Search

63 Background: A novel vaccine strategy may prevent recurrence in high-risk melanoma patients (pts). The TLPLDC vaccine uses yeast cell wall particles (YCWP) to load tumor lysate into autologous dendritic cells (DC). In this phase IIb trial of TLPLDC vs. placebo in resected stage III/IV pts, TLPLDC increased 24 month (mo) disease free survival (DFS) in the per treatment (PT) population. Here, we present a 24mo DFS subgroup analysis and estimated overall 36mo DFS. Methods: Disease-free pts were randomized 2:1 to the TLPLDC vaccine vs. unloaded YCWP+DC at 0, 1, 2, 6, 12, and 18mo. The protocol was amended to allow concurrent adjuvant checkpoint inhibitor (CPI) therapy once approved. The pre-specified PT population included only pts completing the primary vaccine/placebo series (PVS) at 6 mo. Kaplan-Meier estimates of DFS were used to compare treatment arms by stage (III or IV) and CPI therapy (yes/no) in the ITT and PT populations. Results: 144 pts were randomized (103 TLPLDC, 41 placebo); 98 pts (66 TLPLDC, 32 placebo) completed the PVS. There were no clinicopathologic differences between treatment groups. There was no difference in 24mo DFS in stage III pts (n = 112), but in stage IV pts (n = 32), the 24mo DFS was 44% vs 0% (TLPLDC vs placebo) (p = 0.41) in ITT and 73.3% vs. 0% (HR 0.14, p = 0.002) in PT. Stage IV pts were more likely to receive CPI than stage III pts (50% vs. 30%, p = 0.003). There was no difference in 24mo DFS for pts who did not receive CPI (n = 102), but in pts who received CPI (n = 42), the 24mo DFS was 49.3% vs. 31.3% (p = 0.71) in ITT and 68.8% vs. 41.7% (HR 0.46, p = 0.28) in PT, showing a trend toward improved DFS in pts who completed the PVS and received CPI (n = 31). Overall, the 36mo estimated DFS was 34.2% vs. 21.6% (p = 0.89) for ITT and 56.9% vs. 27.9% (p = 0.021) for PT. Conclusions: The TLPLDC vaccine improved DFS in patients completing the PVS at 24 and 36 mos, particularly in the resected stage IV subset. The apparent synergistic effect with TLPLDC + CPI will be confirmed in a phase III study evaluating adjuvant TLPLDC + CPI vs. CPI alone in resected stage IV melanoma pts. Clinical trial information: NCT02301611.

Bridge retrofitting is a billion-dollar industry. Thus, finding effective and economically feasible solutions to strengthen bridges that deteriorate to extend service life until replacement is feasible is a critical global need. There are several types of fiber reinforced polymers (FRP) based repair systems available now commercially to strengthen bridge members including systems that utilize carbon, glass, and now even steel fibers. The latter is a system most often referred to as steel reinforced polymer (SRP) and is considered fairly new to the bridge industry; yet a very promising system due to its close-to-carbon fiber strength, and close-to-glass fiber price. One current research gap for SRP has been the performance of this system relative to exposure to environmental conditioning and its overall durability resilience. In this work, the SRP strengthening system used both micro-fine galvanized and micro-fine brass coated steel fibers to externally reinforce concrete prisms using the recently published American Concrete Institute (ACI) 440.9R-15 approach to evaluate FRP bond behavior. Companion dog-bone style coupon specimens were also prepared using both SRP systems to examine tensile mechanical properties of the SRP system alone. Both types of specimens were exposed to several types of harsh environments including cycles of freeze-thaw, varying temperature, and cycles of humidity. The study investigated accelerated environmental exposure in an environmental chamber as well as direct real-time weather exposure. The environmental chamber involved subjecting the specimens to freeze-thaw cycles, cycles of varying temperature, and humidity cycles. For the real-time weather exposure, the specimens were exposed to daily weather for 12 months in Rolla, Missouri, USA where the city is moderately exposed to freeze-thaw, high-range of temperature fluctuation, and wide ranging humidity levels. The results of the flexural tests conducted indicated that the bond strength between the SRP and concrete interface was reduced by harsh environment. All conditioned specimens had a mode II or mode III bond failure, while the control specimens failed in mode I. Real-time weather specimens failed at lower deformation levels with less concrete-covered substrate than those conditioned in the environmental chamber. An ACI 440 style environmental reduction factor, CE, of 0.75 is suggested for wet-environment and 0.65 for highly aggressive environment based on the work undertaken in the overall study.

During the model membrane formation process from a lipid monolayer of 1,2-dipalmitoyl-sn-glycero-3-phospho-(1′-rac-glycerol) (sodium salt) (DPPG) in air to a lipid bilayer of DPPG/deuterated-DPPG (dDPPG) on water, the intensity of sum frequency generation (SFG) vibrational signals from the DPPG molecules increased by ∼34 times. The increased signal intensity could be caused by inherently different molecular ordering of lipid molecules in the monolayer/bilayer or by optical effects induced by different contacting mediums (prism in air and prism contacting water) (see Figure 2). We resolve the two possibilities by analyzing tilt angles of the methyl groups at DPPG hydrophobic ends for the monolayer/bilayer which reflect the molecular ordering information and by evaluating the Fresnel coefficients which reflect the contacting medium-induced optical effect. DPPG molecules were more ordered after transformation from a lipid monolayer in air to a lipid bilayer on water, which induced a slight signal increase. T...

This study examines the Swedish national educational voucher scheme and changes in social cohesion. We conduct a statistical analysis using data from the 1999 and 2009 rounds of the International Association for the Evaluation of Educational Achievement’s civic education study of 14-year-old students and their attitudes toward the rights of ethnic minorities and immigrants. Using regression models, we do not find evidence of a decline in civic attitudes and therefore social cohesion. We attribute the results to Sweden’s voucher design and context that minimized segregation and preserved civics curricula in all schools.

Water adsorption in porous low-k dielectrics has become a significant challenge for both back-end-of-line integration and reliability. A simple method is proposed here to achieve in situ observation of water structure and water-induced structure changes at the poly(methyl silsesquioxane) (PMSQ) surface and the PMSQ/solid buried interface at the molecular level by combining sum frequency generation (SFG) vibrational spectroscopic and Fourier transform infrared (FTIR) spectroscopic studies. First, in situ SFG investigations of water uptake were performed to provide direct evidence that water diffuses predominantly along the PMSQ/solid interface rather than through the bulk. Furthermore, SFG experiments were conducted at the PMSQ/water interface to simulate water behavior at the pore inner surfaces for porous low-k materials. Water molecules were found to form strong hydrogen bonds at the PMSQ surface, while weak hydrogen bonding was observed in the bulk. However, both strongly and weakly hydrogen bonded water components were detected at the PMSQ/SiO2 buried interface. This suggests that the water structures at PMSQ/solid buried interfaces are also affected by the nature of solid substrate. Moreover, the orientation of the Si-CH3 groups at the buried interface was permanently changed by water adsorption, which might due to low flexibility of Si-CH3 groups at the buried interface. In brief, this study provides direct evidence that water molecules tend to strongly bond (chemisorbed) with low-k dielectric at pore inner surfaces and at the low-k/solid interface of porous low-k dielectrics. Therefore, water components at the surfaces, rather than the bulk, are likely more responsible for chemisorbed water related degradation of the interconnection layer. Although the method developed here was based on a model system study, we believe it should be applicable to a wide variety of low-k materials.

