Stress exposure histories revealed by biochemical changes along accentuated lines in teeth

The regular incremental secretion of enamel and dentine can be interrupted during periods of stress resulting in accentuated growth lines. These accentuated lines, visible under light microscopy, provide a chronology of an individual's stress exposure. Previously, we showed that small biochemical changes along accentuated growth lines detected by Raman spectroscopy, coincided with the timing of medical history events and disruptions of weight trajectory in teeth from captive macaques. Here, we translate those techniques to study biochemical changes related to illness and prolonged medical treatment during early infancy in humans. Chemometric analysis revealed biochemical changes related to known stress-induced changes in circulating phenylalanine as well as other biomolecules. Changes in phenylalanine are also known to affect biomineralization which is reflected in changes in the wavenumbers of hydroxyapatite phosphate bands associated with stress in the crystal lattice. Raman spectroscopy mapping of teeth is an objective, minimally-destructive technique that can aid in the reconstruction of an individual's stress response history and provide important information on the mixture of circulating biochemicals associated with medical conditions, as applied in epidemiological and clinical samples.

Effect of Family Presence on Advanced Trauma Life Support Task Performance During Pediatric Trauma Team Evaluation

IMPORTANCE

In many hospitals, family members are separated from their children during the early phases of trauma care. Including family members during this phase of trauma care varies by institution and is limited by concerns for adverse effects on clinical care.

OBJECTIVE

The aim of this study is to evaluate the effect of family presence (FP) on advanced trauma life support primary and secondary survey task performance by pediatric trauma teams. We hypothesized that trauma care with FP would be noninferior to care when families were absent.

DESIGN

We performed a retrospective video review of consecutive pediatric trauma evaluations. Family presence status was determined by availability of the family.

SETTING

The study was conducted at an American College of Surgeons-designated level I pediatric trauma center that serves the Washington, DC, metropolitan area.

PARTICIPANTS

Participants included patients younger than 16 years of age who met trauma activation criteria and were evaluated by the trauma team in our emergency department.

OUTCOME MEASURES

We compared task performance between patients with and without FP.

RESULTS

Video recordings of 135 trauma evaluations were reviewed. Family was present for 88 (65%) evaluations. Patients with FP were younger (mean age, 6.4 years [SD = 4.1] vs 9.0 years [SD = 4.9]; P < 0.001) and more likely to have sustained blunt injuries (95% vs 85%, P = 0.03). Noninferiority of frequency and timeliness of completion of all primary survey tasks were confirmed for evaluations with FP. Noninferiority of frequencies of secondary survey task completion was confirmed for most tasks except for examination of the neck, pelvis, and upper extremities. Family members did not directly interfere with patient care in any case.

CONCLUSIONS

Performance of most advanced trauma life support tasks during pediatric trauma evaluation was not worsened by FP. Our data provide additional evidence supporting FP during the acute management of injured children.

Perinatal depression among a global sample of Spanish-speaking women: A sequential-process latent growth-curve analysis

BACKGROUND

Despite high rates of perinatal depression among women from diverse backgrounds, the understanding of the trajectory of depressive symptoms is limited. The aim of this study was to investigate the trajectories of depressive symptoms from pregnancy to postpartum among an international sample of pregnant women.

METHODS

Hispanic/Latina (79.2%), Spanish-speaking (81%) pregnant women (N = 1796; Mean age = 28.32, SD = 5.51) representing 78 unique countries/territories participated in this study. A sequential-process latent growth-curve model was estimated to examine general trajectories of depression as well as risk and protective factors that may impact depression levels throughout both the prenatal and postpartum periods.

RESULTS

Overall, depression levels decreased significantly across the entire perinatal period, but this decrease slowed over time within both the prenatal and postpartum periods. Spanish-speaking women, those who were partnered, and those with no history of depression reported lower levels of depression during early pregnancy, but this buffer effect reduced over time. Depression levels at delivery best predicted postpartum depression trajectories (i.e., women with higher levels of depression at delivery were at greater risk for depression postpartum).

LIMITATIONS

Given the emphasis on language and not country or culture of origin this study was limited in its ability to examine the impact of specific cultural norms and expectations on perinatal depression.

CONCLUSIONS

Given these findings, it is imperative that providers pay attention to, and assess for, depressive symptoms and identified buffers for depression, especially when working with women from diverse communities.

Lipid profiles of prostate cancer cells

Lipids are important cellular components which can be significantly altered in a range of disease states including prostate cancer. Here, a unique systematic approach has been used to define lipid profiles of prostate cancer cell lines, using quantitative mass spectrometry (LC-ESI-MS/MS), FTIR spectroscopy and fluorescent microscopy. All three approaches identified significant difference in the lipid profiles of the three prostate cancer cell lines (DU145, LNCaP and 22RV1) and one non-malignant cell line (PNT1a). Specific lipid classes and species, such as phospholipids (e.g., phosphatidylethanolamine 18:1/16:0 and 18:1/18:1) and cholesteryl esters, detected by LC-ESI-MS/MS, allowed statistical separation of all four prostate cell lines. Lipid mapping by FTIR revealed that variations in these lipid classes could also be detected at a single cell level, however further investigation into this approach would be needed to generate large enough data sets for quantitation. Visualisation by fluorescence microscopy showed striking variations that could be observed in lipid staining patterns between cell lines allowing visual separation of cell lines. In particular, polar lipid staining by a fluorescent marker was observed to increase significantly in prostate cancer lines cells, when compared to PNT1a cells, which was consistent with lipid quantitation by LC-ESI-MS/MS and FTIR spectroscopy. Thus, multiple technologies can be employed to either quantify or visualise changes in lipid composition, and moreover specific lipid profiles could be used to detect and phenotype prostate cancer cells.

