Association of Early Dexmedetomidine Utilization With Clinical and Functional Outcomes Following Moderate-Severe Traumatic Brain Injury: A Transforming Clinical Research and Knowledge in Traumatic Brain Injury Study

OBJECTIVE

To examine early sedation patterns, as well as the association of dexmedetomidine exposure, with clinical and functional outcomes among mechanically ventilated patients with moderate-severe traumatic brain injury (msTBI).

DESIGN

Retrospective cohort study with prospectively collected data.

SETTING

Eighteen Level-1 Trauma Centers, United States.

PATIENTS

Adult (age > 17) patients with msTBI (as defined by Glasgow Coma Scale < 13) who required mechanical ventilation from the Transforming Clinical Research and Knowledge in TBI (TRACK-TBI) study.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Using propensity-weighted models, we examined the association of early dexmedetomidine exposure (within the first 5 d of ICU admission) with the primary outcome of 6-month Glasgow Outcomes Scale Extended (GOS-E) and the following secondary outcomes: length of hospital stay, hospital mortality, 6-month Disability Rating Scale (DRS), and 6-month mortality. The study population included 352 subjects who required mechanical ventilation within 24 hours of admission. The initial sedative medication was propofol for 240 patients (68%), midazolam for 59 patients (17%), ketamine for 6 patients (2%), dexmedetomidine for 3 patients (1%), and 43 patients (12%) never received continuous sedation. Early dexmedetomidine was administered in 77 of the patients (22%), usually as a second-line agent. Compared with unexposed patients, early dexmedetomidine exposure was not associated with better 6-month GOS-E (weighted odds ratio [OR] = 1.48; 95% CI, 0.98-2.25). Early dexmedetomidine exposure was associated with lower DRS (weighted OR = -3.04; 95% CI, -5.88 to -0.21). In patients requiring ICP monitoring within the first 24 hours of admission, early dexmedetomidine exposure was associated with higher 6-month GOS-E score (OR 2.17; 95% CI, 1.24-3.80), lower DRS score (adjusted mean difference, -5.81; 95% CI, -9.38 to 2.25), and reduced length of hospital stay (hazard ratio = 1.50; 95% CI, 1.02-2.20).

CONCLUSION

Variation exists in early sedation choice among mechanically ventilated patients with msTBI. Early dexmedetomidine exposure was not associated with improved 6-month functional outcomes in the entire population, although may have clinical benefit in patients with indications for ICP monitoring.

Association of Early Beta-Blocker Exposure and Functional Outcomes in Critically Ill Patients With Moderate to Severe Traumatic Brain Injury: A Transforming Clinical Research and Knowledge in Traumatic Brain Injury Study

OBJECTIVES

We aimed to 1) describe patterns of beta-blocker utilization among critically ill patients following moderate-severe traumatic brain injury (TBI) and 2) examine the association of early beta-blocker exposure with functional and clinical outcomes following injury.

DESIGN

Retrospective cohort study.

SETTING

ICUs at 18 level I, U.S. trauma centers in the Transforming Clinical Research and Knowledge in TBI (TRACK-TBI) study.

PATIENTS

Greater than or equal to 17 years enrolled in the TRACK-TBI study with moderate-severe TBI (Glasgow Coma Scale of <13) were admitted to the ICU after a blunt TBI.

INTERVENTIONS

None.

MEASUREMENTS

Primary exposure was a beta blocker during the first 7 days in the ICU, with a primary outcome of 6-month Glasgow Outcome Scale-Extended (GOSE). Secondary outcomes included: length of hospital stay, in-hospital mortality, 6-month and 12-month mortality, 12-month GOSE score, and 6-month and 12-month measures of disability, well-being, quality of life, and life satisfaction.

MAIN RESULTS

Of the 450 eligible participants, 57 (13%) received early beta blockers (BB+ group). The BB+ group was on average older, more likely to be on a preinjury beta blocker, and more likely to have a history of hypertension. In the BB+ group, 34 participants (60%) received metoprolol only, 19 participants (33%) received propranolol only, 3 participants (5%) received both, and 1 participant (2%) received atenolol only. In multivariable regression, there was no difference in the odds of a higher GOSE score at 6 months between the BB+ group and BB- group (odds ratio = 0.86; 95% CI, 0.48-1.53). There was no association between BB exposure and secondary outcomes.

