A Quantitative Proteome Map of the Human Body.

Determining protein levels in each tissue and how they compare with RNA levels is important for understanding human biology and disease as well as regulatory processes that control protein levels. We quantified the relative protein levels from over 12,000 genes across 32 normal human tissues. Tissue-specific or tissue-enriched proteins were identified and compared to transcriptome data. Many ubiquitous transcripts are found to encode tissue-specific proteins. Discordance of RNA and protein enrichment revealed potential sites of synthesis and action of secreted proteins. The tissue-specific distribution of proteins also provides an in-depth view of complex biological events that require the interplay of multiple tissues. Most importantly, our study demonstrated that protein tissue-enrichment information can explain phenotypes of genetic diseases, which cannot be obtained by transcript information alone. Overall, our results demonstrate how understanding protein levels can provide insights into regulation, secretome, metabolism, and human diseases.

Factors Associated With Physical Restraint in an Urban Emergency Department.

STUDY OBJECTIVE: To determine what patient characteristics were associated with the application of physical restraints in our emergency department (ED). METHODS: This was a retrospective analysis of encounters in the ED of an urban, Level I academic trauma center. We included ED encounters of adult patients (aged ≥18 years) during a 5-year period starting in 2017. We evaluated the independent association of restraint application during an encounter using a generalized estimating equation model. RESULTS: There were 464,031 ED encounters during the time period from 162,244 unique patients, including 34,798 (7.5%) with restraint application, comprising 18,166 unique patients. Several variables were associated with an increased likelihood of restraint use during an encounter. The variable with the highest odds ratio was intoxication with drugs or alcohol (adjusted odds ratio [aOR] 8.29; 95% confidence interval (CI) 7.94 to 8.65). American Indian race was associated with increased odds of restraint application (aOR 1.42; 95% CI 1.31 to 1.54) compared to the reference value of White race. Black race (aOR 0.58; 95% CI 0.55 to 0.61) and Hispanic ethnicity (aOR 0.42; 95% CI 0.37 to 0.48) were associated with lower odds of restraint application. CONCLUSIONS: Drug and alcohol intoxication were most closely associated with restraint. Encounters in which the patient was American Indian had higher odds of restraint, but this study does not replicate prior findings regarding other racial disparities in restraint.

A Practical Solution for Preoxygenation in the Prehospital Setting: A Nonrebreather Mask with Flush Rate Oxygen.

OBJECTIVE: Prehospital clinicians need a practical means of providing adequate preoxygenation prior to intubation. A bag-valve-mask (BVM) can be used for preoxygenation in perfect conditions but is likely to fail in emergency settings. For this reason, many airway experts have moved away from using BVM for preoxygenation and instead suggest using a nonrebreather (NRB) mask with flush rate oxygen.Literature on preoxygenation has suggested that a NRB mask delivering flush rate oxygen (on a 15 L/min O2 regulator, maximum flow, ∼50 L/min) is noninferior to BVM at 15 L/min held with a tight seal. However, in the prehospital setting, where emergency airway management success varies, preoxygenation techniques have not been deeply explored. Our study seeks to determine whether preoxygenation can be optimally performed with NRB at flush rate oxygen. METHODS: We performed a crossover trial using healthy volunteers. Subjects underwent 3-min trials of preoxygenation with NRB mask at 25 L/min oxygen delivered from a portable tank, NRB at flush rate oxygen from a portable tank, NRB with flush rate oxygen from an onboard ambulance tank, and BVM with flush rate oxygen from an onboard ambulance tank. The primary outcome was the fraction of expired oxygen (FeO2). We compared the FeO2 of the BVM-flush to other study groups, using a noninferiority margin of 10%. RESULTS: We enrolled 30 subjects. Mean FeO2 values for NRB-25, NRB-flush ambulance, NRB-flush portable, and BVM-flush were 63% (95% confidence interval [CI] 58-68%), 74% (95%, CI 70-78%), 78% (95%, CI 74-83%), and 80% (95%, CI 75-84%), respectively. FeO2 values for NRB-flush on both portable tank and ambulance oxygen were noninferior to BVM-flush on the ambulance oxygen system (FeO2 differences of 1%, 95% CI -3% to 6%; and 6%, 95% CI 1-10%). FeO2 for the NRB-25 group was inferior to BVM-flush (FeO2 difference 16%, 95% CI 12-21%). CONCLUSIONS: Among healthy volunteers, flush rate preoxygenation using NRB masks is noninferior to BVM using either a portable oxygen tank or ambulance oxygen. This is significant because preoxygenation using NRB masks with flush rate oxygen presents a simpler alternative to the use of BVMs. Preoxygenation using NRB masks at 25 L/min from a portable tank is inferior to BVM at flush rate.

