Objective Response of Saliva Biomarkers After High-Stress and Mass Casualty Scenarios: A Pilot Study.

INTRODUCTION: Surgeons and military personnel are subjected to high-stress scenarios, which leads to greater rates of burnout. There is room to optimize performance and longevity in these careers by better understanding the body's stress response and applying it to stress management training. This study aims to understand the physiological response in those engaged in trauma scenarios by examining 6 hormones and 42 cytokines during the Intensive Surgical and Trauma Skills Course held at Strategic Operations Inc in San Diego, CA. METHODS: Thirty-seven military medical students participated in full immersion, hyper-realistic, and experiential mass casualty high-stress scenarios. Participants were exposed to both operating and emergency room scenarios. Saliva samples were taken after stress inoculation (postinoculation) and again 1 hr after each scenario (recovery). Saliva samples were analyzed using plex assays from Eve Technologies. Data were grouped and analyzed by location and timing using mixed effect nonlinear models. Distributions were compared by location and were analyzed with respect to biomarker levels over the 4-day training period. RESULTS: For emergency room scenarios, there was a decrease in the following cytokines from postinoculation to recovery: epidermal growth factor (EGF), granulocyte colony stimulating factor (G-CSF), epidermal growth factor, granulocyte colony stimulating factor, interleukin 1alpha (IL-1α), interleukin 1beta (IL-1 ß), IL-1RA, IL-4, IL-8, IL-10, IL-18, monocyte chemotactic protein (MCP) 1, macrophage colony stimulating factor (M-CSF), macrophage derived chemokine (MDC), CXC motif ligand 9 (MIG/CXCL9), regulated upon activation, normal T cell expressed and secreted (RANTES), and vascular endothelial growth factor (P < 0.05, t > 3.0). For operating room scenarios, there was a decrease in the following cytokines: EGF, G-CSF, IL-1α, IL-1 ß, IL-1RA, IL-6, IL-8, IL-10, IL-18, M-CSF, MDC, MIG/CXCL9, RANTES, and tumor necrosis factor alpha. In operating room scenarios, an increase in the hormone levels of progesterone and triodothyronine were observed. The cytokines observed in both groups included EGF, IL-1α, RANTES, MDC, EGF, G-CSF, IL-1RA, IL-18, MIG/CXCL9, IL-8, IL-1ß, M-CSF, and IL-10. These significant biomarkers were also graphed and visualized as variable throughout the week. CONCLUSIONS: These preliminary data narrow a wide array of stress biomarkers to a smaller, significant group. Surgeons and military personnel are subjected to extraordinary levels of stress with narrow margins for error. To optimize performance and outcomes, it is pertinent to understand the physiological stress response. Future investigation and pairing of cytokine measurements with neuropsychological and performance-based testing will target opportunities to direct training and identify profiles of individuals well suited for stressful environments.

A distinct immune cytokine profile is associated with morning cortisol and repeated stress.

OBJECTIVE: The objective of this study was to investigate possible immune cytokine trends throughout a week-long surgical simulation mass-casualty training session in order to determine the effects of stress inoculation on the immune system. METHODS: Thirty-seven military medical students participated in a hyper-realistic surgical simulation training event conducted at Strategic Operations site in San Diego, California. Salivary samples were collected every morning of the stress training exercise for 4 consecutive days. Cortisol, along with a panel of 42 immune cytokines, was measured using multiplex enzyme-linked immunosorbent assays from Eve Technologies. The determined concentrations were averaged and plotted on a scatter plot, and then points were fit to a second-order polynomial trendline of best fit to measure. RESULTS: The cytokines epidermal growth factor, growth-related oncogene-α, interleukin (IL)-1α, and platelet-derived growth factor-AA followed a noted pattern of cortisol decrease throughout the week. In addition, cytokines IL-27, granulocyte colony stimulating factor, IL-10, and IL-13 demonstrated a late peak, followed by a return to baseline at the conclusion of training. Finally, the cytokine monocyte chemoattractant protein-1 displayed a decline throughout the week followed by an increase on the last day of stress training. CONCLUSIONS: Altogether, these results help to identify important biomarkers that may help to improve long-term stress adaptation and prevent post-traumatic stress disorder following exposure to repeated stress.

Delayed care in myocardial infarction and ischemic stroke patients during the COVID-19 pandemic.

COVID-19 has profound direct health consequences, however secondary effects were much broader as rates of hospital visits steeply declined for non-COVID-19 concerns, including myocardial infarction (MI) and stroke, with patients choosing to wait longer before symptoms convince them to seek medical attention. Thus, patients where ischemia leads to tissue loss should be a major concern. METHODS: The months of March to June 2019 and 2020 were compared to each other at 4 Denver area hospitals. Reduction in overall ED visits and an increase in patient refusal for emergency transport were clear in the data collected. During this period in 2019, 49 MI and 90 stroke patients were admitted. In 2020 this was 40 and 90 respectively. All were matched for age and gender. For MI patients ejection fraction and door to EKG and intervention times were measured. For stroke patients last known well time, time to evaluation, and modified Rankin scores were measured. RESULTS: 254 (8.12%) patients refused emergency services transportation before the pandemic compared to 479 (18.35%) during the pandemic (p-value <0.001, chi square test). In the MI cohort, no significant difference was detected in measured ejection fraction (48% vs 49% p-value = 0.682). Additionally, no significant difference was detected between door to EKG time or door to MI intervention time. During the pandemic 8 (22%) expired with an MI prior to discharge, compared to 2 (4%) before the pandemic. The stroke cohort Door to Evaluation Time, Time since last well known, and modified Rankin scores were all found to have insignificant differences. DISCUSSION: ED volume was significantly lower during the early stages of the pandemic. During this time however only death from cardiac events increased, in spite of similar ejection fractions at discharge. The cause of this remains unclear as ejection fraction similarities make it less attributable to loss of tissue than to other factors. Patient behavior significantly changed during the pandemic, making this a likely source of the increase in mortality seen.