Nomogram for predicting in-hospital mortality in trauma patients undergoing resuscitative endovascular balloon occlusion of the aorta: a retrospective multicenter study.

Recently, resuscitative endovascular balloon occlusion of the aorta (REBOA) had been introduced as an innovative procedure for severe hemorrhage in the abdomen or pelvis. We aimed to investigate risk factors associated with mortality after REBOA and construct a model for predicting mortality. This multicenter retrospective study collected data from 251 patients admitted at five regional trauma centers across South Korea from 2015 to 2022. The indications for REBOA included patients experiencing hypovolemic shock due to hemorrhage in the abdomen, pelvis, or lower extremities, and those who were non-responders (systolic blood pressure (SBP) < 90 mmHg) to initial fluid treatment. The primary and secondary outcomes were mortality due to exsanguination and overall mortality, respectively. After feature selection using the least absolute shrinkage and selection operator (LASSO) logistic regression model to minimize overfitting, a multivariate logistic regression (MLR) model and nomogram were constructed. In the MLR model using risk factors selected in the LASSO, five risk factors, including initial heart rate (adjusted odds ratio [aOR], 0.99; 95% confidence interval [CI], 0.98-1.00; p = 0.030), initial Glasgow coma scale (aOR, 0.86; 95% CI 0.80-0.93; p < 0.001), RBC transfusion within 4 h (unit, aOR, 1.12; 95% CI 1.07-1.17; p < 0.001), balloon occlusion type (reference: partial occlusion; total occlusion, aOR, 2.53; 95% CI 1.27-5.02; p = 0.008; partial + total occlusion, aOR, 2.04; 95% CI 0.71-5.86; p = 0.187), and post-REBOA systolic blood pressure (SBP) (aOR, 0.98; 95% CI 0.97-0.99; p < 0.001) were significantly associated with mortality due to exsanguination. The prediction model showed an area under curve, sensitivity, and specificity of 0.855, 73.2%, and 83.6%, respectively. Decision curve analysis showed that the predictive model had increased net benefits across a wide range of threshold probabilities. This study developed a novel intuitive nomogram for predicting mortality in patients undergoing REBOA. Our proposed model exhibited excellent performance and revealed that total occlusion was associated with poor outcomes, with post-REBOA SBP potentially being an effective surrogate measure.

Reducing Oxidative Stress and Inflammation by Pyruvate Dehydrogenase Kinase 4 Inhibition Is Important in Prevention of Renal Ischemia-Reperfusion Injury in Diabetic Mice.

Background: Reactive oxygen species (ROS) and inflammation are reported to have a fundamental role in the pathogenesis of ischemia-reperfusion (IR) injury, a leading cause of acute kidney injury. The present study investigated the role of pyruvate dehydrogenase kinase 4 (PDK4) in ROS production and inflammation following IR injury. Methods: We used a streptozotocin-induced diabetic C57BL6/J mouse model, which was subjected to IR by clamping both renal pedicles. Cellular apoptosis and inflammatory markers were evaluated in NRK-52E cells and mouse primary tubular cells after hypoxia and reoxygenation using a hypoxia work station. Results: Following IR injury in diabetic mice, the expression of PDK4, rather than the other PDK isoforms, was induced with a marked increase in pyruvate dehydrogenase E1α (PDHE1α) phosphorylation. This was accompanied by a pronounced ROS activation, as well as tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), interleukin-1ß (IL-1ß), and monocyte chemoattractant protein-1 (MCP-1) production. Notably, sodium dichloroacetate (DCA) attenuated renal IR injury-induced apoptosis which can be attributed to reducing PDK4 expression and PDHE1α phosphorylation levels. DCA or shPdk4 treatment reduced oxidative stress and decreased TNF-α, IL-6, IL-1ß, and MCP-1 production after IR or hypoxia-reoxygenation injury. Conclusion: PDK4 inhibition alleviated renal injury with decreased ROS production and inflammation, supporting a critical role for PDK4 in IR mediated damage. This result indicates another potential target for reno-protection during IR injury; accordingly, the role of PDK4 inhibition needs to be comprehensively elucidated in terms of mitochondrial function during renal IR injury.