Epoxies are widely used as main components in packaging underfills for microelectronics. Their strong adhesion to different substrate materials is an important factor for the functioning of electronic devices. Amines are commonly used cross-linking agents for epoxides. However, the molecular mechanisms of epoxide-amine mixture adhesion to substrate materials remain unclear. In this research we investigated the adhesion mechanism of epoxide-amine mixtures at poly(ethylene terephthalate) (PET) interfaces using attenuated total-internal reflection Fourier transform infrared (ATR-FTIR) spectroscopy and sum frequency generation (SFG) vibrational spectroscopy. Results show that both epoxide and amine could diffuse into the PET film. They could also dissolve or modify the PET film at the interphase region. In the process of epoxy curing on PET, epoxide molecules could cross-link with the modified PET film, providing strong adhesion. This hypothesis was further confirmed by adding reactive and nonreactive silanes to the epoxies and measuring the adhesion strengths of such mixtures to PET. The reactive silanes could cross-link with the system, showing good adhesion, while the nonreactive silane prevented sufficient cross-linking, showing poor adhesion. This research developed an in-depth insight for molecular behaviors at the epoxy/PET interface which helped clarify the related adhesion mechanism.

Understanding molecular structures of buried polymer/metal interfaces is important for the design and development of polymer adhesives used in advanced microelectronic devices and polymer anticorrosion coatings for metals. The buried interfacial molecular structure between polystyrene (PS) and silver (Ag) was investigated using infrared-visible sum frequency generation (SFG) vibrational spectroscopy via a "sandwiched" sample geometry. SFG resonant signals from the phenyl C-H stretching vibrational modes were detected from the PS/Ag interface, suggesting that the PS phenyl groups at this buried polymer/metal interface are ordered. Spectral analysis indicated that the phenyl groups at the buried PS/Ag interface tilt toward the interface, pointing away from the Ag side.

BACKGROUND: Head injury is the most common cause of neurologic disability and mortality in children. Previous studies have demonstrated that depressed skull fractures (SFs) represent approximately one quarter of all SFs in children and approximately 10% percent of hospital admissions after head injury. We hypothesized that nondepressed SFs (NDSFs) in children are not associated with adverse neurologic outcomes. METHODS: Medical records were reviewed for all children 5 years or younger with SFs who presented to our Level I trauma center during a 4-year period. Data collected included patient demographics, Glasgow Coma Scale (GCS) score at admission, level of consciousness at the time of injury, type of SF (depressed SF vs. NDSF), magnitude of the SF depression, evidence of neurologic deficit, and the requirement for neurosurgical intervention. RESULTS: We evaluated 1,546 injured young children during the study period. From this cohort, 563 had isolated head injury, and 223 of them had SF. Of the SF group, 163 (73%) had NDSFs, of whom 128 (78%) presented with a GCS score of 15. None of the NDSF patients with a GCS score of 15 required neurosurgical intervention or developed any neurologic deficit. Of the remaining 35 patients with NDSF and GCS score less than 15, 7 (20%) had a temporary neurologic deficit that resolved before discharge, 4 (11%) developed a persistent neurologic deficit, and 2 died (6%). CONCLUSION: Children 5 years or younger with NDSFs and a normal neurologic examination result at admission do not develop neurologic deterioration. LEVEL OF EVIDENCE: Epidemiological study, level III. Language: en

The objective of this study was to detect and classify the number and size of gaseous microemboli in a simulated pediatric model of cardiopulmonary bypass. Tests were conducted at five different flow rates (400-1,200 ml/min in 200 ml/min increments), pulsatile versus nonpulsatile perfusion modes, and under normothermic, hypothermic, and deep hypothermic (35 degrees C, 25 degrees C, and 15 degrees C) conditions, yielding 180 total experiments. The circuit was primed with lactated Ringer's solution and filled with heparinized bovine blood. At the beginning of each experiment, 5 ml of air were injected into the venous line via the luer port of the oxygenator. Microemboli were quantified and classified by size for 5 minute segments at three transducer sites: postpump, postoxygenator, and postarterial filter. The purge line of the arterial filter was closed during all experiments. In all but one experiment, 90% of emboli at the postpump site were found to be smaller than 40 microm. At the postarterial filter site, nearly 99% of the emboli were smaller than 40 microm. Additionally, increasing microemboli counts were observed when the flow rate was increased and when the temperature was decreased. Lower temperatures, higher flow rates, and pulsatile perfusion were all associated with higher emboli counts. The majority of gaseous microemboli found in the simulated circuit was significantly below 40 microm; the smallest level detectable by traditional Doppler devices.

Background: Melanoma is an immunogenic cancer, yet only 50-60% of tumors respond to current immunotherapy. The autologous tumor lysate, particle loaded, dendritic cell (TLPLDC) vaccine may potentiate an immune response by stimulating T-cells. We are conducting a phase IIb double-blinded randomized trial of TLPLDC to prevent recurrence after resection. Patients who recurred were offered enrollment in an open-label TLPLDC vaccine trial along with standard therapy. Here, we describe characteristics and clinical outcomes of recurred patients that continued on open label TLPLDC vaccination. Methods: Patients with resected no evidence of disease (NED) stage III/IV melanoma were randomized to TLPLDC vs. empty yeast cell wall particle (YCWP) loaded DC in a 2:1 fashion. TLPDC is created by loading autologous tumor lysate into YCWP. This is then introduced ex vivo to the patient’s DC for phagocytosis. 1-1.5x106TLPLDCs are given via intradermal injection monthly x4 followed by boosters at 6 and 9 months. Patients who recurred after receiving TLPLDC (vaccine group, VG) or after empty YCWP (control group, CG) on the trial (primary endpoint) were offered open label TLPLDC vaccination with same dosing schedule along with standard therapy as determined by the patient’s treatment team. Disease status is measured by RECIST criteria. Results: To date, 23 (14 VG and 11 CG) patients have enrolled and been vaccinated, with median follow up (fu) of 7.86 months (mo). The patients received the following additional therapies: surgery, gamma-knife, check point inhibitor, radiation, TVEC, BRAF/MEK, and imantinib. No related toxicities > grade 2 were observed. Of 14 VG patients, 5 were NED when re-enrolled, 9 had measurable disease (MD). Of these, 11 have followed up data, 9 (82%) show disease control (5/5 NED patients remain NED, 4/6 with MD show SD), while 2 (18%) have progressed. Of 9 CG patients, 4 were NED and 5 had measurable disease at time of re-enrollment. Of these, 8 have followed up, 5 (62%) show disease control (2/4 NED remain NED, 1/4 with MD shows regression, 2/4 SD), while 3 (38%) have progressed (2/4 NED, 1/3 with MD). Conclusion: Open label administration of TLPLPDC vaccine after recurrence is demonstrated as a safe therapy and shows potential clinical benefit when combined SOC therapy. Further study is warranted to determine if prior exposure to TLPLDC may provide clinical benefit after the first episode of disease recurrence. Citation Format: Annelies T. Hickerson, Guy T. Clifton, Tommy A. Brown, Jessica L. Cindass, John W. Myers, Timothy J. Vreeland, Diane F. Hale, Kaitlin M. Peace, Doreen O. Jackson, Garth Herbert, Xianzhong Yu, Thomas E. Wagner, George E. Peoples. Prior vaccination with the autologous Tumor Lysate Particle Loaded Dendritic Cell (TLPLDC) Vaccine may impact clinical outcomes in melanoma patients treated with systemic therapies and re-vaccination [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr CT208.