CONCLUSIONS

About one-sixth of subjects in our study received early beta blockers, and within this group, dose, and timing of beta-blocker administration varied substantially. No significant differences in GOSE score at 6 months were demonstrated, although our ability to draw conclusions is limited by overall low total doses administered compared with prior studies.

Umbilical Cord-derived Mesenchymal Stem Cells for COVID-19 Patients with Acute Respiratory Distress Syndrome (ARDS)

The coronavirus SARS-CoV-2 is cause of a global pandemic of a pneumonia-like disease termed Coronavirus Disease 2019 (COVID-19). COVID-19 presents a high mortality rate, estimated at 3.4%. More than 1 out of 4 hospitalized COVID-19 patients require admission to an Intensive Care Unit (ICU) for respiratory support, and a large proportion of these ICU-COVID-19 patients, between 17% and 46%, have died. In these patients COVID-19 infection causes an inflammatory response in the lungs that can progress to inflammation with cytokine storm, Acute Lung Injury (ALI), Acute Respiratory Distress Syndrome (ARDS), thromboembolic events, disseminated intravascular coagulation, organ failure, and death. Mesenchymal Stem Cells (MSCs) are potent immunomodulatory cells that recognize sites of injury, limit effector T cell reactions, and positively modulate regulatory cell populations. MSCs also stimulate local tissue regeneration via paracrine effects inducing angiogenic, anti-fibrotic and remodeling responses. MSCs can be derived in large number from the Umbilical Cord (UC). UC-MSCs, utilized in the allogeneic setting, have demonstrated safety and efficacy in clinical trials for a number of disease conditions including inflammatory and immune-based diseases. UC-MSCs have been shown to inhibit inflammation and fibrosis in the lungs and have been utilized to treat patients with severe COVID-19 in pilot, uncontrolled clinical trials, that reported promising results. UC-MSCs processed at our facility have been authorized by the FDA for clinical trials in patients with an Alzheimer's Disease, and in patients with Type 1 Diabetes (T1D). We hypothesize that UC-MSC will also exert beneficial therapeutic effects in COVID-19 patients with cytokine storm and ARDS. We propose an early phase controlled, randomized clinical trial in COVID-19 patients with ALI/ARDS. Subjects in the treatment group will be treated with two doses of UC-MSC (l00 × 10⁶ cells). The first dose will be infused within 24 hours following study enrollment. A second dose will be administered 72 ± 6 hours after the first infusion. Subject in the control group will receive infusion of vehicle (DPBS supplemented with 1% HSA and 70 U/kg unfractionated Heparin, delivered IV) following the same timeline. Subjects will be evaluated daily during the first 6 days, then at 14, 28, 60, and 90 days following enrollment (see Schedule of Assessment for time window details). Safety will be determined by adverse events (AEs) and serious adverse events (SAEs) during the follow-up period. Efficacy will be defined by clinical outcomes, as well as a variety of pulmonary, biochemical and immunological tests. Success of the current study will provide a framework for larger controlled, randomized clinical trials and a means of accelerating a possible solution for this urgent but unmet medical need. The proposed early phase clinical trial will be performed at the University of Miami (UM), in the facilities of the Diabetes Research Institute (DRI), UHealth Intensive Care Unit (ICU) and the Clinical Translational Research Site (CTRS) at the University of Miami Miller School of Medicine and at the Jackson Memorial Hospital (JMH).

Implementing a declination form programme to improve influenza vaccine uptake by staff in Department of Veterans Affairs spinal cord injury centres: a pilot study

BACKGROUND

Individuals with spinal cord injuries and disorders are at high risk for respiratory and influenza-related complications after developing influenza. These individuals often have frequent contact with the healthcare system. Vaccination rates in healthcare workers at Department of Veterans Affairs (VA) spinal cord injury (SCI) centres have been approximately 50% for several years. Efforts are needed to increase vaccination uptake among SCI HCWs. Declination form programmes (DFPs) in combination with other strategies have resulted in significant increases in influenza vaccination uptake in HCWs.

AIM

Use of external and internal facilitation including local teams and consensus processes to pilot a DFP in two VA SCI centres and evaluate factors influencing implementation.

