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Aims The aims of the Critical Care Cardiology Trials Network (CCCTN) are to develop a registry to investigate the epidemiology of cardiac critical illness and to establish a multicentre research network to conduct randomised clinical trials (RCTs) in patients with cardiac critical illness. Methods and results The CCCTN was founded in 2017 with 16 centres and has grown to a research network of over 40 academic and clinical centres in the United States and Canada. Each centre enters data for consecutive cardiac intensive care unit (CICU) admissions for at least 2 months of each calendar year. More than 20 000 unique CICU admissions are now included in the CCCTN Registry. To date, scientific observations from the CCCTN Registry include description of variations in care, the epidemiology and outcomes of all CICU patients, as well as subsets of patients with specific disease states, such as shock, heart failure, renal dysfunction, and respiratory failure. The CCCTN has also characterised utilization patterns, including use of mechanical circulatory support in response to changes in the heart transplantation allocation system, and the use and impact of multidisciplinary shock teams. Over years of multicentre collaboration, the CCCTN has established a robust research network to facilitate multicentre registry-based randomised trials in patients with cardiac critical illness. Conclusion The CCCTN is a large, prospective registry dedicated to describing processes-of-care and expanding clinical knowledge in cardiac critical illness. The CCCTN will serve as an investigational platform from which to conduct randomised controlled trials in this important patient population.

Purpose Obtaining vascular access in the pediatric population can be challenging, with insertion success rates varying widely based on patient and practitioner associated factors. Difficulty establishing peripheral intravenous access can delay treatment, which can be detrimental in emergent situations. Nurses who are trained in vascular access yield a much higher first attempt success rate, which decreases resource utilization, time to intervention, and complication rate. Fewer insertion attempts can also result in improved outcomes including decreased length of stay and better patient and family perception of pain. Design and methods The Vascular Access Service at our institution developed an extensive training program, which included three stages: didactic learning, simulation training, and insertion validation. Results During the first three months of 2020, there were 54 ultrasound-guided peripheral IVs placed in the pediatric intensive care units, 100% of which were placed by the vascular access service. In the first three months of 2021, 63 ultrasound-guided peripheral IVs were placed, 100% of which were placed by pediatric intensive care unit nurses. Of those placed by pediatric intensive care unit nurses, 52 (82.5%) were placed following their ultrasound-guided peripheral IV training. First time insertion success rates were 86.5% with competency in a diverse patient population of widely varying ages. Conclusions Programs that include repeated simulation experiences may facilitate greater learning and thus increase the confidence of the nurses trained. Improving staff skills for vascular access has promoted independent bedside practice and contributed to a culture of quality and safety for the pediatric patient population.

Background Coronaviruses are important emerging human and animal pathogens. SARS-CoV-2, the virus that causes COVID-19, is responsible for the current global pandemic. Early in the course of the pandemic, New York City became one of the world's "hot spots" with more than 250,000 cases and more than 15,000 deaths. Although medical providers in New York were fortunate to have the knowledge gained in China and Italy before it came under siege, the magnitude and severity of the disease were unprecedented and arguably under appreciated. The surge of patients with significant COVID-19 threatened to overwhelm health care systems, as New York City health systems realized that the number of specialized critical care providers would be inadequate. A large academic medical system recognized that rapid redeployment of noncritical providers into such roles would be needed. An educational gap was therefore identified: numerous providers with minimal critical care knowledge or experience would now be required to provide critical-level patient care under supervision of intensivists. Safe provision of such high level of patient care mandated the development of "educational crash courses." Methods The purpose of this special article is to summarize the approach adopted by the Institute for Critical Care Medicine and Department of Anesthesiology, Perioperative and Pain Medicine's Human Emulation, Education, and Evaluation Lab for Patient Safety and Professional Study Simulation Center in developing a training program for noncritical care providers in this novel disease. Results Using this joint approach, we were able to swiftly educate a wide range of nonintensive care unit providers (such as surgical, internal medicine, nursing, and advanced practice providers) by focusing on refreshing critical care knowledge and developing essential skillsets to assist in the care of these patients. Conclusions We believe that the practical methods reviewed here could be adopted by any health care system that is preparing for an unprecedented surge of critically ill patients.