Massive Sodium Nitrite Overdose: A Case for Prehospital Methylene Blue.

Sodium nitrite overdose leads to profound methemoglobinemia and may quickly progress to death. It is an increasingly common method of suicide and is often fatal. Methylene blue is an effective but time-sensitive antidote that has the potential to save lives when administered early. In this case report, we describe a fatal sodium nitrite overdose and the subsequent creation of a prehospital protocol for our large urban Emergency Medical Services system.

Feasibility and Safety of Oral Risperidone to Treat Prehospital Agitation.

OBJECTIVE: Agitation is a common prehospital problem and frequently presents without a clear etiology. Given the dynamic environment of the prehospital setting, there has historically been a varied approach to treating agitation with a heavy reliance on parenteral medications. Newer best practice guidelines recommend the incorporation of oral medications to treat patients experiencing agitation. Therefore, we evaluated the use of oral risperidone in a single system after a change in protocol occurred. METHODS: This was conducted as a retrospective chart review of an urban/suburban Emergency Medical Services system over the period of 8 months. The first day this medication was implemented throughout the service was included. Charts were included for selection if they included risperidone oral dissolving tablet (ODT) as a charted medication. The primary outcome was administration of additional medications to treat agitation. Exploratory outcome measures included acceptance of medication, documented injury to paramedics, documented injuries to patients, scene times, and adverse events that could possibly be linked to the medication. RESULTS: A total of 552 records were screened for inclusion. Risperidone was offered to 530 patients and accepted by 512 (96.6%). Of these 512 patients, the median age of included patients was 39 years old (IQR 29-52 years old) with a range of 18-89 years old. Rescue or additional medications for agitation were required in 9 (1.8%) cases. There were a total of 4 (0.8%) potential complications following administration of risperidone. There were no reported assaults with subsequent injuries to prehospital personnel or injuries sustained by patients reported in this study. CONCLUSIONS: Risperidone ODT was found to be a safe and effective medication to treat mild agitation in a large urban and suburban EMS system. The need for additional medications to treat agitation was rare, and there were no documented injuries to either patients or paramedics.

S-adenosylmethionine inhibits la ribonucleoprotein domain family member 1 in murine liver and human liver cancer cells.

BACKGROUND AND AIMS: Methionine adenosyltransferase 1A (MAT1A) is responsible for S-adenosylmethionine (SAMe) biosynthesis in the liver. Mice lacking Mat1a have hepatic SAMe depletion and develop NASH and HCC spontaneously. Several kinases are activated in Mat1a knockout (KO) mice livers. However, characterizing the phospho-proteome and determining whether they contribute to liver pathology remain open for study. Our study aimed to provide this knowledge. APPROACH AND RESULTS: We performed phospho-proteomics in Mat1a KO mice livers with and without SAMe treatment to identify SAMe-dependent changes that may contribute to liver pathology. Our studies used Mat1a KO mice at different ages treated with and without SAMe, cell lines, in vitro translation and kinase assays, and human liver specimens. We found that the most striking change was hyperphosphorylation and increased content of La-related protein 1 (LARP1), which, in the unphosphorylated form, negatively regulates translation of 5'-terminal oligopyrimidine (TOP)-containing mRNAs. Consistently, multiple TOP proteins are induced in KO livers. Translation of TOP mRNAs ribosomal protein S3 and ribosomal protein L18 was enhanced by LARP1 overexpression in liver cancer cells. We identified LARP1-T449 as a SAMe-sensitive phospho-site of cyclin-dependent kinase 2 (CDK2). Knocking down CDK2 lowered LARP1 phosphorylation and prevented LARP1-overexpression-mediated increase in translation. LARP1-T449 phosphorylation induced global translation, cell growth, migration, invasion, and expression of oncogenic TOP-ribosomal proteins in HCC cells. LARP1 expression is increased in human NASH and HCC. CONCLUSIONS: Our results reveal a SAMe-sensitive mechanism of LARP1 phosphorylation that may be involved in the progression of NASH to HCC.