Hemostatic effect of fibrinogen concentrate on traumatic massive hemorrhage: a propensity score matching study.

Background: Fibrinogen concentrate (FC) can be administered during massive transfusions to manage trauma-induced coagulopathy. However, its effectiveness in survival remains inconclusive due to scarce high-level evidence. This study aimed to investigate the hemostatic effects of FC regarding mortality in massive hemorrhage caused by trauma. Methods: This retrospective study analyzed 839 patients who received massive transfusions (red blood cells (RBCs) ≥5 units in 4 hours or ≥10 units in 24 hours) at a level I trauma center between 2015 and 2022. Patients who were transferred to other hospitals or were deceased upon arrival, suffered or died from severe brain injury, and were aged 15 years or less were excluded (n=334). 1:2 propensity score matching was performed to compare the 'FC (+)' group who had received FC in 24 hours (n=68) with those who had not ('FC (-)', n=437). The primary outcome was mortality, and the secondary outcomes included transfusion volume. Results: The variables for matching included vital signs, injury characteristics, prehospital time, implementation of resuscitative endovascular balloon occlusion of the aorta, and blood gas analysis results. The administration of FC did not significantly reduce or predict mortality (in-hospital, 24 hours, 48 hours, or 7 days). The FC (-) group received more units of RBC (25.69 units vs. 16.71 units, p<0.001, standardized mean difference [SMD] 0.595), fresh frozen plasma (16.79 units vs. 12.91 units, p=0.023, SMD 0.321), and platelets (8.76 units vs. 5.46 units, p=0.002, SMD 0.446) than the FC (+) group. Conclusion: The use of FC did not show survival benefits but reduced transfusion requirements in traumatic massive hemorrhages, highlighting a need for future investigations. In the future, individualized goal-directed transfusion with FC may play a significant role in treating massive bleeding. Level of evidence: IV, retrospective study having more than one negative criterion.

Dual-frequency piezoelectric micromachined ultrasound transducer based on polarization switching in ferroelectric thin films.

Due to its additional frequency response, dual-frequency ultrasound has advantages over conventional ultrasound, which operates at a specific frequency band. Moreover, a tunable frequency from a single transducer enables sonographers to achieve ultrasound images with a large detection area and high resolution. This facilitates the availability of more advanced techniques that simultaneously require low- and high-frequency ultrasounds, such as harmonic imaging and image-guided therapy. In this study, we present a novel method for dual-frequency ultrasound generation from a ferroelectric piezoelectric micromachined ultrasound transducer (PMUT). Uniformly designed transducer arrays can be used for both deep low-resolution imaging and shallow high-resolution imaging. To switch the ultrasound frequency, the only requirement is to tune a DC bias to control the polarization state of the ferroelectric film. Flextensional vibration of the PMUT membrane strongly depends on the polarization state, producing low- and high-frequency ultrasounds from a single excitation frequency. This strategy for dual-frequency ultrasounds meets the requirement for either multielectrode configurations or heterodesigned elements, which are integrated into an array. Consequently, this technique significantly reduces the design complexity of transducer arrays and their associated driving circuits.

Inhibition of pyruvate dehydrogenase kinase 4 ameliorates kidney ischemia-reperfusion injury by reducing succinate accumulation during ischemia and preserving mitochondrial function during reperfusion.