e21025 Background: The treatment of melanoma has changed drastically with the advent of immunotherapy. The autologous tumor lysate, particle loaded, dendritic cell (TLPLDC) vaccine stimulates T-cells and may work synergistically with other immunotherapies. Here, we describe results in patients (pts) with metastatic melanoma (MM) treated with the TLPLDC vaccine together with other approved therapies. Methods: The TLPLDC vaccine is created using autologous tumor lysate loaded yeast cell wall particles to prime autologous dendritic cells ex-vivo. 1-1.5x106 TLPLDCs are given via intradermal injection monthly x 4 followed by boosters at six and nine months (mo). Pts who recurred while enrolled in our adjuvant phase IIb trial of the TLPLDC vaccine and pts with MM with measurable disease enrolled in a separate phase I/IIa trial were offered vaccination of TLPLDC vaccine in an open-label fashion in addition to other approved therapies as determined by their treating physician. Tumor response is measured by RECIST 1.1 criteria. Results: To date, 50 pts have been enrolled in the two trials (25 pts in each). Of the 42 pts with measureable disease, 30 pts received at least one dose of the vaccine, 11 progressed prior to vaccine administration, and 1 is pending. 2 pts withdrew at 2 and 7 mo. Of the remaining 28 evaluable pts, 13 pts had progressive disease with a median follow-up (f/u) of 3 (range 0-12) mo, 12 pts had stable disease with a median f/u of 7.5 (range 1-23) mo, 2 pts had a partial response with f/u of 7 and 13 mo, and one pt had a complete response with 18 mo of f/u. Overall, in pts with measureable disease, the disease control rate was 54% (15/28) and objective response rate was 11% (3/28). 8 pts were without measurable disease at enrollment, 3 recurred at a median f/u of 8 mo and 5 remain disease-free at a median of 26 mo f/u. No grade ≥ 3 toxicities were observed with combination TLPLDC vaccination and approved systemic therapies. Conclusions: Vaccination with the TLPLDC vaccine in combination with systemic approved therapies in MM pts is well tolerated and may provide clinical benefit in patients with and without measurable disease. Clinical trial information: NCT02678741.

The Anthropocene is recognized (though not yet formally defined) as the time when human impacts are widespread on Earth. While some of the impacts are essential to supporting large human populations and can be sustainable in the long run, others can irretrievably damage the life support systems upon which the global society has come to depend, or spark rapid changes to which societies cannot adapt fast enough. Among these dangerous trends are increasing climate disruption, extinctions, loss of non-human-dominated ecosystems, pollution, and population overgrowth. Interactions between these five trends exacerbate their potential to trigger harmful global change. Reducing the resultant risks requires effective cooperation between scientists and policy makers to develop strategies that guide for environmental health over the next few decades. To that end, the Scientific Consensus on Maintaining Humanity’s Life Support Systems in the 21st Century was written to make accessible to policy makers and others the basic scientific underpinnings and widespread agreement about both the dangers of and the solutions to climate disruption, extinctions, ecosystem loss, pollution and population overgrowth. When it was released in May 2013, the document included endorsements by 522 global change scientists, including dozens of members of various nations’ most highly recognized scientific bodies, from 41 countries around the world. Since then, endorsements have grown to more than 1300 scientists plus more than 1700 others – business people, NGO representatives, students, and the general public – spanning more than 60 countries. Now also available in Spanish and Chinese, the document has proven useful in helping to stimulate national and international agreements. Further information about the genesis, uses, the signatories, and how to endorse it can be found at http://consensusforaction.stanford.edu/ . Such communication between scientists, policy makers, and the public at large will be essential for effective guidance to address global change as the Anthropocene progresses.

BACKGROUND: Occupational status, a core component of socioeconomic status, plays a critical role in the well-being of U.S. workers. Identifying work-related disparities can help target prevention efforts. METHODS: Bureau of Labor Statistics workplace data were used to characterize high-risk occupations and examine relationships between demographic and work-related variables and fatality. RESULTS: Employment in high-injury/illness occupations was independently associated with being male, Black, ≤high school degree, foreign-birth, and low-wages. Adjusted fatal occupational injury rate ratios for 2005-2009 were elevated for males, older workers, and several industries and occupations. Agriculture/forestry/fishing and mining industries and transportation and materials moving occupations had the highest rate ratios. Homicide rate ratios were elevated for Black, American Indian/Alaska Native/Asian/Pacific Islanders, and foreign-born workers. CONCLUSIONS: These findings highlight the importance of understanding patterns of disparities of workplace injuries, illnesses and fatalities. Results can improve intervention efforts by developing programs that better meet the needs of the increasingly diverse U.S. workforce. Am. J. Ind. Med. 9999:1-12, 2014. Published 2014. This article is a U.S. Government work and is in the public domain in the USA. Language: en

In the brain, the components of the fibrinolytic system, tissue plasminogen activator (tPA) and its endogenous inhibitor plasminogen activator inhibitor-1 (PAI-1), regulate various neurophysiological and pathological responses. Fibrinolytic balance depends on PAI-1 and tPA concentrations. The objective of this study is to compare the effects of pulsatile and nonpulsatile perfusion on fibrinolytic balance in children undergoing pediatric cardiopulmonary bypass (CPB). Plasma PAI-1 antigen and tPA antigen were measured in 40 children (n = 20 pulsatile and n = 20 nonpulsatile group). Plasma samples (1.5 mL) were collected (i) prior to incision, (ii) 1 h after CPB, and (iii) 24 h after CPB. PAI-1 and tPA levels were measured at each time point. PAI-1 and tPA levels were significantly increased at 1 h after CPB, followed by a decrease at 24 h. Nonpulsatile but not pulsatile CPB lowered PAI-1 : tPA ratio significantly at 24 h (median PAI-1 : tPA ratio 4.63 ± 0.83:1.98 ± 0.48, P = 0.03, for the nonpulsatile group and 4.50 ± 0.92:3.56 ± 1.28, P = 0.2, for the pulsatile group). These results suggest that pulsatile flow maintains endogenous fibrinolytic balance after pediatric cardiopulmonary bypass. Further studies are needed to define the clinical significance of these differences.

The production of portland cement—the key ingredient in concrete-generates a significant amount of carbon dioxide. However, due to its incredible versatility, availability, and relatively low cost, concrete is the most consumed manufactured material on the planet. One method of reducing concrete’s contribution to greenhouse gas emissions is the use of fly ash to replace a significant amount of the cement. An experimental investigation was conducted to study the shear strength of full-scale beams constructed with both high-volume fly ash concrete (HVFAC)—concrete with at least 50% of the cement replaced with fly ash—and conventional concrete (CC). This experimental program consisted of 16 beams (12 without shear reinforcing and four with shear reinforcing in the form of stirrups). Additionally, three different longitudinal-reinforcement ratios were evaluated within the test matrix. The beams were tested under a simply supported four-point loading condition. The experimental shear strengths of the b...

