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While extracorporeal membrane oxygenation (ECMO) is effective in preventing further hypoxemia and maintains blood flow in endotoxin-induced shock, ECMO alone does not reverse the hypotension. In this study, we tested whether concurrent vasopressor use with ECMO would provide increased circulatory support and blood flow, and characterized regional blood flow distribution to vital organs. Endotoxic shock was induced in piglets to achieve a 30% decrease in mean arterial pressure (MAP). Measurements of untreated pigs were compared to pigs treated with ECMO alone or ECMO and vasopressors. ECMO provided cardiac support during vasodilatory endotoxic shock and improved oxygen delivery, but vasopressor therapy was required to return MAP to normotensive levels. Increased blood pressure with vasopressors did not alter oxygen consumption or extraction compared to ECMO alone. Regional microcirculatory blood flow (RBF) to the brain, kidney, and liver were maintained or increased during ECMO with and without vasopressors. ECMO support and concurrent vasopressor use improve regional blood flow and oxygen delivery even in the absence of full blood pressure restoration. Vasopressor-induced selective distribution of blood flow to vital organs is retained when vasopressors are administered with ECMO.

ObjectiveTo characterize hospitals where military-insured newborns received care and test the association of regional perinatal risk with neonatal intensive care unit (NICU) capacity.Study designWe identified birth hospitals for live newborns October 2015–December 2018 (n = 296,568) and assigned newborns to health service areas (HSAs). Perinatal risk factors and the number of neonatal special care beds and neonatologists were calculated at HSA levels. Cross-sectional correlation analyses assessed perinatal risk factors and capacity across HSAs.Results27.0% (n = 10) of military birth hospitals had special care beds (intermediate and intensive) compared with 44.3% of civilian hospitals (n = 1224; p < 0.05). The number of special care beds and neonatologists per newborn varied more than twofold across regions and were only weakly associated with the proportion of higher risk newborns (R2 < 0.05).ConclusionsThe lack of meaningful association of regional perinatal risk with NICU capacity poses challenges for effective specialized care among military-associated newborns.

ObjectiveThe objective of this study is to discern patterns of serum sodium in a broad cohort of extremely low birth weight (ELBW) infants and associate those patterns with hospital outcomes.Study DesignRetrospective cohort study of ELBW infants from 323 neonatal intensive care units (NICUs) discharged from 2004 to 2014. We included patients who survived at least 7 days and had daily sodium levels available, and categorized infants by their minimum and maximum sodium levels.ResultsWe identified 26,871 infants of whom 12,428 met inclusion criteria. Only 1964 (15.8%) maintained eunatremia for the first week. We found most dysnatremias to be associated with increased overall mortality compared with eunatremic patients including moderate hyponatremia (12.9% vs. 8.6%, p < 0.05) and severe hypernatremia (34.8% vs. 8.6%, p < 0.001). Most of these associations were maintained after regression modeling for mortality.ConclusionSodium fluctuations occurring within the first week of life are associated with increased mortality.

Background: Neonates undergoing clinical evaluations are often subjected to potentially painful phlebotomy for laboratory tests. The use of cord blood laboratory values for admission has been suggested as a means to decrease the risk of painful venipuncture and anemia.Methods: Peripheral and umbilical cord blood complete blood count (CBC) results were obtained from infants who required a CBC. Results were compared using the Sysmex XN heme analyzer (Sysmex, Kobe, Japan).Results: White blood cell (WBC) and hemoglobin (HgB) values were significantly higher in peripheral samples than in cord samples. The mean cord WBC count was 14.1 × 103/mm3 versus 15.6 × 103/mm3 peripherally (p < 0.001). The mean cord HgB was 15.8 g/dL versus 16.8 g/dL peripherally (p < 0.001). Cord platelet (Plt) counts were, conversely, lower in peripheral samples than in cord samples (264.8 × 103/mm3 versus 242.3 × 103/mm3, respectively; p < 0.001). Although statistically different, the mean CBC values from both samples were within the reference ranges. Delayed cord clamping (DCC) increased peripheral versus cord HgB difference nearly threefold (0.6-1.7 g/dL; p = 0.01).Conclusions: Cord blood is an acceptable source for CBC blood sampling in newborn infants and can be used for clinical decisions. CBC laboratory values for cord blood remained within the peripheral blood reference range, with slight variability between the two samples.