Ischemia-reperfusion (IR) injury, a leading cause of acute kidney injury (AKI), is still without effective therapies. Succinate accumulation during ischemia followed by its oxidation during reperfusion leads to excessive reactive oxygen species (ROS) and severe kidney damage. Consequently, the targeting of succinate accumulation may represent a rational approach to the prevention of IR-induced kidney injury. Since ROS are generated primarily in mitochondria, which are abundant in the proximal tubule of the kidney, we explored the role of pyruvate dehydrogenase kinase 4 (PDK4), a mitochondrial enzyme, in IR-induced kidney injury using proximal tubule cell-specific Pdk4 knockout (Pdk4ptKO) mice. Knockout or pharmacological inhibition of PDK4 ameliorated IR-induced kidney damage. Succinate accumulation during ischemia, which is responsible for mitochondrial ROS production during reperfusion, was reduced by PDK4 inhibition. PDK4 deficiency established conditions prior to ischemia resulting in less succinate accumulation, possibly because of a reduction in electron flow reversal in complex II, which provides electrons for the reduction of fumarate to succinate by succinate dehydrogenase during ischemia. The administration of dimethyl succinate, a cell-permeable form of succinate, attenuated the beneficial effects of PDK4 deficiency, suggesting that the kidney-protective effect is succinate-dependent. Finally, genetic or pharmacological inhibition of PDK4 prevented IR-induced mitochondrial damage in mice and normalized mitochondrial function in an in vitro model of IR injury. Thus, inhibition of PDK4 represents a novel means of preventing IR-induced kidney injury, and involves the inhibition of ROS-induced kidney toxicity through reduction in succinate accumulation and mitochondrial dysfunction.

Early experience with resuscitative endovascular balloon occlusion of the aorta for unstable pelvic fractures in the Republic of Korea: a multi-institutional study.

PURPOSE: Recently, trauma centers in the Republic of Korea introduced resuscitative endovascular balloon occlusion of the aorta (REBOA) for application in severe pelvic fracture cases. This study aimed to determine the efficacy of REBOA and its associated factors in enhancing survival. METHODS: Data from patients with severe pelvic injuries at two regional trauma centers from 2016 to 2020 were retrospectively reviewed. Patients were dichotomized into REBOA and no-REBOA groups, and patient characteristics and clinical outcomes were compared using 1:1 propensity score matching. Additional survival-based analysis was performed in the REBOA group. RESULTS: REBOA was performed in 42 of the 174 patients with pelvic fractures. As patients in the REBOA group had more severe injuries than did patients in the no-REBOA group, 1:1 propensity score matching was performed to adjust for severity. After matching, 24 patients were included in each group and mortality was not significantly different (REBOA 62.5% vs. no-REBOA 41.7%, P = 0.149). Kaplan-Meier analysis revealed no significant differences in mortality between the two matched groups (log-rank test, P = 0.408). Among the 42 patients treated with REBOA, 14 survived. Shorter REBOA duration (63 [40-93] vs. 166 [67-193] min, P = 0.015) and higher systolic blood pressure before REBOA (65 [58-76] vs. 54 [49-69] mmHg, P = 0.035) were associated with better survival. CONCLUSIONS: The effectiveness of REBOA has not been definitively established; however, it was not associated with increased mortality in this study. Additional studies are required to better understand how REBOA can be effectively used for treatment.

The temporary abdominal closure techniques used for trauma patients: a systematic review and meta-analysis.

Purpose: The choice of temporary abdominal closure (TAC) method affects the prognosis of trauma patients. Previous studies on TAC are challenging to extrapolate due to data heterogeneity. We aimed to conduct a systematic review and comparison of various TAC techniques. Methods: We accessed web-based databases for studies on the clinical outcomes of TAC techniques. Recognized techniques, including negative-pressure wound therapy with or without continuous fascial traction, skin tension, meshes, Bogota bags, and Wittman patches, were classified via a method of closure such as skin-only closure vs. patch closure vs. vacuum closure; and via dynamics of treatment like static therapy (ST) vs. dynamic therapy (DT). Study endpoints included in-hospital mortality, definitive fascial closure (DFC) rate, and incidence of intraabdominal complications. Results: Among 1,065 identified studies, 37 papers comprising 2,582 trauma patients met the inclusion criteria. The vacuum closure group showed the lowest mortality (13%; 95% confidence interval [CI], 6%-19%) and a moderate DFC rate (74%; 95% CI, 67%-82%). The skin-only closure group showed the highest mortality (35%; 95% CI, 7%-63%) and the highest DFC rate (96%; 95% CI, 93%-99%). In the second group analysis, DT showed better outcomes than ST for all endpoints. Conclusion: Vacuum closure was favorable in terms of in-hospital mortality, ventral hernia, and peritoneal abscess. Skin-only closure might be an alternative TAC method in carefully selected groups. DT may provide the best results; however, further studies are needed.

CPR quality with rotation of every 1 versus 2 minutes as characteristics of rescuers: A randomized crossover simulation study.