Two precast prestressed high-strength concrete and high-strength self-consolidating concrete pedestrian bridges were designed and erected in Rolla, Missouri, for an in situ investigative study to monitor time-dependent losses. Using the temperature and strain data monitored by the vibrating wire strain gauges within the beam cross sections, time-dependent losses were determined and compared between the bridges and various empirical expressions presented by AASHTO and the Precast/Prestresed Concrete Institute.

Background The trauma transfusion literature has yet to resolve which is more important for hemorrhaging patients: transfusing plasma and platelets along with red blood cells (RBCs) early in resuscitation or gradually balancing blood product ratios. In a previous report of PROMMTT results, we found 1) plasma and platelet:RBC ratios increased gradually over the 6 hours following admission, and 2) patients achieving ratios >1:2 (relative to ratios

Surveys are being used increasingly in health-care research to answer questions that may be difficult to answer using other methods. While surveys depend on data that may be influenced by self-report bias, they can be powerful tools as physicians seek to enhance the quality of care delivered or the health care systems they work in. The purpose of this article is to provide readers with a basic framework for understanding survey research, with a goal of creating well-informed consumers. The importance of validation, including pretesting surveys before launch, will be discussed. Highlights from published surveys are offered as supplementary material.

BACKGROUNDThere are few clinical data to guide the use of cryoprecipitate in severely injured trauma patients. Cryoprecipitate is a rich source of fibrinogen and has been associated with improved survival in animal as well as limited human studies. Our objectives were to identify patterns and predic

BACKGROUND: The Focused Assessment with Sonography for Trauma (FAST) examination is an important variable in many retrospective trauma studies. The purpose of this study was to devise an imputation method to overcome missing data for the FAST examination. Owing to variability in patients' injuries and trauma care, these data are unlikely to be missing completely at random, raising concern for validity when analyses exclude patients with missing values. METHODS: Imputation was conducted under a less restrictive, more plausible missing-at-random assumption. Patients with missing FAST examinations had available data on alternate, clinically relevant elements that were strongly associated with FAST results in complete cases, especially when considered jointly. Subjects with missing data (32.7%) were divided into eight mutually exclusive groups based on selected variables that both described the injury and were associated with missing FAST values. Additional variables were selected within each group to classify missing FAST values as positive or negative, and correct FAST examination classification based on these variables was determined for patients with nonmissing FAST values. RESULTS: Severe head/neck injury (odds ratio [OR], 2.04), severe extremity injury (OR, 4.03), severe abdominal injury (OR, 1.94), no injury (OR, 1.94), other abdominal injury (OR, 0.47), other head/neck injury (OR, 0.57), and other extremity injury (OR, 0.45) groups had significant ORs for missing data; the other group's OR was not significant (OR, 0.84). All 407 missing FAST values were imputed, with 109 classified as positive. Correct classification of nonmissing FAST results using the alternate variables was 87.2%. CONCLUSION: Purposeful imputation for missing FAST examinations based on interactions among selected variables assessed by simple stratification may be a useful adjunct to sensitivity analysis in the evaluation of imputation strategies under different missing data mechanisms. This approach has the potential for widespread application in clinical and translational research, and validation is warranted. Language: en

Background Several predictive models have been developed to identify trauma patients who have had severe hemorrhage (SH) and may need a massive transfusion protocol (MTP). However, almost all these models define SH as the transfusion of ≥10 units of red blood cells (RBCs) within 24 hours of ED admission (aka massive transfusion, MT). This definition excludes some patients with SH, especially those who die before a 10th unit of RBCs could be transfused, which calls the validity of these prediction models into question. We show how a latent class model could improve the accuracy of identifying the SH patients.

Introduction Focused assessment with sonography for trauma (FAST) is commonly used to facilitate the timely diagnosis of life-threatening hemorrhage in injured patients. Most patients with positive findings on FAST require laparotomy. Although it is assumed that an increasing time to operation (T-OR) leads to higher mortality, this relationship has not been quantified. This study sought to determine the impact of T-OR on survival in patients with a positive FAST who required emergent laparotomy. Methods We retrospectively analyzed patients from the PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study who underwent laparotomy within 90 minutes of presentation and had a FAST performed. Cox proportional hazards models including Injury Severity Score (ISS), age, base deficit, and hospital site were created to examine the impact of increasing T-OR on in-hospital survival at 24 hours and 30 days. The impact of time from the performance of the FAST examination to operation (TFAST-OR) on in-hospital mortality was also examined using the same model. Results One hundred fifteen patients met study criteria and had complete data. Increasing T-OR was associated with increased in-hospital mortality at 24 hours (hazard ratio [HR], 1.50 for each 10-minute increase in T-OR; confidence interval [CI], 1.14-1.97; p = 0.003) and 30 days (HR, 1.41; CI, 1.18-2.10; p = 0.002). Increasing TFAST-OR was also associated with higher in-hospital mortality at 24 hours (HR, 1.34; CI, 1.03-1.72; p = 0.03) and 30 days (HR, 1.40; CI, 1.06-1.84; p = 0.02). Conclusion In patients with a positive FAST who required emergent laparotomy, delay in operation was associated with increased early and late in-hospital mortality. Delays in T-OR in trauma patients with a positive FAST should be minimized.

Acute lung injury following trauma resuscitation remains a concern despite recent advances. With the use of the PROMMTT study population, the risk of hypoxemia and potential modifiable risk factors are studied.Patients with survival for 24 hours or greater with at least one intensive care unit day were included in the analysis. Hypoxemia was categorized using the Berlin definition for adult respiratory distress syndrome: none (PaO₂-to-FIO₂ ratio [P/F]300 mm Hg), mild (P/F, 201-300 mm Hg), moderate (P/F, 101-200 mm Hg) or severe (P/F ≤ 100 mm Hg). The cohort was dichotomized into those with none or mild hypoxemia and those with moderate or severe injury. Early resuscitation was defined as that occurring 0 hour to 6 hours from arrival; late resuscitation was defined as that occurring 7 hours to 24 hours. Multivariate logistic regression models were developed controlling for age, sex, mechanisms of injury, arrival physiology, individual Abbreviated Injury Scale (AIS) scores, blood transfusions, and crystalloid administration.Of the patients 58.7% (731 of 1,245) met inclusion criteria. Hypoxemia occurred in 69% (mild, 24%; moderate, 28%; severe, 17%). Mortality was highest (24%) in the severe group. During early resuscitation (0-6 h), logistic regression revealed age (odd ratio [OR], 1.02; 95% confidence interval [CI], 1.00-1.04), chest AIS score (OR, 1.31; 95% CI, 1.10-1.57), and intravenously administered crystalloid fluids given in 500 mL increments (OR, 1.12; 95% CI, 1.01-1.25) as predictive of moderate or severe hypoxemia. During late resuscitation, age (OR, 1.02; 95% CI, 1.00-1.04), chest AIS score (OR, 1.33; 95% CI, 1.11-1.59), and crystalloids given during this period (OR, 1.05; 95% CI, 1.01-1.10) were also predictive of moderate-to-severe hypoxemia. Red blood cell, plasma, and platelet transfusions (whether received during early or late resuscitation) failed to demonstrate an increased risk of developing moderate/severe hypoxemia.Severe chest injury, increasing age, and crystalloid-based resuscitation, but not blood transfusions, were associated with increased risk of developing moderate-to-severe hypoxemia following injury.

