Explore the vast range of titles available.

BackgroundStress ulcers in patients with traumatic brain injury (TBI) and spinal cord injury (SCI) present significant morbidity and mortality risks. Despite the low reported stress ulcer rates, stress ulcer prophylaxis (SUP) is widely administered in neurocritical care. It was hypothesized that universal SUP administration may not be associated with reduced rates of complications across all neurocritical care patients.MethodsThis retrospective study encompassed neurocritical care patients aged ≥18 with moderate or severe TBI or SCI, admitted to the intensive care unit (ICU) between October 2020 and September 2021, across six level I trauma centers. Exclusions included patients with an ICU stay <2 days, prior SUP medication use, and pre-existing SUP diagnoses. The primary exposure was SUP, with the primary outcome being clinically significant gastrointestinal bleeds (CSGIBs). Secondary outcomes included pneumonia and in-hospital mortality. Patients were stratified by admission Glasgow Coma Scale (GCS) groups.ResultsAmong 407 patients, 83% received SUP, primarily H2 receptor antagonists (88%) and proton pump inhibitors (12%). Patients on SUP were significantly younger, had lower admission GCS scores, higher Injury Severity Scores, longer ICU stays, and higher rates of mechanical ventilation than non-SUP patients. Overall, CSGIBs were rare (1%) and not significantly different between the SUP and non-SUP groups (p=0.06). However, CSGIBs exclusively occurred in patients with GCS scores of 3–8, and SUP was associated with a significantly lower rate of CSGIBs in this subgroup (p=0.03). SUP was also linked to significantly higher pneumonia rates in both GCS 3–8 and GCS 9–12 patients.ConclusionsThis study highlights the low incidence of CSGIBs in neurocritical trauma patients and suggests potential benefits of SUP, particularly for those with severe neurological impairment. Nevertheless, the increased risk of pneumonia associated with SUP in these patients warrants caution. Further research is crucial to refine SUP guidelines for neurocritical care patients and inform optimal strategies.Level of evidenceLevel III, retrospective.

Introduction Controversary exists around the best surgical management for traumatic geriatric displaced femoral neck fractures. The study objective was to compare outcomes among those managed with a total hip arthroplasty (THA) to those managed with a hemiarthroplasty (HA). Methods This retrospective matched cohort study included geriatric hip fractures (≥65 y/o) admitted 7/1/16-3/31/20. Patients were matched on having an advanced directive, pre-existing dementia, and age. Outcomes included: time to surgery, length of stay (LOS), blood loss volume, and discharge destination. THAs were compared to HAs; an alpha of <.05 indicated statistical significance. Results There were 191 patients: 86% were treated with HA and 14% with THA. Most (40%) were 80-89 years old, 66% were female, and 92% were white. After matching, the groups were well balanced on demographics and baseline characteristics with 27 patients/arm. The median time to surgery was 23 hours for both arms, P = .38. The LOS was significantly longer for those managed with a HA when compared to those managed with a THA, 5.6 vs 4.0 days, P = .001. The median blood loss volume was significantly lower for HAs than for THAs, but the difference was small, 100 vs 120 mL, P = .02. Patients managed with a HA were less likely to be discharged home than those managed with a THA, 22% vs 70%, P = .005. Conclusions While patients managed with a THA had significantly more blood loss than those managed with a HA, the difference in blood loss was small and not clinically relevant. Those managed with a THA experienced a significantly shorter LOS and were more likely to be discharged home than patients managed with a HA. Among a healthier, younger geriatric population, THA may lead to shortened LOS and improved discharge destinations when compared to HA for treatment of femoral neck fractures.