BACKGROUND: Fatigue and rotation time are key factors affecting the quality of cardiopulmonary resuscitation (CPR). This study aimed to investigate the effects of rotation time on CPR duration, and sex on chest compression quality. METHODS: In this randomized crossover simulation study, we enrolled 100 paramedic students stratified by sex and randomly grouped into 28 male and 22 female pairs. In the 2- and 1-minute scenarios, 2 participants performed CPR for 20 minutes with a rotation cycle of 2 minutes and 1 minute, respectively. After taking a break, they changed over and performed CPR again for 20 minutes. The switching of roles was performed with the students positioned on opposite sides of the mannequin. For chest compression quality, a set was defined as CPR performed by 1 pair in a 2-minute scenario for 4 minutes. The quality of CPR in each set was compared between the 2 groups. RESULTS: The 1-minute group showed significantly higher chest compression depth than the 2-minute group (54.0 [51.5-57.0] vs 52.5 [48.5-56.5] mm, P = .001, respectively). The female 2-minute group showed decreased chest compression depth over time, and the 1-minute group showed significantly increased chest compression depth during all sets except the 2nd set (54.0 [51.9-55.1] vs 50.5 [48.5-53.8] mm [P = .030], 52.3 [49.4-54.5] vs 50.8 [47.0-53.1] mm [P = .080], 52.8 [49.8-54.5] vs 48.8 [45.4-51.6] mm [P = .002], 51.5 [48.5-53.3] vs 48.3 [44.5-50.6] mm [P = .004], and 50.8 [48.9-54.1] vs 47.5 [44.6-50.1] mm [P = .001], respectively). The fatigue scores in the 2-minute group were significantly higher during sets 4 and 5 than those in the 1-minute group. CONCLUSION: When rescuer fatigue increases during prolonged CPR owing to their physical strength and skill levels, the rotation of rescuers every minute would be helpful in maintaining high-quality CPR.

Evaluating the sources and fate of nitrate in riparian aquifers under agricultural land using in situ-measured noble gases, stable isotopes, and metabolic genes.

Riparian zones with their buffering ability and abundant water supply are often subjected to intensive agricultural activities. We investigated a riparian aquifer located near a stream in South Korea that recently experienced sharply decreasing groundwater levels and elevated nitrate (NO3-) concentrations, which were attributed to local agricultural activities. Our goal was to identify the predominant nitrogen sources and NO3- removal processes. Multiple approaches including geochemical and isotopic tracers, land-use analysis, metabolic gene quantification, and inert gas tracers were used to elucidate groundwater and nutrient dynamics in stream-side granitic aquifers. The dual isotopic composition of NO3- identified manure and sewage as the major sources of NO3- contamination. Denitrification was the dominant NO3- removal process in the aquifer, as demonstrated by the negative relationship between δ15N and δ18O values in NO3-and NO3-/Cl-. Denitrification and anammox genes were also observed in microbial communities of the aquifer throughout the study site, suggesting that these processes support effective natural NO3- attenuation in groundwater. A mixing model constructed using a catchment-scale dataset including SiO2 concentrations and δ18O-H2O suggested that mixing with paddy soil water was the major driver of denitrification in the aquifer at the study site, where impervious layers provided anaerobic conditions for natural NO3- attenuation. Denitrification reduced the NO3- flux into the nearby stream by up to 114.4 NO3- kg/ha/y (26 kg N/ha/y). The N2 generated by denitrification did not accumulate in the groundwater, but mostly escaped from groundwater to the atmosphere, as demonstrated by the degassed signature of dissolved inert gases below the air saturated water level. This study identified the predominant NO3- sources and conceptualized N cycling in the heavily developed agricultural riparian aquifer using multiple tracers, demonstrating that NO3- is partially removed through denitrification and possibly anammox while N2 mostly escapes into the atmosphere.

Feasibility and Clinical Outcomes of Resuscitative Endovascular Balloon Occlusion of the Aorta in Patients with Traumatic Shock: A Single-Center 5-Year Experience.