Missing data are inherent in clinical research and may be especially problematic for trauma studies. This study describes a sensitivity analysis to evaluate the impact of missing data on clinical risk prediction algorithms. Three blood transfusion prediction models were evaluated using an observational trauma data set with valid missing data.The PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study included patients requiring one or more unit of red blood cells at 10 participating US Level I trauma centers from July 2009 to October 2010. Physiologic, laboratory, and treatment data were collected prospectively up to 24 hours after hospital admission. Subjects who received 10 or more units of red blood cells within 24 hours of admission were classified as massive transfusion (MT) patients. Correct classification percentages for three MT prediction models were evaluated using complete case analysis and multiple imputation. A sensitivity analysis for missing data was conducted to determine the upper and lower bounds for correct classification percentages.PROMMTT study enrolled 1,245 subjects. MT was received by 297 patients (24%). Missing percentage ranged from 2.2% (heart rate) to 45% (respiratory rate). Proportions of complete cases used in the MT prediction models ranged from 41% to 88%. All models demonstrated similar correct classification percentages using complete case analysis and multiple imputation. In the sensitivity analysis, correct classification upper-lower bound ranges per model were 4%, 10%, and 12%. Predictive accuracy for all models using PROMMTT data was lower than reported in the original data sets.Evaluating the accuracy clinical prediction models with missing data can be misleading, especially with many predictor variables and moderate levels of missingness per variable. The proposed sensitivity analysis describes the influence of missing data on risk prediction algorithms. Reporting upper-lower bounds for percent correct classification may be more informative than multiple imputation, which provided similar results to complete case analysis in this study.

For years, scientists from various disciplines have studied the effects of endocrine disrupting chemicals (EDCs) on the health and wellbeing of humans and wildlife. Some studies have specifically focused on the effects of low doses, i.e. those in the range that are thought to be safe for humans and/or animals. Others have focused on the existence of non-monotonic dose-response curves. These concepts challenge the way that chemical risk assessment is performed for EDCs. Continued discussions have clarified exactly what controversies and challenges remain. We address several of these issues, including why the study and regulation of EDCs should incorporate endocrine principles; what level of consensus there is for low dose effects; challenges to our understanding of non-monotonicity; and whether EDCs have been demonstrated to produce adverse effects. This discussion should result in a better understanding of these issues, and allow for additional dialogue on their impact on risk assessment.

BACKGROUND: The classic definition of massive transfusion, 10 or more units of red blood cells (RBCs) in 24 hours, has never been demonstrated as a valid surrogate for severe hemorrhage and can introduce survival bias. In addition, the definition fails to capture other products that the clinician may have immediately available, and may use, during the initial resuscitation. Assuming that units of resuscitative fluids reflect patient illness, our objective was to identify a rate of resuscitation intensity (RI) that could serve as an early surrogate of sickness for patients with substantial bleeding after injury. METHODS: Adult patients surviving at least 30 minutes after admission and receiving one or more RBCs within 6 hours of admission from 10 US Level 1 trauma centers were enrolled in the PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study. Total fluid units were calculated as the sum of the number of crystalloid units (1 L = 1 U), colloids (0.5 L = 1 U), and blood products (1 RBC = 1 U, 1 plasma = 1 U, 6 pack platelets = 1 U). Univariable and multivariable logistic regressions were used to evaluate associations between RI and 6-hour mortality, adjusting for age, center, penetrating injury, weighted Revised Trauma Score (RTS), and Injury Severity Score (ISS). RESULTS: A total of 1,096 eligible patients received resuscitative fluids within 30 minutes, including 620 transfused with blood products. Despite varying products used, the total fluid RI was similar across all sites (3.2T 2.5 U). Patients who received four or more units of any resuscitative fluid had a 6-hour mortality rate of 14.4% versus 4.5% in patients who received less than 4 U. The adjusted odds ratio of 6-hour mortality for patients receiving 4 U or more within 30 minutes was 2.1 (95% confidence interval, 1.2Y3.5). CONCLUSION: Resuscitation with four or more units of any fluid was significantly associated with 6-hour mortality. This study suggests that early RI regardless of fluid type can be used as a surrogate for sickness and mortality in severely bleeding patients. ( JT rauma Acute Care Surg. 2013;74: S16YS23. Copyright * 2013 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.

Aim: In this study, we sought to assess patient awareness and perceptions of an opt-out biorepository. Materials & methods: We conducted exit interviews with adult patients and parents of pediatric patients having their blood drawn as part of their clinical care at Vanderbilt University Medical Center (TN, USA). Results: 32.9% of all patients and parents of pediatric patients report having heard of the opt-out biorepository, while 92.4% approve of this research effort based on a brief description. Awareness that leftover blood could be used for research increased among adult patients during the study period, from 34.3 to 50.0%. Conclusion: These findings will inform ongoing assessments of the suitability of opt-out and opt-in methods as alternatives to written informed consent for inclusion in a biorepository.

The production of portland cement – the key ingredient in concrete – generates a significant amount of carbon dioxide. However, due to its incredible versatility, availability, and relatively low cost, concrete is the most consumed manmade material on the planet. One method of reducing concrete’s contribution to greenhouse gas emissions is the use of fly ash to replace a significant amount of the cement. This paper compares two experimental studies that were conducted to investigate the shear strength of full-scale beams constructed with high-volume fly ash concrete (HVFAC) – concrete with at least 50% of the cement replaced with fly ash. The primary difference between the two studies involved the amount of cementitious material, with one mix having a relatively high total cementitious content (502 kg/m 3 ) and the other mix having a relatively low total cementitious content (337 kg/m 3 ). Both mixes utilized a 70% replacement of portland cement with a Class C fly ash. Each of these experimental programs consisted of eight beams (six without shear reinforcing and two with shear reinforcing in the form of stirrups) with three different longitudinal reinforcement ratios. The beams were tested under a simply supported four-point loading condition. The experimental shear strengths of the beams were compared with both the shear provisions of selected standards (US, Australia, Canada, Europe, and Japan) and a shear database of conventional concrete (CC) specimens. Furthermore, statistical data analyses (both parametric and nonparametric) were performed to evaluate whether or not there is any statistically significant difference between the shear strength of both mixes. Results of these statistical tests show there is no significant difference between the shear strength of these two HVFAC mixes for the beams tested in this investigation.

Less than 5% of chest pain in children is cardiac in origin, yet this complaint still represents one of the top reasons children are referred to pediatric cardiologists. This article describes a patient whose cardiac tumor illustrates the challenges of evaluating pediatric chest pain and the Standardized Clinical Assessment and Management Plan algorithm that can help.