Prehospital Ultrasound Diagnosis of Massive Pulmonary Embolism by Non-Physicians: A Case Series.

Massive pulmonary embolism (hemodynamically unstable, defined as systolic BP <90 mmHg) has significant morbidity and mortality. Point of care ultrasound (POCUS) has allowed clinicians to detect evidence of massive pulmonary embolism much earlier in the patient's clinical course, especially when patient instability precludes computerized tomography confirmation. POCUS detection of massive pulmonary embolism has traditionally been performed by physicians. This case series demonstrates four cases of massive pulmonary embolism diagnosed with POCUS performed by non-physician prehospital personnel.

Prehospital Pericardiocentesis Using a Pneumothorax Needle.

Case: We discuss a patient with a penetrating knife wound to the chest who lost pulses from cardiac tamponade. Prehospital ultrasound was able to quickly identify the tamponade and a pericardiocentesis was performed using a Simplified Pneumothorax Emergency Air Release (SPEARTM) Needle (North American Rescue, LLC, USA) with subsequent return of spontaneous circulation. Discussion: Penetrating chest trauma carries significant morbidity and mortality. In traumatic cardiac arrest due to a penetrating mechanism, it is paramount that the patient be transported to a trauma center as quickly as possible. Prehospital pericardiocentesis is a potential life-saving intervention.

Prehospital Surgical Airway Management: An NAEMSP Position Statement and Resource Document.

Bag-valve-mask ventilation and endotracheal intubation have been the mainstay of prehospital airway management for over four decades. Recently, supraglottic device use has risen due to various factors. The combination of bag-valve-mask ventilation, endotracheal intubation, and supraglottic devices allows for successful airway management in a majority of patients. However, there exists a small portion of patients who are unable to be intubated and cannot be adequately ventilated with either a facemask or a supraglottic airway. These patients require an emergent surgical airway. A surgical airway is an important component of all airway algorithms, and in some cases may be the only viable approach; therefore, it is imperative that EMS agencies that are credentialed to manage airways have the capability to perform surgical airways when appropriate. The National Association of Emergency Medical Services Physicians (NAEMSP) recommends the following for emergency medical services (EMS) agencies that provide advanced airway management.A surgical airway is reasonable in the prehospital setting when the airway cannot be secured by less invasive means.When indicated, a surgical airway should be performed without delay.A surgical airway is not a substitute for other airway management tools and techniques. It should not be the only rescue option available.Success of an open surgical approach using a scalpel is higher than that of percutaneous Seldinger techniques or needle-jet ventilation in the emergency setting.

Emergency Airway Management in a Patient with a T-Tube Tracheal Stent.

BACKGROUND: Abnormal anatomy complicates emergency airway management. In this case, we describe definitive airway management in a critically injured emergency department (ED) patient with a history of partial tracheal resection who had a Montgomery T-tube, a type of T-shaped tracheal stent, in place at the time of the motor vehicle collision. The Montgomery T-tube is not a useful artificial airway during resuscitation, as it lacks a cuff or the necessary adapter for positive pressure ventilation. CASE REPORT: We describe a case of a 51-year-old man who required emergency airway management after a motor vehicle collision. The patient had a Montgomery T-tube in place, which was removed with facilitation by ketamine sedation and topical anesthesia. The patient was successfully intubated through the tracheal stoma after removal of the T-tube. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians must recognize the Montgomery T-tube, which resembles a standard tracheostomy tube externally, and have some understanding of how to manage a critically ill patient with this rare device in place. When a patient with a Montgomery T-tube in place requires positive pressure ventilation, the device may require emergent removal and replacement with a cuffed tracheostomy or endotracheal tube.

An unusual case of epistaxis in a four month old.