Effect of storage temperature on the stability of spray dried bacteriophage powders

This study aimed to assess the robustness of using a spray drying approach and formulation design in producing inhalable phage powders. Two types of Pseudomonas phages, PEV2 (Podovirus) and PEV40 (Myovirus) in two formulations containing different amounts of trehalose (70% and 60%) and leucine (30% and 40%) were studied. Most of the surface of the produced powders was found to be covered in crystalline leucine. The powders were stored at 4 °C and 20 °C under vacuum. The phage stability and in vitro aerosol performance of the phage powders were examined on the day of production and after 1, 3 and 12 months of storage. A minor titer loss during production was observed for both phages (0.2-0.8 log10 pfu/ml). The storage stability of the produced phage powders was found to be phage and formulation dependent. No further reduction in titer occurred for PEV2 powders stored at 4 °C across the study. The formulation containing 30% leucine maintained the viability of PEV2 at 20 °C, while the formulation containing 40% leucine gradually lost titer over time with a storage reduction of ∼0.9 log10 pfu/ml measured after 12 months. In comparison, the PEV40 phage powders generally had a ∼ 0.5 log10 pfu/ml loss upon storage regardless of temperature. When aerosolized, the total in vitro lung doses of PEV2 were of the order of 107 pfu, except the formulation containing 40% leucine stored at 20 °C which had a lower lung dose. The PEV40 powders also had lung doses of 106-107 pfu. The results demonstrate that spray dried Myoviridae and Podoviridae phage in a simple formulation of leucine and trehalose can be successfully stored for one year at 4 °C and 20 °C with vacuum packaging.

Tropoelastin Implants That Accelerate Wound Repair

A novel, pure, synthetic material is presented that promotes the repair of full-thickness skin wounds. The active component is tropoelastin and leverages its ability to promote new blood vessel formation and its cell recruiting properties to accelerate wound repair. Key to the technology is the use of a novel heat-based, stabilized form of human tropoelastin which allows for tunable resorption. This implantable material contributes a tailored insert that can be shaped to the wound bed, where it hydrates to form a conformable protein hydrogel. Significant benefits in the extent of wound healing, dermal repair, and regeneration of mature epithelium in healthy pigs are demonstrated. The implant is compatible with initial co-treatment with full- and split-thickness skin grafts. The implant's superiority to sterile bandaging, commercial hydrogel and dermal regeneration template products is shown. On this basis, a new concept for a prefabricated tissue repair material for point-of-care treatment of open wounds is provided.

Helping Hispanic Dementia Caregivers Cope with Stress Using Technology-based Resources

OBJECTIVES

The objectives of this study were to develop and evaluate a culturally appropriate intervention for Hispanic/Latino caregivers of individuals with dementia, using a structured online program without professional involvement to improve well-being, decrease stress, and reduce depression.

METHODS

The Webnovela Mirela, an online Spanish-language telenovela, was designed specifically to teach caregivers how to cope with dementia caregiving. A prototype of Webnovela Mirela was tested in a pilot study with 25 Hispanic/Latino dementia caregivers, 19 of whom completed the study.

RESULTS

Data were analyzed using paired-samples t-tests. Results indicated a significant decrease from pre- to post-treatment in levels of stress and symptoms of depression (p = .045).

CONCLUSIONS

The pilot study indicated high potential of the Webnovela Mirela to help the target population and demonstrated that the telenovela format is acceptable and helpful for Hispanic dementia caregivers.

CLINICAL IMPLICATIONS

Study outcomes suggested that self-paced approaches with culturally relevant content in an appealing format for the target population have the potential to implement effective interventions. Furthermore, technology enables support programs to reach a broader audience in a cost-effective manner. Of note is the fact that minimal professional and/or personal assistance was required for caregivers to complete this intervention.

Assessment tools for microplastics and natural fibres ingested by fish in an urbanised estuary

Microplastics and fibres occur in high concentrations along urban coastlines, but the occurrence of microplastic ingestion by fishes in these areas requires further investigation. Herein, the ingestion of debris (i.e., synthetic and natural fibres and synthetic fragments of various polymer types) by three benthic-foraging fish species Acanthopagrus australis (yellowfin bream), Mugil cephalus (sea mullet) and Gerres subfasciatus (silverbiddy) in Sydney Harbour, Australia has been quantified and chemically speciated by vibrational spectroscopy to identify the polymer type. Ingested debris were quantified using gut content analysis, and identified using attenuated total reflectance Fourier transform infrared (ATR-FTIR) and Raman microspectroscopies in combination with principal component analysis (PCA). The occurrence of debris ingestion at the time of sampling ranged from 21 to 64% for the three species, and the debris number ranged from 0.2 to 4.6 items per fish for the different species, with ∼53% of debris being microplastic. There was a significant difference in the amount of debris ingested among species; however, there was no difference among species when debris counts were standardised to fish weight or gut content weight, indicating that these species ingest a similar concentration of debris relative to their ingestion rate of other material. ATR-FTIR microspectroscopy successfully identified 72% of debris. Raman spectroscopy contributed an additional 1% of successful identification. In addition, PCA was used to non-subjectively classify the ATR-FTIR spectra resulting in the identification of an additional 9% of the debris. The most common microplastics found were polyester (PET), acrylic-polyester blend, and rayon (semi-synthetic) fibres. The potential of using Raman microspectroscopy for debris identification was investigated and provided additional information about the nature of the debris as well as the presence of specific dyes (and hence potential toxicity).

Unprecedented staining of polar lipids by a luminescent rhenium complex revealed by FTIR microspectroscopy in adipocytes

Fourier transform infrared (FTIR) microspectroscopy and confocal imaging have been used to demonstrate that the neutral rhenium(i) tricarbonyl 1,10-phenanthroline complex bound to 4-cyanophenyltetrazolate as the ancillary ligand is able to localise in regions with high concentrations of polar lipids such as phosphatidylethanolamine (PE), sphingomyelin, sphingosphine and lysophosphatidic acid (LPA) in mammalian adipocytes.

Infrared spectroscopic characterization of monocytic microvesicles (microparticles) released upon lipopolysaccharide stimulation

Microvesicles (MVs) are involved in cell-cell interactions, including disease pathogenesis. Nondestructive Fourier-transform infrared (FTIR) spectra from MVs were assessed as a technique to provide new biochemical insights into a LPS-induced monocyte model of septic shock. FTIR spectroscopy provided a quick method to investigate relative differences in biomolecular content of different MV populations that was complementary to traditional semiquantitative omics approaches, with which it is difficult to provide information on relative changes between classes (proteins, lipids, nucleic acids, carbohydrates) or protein conformations. Time-dependent changes were detected in biomolecular contents of MVs and in the monocytes from which they were released. Differences in phosphatidylcholine and phosphatidylserine contents were observed in MVs released under stimulation, and higher relative concentrations of RNA and α-helical structured proteins were present in stimulated MVs compared with MVs from resting cells. FTIR spectra of stimulated monocytes displayed changes that were consistent with those observed in the corresponding MVs they released. LPS-stimulated monocytes had reduced concentrations of nucleic acids, α-helical structured proteins, and phosphatidylcholine compared with resting monocytes but had an increase in total lipids. FTIR spectra of MV biomolecular content will be important in shedding new light on the mechanisms of MVs and the different roles they play in physiology and disease pathogenesis.-Lee, J., Wen, B., Carter, E. A., Combes, V., Grau, G. E. R., Lay, P. A. Infrared spectroscopic characterization of monocytic microvesicles (microparticles) released upon lipopolysaccharide stimulation.

