal standard. Next, DPPC:DC(8,9)PC liposomes were treated with UV radiation (254 nm). Following this treatment, lipids were extracted from the liposomes and analyzed. The analysis of the lipids before and after UV exposure confirmed a decrease in the signal of DC(8,9)PC of about 90%. In contrast, there was no reduction in DPPC signal.

Characterization of nanoparticles by matrix assisted laser desorption ionization time-of-flight mass spectrometry.

Determining the molecular weight of nanoparticles can be challenging. The molecular weight characterization of dendrimers, for example, with varying covalent and noncovalent modifications is critical to their use as therapeutics. As such, we describe in this chapter a protocol for the analysis of these molecules by matrix assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS).

Processing of loose carbon nanotubes into isolated, high density submicron channels.

Loose multi-wall carbon nanotubes (MWNTs) were processed into a bundle of 19,600 individual channels with an individual channel diameter of 0.4 microm using a fiber drawing process. First, a powder of sodium silicate solution containing purified MWNTs was created. A glass capillary tube was filled with the powder and drawn into fibers. The fibers were cut into segments, bundled and redrawn multiple times to create fibers with multiple channels containing MWNTs. This processing approach created thousands of uniformly ordered channels containing dispersed MWNTs in a glass matrix while simultaneously aligning the MWNTs. The bulk resistivity of the MWNT-silicate channel has been improved by 38% after two consecutive draws as a result of the increased MWNT fraction.

Association of biomolecular resource facilities survey: service laboratory funding.

In 2007, The Association of Biomolecular Resource Facilities (ABRF) Survey Committee surveyed the ABRF membership and scientists at-large concerning the current state of funding in service-oriented laboratories. Questions pertained to services offered, cost recovery, capital equipment funding, and future outlook. The web-based survey, available for 3 weeks, achieved participation from 209 respondents in 13 countries, 77% of which represented academic laboratories. Most respondents (75%) directed their laboratories. Laboratories depend largely on institutional support and customer recharges to fund operations, but National Institutes of Health and National Science Foundation Shared Instrumentation Grant programs are considered critical to meeting future needs. Source allocations supporting capital equipment acquisitions, operations, and laboratory director salary are presented.