Needle decompression in appalachia do obese patients need longer needles?

INTRODUCTION: Needle decompression of a tension pneumothorax can be a lifesaving procedure. It requires an adequate needle length to reach the chest wall to rapidly remove air. With adult obesity exceeding one third of the United States population in 2010, we sought to evaluate the proper catheter length that may result in a successful needle decompression procedure. Advance Trauma Life Support (ATLS) currently recommends a 51 millimeter (mm) needle, while the needles stocked in our emergency department are 46 mm. Given the obesity rates of our patient population, we hypothesize these needles would not have a tolerable success rate of 90%. METHODS: We retrospectively reviewed 91 patient records that had computed tomography of the chest and measured the chest wall depth at the second intercostal space bilaterally. RESULTS: We found that 46 mm needles would only be successful in 52.7% of our patient population, yet the ATLS recommended length of 51 mm has a success rate of 64.8%. Therefore, using a 64 mm needle would be successful in 79% percent of our patient population. CONCLUSION: Use of longer length needles for needle thoracostomy is essential given the extent of the nation's adult obesity population.

Structural analysis of ligand binding and catalysis in chorismate lyase.

Chorismate lyase (CL) removes the pyruvyl group from chorismate to provide 4-hydroxybenzoate (4HB) for the ubiquinone pathway. We previously reported the crystal structure at 1.4A resolution of the Escherichia coli CL with bound 4HB product, showing that the product is bound in an internal cavity behind two flaps. To provide a more complete basis for understanding CL's unusual ligand-binding properties and mechanism of action, we now report four crystal structures of CL mutants and inhibitor complexes, together with binding and activity measurements and molecular dynamics simulations. First, an ultrahigh resolution (1.0A) crystal structure of the CL*product complex reveals details of a substrate-sized internal cavity, also behind the flaps, near the product site. Second, a 2.4A structure of CL complexed with the inhibitor vanillate shows the flaps partly opened relative to their product-bound positions. Third, a 2.0A structure of the G90A mutant with bound product reveals the basis for tighter product binding and kinetic effects of this active site mutation. Fourth, the combination of the G90A mutation with the vanillate inhibitor produces a 1.9A structure containing two inhibitor molecules, one in the product site and the other in the adjacent cavity. The two sites are connected by a short tunnel that is partly open at each end, suggesting that CL may operate via a 2-site or tunnel mechanism.