Effects of storage conditions on the stability of spray dried, inhalable bacteriophage powders

This study aimed to develop inhalable powders containing phages active against antibiotic-resistant Pseudomonas aeruginosa for pulmonary delivery. A Pseudomonas phage, PEV2, was spray dried into powder matrices comprising of trehalose (0-80%), mannitol (0-80%) and l-leucine (20%). The resulting powders were stored at various relative humidity (RH) conditions (0, 22 and 60% RH) at 4°C. The phage stability and in vitro aerosol performance of the phage powders were examined at the time of production and after 1, 3 and 12 months storage. After spray drying, a total of 1.3 log titer reduction in phage was observed in the formulations containing 40%, 60% and 80% trehalose, whereas 2.4 and 5.1 log reductions were noted in the formulations containing 20% and no trehalose, respectively. No further reduction in titer occurred for powders stored at 0 and 22% RH even after 12 months, except the formulation containing no trehalose. The 60% RH storage condition had a destructive effect such that no viable phages were detected after 3 and 12 months. When aerosolised, the total lung doses for formulations containing 40%, 60% and 80% trehalose were similar (in the order of 10⁵ pfu). The results demonstrated that spray drying is a suitable method to produce stable phage powders for pulmonary delivery. A powder matrix containing ≥40% trehalose provided good phage preservation and aerosol performances after storage at 0 and 22% RH at 4°C for 12 months.

Raman spectroscopic analysis of an important Visigothic historiated manuscript

Raman spectroscopy has been used to study fragments of early Visigothic historiated manuscripts from the important mediaeval library at Santo Domingo de Silos which were a part of a Beato dating from the tenth to the mid-eleventh centuries. These fragments are from some of the oldest manuscripts in the scriptorium of the monastery. In this study, a comparison is made between the pigments and inks used on these manuscripts and those used in a previous study of the unique Visigothic Beato de Valcavado in Santa Cruz, Valladolid, completed in the year 970, which is noted for its quality of execution as well as its content and is remarkable eschatologically in being identifiable as the complete work of only a single scribe. For comparative purposes, the pigments and inks used in the Silos Monastery Beato and a series of historiated early manuscripts from mediaeval times through to the Renaissance also held in the monastic library were analysed. Raman spectroscopy identified a range of mineral and organic pigments such as cinnabar, orpiment, minium, azurite and indigo. In addition, a number of admixtures were found, for example, indigo and orpiment to produce vergaut (green) and a mixture of cinnabar with iron-gall ink and cerussite to produce darker and lighter shades of red. Some interesting conclusions were drawn about the use of iron-gall and carbon-based inks.This article is part of the themed issue 'Raman spectroscopy in art and archaeology'.

A Molecular Probe for the Detection of Polar Lipids in Live Cells

Lipids have an important role in many aspects of cell biology, including membrane architecture/compartment formation, intracellular traffic, signalling, hormone regulation, inflammation, energy storage and metabolism. Lipid biology is therefore integrally involved in major human diseases, including metabolic disorders, neurodegenerative diseases, obesity, heart disease, immune disorders and cancers, which commonly display altered lipid transport and metabolism. However, the investigation of these important cellular processes has been limited by the availability of specific tools to visualise lipids in live cells. Here we describe the potential for ReZolve-L1^™ to localise to intracellular compartments containing polar lipids, such as for example sphingomyelin and phosphatidylethanolamine. In live Drosophila fat body tissue from third instar larvae, ReZolve-L1^™ interacted mainly with lipid droplets, including the core region of these organelles. The presence of polar lipids in the core of these lipid droplets was confirmed by Raman mapping and while this was consistent with the distribution of ReZolve-L1^™ it did not exclude that the molecular probe might be detecting other lipid species. In response to complete starvation conditions, ReZolve-L1^™ was detected mainly in Atg8-GFP autophagic compartments, and showed reduced staining in the lipid droplets of fat body cells. The induction of autophagy by Tor inhibition also increased ReZolve-L1^™ detection in autophagic compartments, whereas Atg9 knock down impaired autophagosome formation and altered the distribution of ReZolve-L1^™. Finally, during Drosophila metamorphosis fat body tissues showed increased ReZolve-L1^™ staining in autophagic compartments at two hours post puparium formation, when compared to earlier developmental time points. We concluded that ReZolve-L1^™ is a new live cell imaging tool, which can be used as an imaging reagent for the detection of polar lipids in different intracellular compartments.

Association Between Trauma Center Type and Mortality Among Injured Adolescent Patients

IMPORTANCE

Although data obtained from regional trauma systems demonstrate improved outcomes for children treated at pediatric trauma centers (PTCs) compared with those treated at adult trauma centers (ATCs), differences in mortality have not been consistently observed for adolescents. Because trauma is the leading cause of death and acquired disability among adolescents, it is important to better define differences in outcomes among injured adolescents by using national data.

OBJECTIVES

To use a national data set to compare mortality of injured adolescents treated at ATCs, PTCs, or mixed trauma centers (MTCs) that treat both pediatric and adult trauma patients and to determine the final discharge disposition of survivors at different center types.

DESIGN, SETTING, AND PARTICIPANTS

Data from level I and II trauma centers participating in the 2010 National Trauma Data Bank (January 1 to December 31, 2010) were used to create multilevel models accounting for center-specific effects to evaluate the association of center characteristics (PTC, ATC, or MTC) on mortality among patients aged 15 to 19 years who were treated for a blunt or penetrating injury. The models controlled for sex; mechanism of injury (blunt vs penetrating); injuries sustained, based on the Abbreviated Injury Scale scores (post-dot values <3 or ≥3 by body region); initial systolic blood pressure; and Glasgow Coma Scale scores. Missing data were managed using multiple imputation, accounting for multilevel data structure. Data analysis was conducted from January 15, 2013, to March 15, 2016.