Epistaxis is a routine complaint in Emergency Medicine and presents most commonly in adults and children and its incidence increases with age. It is rare in infants and neonates. We discuss a case of epistaxis in a four-month-old male who presented to a critical access hospital. What initially appeared to be routine brisk epistaxis was later discovered to be a large, complex, epiglottic hemangioma. The patient was stabilized using topical tranexamic acid, nasal packing with ketamine sedation, and sent to a tertiary care center for definitive management. He required advanced airway management in the OR for definitive airway management for airway-obstructing hemangioma excision.

Lysine and Arginine Protein Post-translational Modifications by Enhanced DIA Libraries: Quantification in Murine Liver Disease.

Proteoforms containing post-translational modifications (PTMs) represent a degree of functional diversity only harnessed through analytically precise simultaneous quantification of multiple PTMs. Here we present a method to accurately differentiate an unmodified peptide from its PTM-containing counterpart through data-independent acquisition-mass spectrometry, leveraging small precursor mass windows to physically separate modified peptidoforms from each other during MS2 acquisition. We utilize a lysine and arginine PTM-enriched peptide assay library and site localization algorithm to simultaneously localize and quantify seven PTMs including mono-, di-, and trimethylation, acetylation, and succinylation in addition to total protein quantification in a single MS run without the need to enrich experimental samples. To evaluate biological relevance, this method was applied to liver lysate from differentially methylated nonalcoholic steatohepatitis (NASH) mouse models. We report that altered methylation and acetylation together with total protein changes drive the novel hypothesis of a regulatory function of PTMs in protein synthesis and mRNA stability in NASH.

Methionine Adenosyltransferase α1 Is Targeted to the Mitochondrial Matrix and Interacts with Cytochrome P450 2E1 to Lower Its Expression.

Methionine adenosyltransferase α1 (MATα1, encoded by MAT1A) is responsible for hepatic biosynthesis of S-adenosyl methionine, the principal methyl donor. MATα1 also act as a transcriptional cofactor by interacting and influencing the activity of several transcription factors. Mat1a knockout (KO) mice have increased levels of cytochrome P450 2E1 (CYP2E1), but the underlying mechanisms are unknown. The aims of the current study were to identify binding partners of MATα1 and elucidate how MATα1 regulates CYP2E1 expression. We identified binding partners of MATα1 by coimmunoprecipitation (co-IP) and mass spectrometry. Interacting proteins were confirmed using co-IP using recombinant proteins, liver lysates, and mitochondria. Alcoholic liver disease (ALD) samples were used to confirm relevance of our findings. We found that MATα1 negatively regulates CYP2E1 at mRNA and protein levels, with the latter being the dominant mechanism. MATα1 interacts with many proteins but with a predominance of mitochondrial proteins including CYP2E1. We found that MATα1 is present in the mitochondrial matrix of hepatocytes using immunogold electron microscopy. Mat1a KO hepatocytes had reduced mitochondrial membrane potential and higher mitochondrial reactive oxygen species, both of which were normalized when MAT1A was overexpressed. In addition, KO hepatocytes were sensitized to ethanol and tumor necrosis factor α-induced mitochondrial dysfunction. Interaction of MATα1 with CYP2E1 was direct, and this facilitated CYP2E1 methylation at R379, leading to its degradation through the proteasomal pathway. Mat1a KO livers have a reduced methylated/total CYP2E1 ratio. MATα1's influence on mitochondrial function is largely mediated by its effect on CYP2E1 expression. Patients with ALD have reduced MATα1 levels and a decrease in methylated/total CYP2E1 ratio. Conclusion: Our findings highlight a critical role of MATα1 in regulating mitochondrial function by suppressing CYP2E1 expression at multiple levels.

Video screen viewing and first intubation attempt success with standard geometry video laryngoscope use.