Given the known downstream implications of choice of respiratory support on patient outcomes, all factors influencing these decisions, even those not limited to the patient, warrant close consideration. We examined the effect of emergency department (ED)-specific system factors, such as work load and census, on the use of noninvasive versus invasive respiratory support.We conducted a multi-center retrospective cohort study of all adult subjects with severe COVID-19 requiring an ICU admission from 5 EDs within a single urban health care system. Subject demographics, severity of illness, and the type of respiratory support used were obtained. Using continuous measures of ED census, boarding, and active management, we estimated ED work load for each subjects' ED stay. The subjects were categorized by type(s) of respiratory support used: low-flow oxygen, noninvasive respiratory support (eg, noninvasive ventilation [NIV] and/or high-flow nasal cannula [HFNC]), invasive mechanical ventilation, or invasive mechanical ventilation after trial of NIV/HFNC. We used multivariable logistic regression to examine system factors associated with the type of respiratory support used in the ED.A total of 634 subjects were included. Of these, 431 (70.0%) were managed on low-flow oxygen alone, 108 (17.0%) on NIV/HFNC, 54 (8.5%) on invasive mechanical ventilation directly, and 41 (6.5%) on NIV/HFNC prior to invasive mechanical ventilation in the ED. Higher severity of illness and underlying lung disease increased the odds of requiring invasive mechanical ventilation compared to low-flow oxygen (odds ratio 1.05 [95% CI 1.03-1.07] and odds ratio 3.47 [95% CI 1.37-8.78], respectively). Older age decreased odds of being on invasive mechanical ventilation compared to low-flow oxygen (odds ratio 0.96 [95% CI 0.94-0.99]). As ED work load increased, the odds for subjects to be managed initially with NIV/HFNC prior to invasive mechanical ventilation increased 6-8-fold.High ED work load was associated with higher odds on HFNC/NIV prior to invasive mechanical ventilation.

Patients who develop occult septic shock (OSS) are associated with worse outcomes than those with early septic shock (ESS). Patients with skin and soft tissue infection (SSTI) may have underlying organ dysfunction due to OSS, yet the prevalence and the outcomes of patients with SSTI and early versus occult shock have not been described. This study compared the clinical characteristics of SSTI patients and the prevalence of having no septic shock (NSS), ESS, or OSS.We retrospectively analyzed charts of adult patients who were transferred from any emergency department to our academic center between January 1, 2014, and December 31, 2016. Outcomes of interest were the development of OSS and acute kidney injury (AKI). We performed logistic regressions to measure the association between clinical factors with the outcomes and created probability plots to show the relationship between key clinical variables and outcomes of OSS or AKI.Among 269 patients, 218 (81%) patients had NSS, 16 (6%) patients had ESS, and 35 (13%) patients had OSS. Patients with OSS had higher mean serum lactate concentrations than patients with NSS (3.5 vs. 2.1 mmol/L,13% of the patients with SSTI developed OSS. Patients with OSS had elevated serum lactate concentration and higher SOFA score than those with NSS. Increased SOFA score is a predictor for the development of OSS.

Supplemental Digital Content is available in the text., Objectives: To examine whether increasing time between admission and intubation was associated with mortality in patients with coronavirus disease 2019 who underwent mechanical ventilation. Design: Retrospective cohort study of patients with severe acute respiratory syndrome coronavirus 2 infection who were admitted between January 30, 2020, and April 30, 2020, and underwent intubation and mechanical ventilation prior to May 1, 2020. Patients were followed up through August 15, 2020. Setting: Five hospitals within the Mount Sinai Health System in New York City, NY. Patients: Adult patients with severe acute respiratory syndrome coronavirus 2 infection who underwent intubation and mechanical ventilation. Interventions: Tracheal intubation and mechanical ventilation. Measurements and Main Results: The primary outcome was in-hospital mortality. A hospital-stratified time-varying Cox model was used to evaluate the effect of time from admission to intubation on in-hospital death. A total of 755 adult patients out of 5,843 admitted with confirmed severe acute respiratory syndrome coronavirus 2 infection underwent tracheal intubation and mechanical ventilation during the study period. The median age of patients was 65 years (interquartile range, 56–72 yr) and 64% were male. As of the time of follow-up, 121 patients (16%) who were intubated and mechanically ventilated had been discharged home, 512 (68%) had died, 113 (15%) had been discharged to a skilled nursing facility, and 9 (1%) remained in the hospital. The median time from admission to intubation was 2.3 days (interquartile range, 0.6–6.3 d). Each additional day between hospital admission and intubation was significantly associated with higher in-hospital death (adjusted hazard ratio, 1.03; 95% CI, 1.01–1.05). Conclusions: Among patients with coronavirus disease 2019 who were intubated and mechanically ventilated, intubation earlier in the course of hospital admission may be associated with improved survival.