EXPOSURES

Type of trauma center.

MAIN OUTCOMES AND MEASURES

Mortality at each center type.

RESULTS

Among 29 613 injured adolescents (mean [SD] age, 17.3 [1.4] years; 72.7% male), most were treated at ATCs (20 402 [68.9%]), with the remainder at MTCs (7572 [25.6%]) or PTCs (1639 [5.5%]). Adolescents treated at PTCs were more likely to be injured by a blunt than penetrating injury mechanism (91.4%) compared with those treated at ATCs (80.4%) or MTCs (84.6%). Mortality was higher among adolescents treated at ATCs and MTCs than those treated at PTCs (3.2% and 3.5% vs 0.4%; P < .001). The adjusted odds of mortality were higher at ATCs (odds ratio, 4.19; 95% CI, 1.30-13.51) and MTCs (odds ratio, 6.68; 95% CI, 2.03-21.99) compared with PTCs but was not different between level I and II centers (odds ratio, 0.76; 95% CI, 0.59-0.99).

CONCLUSION AND RELEVANCE

Mortality among injured adolescents was lower among those treated at PTCs, compared with those treated at ATCs and MTCs. Defining resource and patient features that account for these observed differences is needed to optimize adolescent outcomes after injury.

Note: A simple sample transfer alignment for ultra-high vacuum systems

The alignment of ultra-high-vacuum sample transfer systems can be problematic when there is no direct line of sight to assist the user. We present the design of a simple and cheap system which greatly simplifies the alignment of sample transfer devices. Our method is based on the adaptation of a commercial digital camera which provides live views from within the vacuum chamber. The images of the camera are further processed using an image recognition and processing code which determines any misalignments and reports them to the user. Installation has proven to be extremely useful in order to align the sample with respect to the transfer mechanism. Furthermore, the alignment software can be easily adapted for other systems.

Use of Payer as a Proxy for Health Insurance Status on Admission Results in Misclassification of Insurance Status among Pediatric Trauma Patients

The purpose of this study was to quantify health insurance misclassification among children treated at a pediatric trauma center and to determine factors associated with misclassification. Demographic, medical, and financial information were collected for patients at our institution between 2008 and 2010. Two health insurance variables were created: true (insurance on hospital admission) and payer (source of payment). Multivariable logistic regression was used to determine which factors were independently associated with health insurance misclassification. The two values of health insurance status were abstracted from the hospital financial database, the trauma registry, and the patient medical record. Among 3630 patients, 123 (3.4%) had incorrect health insurance designation. Misclassification was highest in patients who died: 13.9 per cent among all deaths and 30.8 per cent among emergency department deaths. The adjusted odds of misclassification were 6.7 (95% confidence interval: 1.7, 26.6) among patients who died and 16.1 (95% confidence interval: 3.2, 80.77) among patients who died in the emergency department. Using payer as a proxy for health insurance results in misclassification. Approaches are needed to accurately ascertain true health insurance status when studying the impact of insurance on treatment outcomes.

Use of Payer as a Proxy for Health Insurance Status on Admission Results in Misclassification of Insurance Status among Pediatric Trauma Patients

The purpose of this study was to quantify health insurance misclassification among children treated at a pediatric trauma center and to determine factors associated with misclassification. Demographic, medical, and financial information were collected for patients at our institution between 2008 and 2010. Two health insurance variables were created: true (insurance on hospital admission) and payer (source of payment). Multivariable logistic regression was used to determine which factors were independently associated with health insurance misclassification. The two values of health insurance status were abstracted from the hospital financial database, the trauma registry, and the patient medical record. Among 3630 patients, 123 (3.4%) had incorrect health insurance designation. Misclassification was highest in patients who died: 13.9 per cent among all deaths and 30.8 per cent among emergency department deaths. The adjusted odds of misclassification were 6.7 (95% confidence interval: 1.7, 26.6) among patients who died and 16.1 (95% confidence interval: 3.2, 80.77) among patients who died in the emergency department. Using payer as a proxy for health insurance results in misclassification. Approaches are needed to accurately ascertain true health insurance status when studying the impact of insurance on treatment outcomes.

Uncovering system-specific stress signatures in primate teeth with multimodal imaging

Early life stress can disrupt development and negatively impact long-term health trajectories. Reconstructing histories of early life exposure to external stressors is hampered by the absence of retrospective time-specific biomarkers. Defects in tooth enamel have been used to reconstruct stress but the methods used are subjective and do not identify the specific biological systems impacted by external stressors. Here we show that external physical and social stressors impart biochemical signatures in primate teeth that can be retrieved to objectively reconstruct the timing of early life developmental disruptions. Using teeth from captive macaques, we uncovered elemental imprints specific to disruptions of skeletal growth, including major disruptions in body weight trajectory and moderate to severe illnesses. Discrete increases in heat shock protein-70 expression in dentine coincided with elemental signatures, confirming that elemental signals were associated with activation of stress-related pathways. To overcome limitations of conventional light-microscopic analysis, we used high resolution Raman microspectral imaging to identify structural and compositional alterations in enamel and dentine that coincided with elemental signatures and with detailed medical and behavioural data. Integrating these objective biochemical markers with temporal mapping of teeth enables the retrospective study of early life developmental disruptions and their ensuing health sequelae.

Mechanisms of murine cerebral malaria: Multimodal imaging of altered cerebral metabolism and protein oxidation at hemorrhage sites

Using a multimodal biospectroscopic approach, we settle several long-standing controversies over the molecular mechanisms that lead to brain damage in cerebral malaria, which is a major health concern in developing countries because of high levels of mortality and permanent brain damage. Our results provide the first conclusive evidence that important components of the pathology of cerebral malaria include peroxidative stress and protein oxidation within cerebellar gray matter, which are colocalized with elevated nonheme iron at the site of microhemorrhage. Such information could not be obtained previously from routine imaging methods, such as electron microscopy, fluorescence, and optical microscopy in combination with immunocytochemistry, or from bulk assays, where the level of spatial information is restricted to the minimum size of tissue that can be dissected. We describe the novel combination of chemical probe-free, multimodal imaging to quantify molecular markers of disturbed energy metabolism and peroxidative stress, which were used to provide new insights into understanding the pathogenesis of cerebral malaria. In addition to these mechanistic insights, the approach described acts as a template for the future use of multimodal biospectroscopy for understanding the molecular processes involved in a range of clinically important acute and chronic (neurodegenerative) brain diseases to improve treatment strategies.