METHODS

Implementation meetings and a consensus-building process with leadership and implementation team members were conducted, along with semi-structured post-implementation interviews with members of each implementation team (N = 7).

FINDINGS

The DFP was well accepted and easy to use. Leadership was a key facilitator for DFP implementation. Barriers included difficulty communicating with HCWs working during early/late shifts. Participation was 100% at Site 1 and 48% at Site 2.

CONCLUSION

Use of local teams and consensus to identify strategies to implement a DFP is feasible and effective for achieving moderate-to-high levels of participation in the programme.

Noise analysis and performance comparison of low current measurement systems for biomedical applications

In this paper, we report on the noise analysis of low current measurement systems for biomedical applications and their fundamental limits. We analyzed resistive feedback, capacitive feedback and current amplifier circuits for low current measurement systems. Detailed noise analysis for different biomedical applications are presented and matched with measurement data using a 0.5-μm fabrication process. Based on the theoretical analysis and the corresponding measurement results, the capacitive feedback system provides better noise performance for the measurement of low current than the others. The capacitive feedback circuit is capable of measuring 750 fA RMS at a 10 kHz sampling rate, whereas the resistive feedback provides 4 pA and the current conveyor provides 600 pA at the same bandwidth. This paper provides design guidelines to maximize the performance of low current measuring system for biomedical instrumentation and to provide the best performance available with CMOS technologies.

The Child Behavior Checklist (CBCL) and the CBCL-bipolar phenotype are not useful in diagnosing pediatric bipolar disorder

OBJECTIVES

Previous studies have suggested that the sum of Attention, Aggression, and Anxious/Depressed subscales of Child Behavior Checklist (CBCL-PBD; pediatric bipolar disorder phenotype) may be specific to pediatric bipolar disorder (BP). The purpose of this study was to evaluate the usefulness of the CBCL and CBCL-PBD to identify BP in children <12 years old.

METHODS

A sample of children with BP I, II, and not otherwise specified (NOS) (n = 157) ascertained through the Course and Outcome for Bipolar Disorder in Youth (COBY) study were compared with a group of children with major depressive/anxiety disorders (MDD/ANX; n = 101), disruptive behavior disorder (DBD) (n = 127), and healthy control (HC) (n = 128). The CBCL T-scores and area under the curve (AUC) scores were calculated and compared among the above-noted groups.

RESULTS

Forty one percent of BP children did not have significantly elevated CBCL-PBD scores (>or=2 standard deviations [SD]). The sensitivity and specificity of CBCL-PBD >or= 2 SD for diagnosis of BP was 57% and 70-77%, respectively, and the accuracy of CBCL-PBD for identifying a BP diagnosis was moderate (AUC = 0.72-0.78).

CONCLUSION

The CBCL and the CBCL-PBD showed that BP children have more severe psychopathology than HC and children with other psychopathology, but they were not useful as a proxy for Diagnostic and Statistical Manual of Mental Disorders, 4(th) edition (DSM-IV) diagnosis of BP.

A phase II, multicenter trial of weekly topotecan in patients with recurrent platinum-sensitive epithelial cancers of the ovary and peritoneum

The purpose of this study was to evaluate the response rate and toxicity of weekly topotecan in patients with recurrent platinum-sensitive epithelial cancers of the ovary and peritoneum. Thirty-nine platinum-sensitive recurrent ovarian cancer patients received topotecan (4 mg/m2) intravenously day 1, day 8, day 15, every 28 days. Colony-stimulating factors were excluded from the study. Clinical response was assessed by clinical, serologic, and radiographic measures at the conclusion of cycle four. Patients received 136 cycles of topotecan (median = 3; range 1–6) and were evaluated for response and toxicity. Median number of prior regimens was one. Grade 3/4 neutropenia developed in 3 (7.7%) patients. Grade 3 thrombocytopenia was seen in one (2.6%) patient, with no incidence of grade 4 thrombocytopenia. There was no evidence of grade 3 anemia, but one patient (2.6%) was associated with grade 4 anemia. There was no grade 3 or 4 neuropathy. We encountered 18 dose reductions following less than or equal to grade 2 myelosuppression, necessitating the removal of eight (20.5%) patients prior to cycle four. Twenty-one (53.8%) patients were removed from the study due to disease progression. Following the completion of cycle four, four (10.3%) patients demonstrated stable disease and four (10.3%) patients exhibited a partial response. There were no complete responses. Median disease-free survival was 12 weeks. Weekly topotecan (4 mg/m2) demonstrated modest activity and was moderately well tolerated. However, the significant number of dose reductions and high incidence of patients who demonstrated disease progression suggests additional modifications with this specific regimen are necessary.