The objective of this study was to evaluate the hemodynamic performance and gaseous microemboli (GME) handling ability of a simulated neonatal extracorporeal life support (ECLS) circuit with an in-line continuous renal replacement therapy (CRRT) device. The circuit consisted of a Maquet RotaFlow centrifugal pump or HL20 roller pump, Quadrox-iD Pediatric diffusion membrane oxygenator, 8-Fr arterial cannula, 10-Fr venous cannula, and Better-Bladder (BB) with "Y" connector. A second Quadrox-I Adult oxygenator was added postarterial cannula for GME experiments. The circuit and pseudo-patient were primed with lactated Ringer's solution and packed human red blood cells (hematocrit 40%). All hemodynamic trials were conducted at ECLS flow rates ranging from 200 to 600 mL/min and CRRT flow rate of 75 mL/min at 36°C. Real-time pressure and flow data were recorded with a data acquisition system and GME were detected and characterized using the Emboli Detection and Classification Quantifier System. CRRT was added at distinct locations such that blood entered CRRT between the pump and oxygenator (A), recirculated through the pump (B), or bypassed the pump (C). With the centrifugal pump, all CRRT positions had similar flow rates, mean arterial pressure (MAP), and total hemodynamic energy (THE) loss. With the roller pump, C demonstrated increased flow rates (293.2-686.4 mL/min) and increased MAP (59.4-75.5 mm Hg) (P 0.01); B had decreased flow rates (129.7-529.7 mL/min), and MAP (34.2-45.0 mm Hg) (P 0.01); A maintained the same when compared to without CRRT. At 600 mL/min C lost more THE (81.4%) (P 0.01) with a larger pressure drop across the oxygenator (95.6 mm Hg) (P 0.01) than without CRRT (78.3%; 49.1 mm Hg) (P 0.01). C also demonstrated a poorer GME handling ability using the roller pump, with 87.1% volume and 17.8% count reduction across the circuit, compared to A and B with 99.9% volume and 65.8-72.3% count reduction. These findings suggest that, in contrast to A and B, adding CRRT at position C is unsafe and not advised for clinical use.

To evaluate efficacy and safety of a novel device that combines an inferior vena cava (IVC) filter and central venous catheter (CVC) for prevention of pulmonary embolism (PE) in critically ill patients.In a multicenter, prospective, single-arm clinical trial, the device was inserted at the bedside without fluoroscopy and subsequently retrieved before transfer from the intensive care unit (ICU). The primary efficacy endpoint was freedom from clinically significant PE or fatal PE 72 hours after device removal or discharge, whichever occurred first. Secondary endpoints were incidence of acute proximal deep venous thrombosis (DVT), catheter-related thrombosis, catheter-related bloodstream infections, major bleeding events, and clinically significant thrombus (occupying25% of volume of filter) detected by cavography before retrieval.The device was placed in 163 critically ill patients with contraindications to anticoagulation; 151 (93%) were critically ill trauma patients, 129 (85%) had head or spine trauma, and 102 (79%) had intracranial bleeding. The primary efficacy endpoint was achieved for all 163 (100%) patients (95% confidence interval [CI], 97.8%-100%, P.01). Diagnosis of new or worsening acute proximal DVT was time dependent with 11 (7%) occurring during the first 7 days. There were no (0%) catheter-related bloodstream infections. There were 5 (3.1%) major bleeding events. Significant thrombus in the IVC filter occurred in 14 (8.6%) patients. Prophylactic anticoagulation was not initiated for a mean of 5.5 days ± 4.3 after ICU admission.This novel device prevented clinically significant and fatal PE among critically ill trauma patients with low risk of complications.

Background Crotaline envenomation clinical manifestations vary considerably among patients. Current recommendations for treatment with Crotalidae polyvalent immune Fab require assessment of envenomation control. Determining control of envenomation, particularly when patients are evaluated by different providers in separate clinical settings, can be difficult. Objective To determine if a difference in total vials of Crotalidae antivenin therapy exists between pre-protocol and post-Snakebite Severity Score (SSS) protocol. Methods Retrospective medical record review at an academic medical and regional Level I trauma center. Resource utilization in patients with a diagnosis of “snakebite” was compared between patients treated pre- and post-SSS protocol implementation. Results One hundred forty-six patients were included in the evaluation. One hundred twenty-seven (87.0%) patients received antivenin, n = 80 (90.9%) in the pre-protocol group and n = 47 (81.0%) in the post-protocol group. Median total number of antivenin vials per patient was lower in the post-protocol group than the pre-protocol group, 16 (10–24 interquartile range) vs. 12 (10–16 interquartile range), p = 0.006. This decreased utilization correlates to an approximate $13,200 savings per patient. Hospital and intensive care unit length of stay, opioid use, incidence of blood product transfusion, need for surgical intervention, or need for intubation were not different between groups. Conclusions A snakebite protocol with SSS utilization to guide antivenin administration results in significantly decreased antivenin therapy in snakebite patients without increase in other health care utilization.

The need for repair and rehabilitation is a crucial issue today in order to maintain a safe and efficient transportation network. One of the most recent innovative composite materials that has been proposed to the market is a fabric reinforced cementitious matrix (FRCM) strengthening system. This system consists of two components: a structural reinforcement mesh and a cementitious matrix. The structural reinforcement mesh consists of a polyparaphenylene benzobisoxazole (or PBO) fiber composite, while the cementitious matrix is a nontoxic grout system based on portland cement with a low dosage of dry polymers. The first aim of this study was to evaluate the fatigue resistance of reinforced concrete (RC) beams strengthened with FRCM under fatigue loading and postfatigue flexural strength to failure. The second aim was to investigate the durability performance of the FRCM after exposure to environmental conditioning including temperature, moisture, and sustained stress. All of the beam specimens exam...

The purpose of this retrospective study was to examine the relationship between demographic and educational variables and student performance on an internal medicine (IM) clerkship in order to target areas for educational intervention and potential early remediation. This study examined data associated with third-year medical student performance (N = 505) during the IM clerkship at Baylor Scott & White, Temple/Texas A&M Health Science Center College of Medicine from 2005 to 2011. Multiple regression analysis (N = 341) showed that a model containing the following variables was significantly associated with scores on the National Board of Medical Examiners (NBME) subject exam, accounting for 46.5% of the variance: Objective Structured Clinical Exam (OSCE), Medical College Admissions Test (MCAT), US Medical Licensing Exam (USMLE) Step 1, second-year grade point average (GPA), and clinical evaluation. A model containing USMLE Step 1, clinical evaluation, and NBME was significantly associated with OSCE score, accounting for 30% of the variance. Additionally, a model containing age, MCAT score, undergraduate GPA, NBME subject exam score, and OSCE was significantly associated with clinical evaluation score, accounting for 22% of score variance. Age accounted for the most unique variance in clinical evaluation score. Gender and IM interest group were not significantly associated with any outcome variable. In conclusion, in contrast to previous studies in the field, we did not find a significant association between undergraduate GPA and NBME score. Our findings supply further evidence that the OSCE, typically believed to be a clinical performance exam, actually assesses a broader set of domains. Interest group membership did not confer any academic benefit to medical students in IM clerkships in our study.