Introduction The surgical approach of hemiarthroplasty for displaced femoral neck fractures remains debated. The study objective was to compare in-hospital outcomes for geriatric displaced femoral neck fractures treated with hemiarthroplasty based on surgical approach (direct lateral vs. posterior approach). Materials and Methods This retrospective cohort study included geriatric patients (≥60 y/o) admitted 7/1/2016-3/31/2020 treated with hemiarthroplasty. Outcomes included: operative time (incision to closure), length of stay (HLOS), and blood loss volume (mL). The Harding direct lateral approach was compared to the posterior approach; P < .05. Results There were 164 patients (59% direct lateral, 41% posterior). Patients treated with the direct lateral approach had an advanced directive (P = .03), dementia, (P = .03), or were functionally dependent (P = .03) more often than patients treated with the posterior approach. Time to surgery was comparable between groups (P = .52). The direct lateral approach was associated with a shorter operative time (2.3 vs. 2.8 h, P = .03), a longer HLOS (5.0 vs. 4.0 days, P < .01), and a lower median volume of blood loss (50 vs. 100 mL, P = .01), than the posterior approach, respectively. In a stratified analysis, for those who were not functionally dependent, did not have dementia or an advanced directive, the direct lateral approach led to a longer HLOS (P = .03) and shorter operative time (P = .04) than the posterior approach. Whereas among those who were functionally dependent, had dementia or had an advanced directive, the direct lateral approach led to less blood loss (P = .02) than the posterior approach. Discussion While those treated with the direct lateral approach lost significantly less blood, they had a significantly longer HLOS than those treated with the posterior approach. Comorbidities significantly modified outcomes, which may suggest their presence could assist with treatment decisions. Conclusions This study found neither approach, the direct lateral nor posterior, to be superior. Surgical approach could remain physician preference.

Background Patients with hemodynamically unstable pelvic fractures have high mortality due to delayed hemorrhage control. We hypothesized that the availability of interventional radiology (IR) for angioembolization may vary in spite of the mandated coverage at US Level I trauma centers, and that the priority treatment sequence would depend on IR availability. Methods This survey was designed to investigate IR availability and pelvic fracture management practices. Six email invitations were sent to 158 trauma medical directors at Level I trauma centers. Participants were allowed to skip questions and irrelevant questions were skipped; therefore, not all questions were answered by all participants. The primary outcome was the priority treatment sequence for hemodynamically unstable pelvic fractures. Predictor variables were arrival times for IR when working off-site and intervention preparation times. Kruskal-Wallis and ordinal logistic regression were used; alpha = 0.05. Results Forty of the 158 trauma medical directors responded to the survey (response rate: 25.3%). Roughly half of participants had 24-h on-site IR coverage, 24% (4/17) of participants reported an arrival time ≥ 31 min when IR was on-call. 46% (17/37) of participants reported an IR procedure setup time of 31–120 min. Arrival time when IR was working off-site, and intervention preparation time did not significantly affect the sequence priority of angioembolization for hemodynamically unstable pelvic fractures. Conclusions Trauma medical directors should review literature and guidelines on time to angioembolization, their arrival times for IR, and their procedural setup times for angioembolization to ensure utilization of angioembolization in an optimal sequence for patient survival.

Introduction There is a lack of data on the use and effectiveness of pre-hospital pelvic circumferential compression devices (PCCD) as a temporary intervention for pelvic fracture management; they are thought to decrease pelvic volume and hemorrhage but are not without risks. The purpose of this study is to examine pre-hospital PCCD practices at US Level I trauma centers. Methods This was a prospective cross-sectional survey of trauma medical directors at US Level I trauma centers. The aim of this study was to describe patterns of pre-hospital PCCD utilization for pelvic fractures. Responses were compared by region, length in time the center was designated Level I, trauma patient volume, pelvic management guideline followed and blood product guidelines. Data were compared using Fisher’s exact and chi-squared tests. Results Of the 158 Level I trauma centers invited, 25% responded. All Level I trauma centers use in-hospital PCCDs, whereas 71% of participant’s paramedic agencies trained on pre-hospital PCCD application. Of those, 44% trained to apply pre-hospital PCCDs to all suspected pelvic fractures. A higher proportion of high-volume centers (77%) than low-volume centers (25%) trained on pre-hospital PCCD placement, p  = 0.06. PCCD practices were not dependent on the trauma center’s region, trauma volume, length in time as a Level I trauma center, or pelvic fracture guideline followed. Conclusions There is widespread application of in-hospital and pre-hospital PCCD at US Level I trauma centers, however pre-hospital PCCDs are not applied to all suspected pelvic fractures. Future studies should focus on efficacy, safety, and contraindications for pre-hospital PCCDs.

