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.