Much of the research on the strengthening of masonry structures has focused on strengthening ofunreinforcedmasonry structures; as a result, most strengthening design guidelines are limited to this type of structural strengthening. In addition, only a limited experimental database of reinforced masonry structures with strengthening is available. The main purpose of this research is to study the behavior of fully grouted reinforced masonry walls strengthened with Fiber Reinforced Cementitious Matrix (FRCM) system under out-of-plane action. Seven reinforced masonry walls strengthened in flexure using (FRCM) were built as a part of this study. Two reinforced walls constructed in running and stack bond pattern were investigated as control specimens and the other specimens were strengthened using different types of fibers. FRCM strengthening composite materials consisted of one or two plies of fabric embedded in cementitious mortar. The test results indicated that the FRCM system is a very effective technique for upgrading flexural capacity of masonry walls and improve the behavior of stack wall.‌‌

Fiber-reinforced polymers (FRP) were recently used as a replacing reinforcement in concrete structures in view of their excellent resistance to corrosion, light weight, and high specific strength. A state of art of using carbon fiber grids as an internal reinforcement with self- consolidate concrete in two-way slab systems is presented here. The experimental program included studying the flexural performance of the carbon fiber grid as in comparison with the conversional welded steel wire mesh. This work is expected to find its application in parking garages to enhance the durability performance and extend the service life of the concrete slab members. The load –deflection curves, ultimate loads, energy absorption, and failure mode of simply supported slabs with different aspect ratios are discussed. The test results for simply supported slabs with aspect ratio of (1:1) showed that the FRP grid tended to fall within the criteria of minimum load requirements per ASCE7 as the steel wire reinforcement did. In addition, the slabs observed a limit of deflection (L/360) at approximately 50% of their ultimate loads.

Occult coronary artery obstruction can be a late source of morbidity and mortality following the arterial switch operation for transposition of the great arteries. We describe a case of undiagnosed left coronary ostial obstruction in a teenager which may have contributed to perioperative ventricular dysfunction and subsequent mortality following a reoperation many years after arterial switch.

Recent research has been conducted to evaluate the benefits provided by externally-applied discrete fiber-reinforced polyurea (DFRP) coating systems. This coating was proposed to allow for ease of construction in repair-retrofit situations and to provide multihazard benefits, ranging from blast or impact fragmentation mitigation to seismic reinforcement and general strengthening. This phase of research investigated the flexural and shear reinforcement capabilities of the systems. Testing parameters included type of structural failure, polyurea, and fiber volume fraction. Additionally, the effects of the thickness of the composite system were considered. Concrete beam specimens were fabricated and coated per the designed test matrix and subjected to four-point bending. Analysis was based on ultimate capacity, deflection, overall ductility, and the qualitative observations of coating adhesion and fragmentation confinement. In addition, a theoretical model was developed and validated to describe the flexural behavior of the polyurea-coated beams and to normalize the test data for comparison. Results presented in this paper suggest measurable strengthening for both flexural and shear capacity provided by the coating system and substantial gains in ductility. DOI: 10.1061/(ASCE)CC.1943-5614.0000308. © 2013 American Society of Civil Engineers. CE Database subject headings: Fiber reinforced polymer; Rehabilitation; Reinforced concrete; Flexural strength; Shear strength; Model verification.

Every year concrete production exceeds 6.5 billion tons worldwide, nearly 1 ton for every man, woman, and child on the planet. In fact, concrete is used 10 times more than any other building material in the world, primarily because of its incredible versatility, availability, and relatively low cost. Unfortunately, the production of portland cement—the key ingredient in concrete—generates approximately a pound of carbon dioxide for every pound of cement produced. One method of reducing concrete's carbon footprint is to replace a significant amount of the cement with fly ash, a by-product of coal-burning thermal power stations. This paper presents the results of an investigation of the shear strength of full-scale reinforced concrete beams constructed with both high-volume fly ash concrete (concrete with at least 50% of the cement replaced with fly ash) and conventional concrete. A test matrix of 16 beams included 12 beams without shear reinforcing and four with shear reinforcing in the form of stirrups; eight beams were constructed from each concrete type. Evaluation of the test results included a comparison with U.S. and international design codes, an examination based on AASHTO load and resistance factor design provisions of the longitudinal strains and angle of the critical flexure-shear crack, a comparison with an extensive database of shear tests on conventional concrete, and a detailed statistical study. The results revealed that the high-volume fly ash concrete beams had higher shear strengths than the conventional concrete beams tested in this investigation.

Background: Coarctation is a congenital narrowing of the aorta that often requires repair during infancy. The subclavian flap aortoplasty was once widely favored for its avoidance of a circumferential suture line and low incidence of recoarctation. The aim of this study is to report the long-term results of the subclavian flap repair for coarctation of the aorta in infants. Methods: Our operative database was queried for infants with coarctation who underwent subclavian flap aortoplasty from 1966 to 1991. Medical records were reviewed for patient characteristics and outcomes. Survivors were identified for additional phone interview. Results: Fifty-five patients met the inclusion criteria. There were 7 early deaths (in hospital), 11 late deaths, 5 patients lost to follow-up, and 32 known long-term survivors with a mean follow-up of 22.0 years (range 2.4-34.9). Hospital mortality was not associated with patient characteristics but was associated with earlier year of surgery ( P = .015). A trend toward decreased overall survival was seen in patients with coarctation with associated cardiac defects ( P = .072). Reintervention for recoarctation was required in 3 (6.6%) patients and was not related to the patient characteristics. There were no apparent complications related to subclavian artery sacrifice. Conclusions: Subclavian flap aortoplasty provides excellent long-term results for the repair of coarctation in infants. The incidence of recoarctation requiring reintervention is low and compares favorably with other techniques. Compromise of growth or function of the left arm was not appreciated. The subclavian flap technique remains a viable surgical option for the repair of coarctation in infants.

Early predictors of massive transfusion (MT) would prevent undertriage of patients likely to require MT. This study validates triggers using the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study.All enrolled patients in PROMMTT were analyzed. The initial emergency department value for each trigger (international normalized ratio [INR], systolic blood pressure, hemoglobin, base deficit, positive result for Focused Assessment for the Sonography of Trauma examination, heart rate, temperature, and penetrating injury mechanism) was compared for patients receiving MT (≥ 10 U of packed red blood cells in 24 hours) versus no MT. Adjusted odds ratios (ORs) for MT are reported using multiple logistic regression. If all triggers were known, a Massive Transfusion Score (MTS) was created, with 1 point assigned for each met trigger.A total of 1,245 patients were prospectively enrolled with 297 receiving an MT. Data were available for all triggers in 66% of the patients including 67% of the MTs (199 of 297). INR was known in 87% (1,081 of 1,245). All triggers except penetrating injury mechanism and heart rate were valid individual predictors of MT, with INR as the most predictive (adjusted OR, 2.5; 95% confidence interval, 1.7-3.7). For those with all triggers known, a positive INR trigger was seen in 49% receiving MT. Patients with an MTS of less than 2 were unlikely to receive MT (negative predictive value, 89%). If any two triggers were present (MTS ≥ 2), sensitivity for predicting MT was 85%. MT was present in 33% with an MTS of 2 greater compared with 11% of those with MTS of less than 2 (OR, 3.9; 95% confidence interval, 2.6-5.8; p0.0005).Parameters that can be obtained early in the initial emergency department evaluation are valid predictors for determining the likelihood of MT.Diagnostic, level II.

