Coil Embolization as a Life-Saving Treatment for Pulmonary Artery Perforation Secondary to Large-Bore Catheterization.

We present a case of left pulmonary artery perforation during mechanical thrombectomy for treatment of pulmonary embolism. The patient's condition became hemodynamically unstable, with massive hemoptysis requiring intubation and multiple vasopressor agents. Prompt balloon tamponade and 0.035-mm coil embolization halted the extravasation. Coil embolization can be a lifesaving treatment for large vessel perforations. (Level of Difficulty: Intermediate.).

Laboratory Evaluation of Shell Add-On Products for American Football Helmets for Professional Linemen.

The Guardian Cap NXT (GC NXT) and the ProTech Helmet Cap (ProTech) are commercially available aftermarket products designed to augment the energy attenuation characteristics of American football helmets. The ability of these helmet shell add-on products to mitigate the severity of impacts typically experienced by professional offensive and defensive linemen was evaluated for seven helmet models using two test series. In linear impactor tests, the GC NXT reduced head impact severity as measured by the head acceleration response metric (HARM) by 9% relative to the helmets only, while the ProTech reduced HARM by 5%. While both products significantly improved the performance of the football helmets tested overall, effects varied by impact condition and helmet model with the add-ons worsening helmet performance in some conditions. The GC NXT had a strong effect size (Cohen's d = 0.8) whereas the ProTech had a medium effect (Cohen's d = 0.5). A second study investigated add-on performance for helmet-to-helmet impacts with eccentric impact vectors and resulted in a mixture of increased and decreased HARM when either add-on was placed on one or both helmets. Estimated risk for serious neck injury with add-ons and without differed by less than 4% for these eccentric impacts.

Identification of an Emergent Pathogen, Bartonella vinsonii, Using Next-Generation Sequencing in a Patient With Culture-Negative Endocarditis.

Diagnosis and treatment of culture negative endocarditis remains a challenge. This report describes a rare cause of endocarditis in humans, Bartonella vinsonii, identified through next generation sequencing of plasma microbial cell-free DNA with confirmation of cardiac valve tissue infection through immunohistochemical staining and polymerase chain reaction.

Logistical, Financial, and Psychological Impact of the COVID-19 Pandemic on Cardiac Catheterization Lab Nurses and Technologists: A U.S. National Survey.

OBJECTIVES: Coronavirus 2019 (COVID-19) significantly impacted cardiac care delivery in a manner that has not been previously experienced in the United States. Attention and resources have focused on physicians, patients, and healthcare systems with little information regarding the effects on nurses and technologists in the cardiac catheterization laboratory (CCL). METHODS: A national, online survey was conducted for nurses and technologists working in the CCL in the United States. The survey was self administered, anonymous, and included 45 questions assessing baseline demographics, logistical changes to workflow and responsibilities, staff preparedness, and mental health. RESULTS: A total of 450 respondents completed the survey, including 283 nurses (63%) and 167 technologists (37%). A total of 349 (78%) were female and mean age range was 41-50 years. Responses indicated that 68% were the primary financial provider for their families, and 74% experienced >75% decrease in case volume despite a low inpatient COVID-19 census (54% of respondents with census <10%). There were high rates of direct care for COVID-19 patients (47%), relocation (45%), lay-off/furloughs of part-time or per diem staff (42%), lay-offs of full-time staff (12%), and decreased work hours (65%). A total of 95% expressed decreased morale with an increase in mental distress, including depression (36%). Predictors of depression included relocation status, staff preparedness, and work hours. CONCLUSION: Logistical changes to CCL staffing resulted in relocation, lay-offs, furloughs, and diminished work hours, with financial and emotional ramifications. Particular attention should be paid to those in large urban hospitals, those at risk for relocation, layoffs, and furloughs, and when preparedness and administrative communication is perceived as poor.

Utilization Rates of Diagnostic and Therapeutic Vascular Procedures Among Patients Undergoing Lower Extremity Amputations in a Rural Community Hospital: A Clinicopathological Correlation.