STUDY OBJECTIVES: Direct laryngoscopy (DL) is the traditional approach for emergency intubation but video laryngoscopy (VL) is gaining popularity. Some studies have demonstrated higher first-attempt success with VL, particularly in difficult airways. In real-world settings, physicians choose whether or not to view the video screen when utilizing VL devices for tracheal intubation. Therefore, we sought to determine whether screen viewing is associated with higher intubation first-attempt success in clinical practice. METHODS: In this retrospective, observational investigation, we studied consecutive adult emergency department intubations at an urban, academic medical center during the calendar year 2013. Cases were identified from the electronic medical record and analyzed using standard video review methodology. We compared first-attempt success rates when standard geometry Macintosh VL was used, stratified by whether the screen was viewed or not. RESULTS: Of the 593 cases with videos available for review, 515 (87%) were performed with a standard geometry Macintosh video laryngoscope. First-attempt success was not significantly different when the screen was viewed (195/207; 94% [95%CI 91-97]) compared to when the screen was not viewed (284/301; 94% [95%CI 92-97]). The median first-attempt duration was longer when the screen was viewed compared to when the screen was not viewed (45 versus 33 s; median difference 12 s [95%CI 10-15 s]). CONCLUSION: In this study of orotracheal intubations performed by emergency physicians with Macintosh-style VL, the first-attempt success rate was high. The success rate was similar whether or not the intubating physician chose to view the video screen.

First attempt success with continued versus paused chest compressions during cardiac arrest in the emergency department.

AIM: Tracheal intubation is associated with interruption in cardiopulmonary resuscitation (CPR). Current knowledge of tracheal intubation during active CPR focuses on the out-of-hospital environment. We aim to describe characteristics of tracheal intubation during active CPR in the emergency department (ED) and determine whether first attempt success was associated with CPR being continued vs paused. MEASUREMENTS: We reviewed overhead video from adult ED patients receiving chest compressions at the start of the orotracheal intubation attempt. We recorded procedural detail including method of CPR, whether CPR was continued vs paused, and first attempt intubation success (primary outcome). We performed logistic regression to determine whether continuing CPR was associated with first attempt success. RESULTS: We reviewed 169 instances of tracheal intubation, including 143 patients with continued CPR and 26 patients with paused CPR. Those with paused CPR were more likely to be receiving manual rather than mechanical chest compressions. Video laryngoscopy and bougie use were common. First attempt success was higher in the continued CPR group (87%, 95% CI 81% to 92%) than the interrupted CPR group (65%, 95% CI 44% to 83%, difference 22% [95% CI 3% to 41%]). The multivariable model demonstrated an adjusted odds ratio of 0.67 (95% CI 0.17 to 2.60) for first attempt intubation success when CPR was interrupted vs continued. CONCLUSIONS: It was common to continue CPR during tracheal intubation, with success comparable to that achieved in patients without cardiac arrest. It is reasonable to attempt tracheal intubation without interrupting CPR, pausing only if necessary.

Hyperphosphorylation of hepatic proteome characterizes nonalcoholic fatty liver disease in S-adenosylmethionine deficiency.

Methionine adenosyltransferase 1a (MAT1A) is responsible for hepatic S-adenosyl-L-methionine (SAMe) biosynthesis. Mat1a -/- mice have hepatic SAMe depletion, develop nonalcoholic steatohepatitis (NASH) which is reversed with SAMe administration. We examined temporal alterations in the proteome/phosphoproteome in pre-disease and NASH Mat1a -/- mice, effects of SAMe administration, and compared to human nonalcoholic fatty liver disease (NAFLD). Mitochondrial and peroxisomal lipid metabolism proteins were altered in pre-disease mice and persisted in NASH Mat1a -/- mice, which exhibited more progressive alterations in cytoplasmic ribosomes, ER, and nuclear proteins. A common mechanism found in both pre-disease and NASH livers was a hyperphosphorylation signature consistent with casein kinase 2α (CK2α) and AKT1 activation, which was normalized by SAMe administration. This was mimicked in human NAFLD with a metabolomic signature (M-subtype) resembling Mat1a -/- mice. In conclusion, we have identified a common proteome/phosphoproteome signature between Mat1a -/- mice and human NAFLD M-subtype that may have pathophysiological and therapeutic implications.

PINE: An Automation Tool to Extract and Visualize Protein-Centric Functional Networks.