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has recently gained popularity as an adjunct to resuscitation of patients with traumatic shock. However, the effectiveness of REBOA is still debated because of inconsistent indications across centers and the lack of medical records. The purpose of this study was to investigate the effectiveness and feasibility of REBOA by analyzing clinical results from a single center. Methods: This study included 96 patients who underwent REBOA between August 2016 and September 2021 at a regional trauma center according to the center's treatment algorithm for traumatic shock. Medical records, including the time of the decision to conduct the REBOA procedure, time of operation, type of aortic occlusion, and clinical outcomes, were collected prospectively and analyzed retrospectively. Patients were classified by REBOA protocol (group 1, 2, or 3) and survival status (survivor or non-survivor) for analysis. Results: The overall success rate of the procedure was 97.9%, and the survival rate was 32.6%. In survivors, blood pressure was higher than in non-survivors both before the REBOA procedure (p=0.002) and after aortic occlusion (p=0.03). The total aortic occlusion time was significantly shorter (p=0.001) and the proportion of partial aortic occlusion was significantly higher (p=0.014) among the survivors. The non-survivors had more acidosis (p<0.001) and higher lactate concentrations (p<0.001) than the survivors. Conclusion: REBOA may be a feasible bridge therapy for resuscitation of patients with traumatic shock. Prompt and accurate decision-making to perform REBOA followed by damage control surgery could improve survival rates and clinical outcomes.

Genomic Analysis of Halotolerant Bacterial Strains Martelella soudanensis NC18T and NC20.

Two novel, halotolerant strains of Martelella soudanensis, NC18T and NC20, were isolated from deep subsurface sediment, deeply sequenced, and comparatively analyzed with related strains. Based on a phylogenetic analysis using 16S rRNA gene sequences, the two strains grouped with members of the genus Martelella. Here, we sequenced the complete genomes of NC18T and NC20 to understand the mechanisms of their halotolerance. The genome sizes and G+C content of the strains were 6.1 Mb and 61.8 mol%, respectively. Moreover, NC18T and NC20 were predicted to contain 5,849 and 5,830 genes, and 5,502 and 5,585 protein-coding genes, respectively. Both strains contain the identically predicted 6 rRNAs and 48 tRNAs. The harboring of halotolerant-associated genes revealed that strains NC18T and NC20 might tolerate high salinity through the accumulation of potassium ions in a "salt-in" strategy induced by K+ uptake protein (kup) and the K+ transport system (trkAH and kdpFABC). These two strains also use the ectoine transport system (dctPQM), the glycine betaine transport system (proVWX), and glycine betaine uptake protein (opu) to accumulate "compatible solutes," such as ectoine and glycine betaine, to protect cells from salt stress. This study reveals the halotolerance mechanism of strains NC18T and NC20 in high salt environments and suggests potential applications for these halotolerant and halophilic strains in environmental biotechnology.

Development of a limitless scale-up photobioreactor for highly efficient photosynthesis-based polyhydroxybutyrate (PHB)-producing cyanobacteria.

Photosynthetic polyhydroxybutyrate (PHB) production is an attractive technology for realizing a sustainable society by simultaneously producing useful biodegradable plastics and mitigating CO2. It is necessary to establish an economical large-scale photobioreactor (PBR) capable of effectively cultivating photosynthetic microorganisms such as cyanobacteria. A roll-to-roll winding machine/heat-sealer hybrid system for fabricating an easy-to-scale-up PBR was developed in the present study. The baffle design was optimized to facilitate mass transfer within the PBR, and the operating conditions of the gas sparger were investigated to maximize the CO2 transfer efficiency. The newly developed PBR was able to produce biomass of PHB content 10.7 w/w% at a rate of 6.861 g m-2 d-1, 21 % improved biomass productivity compared with the existing PBR. It was confirmed that biomass productivity was maintained even when PBR was scaled up to 2 tons. Consequently, the newly developed PBR is expected to improve the feasibility of photosynthetic PHB production.

Physicochemical and isotopic properties of ambient aerosols and precipitation particles during winter in Seoul, South Korea.