BACKGROUND: Significant geographical variations exist in amputation rates and utilization of diagnostic and therapeutic vascular procedures before lower extremity amputations in the United States. The purpose of this study was to evaluate the rates of diagnostic and therapeutic vascular procedures in the year prior to amputation in a contemporary population and correlate with pathological findings of the amputation specimens. METHODS: A retrospective analysis was conducted of non-traumatic amputations from 2011 to 2017 at a rural community hospital. We reviewed the proportion of patients undergoing diagnostic (ankle brachial index with duplex ultrasound, computerized tomography angiogram and invasive angiogram) and therapeutic (endovascular and surgical revascularization) vascular procedures in the year prior to amputation. Prevalence of tissue viability and osteomyelitis were evaluated in all amputated specimens and atherosclerotic vascular disease (ASVD) was evaluated in major amputations. We also analyzed primary amputation rates among different subgroups. RESULTS: 698 patients were included with 248 (36%) major amputations and 450 (64%) minor amputations. Any diagnostic procedure was performed in 59% of the major amputations and 49% of the minor amputations (P = 0.01). Any therapeutic revascularization procedure was performed in 34% of the major amputations and 28% of the minor amputations (P = 0.08). The pathology of major amputation specimens revealed severe ASVD in 57% and mild-moderate ASVD in 27% of specimens. Tissue viability was significantly higher in major amputations (90% vs 30%, P = 0.04) and osteomyelitis was significantly higher in minor amputations (50% vs 14%, P = 0.03). Primary amputations were performed in 66% of major amputations, 72% of minor amputations, 81% with mild to moderate ASVD and 54% with severe ASVD. CONCLUSION: Diagnostic and therapeutic vascular procedures appear under-utilized for patients undergoing lower extremity amputations at a rural community hospital. ASVD rates and tissue viability imply that revascularization could be of significant benefit to avoid major amputation.

Laboratory Reconstructions of Concussive Helmet-to-Helmet Impacts in the National Football League.

Seventeen concussive helmet-to-helmet impacts occurring in National Football League (NFL) games were analyzed using video footage and reconstructed by launching helmeted crash test dummies into each other in a laboratory. Helmet motion on-field and in the laboratory was tracked in 3D before, during, and after impact in multiple high frame rate video views. Multiple (3-10) tests were conducted for each of the 17 concussive cases (100 tests total) with slight variations in input conditions. Repeatability was assessed by duplicating one or two tests per case. The accuracy of the input conditions in each reconstruction was assessed based on how well the closing velocity, impact locations, and the path eccentricity of the dummy heads matched the video analysis. The accuracy of the reconstruction output was assessed based on how well the changes in helmet velocity (translational and rotational) from the impact matched the video analysis. The average absolute error in helmet velocity changes was 24% in the first test, 20% in the tests with the most accurate input configuration, and 14% in the tests with minimal error. Coefficients of variation in 22 repeated test conditions (1-2 per case) averaged 3% for closing velocity, 7% for helmet velocity changes, and 8% for peak head accelerations. Iterative testing was helpful in reducing error. A combination of sophisticated video analysis, articulated physical surrogates, and iterative testing was required to reduce the error to within half of the effect size of concussion.

Characterization of Concussive Events in Professional American Football Using Videogrammetry.

Sports concussions offer a unique opportunity to study head kinematics associated with mild traumatic brain injury. In this study, a model-based image matching (MBIM) approach was employed to analyze video footage of 57 concussions which occurred in National Football League (NFL) games. By utilizing at least two camera views, higher frame rate footage (> 60 images s-1), and laser scans of the field and helmets involved in each case, it was possible to calculate the change in velocity of the helmet during impact in six degrees of freedom. The average impact velocity for these concussive events was 8.9 ± 2.0 m s-1. The average changes in translational and rotational velocity for the concussed players' helmets were 6.6 ± 2.1 m s-1 and 29 ± 13 rad s-1, respectively. The average change in translational velocity was higher for helmet-to-ground (n = 16) impacts compared to helmet-to-helmet (n = 30) or helmet-to-shoulder (n = 11) events (p < 0.001), while helmet-to-shoulder impacts had a smaller change in rotational velocity compared to the other impact sources (p < 0.001). By quantifying the impact velocities and locations associated with concussive impacts in professional American football, this study provides information that may be used to improve upon current helmet testing methodologies.

Comparison of Laboratory and On-Field Performance of American Football Helmets.