Recent surges in mass spectrometry-based proteomics studies demand a concurrent rise in speedy and optimized data processing tools and pipelines. Although several stand-alone bioinformatics tools exist that provide protein-protein interaction (PPI) data, we developed Protein Interaction Network Extractor (PINE) as a fully automated, user-friendly, graphical user interface application for visualization and exploration of global proteome and post-translational modification (PTM) based networks. PINE also supports overlaying differential expression, statistical significance thresholds, and PTM sites on functionally enriched visualization networks to gain insights into proteome-wide regulatory mechanisms and PTM-mediated networks. To illustrate the relevance of the tool, we explore the total proteome and its PTM-associated relationships in two different nonalcoholic steatohepatitis (NASH) mouse models to demonstrate different context-specific case studies. The strength of this tool relies in its ability to (1) perform accurate protein identifier mapping to resolve ambiguity, (2) retrieve interaction data from multiple publicly available PPI databases, and (3) assimilate these complex networks into functionally enriched pathways, ontology categories, and terms. Ultimately, PINE can be used as an extremely powerful tool for novel hypothesis generation to understand underlying disease mechanisms.

Consistent head up cardiopulmonary resuscitation haemodynamics are observed across porcine and human cadaver translational models.

AIM: The objectives were: 1) replicate key elements of Head Up (HUP) cardiopulmonary resuscitation (CPR) physiology in a traditional swine model of ventricular fibrillation (VF), 2) compare HUP CPR physiology in pig cadavers (PC) to the VF model 3) develop a new human cadaver (HC) CPR model, and 4) assess HUP CPR in HC. METHODS: Nine female pigs were intubated, and anesthetized. Venous, arterial, and intracranial access were obtained. After 6 min of VF, CPR was performed for 2 min epochs as follows: Standard (S)-CPR supine (SUP), Active compression decompression (ACD) CPR + impedance threshold device (ITD-16) CPR SUP, then ACD + ITD HUP CPR. The same sequence was performed in PC 3 h later. In 9 HC, similar vascular and intracranial access were obtained and CPR performed for 1 min epochs using the same sequence as above. RESULTS: The mean cerebral perfusion pressure (CerPP, mmHg) was 14.5 ±â€¯6 for ACD + ITD SUP and 28.7 ±â€¯10 for ACD + ITD HUP (p = .007) in VF, -3.6 ±â€¯5 for ACD + ITD SUP and 7.8 ±â€¯9 for ACD + ITD HUP (p = .007) in PC, and 1.3 ±â€¯4 for ACD + ITD SUP and 11.3 ±â€¯5 for ACD + ITD HUP (p = .007) in HC. Mean systolic and diastolic intracranial pressures (ICP) (mmHg) were significantly lower in the ACD + ITD HUP group versus the ACD + ITD SUP group in all three CPR models. CONCLUSION: HUP CPR decreased ICP while increasing CerPP in pigs in VF as well as in PC and HC CPR models. This first-time demonstration of HUP CPR physiology in humans provides important implications for future resuscitation research and treatment.

Head and thorax elevation during active compression decompression cardiopulmonary resuscitation with an impedance threshold device improves cerebral perfusion in a swine model of prolonged cardiac arrest.

AIM OF THE STUDY: As most cardiopulmonary resuscitation (CPR) efforts last longer than 15min, the aim of this study was to compare brain blood flow between the Head Up (HUP) and supine (SUP) body positions during a prolonged CPR effort of 15min, using active compression-decompression (ACD) CPR and impedance threshold device (ITD) in a swine model of cardiac arrest. METHODS: Ventricular fibrillation (VF) was induced in anesthetized pigs. After 8min of untreated VF followed by 2min of ACD-CPR+ITD in the SUP position, pigs were randomized to 18min of continuous ACD-CPR+ITD in either a 30° HUP or SUP position. Microspheres were injected before VF and then 5 and 15min after start of CPR. RESULTS: The mean blood flow (ml/min/g, mean±SD) to the brain after 15min of CPR was 0.42±0.05 in the HUP group (n=8) and 0.21±0.04 SUP (n=10), respectively, (p<0.01). The HUP group also had statistically significantly lower intracranial pressures and higher calculated cerebral perfusion pressures after 5, 15, 19 (before adrenaline) and 20 (after adrenaline) minutes of HUT versus SUP CPR. CONCLUSIONS: After prolonged ACD-CPR+ITD in the HUP position, brain blood flow was 2-fold higher versus the SUP position. These positive findings provide strong pre-clinical support to proceed with a clinical evaluation of elevation of the head and thorax during ACD-CPR+ITD in humans in cardiac arrest.