The aim of this study was to characterize the physicochemical properties and microbial communities of particulate matter (PM) in Seoul, Korea. We collected long-term (2017-2019) precipitation samples and PM10 and PM2.5 monitoring data to determine the impact of soluble and insoluble chemical species on the soil surface. Ambient PM10 concentrations were higher than PM2.5 concentrations during the monitoring period, but both decreased during rainfall due to the washing effect of precipitation. PM2.5 particles had a "fluffy" shape and contained sulfur (0.2%), but suspended particles (SPs) contained many carbon particles (approximately 60%). Spherical particles containing metal oxides, Fe and Al, might be originated from coal combustion, wild fires, and metal-refining processes under high-temperature conditions. Dissolved ions in precipitation included those eluted from salts and coal combustion based on the correlation coefficients of Na and Cl (R = 0.953) and F and NO3 (R = 0.706). The δ15N-NO3 and δ34S-SO4 of precipitation were enriched as the atmospheric temperature decreased from 9.8 to -1.6°C, implying the influence of domestic coal combustion. Backward trajectories showed that, in winter, air parcels passed through industrialized cities from China to South Korea. The microbial communities associated with PM were strongly influenced by atmospheric conditions. Proteobacteria (range from 4.6 to 76.7%) and Firmicutes (range from 6.0 to 91.4%) were the most dominant phyla and were significantly affected by changes in the PM2.5 environment. The results indicate that the acidity of precipitation and the composition of aerosols were affected by fossil fuel combustion and mineral dust, and that atmospheric conditions may change as PM2.5 concentrations increase.

Current management and clinical outcomes for patients with haemorrhagic shock due to pelvic fracture in Korean regional trauma centres: A multi-institutional trial.

INTRODUCTION: The purpose of this study was to evaluate the current management and clinical outcomes in patients with hemodynamic instability due to pelvic fracture in three regional trauma centres in Korea. PATIENTS AND METHODS: Three regional trauma centres participated in this study, and 157 patients who were admitted between January 2015 and December 2018 were enroled. Clinical data were collected prospectively as part of the Korean trauma data bank and were analysed retrospectively. RESULTS: The mean age was 59.3 years, and 107 of 157 (68.2%) were male patients. The most common cause of injury was auto-pedestrian accidents, followed by falls and motor vehicle crashes. The mean admission systolic blood pressure and serum lactate level were 86.7 mmHg and 6.68 mmol/L, respectively. Twenty-four patients (15.3%) had a cardiac arrest in the emergency department (ED). The mean injury severity score was 39.1, and the mean probability of survival (Trauma and Injury Severity Score) was 48.7%. Sixty-six patients (42%) underwent pelvic angiography; 89 (56.7%), preperitoneal pelvic packing (PPP); 27 (17.2%), resuscitative endovascular balloon occlusion of the aorta (REBOA); 20 (12.7%), pelvic external fixation (PEF); and 13 patients (8.3%), internal iliac artery ligation (IIAL). Seventy-three patients (46.5%) died, including 40 (25.5%) who died from acute haemorrhage. With each year, the rates of REBOA and pelvic binder use continued to increase (p<0.001 and p = 0.005, respectively), but the number of PEF cases significantly decreased (p = 0.006). Age, initial lactate, low revised trauma score (RTS), combined abdominal injury, REBOA, and 4-hour requirement of packed red blood cells were independent risk factors associated with mortality, whereas during the period of 2017 and 2018, there were protective factors. The risk factors of mortality due to haemorrhage were cardiac arrest in the ED, RTS, combined chest and abdominal injuries, and IIAL. CONCLUSIONS: Since the establishment of regional trauma centres, the clinical outcomes of patients with hemodynamic instability due to pelvic fracture have significantly improved. As a haemostatic procedure for these patients, PEF has been used less frequently, while pelvic binder and REBOA showed significant increase in their use.

Laparoscopic repair of combined extra- and intraperitoneal bladder ruptures in a patient with blunt trauma: Use of the bladder suspension method.