Power spectral density estimation and tracking nonstationary pressure signals based on Kalman filtering

We describe an algorithm to estimate and track slow changes in power spectral density (PSD) of nonstationary pressure signals. The algorithm is based on a Kalman filter that adaptively generates an estimate of the autoregressive model parameters at each time instant. The algorithm exhibits superior PSD tracking performance in nonstationary pressure signals than classical nonparametric methodologies, and does not assume a piecewise stationary model of the data. Furthermore, it provides better time-frequency resolution, and is robust to model mismatches. We demonstrate its usefulness by a sample application involving PSD estimation and tracking of short records of simulated pressure waveforms. This algorithm is intended for applications were the PSD must be estimated and tracked during short transient periods, possibly after clinical interventions.

Calibrating an intracranial pressure dynamics model with clinical data - a progress report

We describe the calibration of a computer model of intracranial pressure (ICP) dynamics to correspond with annotated clinical data taken from a patient being treated for elevated ICP due to a traumatic brain injury. The research protocol employed during treatment includes adjusting the elevation of the head of the bed, adjusting the ventilator settings to induce mild hyperventilation and hypoventilation, and adjusting the height of the cerebrospinal fluid drainage system. The model behavior corresponds to the experimental data quite well in the case of the changing the head of the bed, but less well in the case of changing the ventilator settings.

A novel statistical model for simulation of arterial and intracranial pressure

We describe a novel statistical model of pressure signals that incorporates the effects of respiration on arterial (ABP) and intracranial pressure (ICP). This model can be used to synthesize pulsatile ABP and ICP signals with similar time, frequency, and variability characteristics of real pressure signals. These synthetic signals can be used during the development, simulation, or quantitative assessment of biomedical algorithms in a variety of applications.

Mechanical vasoconstriction for a cerebral myogenic autoregulatory model

This work presents the design of a mechanical vasoconstriction mechanism with application for cerebral autoregulation. The relationship between the applied voltage of a DC motor and the tension within a pressurized vessel wall was utilized for constricting an arteriole segment within an intracranial vascular model. Using current proportional to the string tension, options for closed loop feedback control are considered.

Combinatorial complexity and dynamical restriction of network flows in signal transduction

The activities and interactions of proteins that govern the cellular response to a signal generate a multitude of protein phosphorylation states and heterogeneous protein complexes. Here, using a computational model that accounts for 307 molecular species implied by specified interactions of four proteins involved in signalling by the immunoreceptor FcepsilonRI, we determine the relative importance of molecular species that can be generated during signalling, chemical transitions among these species, and reaction paths that lead to activation of the protein tyrosine kinase (PTK) Syk. By all of these measures and over two- and ten-fold ranges of model parameters--rate constants and initial concentrations--only a small portion of the biochemical network is active. The spectrum of active complexes, however, can be shifted dramatically, even by a change in the concentration of a single protein, which suggests that the network can produce qualitatively different responses under different cellular conditions and in response to different inputs. Reduced models that reproduce predictions of the full model for a particular set of parameters lose their predictive capacity when parameters are varied over two-fold ranges.

Pulse and mean intracranial pressure analysis in pediatric traumatic brain injury

OBJECTIVE

We investigated the relationship between the intracranial pulse pressure (ICPpp) and the mean intracranial pressure (ICP(M)) in pediatric patients with traumatic brain injury (TBI).

METHODS

We screened ICP records of 42 patients admitted to the Pediatric Intensive Care Unit at Doernbecher Children's Hospital (OHSU) for segments in which the ICPM varied at least 5 mmHg. We found 54 ICP segments in 9 pediatric TBI patients (ages 0.2-17.8 years, mean = 9.9). ICP was continuously monitored (fs = 125 Hz). We used an automatic algorithm to detect ICP beat components. We then calculated the ICPpp and ICPM for each beat and created density plots of ICPpp vs. ICPM.