The relationship between laboratory and on-field performance of football helmets was assessed for 31 football helmet models selected from those worn by players in the 2015-2019 National Football League (NFL) seasons. Linear impactor tests were conducted with helmets placed on an instrumented Hybrid III head and neck assembly mounted on a sliding table. Based on impacts to each helmet at six impact locations and three velocities, a helmet performance score (HPS) was calculated using a linear combination of the head injury criterion (HIC) and the diffuse axonal multi-axis general evaluation (DAMAGE). To determine the on-field performance of helmets, helmet model usage, player participation, and incident concussion data were collected from the five NFL seasons and used to calculate helmet model-specific concussion rates. Comparison of laboratory HPS to the helmet model-specific concussion rates on a per play basis showed a positive correlation (r2 = 0.61, p < 0.001) between laboratory and on-field performance of helmet models, indicating that helmets which exhibited reduced impact severity in the laboratory tests were also generally associated with lower concussion rates on-field. Further analysis showed that NFL-prohibited helmet models exhibited a significantly higher odds of concussion (OR 1.24; 95% CI 1.04-1.47; p = 0.017) relative to other helmet models.

Development and Evaluation of a Test Method for Assessing the Performance of American Football Helmets.

As more is learned about injury mechanisms of concussion and scenarios under which injuries are sustained in football games, methods used to evaluate protective equipment must adapt. A combination of video review, videogrammetry, and laboratory reconstructions was used to characterize concussive impacts from National Football League games during the 2015-2017 seasons. Test conditions were generated based upon impact locations and speeds from this data set, and a method for scoring overall helmet performance was created. Head kinematics generated using a linear impactor and sliding table fixture were comparable to those from laboratory reconstructions of concussive impacts at similar impact conditions. Impact tests were performed on 36 football helmet models at two laboratories to evaluate the reproducibility of results from the resulting test protocol. Head acceleration response metric, a head impact severity metric, varied 2.9-5.6% for helmet impacts in the same lab, and 3.8-6.0% for tests performed in a separate lab when averaged by location for the models tested. Overall inter-lab helmet performance varied by 1.1 ± 0.9%, while the standard deviation in helmet performance score was 7.0%. The worst helmet performance score was 33% greater than the score of the best-performing helmet evaluated by this study.

Surface Contact Features, Impact Obliquity, and Preimpact Rotational Motion in Concussive Helmet-to-Ground Impacts: Assessment via a New Impact Test Device.

This paper reports the development of a test device for replicating unique features of concussion-causing helmet-to-ground impacts. Helmet-to-ground impacts are characterized by an oblique impact velocity vector, preimpact rotational motion of the helmeted head, and an impact into a compliant frictional surface of unknown effective mass. No helmet assessment testing program replicates these impact characteristics, yet they influence brain injury risk and therefore may influence helmet design priorities. To replicate these mechanics, the carriage of a drop tower was modified by the addition of a curvilinear bearing track and a hinged torso-neck fixture to which a helmeted head of a Hybrid III anthropomorphic test device was mounted. Preimpact rotational motion of the head was imparted by forcing a link arm to follow the curvilinear path as the carriage fell under gravity. At impact, the rotating helmeted head struck a vertically mounted surface. The ground impact features of head kinematics are illustrated by comparing rear impacts into a rigid, low-friction surface against those into a compliant frictional surface simulating turf. With the rigid, low-friction surface, the head experienced a change in rotational rate of approximately 40 rad/s, which corresponded to a peak rotational acceleration of approximately αy = - 4000 rad/s2. In contrast, peak rotational acceleration with the compliant frictional surface was approximately αy = - 1000 rad/s2 while the helmet was in contact with the surface. Neck loads were significantly greater with the compliant frictional surface. Translational head acceleration was less sensitive to the surface characteristics, with the peak of the anterior-posterior component essentially unchanged.

Acute Flaccid Myelitis Among Hospitalized Children in Texas, 2016.

BACKGROUND: Acute flaccid myelitis is characterized by acute-onset flaccid limb weakness with predominantly gray matter lesions in the spinal cord spanning one or more segments. Rates of full recovery are poor, and there is no standard treatment or definitive cause. METHODS: This is a retrospective review of children diagnosed with acute flaccid myelitis in Texas during 2016. Patients were identified through a Texas collaborative of six hospitals in four major metropolitan areas. Data abstraction included health history, illness presentation, medical treatments, laboratory studies, imaging data, recovery, and ability to perform activities of daily living up to approximately two years from illness onset. RESULTS: Among all sites, 21 patients met inclusion criteria. Treatments varied with the most common being intravenous immunoglobulin, high-dose methylprednisolone, and plasmapheresis. No differences were seen in response to medical treatments. A potential etiology was found in 12 (57%) cases, including four with enterovirus D68. Five cases recovered fully. Of the 16 patients without full recovery, abilities ranged from (1) able to perform all activities of daily living for age independently (n = 5), (2) mild deficits (n = 5), and (3) substantial reliance on caregivers for activities of daily living (n = 6). CONCLUSION: Many reports describe symptoms and outcomes of acute flaccid myelitis, but limited data are available on long-term functional outcomes. We were unable to make a strong case for any single cause or treatment modality. Fortunately, the majority of patients (15, 71%) were able to perform activities of daily living with complete independence or only mild deficits.