Urinary bladder rupture is commonly due to blunt abdominal trauma rather than penetrating trauma. Intraperitoneal bladder rupture (IBR) is a concrete indication of surgical management. On the other hand, surgeons should perform surgeries in patients with extraperitoneal bladder rupture (EBR) solely in complicated cases. Uncomplicated EBR is managed conservatively. Laparoscopic repair is safe and effective for the treatment of IBR. However, there are no contemporary guidelines on the application of laparoscopy for the management of EBR. Herein, we describe a case of combined EBR and IBR in a hemodynamically stable 45-year-old patient who sustained injuries after falling. Intravesical repair of EBR and intracorporeal repair of IBR with the bladder suspension method were successfully performed with laparoscopy. This is a rare case describing the feasibility of laparoscopic suturing for combined EBR and IBR in a patient with blunt trauma.

Characterization of Martelella soudanensis sp. nov., Isolated from a Mine Sediment.

Gram-stain-negative, strictly aerobic, non-spore-forming, non-motile, and rod-shaped bacterial strains, designated NC18T and NC20, were isolated from the sediment near-vertical borehole effluent originating 714 m below the subsurface located in the Soudan Iron Mine in Minnesota, USA. The 16S rRNA gene sequence showed that strains NC18T and NC20 grouped with members of the genus Martelella, including M. mediterranea DSM 17316T and M. limonii YC7034T. The genome sizes and G + C content of both NC18T and NC20 were 6.1 Mb and 61.8 mol%, respectively. Average nucleotide identity (ANI), the average amino acid identity (AAI), and digital DNA-DNA hybridization (dDDH) values were below the species delineation threshold. Pan-genomic analysis showed that NC18T, NC20, M. mediterranea DSM 17316T, M. endophytica YC6887T, and M. lutilitoris GH2-6T had 8470 pan-genome orthologous groups (POGs) in total. Five Martelella strains shared 2258 POG core, which were mainly associated with amino acid transport and metabolism, general function prediction only, carbohydrate transport and metabolism, translation, ribosomal structure and biogenesis, and transcription. The two novel strains had major fatty acids (>5%) including summed feature 8 (C18:1 ω7c and/or C18:1 ω6c), C19:0 cyclo ω8c, C16:0, C18:1 ω7c 11-methyl, C18:0, and summed feature 2 (C12:0 aldehyde and/or iso-C16:1 I and/or C14:0 3-OH). The sole respiratory quinone was uniquinone-10 (Q-10). On the basis of polyphasic taxonomic analyses, strains NC18T and NC20 represent novel species of the genus Martelella, for which the name Martelella soudanensis sp. nov. is proposed. The type strain is NC18T (=KTCT 82174T = NBRC 114661T).

Unusual airway obstruction due to thoracic duct injury after whiplash injury.

Traumatic chylothorax is a rare condition following blunt trauma. Although a chyle leak resulting from direct damage to the duct may occur at any level because of an anatomical variation, an airway obstruction due to thoracic duct injury after blunt trauma has never been described. Here, we report a very unusual case with airway obstruction due to thoracic duct injury after whiplash injury. A 60-year-old man presented to the emergency department with allodynia after blunt trauma. Initial chest computed tomography (CT) showed a prevertebral hematoma and pneumomediastinum from C2 to T3 spinal level without vertebral fracture. Seven days later, repeat CT showed an increased amount of mediastinal and prevertebral fluid collection extending to the upper neck level with airway compression. He underwent an operation to drain the fluid via a neck incision and a thoracic duct ligation via right thoracotomy and was discharged without complaint. The findings suggest that if hematoma and pneumomediastinum are found in the prevertebral space at the level of the cervical and upper thoracic spine, the patient should be closely observed to exclude the complication of airway obstruction caused by thoracic duct injury.

Orphan nuclear receptor ERR-γ regulates hepatic FGF23 production in acute kidney injury.