RESULTS

The coefficient of linear correlation was r > 0.70 in 43/54 segments (p < 0.01). We found that an underlying linear relationship exits between ICPpp and ICPM in most 1-hour records of pediatric patients with TBI. This finding is consistent with the data in adult studies, suggesting that children with TBI demonstrate similar changes in brain compliance. However, density plots revealed that there are also nonlinear ICPpp-ICPM patterns present that are not captured by linear metrics.

CONCLUSION

Although there is an underlying linear relationship between ICPpp and ICPM, nonlinear patterns are also present. Further research is required to determine if specific nonlinear ICPpp-ICPM patterns correlate with clinically significant information.

A computer model of intracranial pressure dynamics during traumatic brain injury that explicitly models fluid flows and volumes

A model of intracranial pressure (ICP) dynamics that uses fluid volumes as primary state variables is presented, along with clinical data for two subjects with elevated ICP. The data includes annotations to indicate the precise timing of clinical changes in cerebral spinal fluid drainage, head of bed elevation, and minute ventilation. The response to changes in the clinical parameters was used to calibrate the model to correspond to specific subjects by estimating values for key characteristics such as hematoma volume and CSF uptake resistance. The error in mean ICP predicted by the model was less than 2 mmHg when cerebral spinal fluid is drained and the head of bed elevation was increased. The error in mean ICP predicted by the model exceeded 5 mmHg during an episode when the head of bed was decreased and also during a reduction in minute ventilation. The estimated values for hematoma volume and other subject characteristics were plausible but could not be verified empirically.

On the evolution of early development in the Nematoda

The phylum Nematoda serves as an excellent model system for exploring how development evolves, using a comparative approach to developmental genetics. More than 100 laboratories are studying developmental mechanisms in the nematode Caenorhabditis elegans, and many of the methods that have been developed for C. elegans can be applied to other nematodes. This review summarizes what is known so far about steps in early development that have evolved in the nematodes, and proposes potential experiments that could make use of these data to further our understanding of how development evolves. The promise of such a comparative approach to developmental genetics is to fill a wide gap in our understanding of evolution--a gap spanning from mutations in developmental genes through to their phenotypic results, on which natural selection may act.

Uncoupling and recoupling of autonomic regulation of the heart beat in pediatric septic shock

Healthy physiological systems exhibit marked signal variability and complexity, whereas diseased systems generally show a loss of variability, decreased complexity ("decomplexification"), and increased regularity. The goal of this study was to evaluate the uncoupling and recoupling phenomenon in children with septic shock by observing serial changes in heart rate variability metrics. Data were collected from 7 children with septic shock by using the computer system in the Complex Systems Laboratory at Oregon Health Sciences University. Heart rate time series were constructed and analyzed by using the Hales Research System at intervals of 6 h during pediatric intensive care unit (PICU) hospitalization. These power spectral values were then plotted vs. time. Six of seven patients showed an increase over time in low-frequency heart rate power and the low-/high-frequency ratio, whereas high-frequency heart rate power decreased. We also compared the change in mean heart rate, heart rate standard deviation, and power spectral values during the first 24 h of PICU hospitalization vs. the remainder of the PICU stay (for the 5 patients with a PICU length of stay > 48 h). Compared to the initial 24 h in the PICU, low-frequency power and the low-/high-frequency ratio increased, whereas high-frequency power decreased over the course of the illness. This report shows the potential value of monitoring the uncoupling and recoupling phenomenon in patients with septic shock. Our results are in agreement with other investigators who report evidence of decomplexification both in experimental models of sepsis and in clinical studies and provide direction for further work.

Computer-assisted learning in critical care: from ENIAC to HAL

Computers are commonly used to serve many functions in today's modern intensive care unit. One of the most intriguing and perhaps most challenging applications of computers has been to attempt to improve medical education. With the introduction of the first computer, medical educators began looking for ways to incorporate their use into the modern curriculum. Prior limitations of cost and complexity of computers have consistently decreased since their introduction, making it increasingly feasible to incorporate computers into medical education. Simultaneously, the capabilities and capacities of computers have increased. Combining the computer with other modern digital technology has allowed the development of more intricate and realistic educational tools. The purpose of this article is to briefly describe the history and use of computers in medical education with special reference to critical care medicine. In addition, we will examine the role of computers in teaching and learning and discuss the types of interaction between the computer user and the computer.