Validation of a videogrammetry technique for analysing American football helmet kinematics.

Professional American football games are recorded in digital video with multiple cameras, often at high resolution and high frame rates. The purpose of this study was to evaluate the accuracy of a videogrammetry technique to calculate translational and rotational helmet velocity before, during and after a helmet impact. In total, 10 football impacts were staged in a National Football League (NFL) stadium by propelling helmeted 50th percentile male crash test dummies into each other or the ground at speeds and orientations representative of concussive impacts for NFL players. The tests were recorded by experienced sports film crews to obtain video coverage and quality typically available for NFL games. A videogrammetry procedure was used to track the position and rotation of the helmet throughout the relevant time interval of the head impact. Compared with rigidly mounted retroreflective marker three dimensional (3-D) motion tracking that was concurrently collected in the experiments, videogrammetry accurately calculated changes in translational and rotational velocity of the helmet using high frame rate (two cameras at 240 Hz) video (7% and 15% error, respectively). Low frame rate (2 cameras at 60 Hz) video was adequate for calculating pre-impact translational velocity but not for calculating the translational or rotational velocity change of the helmet during impact.

The biomechanics of concussive helmet-to-ground impacts in the National Football league.

This paper presents a detailed characterization of helmet-to-ground impacts in the National Football League. Video analysis was performed for 16 head-to-ground impacts that caused concussions. Average resultant closing velocity was 8.3 m/s at an angle nearly 45° to the surface. Preimpact rotational velocity of the helmet ranged from negligible to as high as 54.1 rad/s. Helmet impacts were concentrated on the posterior and lateral aspects. To study the interaction in greater detail, a helmeted anthropomorphic test device (ATD) was launched over a football field and fell to the ground in various impact conditions. Substantial decoupling between the helmet and the head was observed, such that the head rebounded within the helmet and underwent changes in linear and rotational motion greater than those of the helmet. Vertical helmet rebound was also observed; the helmet underwent a change in vertical velocity on average 24% greater than the vertical component of its closing velocity. Frictional interaction between the helmet and the ground surface caused the helmet to undergo an average horizontal change in velocity of 57% of the horizontal component of its closing velocity. Finally, the duration of a helmet-to-ground impact was generally in the range of 15 - 30 ms, suggesting that the impact surface provides little ride-down. Lengthening this duration could be beneficial both by reducing the peak linear and rotational acceleration and by shifting the impact toward a time regime where brain strain is related to rotational acceleration rather than rotational velocity.

Correction: A feasibility study of returning clinically actionable somatic genomic alterations identified in a research laboratory.

[This corrects the article DOI: 10.18632/oncotarget.16018.].

Relative Motion Between the Helmet and the Head in Football Impact Test.

Approximately 1.6-3.8 million sports-related traumatic brain injuries occur each year in the U.S. Researchers track the head motion using a variety of techniques to study the head injury biomechanics. To understand how helmets provide head protection, quantification of the relative motion between the head and the helmet is necessary. The purpose of this study was to compare helmet and head kinematics and quantify the relative motion of helmet with respect to head during experimental representations of on-field American football impact scenarios. Seven helmet-to-helmet impact configurations were simulated by propelling helmeted crash test dummies into each other. Head and helmet kinematics were measured with instrumentation and an optical motion capture system. The analysis of results, from 10 ms prior to the helmet contact to 20 ms after the loss of helmet contact, showed that the helmets translated 12-41 mm and rotated up to 37 deg with respect to the head. The peak resultant linear acceleration of the helmet was about 2-5 times higher than the head. The peak resultant angular velocity of the helmet ranged from 37% less to 71% more than the head, depending on the impact conditions. The results of this study demonstrate that the kinematics of the head and the helmet are noticeably different and that the helmet rotates significantly with respect to the head during impacts. Therefore, capturing the helmet kinematics using a video motion tracking methodology is not sufficient to study the biomechanics of the head. Head motion must be measured independently of the helmet.