Streptococcus agalactiae (Group B Streptococcus, GBS) normally colonizes healthy adults but can cause invasive disease, such as meningitis, in the newborn. To gain access to the central nervous system, GBS must interact with and penetrate brain or meningeal blood vessels; however, the exact mechanisms are still being elucidated. Here, we investigate the contribution of BspC, an antigen I/II family adhesin, to the pathogenesis of GBS meningitis. Disruption of the bspC gene reduced GBS adherence to human cerebral microvascular endothelial cells (hCMEC), while heterologous expression of BspC in non-adherent Lactococcus lactis conferred bacterial attachment. In a murine model of hematogenous meningitis, mice infected with ΔbspC mutants exhibited lower mortality as well as decreased brain bacterial counts and inflammatory infiltrate compared to mice infected with WT GBS strains. Further, BspC was both necessary and sufficient to induce neutrophil chemokine expression. We determined that BspC interacts with the host cytoskeleton component vimentin and confirmed this interaction using a bacterial two-hybrid assay, microscale thermophoresis, immunofluorescent staining, and imaging flow cytometry. Vimentin null mice were protected from WT GBS infection and also exhibited less inflammatory cytokine production in brain tissue. These results suggest that BspC and the vimentin interaction is critical for the pathogenesis of GBS meningitis.

We examined natural and anthropogenic controls on terrestrial evapotranspiration (ET) changes from 1982 to 2010 using multiple estimates from remote sensing-based datasets and process-oriented land surface models. A significant increasing trend of ET in each hemisphere was consistently revealed by observationally-constrained data and multi-model ensembles that considered historic natural and anthropogenic drivers. The climate impacts were simulated to determine the spatiotemporal variations in ET. Globally, rising CO2 ranked second in these models after the predominant climatic influences, and yielded decreasing trends in canopy transpiration and ET, especially for tropical forests and high-latitude shrub land. Increasing nitrogen deposition slightly amplified global ET via enhanced plant growth. Land-use-induced ET responses, albeit with substantial uncertainties across the factorial analysis, were minor globally, but pronounced locally, particularly over regions with intensive land-cover changes. Our study highlights the importance of employing multi-stream ET and ET-component estimates to quantify the strengthening anthropogenic fingerprint in the global hydrologic cycle.

BackgroundExtracorporeal Membrane Oxygenation (ECMO) provides a heart-lung bypass for patients with life-threatening cardiorespiratory failure. It is a classic low-volume, a high-risk procedure that requires specialized training to develop and maintain competence. Therefore, our ability to train efficiently and effectively is essential. The purpose of this study is to determine if specific participant training or experience leads to better performance in emergency ECMO scenarios during high-fidelity simulation training.MethodsFifty-one physicians, nurses, and respiratory/medical technicians participated in a study comparing an animal model vs. simulation-based ECMO education. All completed a multiple-choice questionnaire about prior ECMO experience and other demographics, as well as a four-hour pre-lab didactic session. They completed individual ECMO scenarios with both modalities during two sessions, and task completion times (minutes) and scores (percentage) were measured using a validated ECMO skills assessment tool. The scores of the 19 participants who completed the simulation-based scenarios during their first session were further analyzed in the context of their self-reported ECMO experience, and participants were divided into a novice group and an experienced group. Statistical testing included the Mann-Whitney U test (times) and Fisher’s exact test (scores).ResultsData from the 19 participants who completed the simulation-based ECMO training on the first session showed no statistically significant differences in the task completion time or scores among those in the novice group vs. the experienced group in the years of ECMO experience category (28 vs. 34 minutes; p=0.66 and 61% vs. 62%; p=0.54), a number of cannulations category (30 vs. 25 minutes; p=0.11 and 59% vs. 62%; p=0.82) or the number of ECMO patients cared for category (28 vs. 34 minutes; p=0.30 and 57% vs. 62%; p=0.54). Findings were similar for both the lecture-based training and simulation-based training categories, respectively (33 vs. 28 minutes; p=0.71 and 62% vs. 60%; p=0.91 and 34 vs. 28 minutes; p=0.74 and 63% vs. 58%; p=0.12).ConclusionAmong this small subset of participants, we observed no statistically significant differences in performance based on participant experience during simulation-based ECMO scenarios. The didactic/review sessions preceding the training may have contributed to an effective form of training for participants with no prior ECMO experience. Due to the small sample size of this study, further studies are needed to better elucidate what factors lead to better performance in emergency ECMO scenarios.