Participants in an underserved minority population in the United States were randomly assigned to receive a polypill that included low doses of atorvastatin, amlodipine, losartan, and hydrochlorothiazide or to receive usual care. At 12 months, systolic blood pressure and LDL cholesterol levels were significantly lower in the polypill group.

This grounded, interpretive study of an agricultural company contributes to the understanding of organizational identification by considering the various sources employees draw on and direct toward in forming relationships with their organizations. The conceptualization of identification “sources” supplants the identification terms targets and resources that are commonly used in identification literature, to address the less conscious and more emotional, integrative, self-referential facets of the identification process. Through written accounts, employees revealed multiple sources of identification, grounded in aspects both external and internal to the organization. An identity shift was also located in the narratives as some employees struggled with the tension between farming/family values and corporate philosophies embedded in the term agribusiness. A model demonstrating the role of sources in the identification process is proposed as a theoretical addition to organizational identification research. Practical implications and future directions are also discussed.

Background Natriuretic peptide (NP) hormones, atrial NP (ANP) and B-type NP (BNP), exert cardiovascular and metabolically protective effects. When measured by conventional immunoassay methods, NP levels are lower in obese, black, and insulin-resistant individuals, suggesting these groups may experience a relative NP deficiency. However, immunoassay measurements are likely poor determinants of physiologically relevant NPs as the immunoassay inadvertently captures predominantly inactive truncated peptides due to poor specificity and rapid degradation of the bioactive form. We have developed and validated a novel ultra performance liquid chromatography tandem mass spectrometry (UPLC-MS/MS) assay1 that specifically measures bioactive BNP (BNPMS) and ANP (ANPMS). Relationships between bioactive NPs measured by mass spectrometry (MS) with BMI, race, and glucose metabolism are not well-understood. Methods We measured bioactive BNP and ANP using a novel UPLC-MS/MS assay in 26 veterans without heart failure, diabetes, or significant cardiac/pulmonary/renal/hepatic disease. We also determined BNP using conventional immunoassay (BNPia), age, sex, race, BMI, fasting glucose, and HbA1c. We assessed relationships of NPs with continuous variables using Spearman's correlation and multivariable linear regression, and with categorical variables using Wilcoxon rank-sum. Results Among 26 veterans (aged 25-55, 69% male), 8 were lean (BMI 23.1 +/- 1.4 kg/m2) and 18 were obese (BMI 34 +/- 2.9 kg/m2). ANPMS was negatively associated with BMI (rs=-0.59, p=0.0015). Moreover, when analyzed by BMI category, ANPMS was lower in obese compared with lean individuals (mean 113.9 +/- 74.9 vs. mean 220 +/- 173.7 pg/mL, respectively, p=0.020). BNPMS was lower in blacks; all 5 black individuals had undetectably low BNPMS (<5 pg/mL), whereas whites had a higher mean BNPMS (19.3 pg/mL, p=0.011). BNPMS was negatively associated with fasting glucose (p=0.03) in multivariable regression models adjusted for age, sex, race, and BMI. BNPMS was not significantly associated with BNPia, possibly partially due to the large percentage whose BNPMS and/or BNPia was undetectably low (44% and 56%, respectively) in this non-heart failure cohort. Discussion Using a novel UPLC-MS/MS technique, we found that ANPMS is lower in obesity, and BNPMS is lower in black individuals and in those with higher fasting glucose. Our results are consistent with relationships of NPs assessed by traditional immunoassay methods from large epidemiologic studies. Our findings are particularly striking as our sample size was relatively small compared with epidemiologic studies. Our analyses of bioactive NP levels by this specific methodology support the emerging hypothesis that obese and black individuals experience a relative NP deficiency. Future large-scale studies quantifying bioactive NPs by MS are warranted to refine the phenotyping of individuals with relative NP deficiency and determine whether relative NP deficiency contributes to greater cardiometabolic risk. 1Reference: Dillon EM et al. Active BNP Measured by Mass Spectrometry and Response to Sacubitril/Valsartan. Journal of Cardiac Failure. 2021 Nov. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m., Monday, June 13, 2022 1:12 p.m. - 1:17 p.m.