Dorsal and snail homologs in leech development

As part of an examination of how developmental mechanisms such as axis specification, cell fate specification, and segmentation have evolved, we have cloned homologs of the Drosophila melanogaster genes dorsal and snail from the glossiphoniid leech Helobdella robusta. Sequences from one dorsal-class gene (Hro-dl) and two snail-class genes (Hro-sna1 and Hro-sna2) were identified. Polyclonal antibodies were raised against the most conserved domains of HRO-DL and HRO-SNA1. Nuclear staining appeared for both proteins in mid-embryogenesis, in mesodermal and ectodermal precursors. During segmentation, segmentally iterated stripes of cells with strong HRO-DL staining appeared. The stripes of HRO-DL staining were first concentrated in the cytoplasm of cells, and later in the nuclei. Around this time, HRO-SNA levels also appeared in nuclei in segmentally iterated stripes. The localization of HRO-DL and HRO-SNA proteins raise the possibility that these genes are part of a conserved genetic pathway that, instead of specifying the dorsoventral axis and the mesoderm as in flies, might play a role in the diversification of cell types within segment primordia during leech development.

Kinetic proofreading models for cell signaling predict ways to escape kinetic proofreading

In the context of cell signaling, kinetic proofreading was introduced to explain how cells can discriminate among ligands based on a kinetic parameter, the ligand-receptor dissociation rate constant. In the kinetic proofreading model of cell signaling, responses occur only when a bound receptor undergoes a complete series of modifications. If the ligand dissociates prematurely, the receptor returns to its basal state and signaling is frustrated. We extend the model to deal with systems where aggregation of receptors is essential to signal transduction, and present a version of the model for systems where signaling depends on an extrinsic kinase. We also investigate the kinetics of signaling molecules, "messengers," that are generated by aggregated receptors but do not remain associated with the receptor complex. We show that the extended model predicts modes of signaling that exhibit kinetic discrimination for some range of parameters but for other parameter values show little or no discrimination and thus escape kinetic proofreading. We compare model predictions with experimental data.

Anatomy of the peripheral nervous system

This article is an overview of the structure and components of the peripheral nervous system. The fine structure and gross anatomy of peripheral nerves and ganglia are described. A functional and regional approach is used to highlight principles on which the peripheral nervous system is designed. Finally, the somatic and autonomic nervous systems are contrasted to underscore similarities between the two systems.

Appointment scheduling system: a vehicle for increased productivity

Operations management is the design and control of systems responsible for the productive use of human resources, equipment, and facilities in the development of a product or service. Applying those concepts to appointment scheduling can coordinate efficient use of resources. The focus of this paper is to assist the dentist and dental team in creating an appointment scheduling system that maximizes productivity and profitability.

Calculations show substantial serial engagement of T cell receptors

The serial engagement model provides an attractive and plausible explanation for how a typical antigen presenting cell, exhibiting a low density of peptides recognized by a T cell, can initiate T cell responses. If a single peptide displayed by a major histocompatibility complex (MHC) can bind, sequentially, to different T cell receptors (TCR), then a few peptides can activate many receptors. To date, arguments supporting and questioning the prevalence of serial engagement have centered on the down-regulation of TCR after contact of T cells with antigen presenting cells. Recently, the existence of serial engagement has been challenged by the demonstration that engagement of TCR can down-regulate nonengaged bystander TCR. Here we show that for binding and dissociation rates that characterize interactions between T cell receptors and peptide-MHC, substantial serial engagement occurs. The result is independent of mechanisms and measurements of receptor down-regulation. The conclusion that single peptide-MHC engage many TCR, before diffusing out of the contact region between the antigen-presenting cell and the T cell, is based on a general first passage time calculation for a particle alternating between states in which different diffusion coefficients govern its transport.

Embryonic polarity: a role for microtubules

Researchers have suspected that initial polarization of the Caenorhabditis elegans embryo might be directed by microtubules, but demonstrating this has faced obstacles. A new study has cleverly bypassed these obstacles.