The Eighth International Conference on Pediatric Mechanical Circulatory Support Systems and Pediatric Cardiopulmonary Perfusion was held at the Galatasaray University, Istanbul, Turkey, June 13–16, 2012 (Fig. 1).Atif Akcevin, MD, was the local chair of the conference. The scientific co-chairs of the eighth event were Atif Akcevin, Tijen Alkan-Bozkaya, Ihsan Bakir, Hakan Ceyran, Yves Durandy, Huriyet Ersayin-Kantas, Colleen E. Gruenwald, David Palanzo, Linda Pauliks, Kerem Pekkan, Chitra Ravishankar, Eugen Sandica, Kyung Sun, Riza Turkoz, Akif Undar, Bonnie Weaver, and John L. Myers. As we stated in the past seven editorials, the overall objective of the meeting was and still is to bring together internationally known clinicians, bioengineers, and basic scientists involved in research on pediatric mechanical circulatory support systems and pediatric cardiopulmonary bypass procedures. Primarily, we focus to explicitly describe the problems with current pediatric mechanical circulatory support systems, methods, and techniques during acute and chronic support and to suggest solutions and future directions for research (1–3). Over 200 participants from 20 countries participated at the eighth annual event. One hundred one formal presentations including a keynote lecture, 40 invited lectures, 29 oral, and 32 poster presentations began on Thursday morning June 14, 2012 and continued through Saturday evening June 16, 2012. To date, over 800 presentations (320 invited lectures, 220 slide, and 260 poster presentations) and 400 peer-reviewed articles were published based on this unique event (http://pennstatehershey.org/web/ pedscpb/home). It was a great honor to have William S. Pierce, MD, from Penn State Hershey College of Medicine, as the keynote lecturer. His lecture entitled “A 40-Year Odyssey in Mechanical Circulatory Support” was a great historic lecture and it was a privilege to listen to his talk (Figs. 2 and 3a,b). In addition, platform presentations took place in 2-h blocks during the morning and afternoon sessions on Thursday, Friday, and Saturday. Plenary sessions were held throughout the conference focusing on key topics including “Managing the Single Ventricle Patient from Fetus to Definite Treatment” (led by co-chairs David Anderson, MD, and John L. Myers, MD), “Pediatric MCS—Devices & Outcomes” (led by co-chairs William S. Pierce, MD, and Kyung Sun, MD, PhD, MBA), “Bioengineering Approaches in Pediatric Cardiovascular Medicine” (led by Akif Undar, PhD, and Jeffrey D. Zahn, PhD), “Extracorporeal Life Support” (led by Chitra Ravishankar, MD, and Bonnie Weaver, RN, CCRN), “Multi-Disciplinary Team Approach to Solve the Complex Problems in Neonatal and Pediatric Cardiac Surgery” (led by Ihsan Bakir, MD [Turkey], and Tayyar Sarioglu, MD), “Cardiopulmonary Perfusion” (led by Colleen E. Gruenwald, PhD, and David Palanzo, CCP), “Myocardial Protection during CPB” doi:10.1111/j.1525-1594.2012.01562.x FIG. 1. Halil Tűrkoglu, William S. Pierce, PeggyJayne Pierce, Akif Undar, Ihsan Bakir, and John L. Myers. bs_bs_banner

Background We sought to determine whether aggressive resuscitation in trauma patients presenting without vital signs, or "dead on arrival," was futile. We also sought to determine whether organ donation was an unexpected benefit of aggressive resuscitation. Study Design We conducted a review of adults presenting to our Level I trauma center with no signs of life (pulse = 0 beats/min; systolic blood pressure = 0 mmHg; and no evidence of neurologic activity, Glasgow Coma Scale score = 3). Primary end point was survival to hospital discharge or major organ donation (ie heart, lung, kidney, liver, or pancreas were harvested). We compared our survival rates with those of the National Trauma Data Bank in 2012. Patient demographics, emergency department vital signs, and outcomes were analyzed. Results Three hundred and forty patients presented with no signs of life to our emergency department after injury (median Injury Severity Score = 40). There were 7 survivors to discharge, but only 5 (1.5%) were functionally independent (4 were victims of penetrating trauma). Of the 333 nonsurvivors, 12 patients (3.6%) donated major organs (16 kidneys, 2 hearts, 4 livers, and 2 lungs). An analysis of the National Trauma Data Bank yielded a comparable survival rate for those presenting dead on arrival, with an overall survival rate of 1.8% (100 of 5,384); 2.3% for blunt trauma and 1.4% for penetrating trauma. Conclusions Trauma patients presenting dead on arrival rarely (1.5%) achieve functional independence. However, organ donation appears to be an under-recognized outcomes benefit (3.6%) of the resuscitation of injury victims arriving without vital signs.

The hybrid composite beam (HCB) is a novel idea that combines conventional construction materials (i.e., steel and concrete) with fiber-reinforced polymer (FRP) composites in a new configuration. This hybridization aims to optimize the beam’s structural performance and produce a structural element that is more durable than conventional members. This study examined the durability of a commercial glass FRP (GFRP) laminate that was used to encase the HCB elements in a recently constructed HCB bridge. The E-glass/vinyl ester laminate was subjected to five aging regimes. These conditioning regimes simulated an alkaline attack, a salt attack, a salt attack that was preceded by ultraviolet (UV) irradiation exposure, and sustained stresses that were accompanied by controlled thermal cycles and natural weathering. The durability of the E-glass/vinyl ester laminate was examined in terms of changes that occurred in the ultimate tensile strength. A microstructural analysis was performed on both unconditioned ...

A retrospective review of 77 pediatric and neonatal extracorporeal membranous oxygenation (ECMO) patients who received recombinant antithrombin III (ATIII) for ATIII activity greater than 80% was conducted. Anticoagulation management was per institutional protocol. An ATIII activity greater than 80% was targeted. Diagnosis, reason for ECMO cannulation, blood product usage, heparin dosing, ATIII activity and doses, thrombotic and bleeding complications, hours on ECMO, and mortality were recorded. We calculated patient-level summary statistics and assessed differences between groups using χ tests (categorical variables) and Wilcoxon rank sum tests (continuous variables). Hierarchical generalized linear models were developed to model bleeding and thrombotic complications. The majority (n = 75) received venoarterial ECMO and had cardiac diagnoses (n = 62). Antithrombin III activity was below 80% for an average of 5.2 hours per patient. Antithrombin III activity less than 80% was not associated with thrombotic complications (odds ratio [OR] = 1.02, 95% confidence interval [CI] = 0.97-1.06, p = 0.86). Antithrombin III activity greater than 80% was not associated with bleeding complications (OR = 1.06, 95% CI = 1.01-1.11, p = 0.44). Duration of ECMO was an independent predictor of thrombotic complications (OR = 1.08, 95% CI = 1.02-1.11, p = 0.02). There were no independent predictors of bleeding complications. Antithrombin III activity correlated with anti Xa activity (r = 0.367, p < 0.001) but not with other measures of anticoagulation or with heparin dose (r = 0.16, p = 0.165). ATIII activity was not associated with bleeding, thrombosis, or heparin dose. Antithrombin III activity was associated with anti Xa activity but not with traditional measures of anticoagulation. Antithrombin III replacement for an activity less than 80% did not increase bleeding.