Development of Open-Source Dummy and Impactor Models for the Assessment of American Football Helmet Finite Element Models.

The objective of this study was to develop and validate a set of Hybrid-III head and neck (HIII-HN) and impactor models that can be used to assess American football design modifications with established dummy-based injury metrics. The model was validated in two bare-head impact test configurations used by the National Football League and research groups to rank and assess helmet performance. The first configuration was a rigid pendulum impact to three locations on the HIII head (front, rear, side) at 3 m/s. The second configuration was a set of eight 5.5 m/s impacts to the HIII head at different locations using a linear impactor with a compliant end cap. The ISO/TS 18571 objective rating metric was used to quantify the correlation between the experimental and model head kinematics (linear and rotational velocity and acceleration) and neck kinetics (neck force and moment). The HIII-HN model demonstrated good correlation with overall mean ISO scores of 0.69-0.78 in the pendulum impacts and 0.65-0.81 in the linear impacts. These publically available models will serve as an in silico design platform that will be useful for investigating novel football helmet designs and studying human head impact biomechanics, in general.

Identification of Actionable Genomic Alterations Using Circulating Cell-Free DNA.

PURPOSE: Cell-free DNA (cfDNA) next-generation sequencing is a noninvasive approach for genomic testing. We report the frequency of identifying alterations and their clinical actionability in patients with advanced/metastatic cancer. PATIENTS AND METHODS: Prospectively consented patients had cfDNA testing performed. Alterations were assessed for therapeutic implications. RESULTS: We enrolled 575 patients with 37 tumor types. Of these patients, 438 (76.2%) had at least one alteration detected, and 205 (35.7%) had one or more alterations of high potential for clinical action. In diseases with 10 or more patients enrolled, 50% or more had at least one alteration deemed of high potential for clinical action. Trials were identified in 80% of patients (286 of 357) with any alteration and in 92% of patients (188 of 205) with one or more alterations of high potential for clinical action of whom 57.6% (118 of 205) had 6 or more months of follow-up available. Of these patients, 10% (12 of 118) had received genomically matched therapy through enrollment in clinical trials (n = 8), off-label drug use (n = 3), or standard of care (n = 1). Although 88.6% of all patients had a performance status of 0 or 1 upon enrollment, the primary reason for not acting on alterations was poor performance status at next treatment change (28.1%; 27 of 96). CONCLUSION: cfDNA testing represents a readily accessible method for genomic testing and allows for detection of genomic alterations in most patients with advanced disease. Utility may be higher in patients interested in investigational therapeutics with adequate performance status. Additional study is needed to determine whether utility is enhanced by testing earlier in the treatment course.

An Injury Risk Function for the Leg, Foot, and Ankle Exposed to Axial Impact Loading Using Force and Impulse.

Most injury risk functions (IRFs) for dynamic axial loading of the leg have been targeted toward automotive applications such as predicting injury caused by intrusion into the occupant compartment from frontal collisions. Recent focus on leg injuries in the military has led to questions about the applicability of these IRFs shorter duration, higher amplitude loading associated with underbody blast (UBB). To investigate these questions, data were collected from seven separate test series that subjected post-mortem human legs to axial impact. A force and impulse-based Weibull survival model was developed from these studies to estimate fracture risk. Specimen age was included as a covariate to reduce variance and improve survival model fit. The injury criterion estimated 50% risk of injury for a leg exposed to 13 N s of impulse at peak force and 8.07 kN of force for force durations less than and greater than half the natural period of the leg, respectively. A supplemental statistical analysis estimated that the proposed IRF improves injury prediction accuracy by more than 9% compared to the predictions from automobile-based risk functions developed for automotive intrusion. The proposed leg IRF not only improves injury prediction for higher rate conditions but also provides a single injury prediction tool for an expanded range of load durations ranging from 5 to 90 ms, which spans both automotive and military loading environments.

Contemporary nursing care in transcatheter aortic valve replacement.

The purpose of this article is to inform nurses of the latest trend in the care of patients with aortic stenosis using transcatheter aortic valve replacement and pertinent knowledge regarding the care of these patients.