Effect of a checklist on advanced trauma life support task performance during pediatric trauma resuscitation

OBJECTIVES

Advanced Trauma Life Support (ATLS) has been shown to improve outcomes related to trauma resuscitation; however, omissions from this protocol persist. The objective of this study was to evaluate the effect of a trauma resuscitation checklist on performance of ATLS tasks.

METHODS

Video recordings of resuscitations of children sustaining blunt or penetrating injuries at a Level I pediatric trauma center were reviewed for completion and timeliness of ATLS primary and secondary survey tasks, with and without checklist use. Patient and resuscitation characteristics were obtained from the trauma registry. Data were collected during two 4-month periods before (n = 222) and after (n = 213) checklist implementation. The checklist contained 50 items and included four sections: prearrival, primary survey, secondary survey, and departure plan.

RESULTS

Five primary survey ATLS tasks (cervical spine immobilization, oxygen administration, palpating pulses, assessing neurologic status, and exposing the patient) and nine secondary survey ATLS tasks were performed more frequently (p ≤ 0.01 for all) and vital sign measurements were obtained faster (p ≤ 0.01 for all) after the checklist was implemented. When controlling for patient and event-specific characteristics, primary and secondary survey tasks overall were more likely to be completed (odds ratio [OR] = 2.66, primary survey; OR = 2.47, secondary survey; p < 0.001 for both) and primary survey tasks were performed faster (p < 0.001) after the checklist was implemented.

CONCLUSIONS

Implementation of a trauma checklist was associated with greater ATLS task performance and with increased frequency and speed of primary and secondary survey task completion.

Factors affecting team size and task performance in pediatric trauma resuscitation

OBJECTIVES

Varying team size based on anticipated injury acuity is a common method for limiting personnel during trauma resuscitation. While missing personnel may delay treatment, large teams may worsen care through role confusion and interference. This study investigates factors associated with varying team size and task completion during trauma resuscitation.

METHODS

Video-recorded resuscitations of pediatric trauma patients (n = 201) were reviewed for team size (bedside and total) and completion of 24 resuscitation tasks. Additional patient characteristics were abstracted from our trauma registry. Linear regression was used to assess which characteristics were associated with varying team size and task completion. Task completion was then analyzed in relation to team size using best-fit curves.

RESULTS

The average bedside team ranged from 2.7 to 10.0 members (mean, 6.5 [SD, 1.7]), with 4.3 to 17.7 (mean, 11.0 [SD, 2.8]) people total. More people were present during high-acuity activations (+4.9, P < 0.001) and for patients with a penetrating injury (+2.3, P = 0.002). Fewer people were present during activations without prearrival notification (-4.77, P < 0.001) and at night (-1.25, P = 0.002). Task completion in the first 2 minutes ranged from 4 to 19 (mean, 11.7 [SD, 3.8]). The maximum number of tasks was performed at our hospital by teams with 7 people at the bedside (13 total).

CONCLUSIONS

Resuscitation task completion varies by team size, with a nonlinear association between number of team members and completed tasks. Management of team size during high-acuity activations, those without prior notification, and those in which the patient has a penetrating injury may help optimize performance.

Effect of a checklist on advanced trauma life support workflow deviations during trauma resuscitations without pre-arrival notification

BACKGROUND

Trauma resuscitations without pre-arrival notification are often initially chaotic, which can potentially compromise patient care. We hypothesized that trauma resuscitations without pre-arrival notification are performed with more variable adherence to ATLS protocol and that implementation of a checklist would improve performance.

STUDY DESIGN

We analyzed event logs of trauma resuscitations from two 4-month periods before (n = 222) and after (n = 215) checklist implementation. Using process mining techniques, individual resuscitations were compared with an ideal workflow model of 6 ATLS primary survey tasks performed by the bedside evaluator and given model fitness scores (range 0 to 1). Mean fitness scores and frequency of conformance (fitness = 1) were compared (using Student's t-test or chi-square test, as appropriate) for activations with and without notification both before and after checklist implementation. Multivariable linear regression, controlling for patient and resuscitation characteristics, was also performed to assess the association between pre-arrival notification and model fitness before and after checklist implementation.

RESULTS

Fifty-five (12.6%) resuscitations lacked pre-arrival notification (23 pre-implementation and 32 post-implementation; p = 0.15). Before checklist implementation, resuscitations without notification had lower fitness (0.80 vs 0.90; p < 0.001) and conformance (26.1% vs 50.8%; p = 0.03) than those with notification. After checklist implementation, the fitness (0.80 vs 0.91; p = 0.007) and conformance (26.1% vs 59.4%; p = 0.01) improved for resuscitations without notification, but still remained lower than activations with notification. In multivariable analysis, activations without notification had lower fitness both before (b = -0.11, p < 0.001) and after checklist implementation (b = -0.04, p = 0.02).

CONCLUSIONS

Trauma resuscitations without pre-arrival notification are associated with a decreased adherence to key components of the ATLS primary survey protocol. The addition of a checklist improves protocol adherence and reduces the effect of notification on task performance.

A natural functionally graded biocomposite coating--human enamel

Human enamel has been found to be a coating with excellent mechanical performance, and has undergone extensive investigation and discussion. However, most of the reported studies consider the enamel as a homogeneous anisotropic biocomposite. The current study illustrated the graded properties of the biocomposite from its functional load-bearing direction. Within the thickness of the enamel, from the outer surface towards the enamel-dentin junction (EDJ), the elastic modulus (E(x)) and hardness (H(x)) of enamel exist in an exponential relationship with normalized thickness (x) as E(x)=111.64x(0.18) (R(2)=0.94) and H(x)=4.41x(0.16) (R(2)=0.87) GPa, respectively. Moreover, the creep ability of enamel increases towards the EDJ. The graded properties of the biocomposite can be explained by both microstructural and compositional changes along the thickness of the material towards the EDJ. Finite element analysis indicates that the graded properties of enamel have important roles in reducing the enamel-dentin interface stresses and maintaining the integrity of the multilayer tooth structure. The results provide a new angle to understand the excellent mechanical behaviour of the multilayer tooth structure and may inspire the development of new functionally graded materials and coating structures.