Fibroblast growth factor 23 (FGF23), a hormone generally derived from bone, is important in phosphate and vitamin D homeostasis. In acute kidney injury (AKI) patients, high-circulating FGF23 levels are associated with disease progression and mortality. However, the organ and cell type of FGF23 production in AKI and the molecular mechanism of its excessive production are still unidentified. For insight, we investigated folic acid (FA)-induced AKI in mice. Interestingly, simultaneous with FGF23, orphan nuclear receptor ERR-γ expression is increased in the liver of FA-treated mice, and ectopic overexpression of ERR-γ was sufficient to induce hepatic FGF23 production. In patients and in mice, AKI is accompanied by up-regulated systemic IL-6, which was previously identified as an upstream regulator of ERR-γ expression in the liver. Administration of IL-6 neutralizing antibody to FA-treated mice or of recombinant IL-6 to healthy mice confirms IL-6 as an upstream regulator of hepatic ERR-γ-mediated FGF23 production. A significant (P < 0.001) interconnection between high IL-6 and FGF23 levels as a predictor of AKI in patients that underwent cardiac surgery was also found, suggesting the clinical relevance of the finding. Finally, liver-specific depletion of ERR-γ or treatment with an inverse ERR-γ agonist decreased hepatic FGF23 expression and plasma FGF23 levels in mice with FA-induced AKI. Thus, inverse agonist of ERR-γ may represent a therapeutic strategy to reduce adverse plasma FGF23 levels in AKI.

Comparison of the effects of shortening rest intervals on the quality of cardiopulmonary resuscitation, physiological parameters, and hemodynamic parameters in well-trained rescuers: Randomized simulation study.

BACKGROUND: Cardiopulmonary resuscitation (CPR) performance depends on individual ability and training. Well-trained or professional rescuers can maintain high-quality CPR for longer than laypeople. This study aimed to examine the effects of reducing resting intervals on CPR performance, physiological parameters, and hemodynamic parameters during prolonged CPR in well-trained providers. METHODS: The study enrolled 90 volunteers from the paramedic students of our institution. They were randomly divided into 3 groups: 2 minutes, 1 minute 45 seconds, and 1 minute 30 seconds rest groups. Each participant performed 5 cycles of chest compression only CPR (2 min/cycle) with different resting intervals according to grouping. CPR quality, physiological variations, and hemodynamic variations were measured for each cycle and compared across the groups. RESULTS: Of the 90 volunteers, 79 well-trained providers were finally included. The variation of the average chest compression depth across the 5 cycles showed significant differences between the 3 groups: from cycle 1 to 2: 1.2 (3.1) mm, -0.8 (2.0) mm, and -2.0 (3.0) mm in the 2 minutes, 1 minute 45 seconds, and 1 minute 30 seconds groups, respectively (P < .001); from cycle 1 to 3: 0.0 (3.0) mm, -0.7 (3.2) mm, and -2.6 (3.9) mm, respectively (P = .030). However, all 3 groups maintained the recommended rate and chest compression depth for all 5 cycles. Physiological and hemodynamic parameters showed no significant differences between the groups. CONCLUSIONS: Well-trained providers were able to maintain high-quality CPR despite reducing rest intervals. Adjusting the rest interval may help maintain overall CPR quality in special situations or where layperson rescuers are involved.

A course on endovascular training for resuscitative endovascular balloon occlusion of the aorta: a pilot study for residents and specialists.

PURPOSE: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as a salvage technique changing the paradigm in the management of noncompressible torso hemorrhage. However, training for the REBOA procedure is rarely performed. The endovascular training for REBOA (ET-REBOA) course was conducted to develop the endovascular skills of participants. METHODS: Sixteen residents and 12 specialists participated in this educational course. All participants were provided with precourse learning materials. The ET-REBOA course consisted of 2 sections; an ultrasound-guided sheath insertion on the puncture model, and a balloon manipulation on the vascular circuit model. A 13-item procedure checklist and the time required to perform the procedure were examined. Pre/post self-reported confidence score and course satisfaction questionnaire were obtained. RESULTS: Twenty-eight participants performed the 56 REBOA procedures. On the first attempt, the median total time for REBOA from ultrasound-guided vascular access to balloon inflation was 1,139 ± 250 seconds in the resident group and 828 ± 280 seconds in the specialist group. The median shortened time for completion was 273 seconds and 290 seconds respectively. A significant decrease in procedure task time was observed between first and second attempts in the resident group (P = 0.016), specialist group (P = 0.004), and in total among all participants (P < 0.001). CONCLUSION: The ET-REBOA course significantly decreased the time taken to perform the REBOA procedure with high satisfaction of the participants. The course could be an effective curriculum for the development of endovascular skills for performing REBOA.