Background: Animal models and human genetic investigations suggest that lower levels of natriuretic peptides (NP), which are cardiac-derived hormones, are associated with the development of obesity, insulin resistance, type 2 diabetes, and hypertension. However, whether lower resting NP levels in humans reflect a true hormone deficiency (analogous to other hormone deficiencies like adrenal insufficiency) is unknown, in part, because a diagnostic test for NP deficiency is currently lacking. One strategy for developing a diagnostic test for NP deficiency is to identify a stimulus that provokes an increase in NP concentrations. Dexamethasone is a potent stimulus for NP production in animals, but its effect on NP levels in humans is not well defined. Objective: We sought to define the effects of dexamethasone on circulating NPs over time in healthy humans. We hypothesized that dexamethasone would stimulate increases in NP levels, and that we could characterize the magnitude and timing of the changes as a primary step toward developing a diagnostic test for NP deficiency. Methods: 10 healthy, lean women (mean age 28 + 5 years, mean BMI 22.5 + 1.6 kg/m2) received a single 4 mg IV dose of dexamethasone after an overnight fast. Plasma levels of N-terminal pro-atrial natriuretic peptide (NT-proANP) and N-terminal pro- b-type natriuretic peptide (NT-proBNP) were serially measured during 2 time periods following dexamethasone: 1) “Acute Phase”: 0-8 hours, and 2) “Extended Phase”: at 24, 48, and 72 hours. Changes in NPs were analyzed using a piecewise random effects model for the 2 time periods. Results: During the Acute Phase after dexamethasone, a biphasic change in NT-proANP was observed (nonlinear, p<0.001). Median NT-proANP initially increased, with a peak increase of 24% occurring at 2.5 hours, and thereafter decreased until 8 hours (to 21% below baseline). During the “Extended Phase,” NT-proANP levels rebounded (p<0.001) and returned to near baseline by 72 hours. Next, median NT-proBNP increased during the Acute Phase (p= 0.016), with a peak increase of 27% occurring at 8 hours, and subsequently declined during the Extended Phase (p= 0.04) to a median value 24% lower than baseline at 72 hours. Discussion: Dexamethasone appears to acutely stimulate NP production in humans, as evidenced by an initial increase, followed by a subsequent decline, in circulating NP levels. The time course differs between NT-proANP and NT-proBNP, with NT-proANP peaking earlier than NT-proBNP. These pilot data may inform larger studies for establishing population norms for the NP response to glucocorticoids and evaluating whether a NP stimulation test with glucocorticoids may be a useful test for diagnosing NP deficiency.

Calcitonin gene-related peptide (CGRP) is a widely expressed neuropeptide that has a major role in sensory neurotransmission. The CGRP receptor is a heterodimer of the calcitonin receptor-like receptor (CLR) class B G-protein-coupled receptor and a type 1 transmembrane domain protein, receptor activity-modifying protein 1 (RAMP1). Here we report the structure of the human CGRP receptor in complex with CGRP and the G s -protein heterotrimer at 3.3 Å global resolution, determined by Volta phase-plate cryo-electron microscopy. The receptor activity-modifying protein transmembrane domain sits at the interface between transmembrane domains 3, 4 and 5 of CLR, and stabilizes CLR extracellular loop 2. RAMP1 makes only limited direct contact with CGRP, consistent with its function in allosteric modulation of CLR. Molecular dynamics simulations indicate that RAMP1 provides stability to the receptor complex, particularly in the positioning of the extracellular domain of CLR. This work provides insights into the control of G-protein-coupled receptor function. The structure of a complex containing calcitonin gene-related peptide, the human calcitonin gene-related peptide receptor and the G s heterotrimer, determined using Volta phase-plate cryo-electron microscopy, provides structural insight into the regulation of G-protein-coupled receptors by receptor activity modifying protein 1.