Assessment of workload during pediatric trauma resuscitation

BACKGROUND

Trauma resuscitations are high-pressure, time-critical events during which health care providers form ad hoc teams to rapidly assess and treat injured patients. Trauma team members experience varying levels of workload during resuscitations resulting from the objective demands of their role-specific tasks, the circumstances surrounding the event, and their individual previous experiences. The goal of this study was to determine factors influencing workload experienced by trauma team members during pediatric trauma resuscitations.

METHODS

Workload was measured using the National Aeronautics and Space Administration Task Load Index (TLX). TLX surveys were administered to four trauma team roles: charge nurse, senior surgical resident (surgical coordinator), emergency medicine physician, and junior surgical resident or nurse practitioner (bedside clinician). A total of 217 surveys were completed. Univariate and multivariate statistical techniques were used to examine the relationship between workload and patient and clinical factors.

RESULTS

Bedside clinicians reported the highest total workload score (208.7), followed by emergency medicine physicians (156.3), surgical coordinators (144.1), and charge nurses (129.1). Workload was higher during higher-level activations (235.3), for events involving intubated patients (249.0), and for patients with an Injury Severity Score greater than 15 (230.4) (p, 0.001 for all). When controlling for potential confounders using multiple linear regression, workload was increased during higher level activations (79.0 points higher, p = 0.01) and events without previous notification (38.9 points higher, p = 0.03). Workload also remained significantly higher for the bedside clinician compared with the other three roles (p ≤ 0.005 for all).

CONCLUSION

Workload during pediatric trauma resuscitations differed by team role and was increased for higher-level activations and events without previous notification. This study demonstrates the validity of the TLX as a tool to measure workload in trauma resuscitation.

LEVEL OF EVIDENCE

Prognostic study, level II.

Risk of injury in basketball, football, and soccer players, ages 15 years and older, 2003-2007

CONTEXT

A major challenge in the field of sports injury epidemiology is identifying the appropriate denominators for injury rates.

OBJECTIVE

To characterize risk of injury from participation in basketball, football, and soccer in the United States, using hours of participation as the measure of exposure, and to compare these rates with those derived using population estimates in the denominator.

DESIGN

Descriptive epidemiology study.

SETTING

United States, 2003-2007.

PARTICIPANTS

People ages 15 years and older who experienced an emergency department-treated injury while playing basketball, football, or soccer.

MAIN OUTCOME MEASURE(S)

Rates of emergency department-treated injuries resulting from participation in basketball, football, or soccer. Injury rates were calculated for people ages 15 and older for the years 2003-2007 using the U.S. population and hours of participation as the denominators. The risk of injury associated with each of these sports was compared for all participants and by sex.

RESULTS

From 2003 through 2007, annual injury rates per 1000 U.S. population were as follows: 1.49 (95% confidence interval [CI] = 1.30, 1.67) in basketball, 0.93 (95% CI = 0.82, 1.04) in football, and 0.43 (95% CI = 0.33, 0.53) in soccer. When the denominator was hours of participation, the injury rate in football (5.08 [95% CI = 4.46, 5.69]/10 000 hours) was almost twice as high as that for basketball (2.69 [95% CI = 2.35, 3.02]/10 000 hours) and soccer (2.69 [95% CI = 2.07, 3.30]/10 000 hours).

CONCLUSIONS

Depending on the choice of denominator, interpretation of the risk of an emergency department-treated injury in basketball, football, or soccer varies greatly. Using the U.S. population as the denominator produced rates that were highest in basketball and lowest in soccer. However, using hours of participation as a more accurate measure of exposure demonstrated that football had a higher rate of injury than basketball or soccer for both males and females.

FTIR imaging of brain tissue reveals crystalline creatine deposits are an ex vivo marker of localized ischemia during murine cerebral malaria: general implications for disease neurochemistry

Phosphocreatine is a major cellular source of high energy phosphates, which is crucial to maintain cell viability under conditions of impaired metabolic states, such as decreased oxygen and energy availability (i.e., ischemia). Many methods exist for the bulk analysis of phosphocreatine and its dephosphorylated product creatine; however, no method exists to image the distribution of creatine or phosphocreatine at the cellular level. In this study, Fourier transform infrared (FTIR) spectroscopic imaging has revealed the ex vivo development of creatine microdeposits in situ in the brain region most affected by the disease, the cerebellum of cerebral malaria (CM) diseased mice; however, such deposits were also observed at significantly lower levels in the brains of control mice and mice with severe malaria. In addition, the number of deposits was observed to increase in a time-dependent manner during dehydration post tissue cutting. This challenges the hypotheses in recent reports of FTIR spectroscopic imaging where creatine microdeposits found in situ within thin sections from epileptic, Alzheimer's (AD), and amlyoid lateral sclerosis (ALS) diseased brains were proposed to be disease specific markers and/or postulated to contribute to the brain pathogenesis. As such, a detailed investigation was undertaken, which has established that the creatine microdeposits exist as the highly soluble HCl salt or zwitterion and are an ex-vivo tissue processing artifact and, hence, have no effect on disease pathogenesis. They occur as a result of creatine crystallization during dehydration (i.e., air-drying) of thin sections of brain tissue. As ischemia and decreased aerobic (oxidative metabolism) are common to many brain disorders, regions of elevated creatine-to-phosphocreatine ratio are likely to promote crystal formation during tissue dehydration (due to the lower water solubility of creatine relative to phosphocreatine). The results of this study have demonstrated that although the deposits do not occur in vivo, and do not directly play any role in disease pathogenesis, increased levels of creatine deposits within air-dried tissue sections serve as a highly valuable marker for the identification of tissue regions with an altered metabolic status. In this study, the location of crystalline creatine deposits were used to identify whether an altered metabolic state exists within the molecular and granular layers of the cerebellum during CM, which complements the recent discovery of decreased oxygen availability in the brain during this disease.

Compliance with barrier precautions during paediatric trauma resuscitations

PURPOSE

Barrier precautions protect patients and providers from blood-borne pathogens. Although barrier precaution compliance has been shown to be low among adult trauma teams, it has not been evaluated during paediatric resuscitations in which perceived risk of disease transmission may be low. The purpose of this study was to identify factors associated with compliance with barrier precautions during paediatric trauma resuscitations.