IntroductionExtracorporeal membrane oxygenation (ECMO) is a classic low-volume high-risk procedure that requires just in time and/or refresher training through animal or simulation modalities. This manuscript evaluated the performance of ECMO personnel trained with both modalities to determine which is better suited for ECMO skills training.MethodsParticipants (physicians, nurses and respiratory/medical technicians) completed a series of ECMO scenarios with synthetic tissue cannulation task trainer as well as a live tissue model. Objective performance quality was based on task completion using a validated ECMO skills assessment tool.ResultsThirty-eight individuals completed this study. Participants completed individual scenario tasks 3 min faster using the simulator (26 min vs 29 min; p=0.03). No differences were seen in percentage of individual tasks completed. In the group scenarios, participants completed a higher percentage of critical tasks using the simulator (97%) versus the animal model (91%; p=0.05), but no differences were seen in task completion times. Additionally, no differences were seen in either lab-based or participants’ prelab cognitive scores.ConclusionsRegardless of their self-assessment or experience, participants’ objective performances were similar among both animal and simulation labs. Task completion times were quicker with simulation model. The distinction between simulation versus animal model may be less important as both demonstrate benefit in development of and/or maintaining skill competency. In the era of questioning the need for and costs of live tissue training, expanding the role of simulation may achieve similar training goals.

The continental shelves of the Arctic Ocean and surrounding seas contain large stocks of organic matter (OM) and methane (CH 4 ), representing a potential ecosystem feedback to climate change not included in international climate agreements. We performed a structured expert assessment with 25 permafrost researchers to combine quantitative estimates of the stocks and sensitivity of organic carbon in the subsea permafrost domain (i.e. unglaciated portions of the continental shelves exposed during the last glacial period). Experts estimated that the subsea permafrost domain contains ∼560 gigatons carbon (GtC; 170–740, 90% confidence interval) in OM and 45 GtC (10–110) in CH 4 . Current fluxes of CH 4 and carbon dioxide (CO 2 ) to the water column were estimated at 18 (2–34) and 38 (13–110) megatons C yr −1 , respectively. Under Representative Concentration Pathway (RCP) RCP8.5, the subsea permafrost domain could release 43 Gt CO 2 -equivalent (CO 2 e) by 2100 (14–110) and 190 Gt CO 2 e by 2300 (45–590), with ∼30% fewer emissions under RCP2.6. The range of uncertainty demonstrates a serious knowledge gap but provides initial estimates of the magnitude and timing of the subsea permafrost climate feedback.

The continental shelves of the Arctic Ocean and surrounding seas contain large stocks of organic matter (OM) and methane (CH4), representing a potential ecosystem feedback to climate change not included in international climate agreements. We performed a structured expert assessment with 25 permafrost researchers to combine quantitative estimates of the stocks and sensitivity of organic carbon in the subsea permafrost domain (i.e. unglaciated portions of the continental shelves exposed during the last glacial period). Experts estimated that the subsea permafrost domain contains ~560 gigatons carbon (GtC; 170–740, 90% confidence interval) in OM and 45 GtC (10–110) in CH4. Current fluxes of CH4 and carbon dioxide (CO2) to the water column were estimated at 18 (2–34) and 38 (13–110) megatons C yr−1, respectively. Under Representative Concentration Pathway (RCP) RCP8.5, the subsea permafrost domain could release 43 Gt CO2-equivalent (CO2e) by 2100 (14–110) and 190 Gt CO2e by 2300 (45–590), with ~30% fewer emissions under RCP2.6. The range of uncertainty demonstrates a serious knowledge gap but provides initial estimates of the magnitude and timing of the subsea permafrost climate feedback.