METHODS

Video recordings of resuscitations performed on injured children (<18 years old) were reviewed to determine compliance with an established policy requiring gowns and gloves. Depending on activation level, trauma team members included up to six physicians, four nurses, and a respiratory therapist. Multivariate logistic regression was used to determine the effect of team role, resuscitation factors, and injury mechanism on barrier precaution compliance.

RESULTS

Over twelve weeks, 1138 trauma team members participated in 128 resuscitations (4.7% penetrating injuries, 9.4% highest level activations). Compliance with barrier precautions was 81.3%, with higher compliance seen among roles primarily at the bedside compared to positions not primarily at the bedside (90.7% vs. 65.1%, p<0.001). Bedside residents (98.4%) and surgical fellows (97.6%) had the highest compliance, while surgical attendings (20.8%) had the lowest (p<0.001). Controlling for role, increased compliance was observed during resuscitations of patients with penetrating injuries (OR=3.97 [95% CI: 1.35-11.70], p=0.01), during resuscitations triaged to the highest activation level (OR=2.61 [95% CI: 1.34-5.10], p=0.005), and among team members present before patient arrival (OR=4.14 [95% CI: 2.29-7.39], p<0.001).

CONCLUSIONS

Compliance with barrier precautions varies by trauma team role. Team members have higher compliance when treating children with penetrating and high acuity injuries and when arriving before the patient. Interventions integrating barrier precautions into the workflow of team members are needed to reduce this variability and improve compliance with universal precautions during paediatric trauma resuscitations.

Markers of inflammation, metabolic risk factors, and incident heart failure in American Indians: the Strong Heart Study

Inflammation may play a role in increased risk of heart failure (HF) that is associated with obesity, metabolic syndrome (MS), and diabetes. This study investigated associations between inflammatory markers, MS, and incident HF in a population with a high prevalence of diabetes, obesity, and MS. The cohort consisted of 3098 American Indians without prevalent cardiovascular disease who had C-reactive protein (CRP) and fibrinogen measured at the Strong Heart Study phase II examination. Independent associations between inflammatory markers, MS, and HF were analyzed by Cox hazard models. During a mean follow-up of 11 years, 218 participants developed HF. After the adjustment for cardiovascular risk factors, fibrinogen, (hazard ratio [HR], 1.36; 95% confidence interval [CI], 1.15-1.59) but not CRP (HR, 1.25; 95% CI, 0.97-1.32) remained a significant HF predictor. In individuals without diabetes, concomitant presence of MS and elevated CRP or fibrinogen increased HF risk (for MS and CRP: HR, 2.02; 95% CI, 0.95-4.31; for CRP and fibrinogen: HR, 1.75; 95% CI, 0.83-3.72). In a population with a high prevalence of obesity, MS, and diabetes, elevated CRP and fibrinogen increased HF risk. These associations are attenuated by the adjustments for conventional risk factors suggesting that inflammation acts in concert with metabolic and clinical risk factors in increasing HF risk.

A Raman spectroscopic study of a fulgurite

A Raman microspectroscopic study of several fulgurites has been undertaken. A fulgurite is an amorphous mineraloid, a superheated glassy solid that is formed when a lightning bolt hits a sandy or rocky ground and thermal energy is transferred. The Raman spectra revealed several forms of crystalline and fused silica and also the presence of polyaromatic hydrocarbons found in an interfacial zone of a glass bubble. This, together with the presence of anatase, a low-temperature polymorph of TiO(2), suggested that some regions of the fulgurite specimen were not subjected to temperatures of 1800 degrees C, which are attained when lightning hits the surface of sand or a rock.

Relationship between glycemic control and depression among American Indians in the Strong Heart Study

OBJECTIVES

To examine the relationship between depression and glycemic control in the Strong Heart Study (SHS), a longitudinal study of cardiovascular disease in American Indians.

METHODS

This cross-sectional analysis focused on the relationship between depression, diabetes and glycemic control among 2832 individuals aged > or =15 years. Depression was measured by the Center for Epidemiologic Studies of Depression Scale and diabetes by American Diabetes Association criteria. An ordered logit regression model was used to assess whether diabetes was related to level of depression (none, mild, moderate, severe). Multiple logistic regression was used to explore the relationship between A1c and severe depression in participants with diabetes.

RESULTS

Rates of depression were higher in men and women with diabetes when compared to those without diabetes, respectively (P<.05). For every 1-U increase in A1c, the odds of severe depression increased by 22% (OR 1.22, 95% CI: 1.05-1.42). Female sex (OR 2.97, 95% CI: 1.32-6.69) and body mass index (BMI) (OR 1.04, 95% CI: 1.00-1.08) also were significantly associated with increased risk for severe depression. Although BMI appears to be significantly associated with increased risk for severe depression, the magnitude of this effect was small.

CONCLUSIONS

Individuals with diabetes have higher rates of depression than those without diabetes, consistent with other populations. There is a positive relationship between severity of depression and A1c levels; men and women with severe depression have higher A1c levels than those with moderate-to-no depression.

Vibrational spectroscopic mapping and imaging of tissues and cells

Vibrational spectroscopic mapping (point-by-point measurement) and imaging of biological samples (cells and tissues) covering Fourier-transform infrared (FTIR) and Raman spectroscopies has opened up many exciting new avenues to explore biochemical architecture and processes within healthy and diseased cells and tissues, including medical diagnostics and drug design.

Fatty acid consumption and metabolic syndrome components: the GOCADAN study

Fatty acids (FAs) have been related to changes in glucose and lipid metabolism. In this article, the authors assess the association between intake of specific FAs and components of the metabolic syndrome (MS) in adult Eskimos. A total of 691 Inupiat Eskimos (325 men and 366 women), aged 34 to 75 years, were examined as part of the Genetics of Coronary Artery Disease in Alaska Natives (GOCADAN) study. The investigation included a physical examination, blood pressure measurements, blood sampling under fasting conditions, 2-hour oral glucose tolerance test, and a personal interview including a validated food frequency questionnaire. Components of MS were defined according to the Third Report of the National Cholesterol Education Program Adult Treatment Panel criteria. Consumption of individual FAs showed associations with MS components. Long-chain omega-3 FAs, from fish and sea mammals, were associated with lower blood pressure, serum triglycerides, and 2-hour glucose and higher high-density lipoprotein cholesterol, fasting insulin, and homeostasis model assessment. Saturated fat consumption was associated with higher triglyceride levels and blood pressure. Trans-FA consumption was associated with higher blood pressure. Consumption of long-chain omega-3 FAs from marine sources may improve certain MS components, and thus may reduce risk for cardiovascular disease. High consumption of saturated FAs and trans-FAs may have an adverse effect on MS.

The Rio Tinto Mars analogue site: an extremophilic Raman spectroscopic study

The Rio Tinto site is recognised as a terrestrial Mars analogue because of the presence of jarosite and related sulfates which have recently been identified by the NASA Mars Exploration Rover "Opportunity" in the El Capitan region of Meridiani Planum on Mars. It has long been known that acidophilic microbial action is responsible for the deep blood-red colour of the water in Rio Tinto, where the pH varies from about 1.5 to 3.0 and the water is rich in iron and sulfur. Following recent Raman spectroscopic characterisation of the mineral phases of the Rio Tinto system, we report here a study of the biological components found in several specimens of deposited minerals and near the waterside that were collected during a GeoRaman VI Conference organized field trip in 2006. Key biosignatures were found for carotenoids, scytonemin and mycosporine-like amino acids, which are indicative of the biological colonisation of exposed mineral substrates; information from this study will be useful for targeting Martian sites using a miniaturized Raman instrument where the biosignatures of relict or extant life could remain in the geological record.

Characterization of nanoindentation-induced residual stresses in human enamel by Raman microspectroscopy

The objective of this research was to investigate nanoindentation-induced residual stresses in human enamel using Raman microspectroscopy and establish if this approach can be used as a stress meter. Healthy human premolars and sintered hydroxyapatite samples were embedded, cut, and the surfaces were polished finely with a 0.05 microm polishing paste before Berkovich and spherical indentations were made with a force of 100 mN. Spectra were collected using a Renishaw Raman InVia reflex microscope equipped with an air-cooled charge-coupled device (CCD) camera. Sample excitation was achieved using either an argon ion laser emitting at 514.5-nm or a NIR diode laser emitting at 830-nm. The residual micro stresses within and surrounding the indentation impressions were monitored by mapping the position of the nu(1)(PO(4)) band of (crystalline) hydroxyapatite. The Raman maps coincided well with the optical micrographs of the samples. Despite the presence of a fluorescence background from the organic component of human enamel, spectra collected using 514.5-nm excitation exhibited more significant shifts in the position of the nu(1)(PO(4)) band than spectra collected using 830-nm excitation. This implies that the former excitation may be a more appropriate excitation for stress detection. It was concluded that Raman microspectroscopy provides a novel high-resolution and non-destructive method for exploring the role of microstructure on the residual stress distribution within natural biocomposites.

Descriptive epidemiology of collegiate women's lacrosse injuries: National Collegiate Athletic Association Injury Surveillance System, 1988-1989 through 2003-2004

OBJECTIVE

To review 16 years of National Collegiate Athletic Association injury surveillance data for women's lacrosse and identify potential areas for injury prevention initiatives.

BACKGROUND

Women's lacrosse is a fast-paced, primarily noncontact sport. Participation in collegiate women's lacrosse almost doubled between the 1988-1989 and 2003-2004 seasons. Lacrosse equipment consists of sticks made of wood or a synthetic material and a hard rubber ball. Until recently, mouth guards were the only required protective equipment.

MAIN RESULTS

Collegiate women's lacrosse game injury rates increased over the 16-year study period. More than 60% of all severe game injuries were lower extremity sprains and strains and knee internal derangements, most frequently the result of noncontact incidents. The most common injury scenarios by injury mechanism and player activity were no contact while ball handling (16.4%) and contact from a stick while ball handling (10.5%). Contact from a stick or a ball accounted for 5.6% and 5.2% of injuries sustained during shooting activities, respectively. Approximately 22% of all game and 12% of all practice injuries involved the head and neck. Contact from a stick accounted for the majority (56.0%) of above-the-neck injuries in games; contact from the ball accounted for 20.0% of these injuries. Participants had 5 times the risk of sustaining a concussion in a game as in a practice (0.70 versus 0.15 injuries per 1000 athletic-exposures, rate ratio = 4.7, 95% confidence interval = 3.8, 6.5).

RECOMMENDATIONS

To reduce the lower extremity injuries that comprise the greatest injury burden in women's lacrosse, future researchers should evaluate proprioceptive, plyometric, and balance training interventions designed specifically for female players. Other research areas of great interest involve determining whether protective eyewear (mandated in 2004) reduces injuries to the eye, orbit, and nasal area and identifying any unintended consequences of the mandate, such as increased risk of injuries to other areas of the face or more aggressive play.

Cross-sectional relationship of reported fatigue to obesity, diet, and physical activity: results from the third national health and nutrition examination survey

STUDY OBJECTIVES

Reported daytime fatigue may be influenced by modifiable risk factors. We hypothesized that daytime fatigue is associated with less-favorable lifestyle factors, including high body mass index, higher intake of dietary fat, and limited physical activity.

DESIGN

Cross-sectional analysis.

SETTING

Population-based survey.

PARTICIPANTS

Participants aged 20 to 59 years in the Third National Health and Nutrition Examination Survey.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

We examined relationships between responses to the question, "Right now would you say you are feeling energetic, fresh, average, tired or exhausted?" and body mass index, waist circumference, leisure time physical activity, and macronutrient intake. Analyses included only people who reported getting their usual amount of sleep the night before the evaluation and controlled for age, sex, and ethnicity; 5.6%, 14.6%, 58.3%, 19.5%, and 2.0% reported that they felt "energetic," "fresh," "average," "tire d," and "ex hausted" respectively. There was a U-shaped association across the categories of fatigue for physical activity, body mass index, and waist circumference, with the healthiest lifestyle factors being associated with reporting feeling "fresh." Relative to the fresh group, average, tired and exhausted participants were 1.6, 1.9, and 3.8 times more likely to report insufficient physical activity, all statistically different from the fresh group. This pattern was also observed for body mass index and waist circumference and persisted after adjustment for covariates and exclusion of individuals with depression.

CONCLUSIONS

In adults aged 20 to 59 years in the United States, self-reported fatigue is associated with higher body mass index, higher waist circumference, and a reduced likelihood of getting recommended levels of physical activity.