Objectives To respond to the new recommendations for delaying tracheostomy for coronavirus disease 2019 patients to day 21 post-intubation to ensure viral clearance. Design Prospective observational cohort from April 1, 2020, to April 30, 2020, with 60 days follow-up. Setting Academic medical center with nine adult ICUs dedicated to caring for coronavirus disease 2019 patients requiring mechanical ventilation. Patients Mechanically ventilated patients with coronavirus disease 2019 pneumonia requiring tracheostomy for prolonged ventilatory support. Interventions Adherence to the standard of care for timing of tracheostomy as deemed necessary by the intensivist without delay and utilizing the existing tracheostomy team in performing the needed procedures within 1 day of the request. Measurements and main results One hundred eleven patients with coronavirus disease 2019 received tracheostomy in the month of April 2020. Median time to tracheostomy was 11 days. All procedures were performed percutaneously at bedside under bronchoscopic guidance. Sixty-three percent of patients who received tracheostomy either weaned or discharged alive within 60 days of the procedure. Performing tracheostomy on these patients without delay did not lead to coronavirus disease 2019 viral transmission to the tracheostomy team as evident by lack of symptoms and negative antibody testing. Conclusions Adherence to standard of care in timing of tracheostomy is safe. Recommending delaying the procedure may lead to harmful consequences from prolonging mechanical ventilation and sedation without apparent benefit.

Author(s): Ditkowsky, Jared; Lieber, Adam C.; Leibner, Evan S.; Genes, Nicholas | Abstract: Introduction: In early March 2020, coronavirus 2019 (COVID-19) spread rapidly in New York City. Shortly thereafter, in response to the shelter-in-place orders and concern for infection, emergency department (ED) volumes decreased. While a connection between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and hyperglycemia/insulin deficiency is well described, its direct relation to diabetic ketoacidosis (DKA) is not. In this study we describe trends in ED volume and admitted patient diagnoses of DKA among five of our health system’s EDs, as they relate to peak SARS-CoV-2 activity in New York City.Methods: For the five EDs in our hospital system, deidentified visit data extracted for routine quality review was made available for analysis. We looked at total visits and select visit diagnoses related to DKA, across the months of March, April and May 2019, and compared those counts to the same period in 2020.Results: A total of 93,218 visits were recorded across our five EDs from March 1–May 31, 2019. During that period there were 106 diagnoses of DKA made in the EDs (0.114% of visits). Across the same period in 2020 there were 59,009 visits, and 214 diagnoses of DKA (0.363% of visits)Conclusion: Despite a decrease in ED volume of 26.9% across our system during this time period, net cases of DKA diagnoses rose drastically by 70.1% compared to the prior year.

The coronavirus disease 2019 (COVID-19) pandemic mandated rapid, flexible solutions to meet the anticipated surge in both patient acuity and volume. This paper describes one institution's emergency department (ED) innovation at the center of the COVID-19 crisis, including the creation of a temporary ED-intensive care unit (ICU) and development of interdisciplinary COVID-19-specific care delivery models to care for critically ill patients. Mount Sinai Hospital, an urban quaternary academic medical center, had an existing five-bed resuscitation area insufficiently rescue due to its size and lack of negative pressure rooms. Within 1 week, the ED-based observation unit, which has four negative pressure rooms, was quickly converted into a COVID-19-specific unit, split between a 14-bed stepdown unit and a 13-bed ED-ICU unit. An increase in staffing for physicians, physician assistants, nurses, respiratory therapists, and medical technicians, as well as training in critical care protocols and procedures, was needed to ensure appropriate patient care. The transition of the ED to a COVID-19-specific unit with the inclusion of a temporary expanded ED-ICU at the beginning of the COVID-19 pandemic was a proactive solution to the growing challenges of surging patients, complexity, and extended boarding of critically ill patients in the ED. This pandemic underscores the importance of ED design innovation with flexible spacing, interdisciplinary collaborations on structure and services, and NP ventilation systems which will remain important moving forward.

The United States Navy originally utilized the concept of damage control to describe the process of prioritizing the critical repairs needed to return a ship safely to shore during a maritime emergency. To pursue a completed repair would detract from the goal of saving the ship. This concept of damage control management in crisis is well suited to the care of the critically ill trauma patient, and has evolved into the standard of care. Damage control resuscitation is not one technique, but, rather, a group of strategies which address the lethal triad of coagulopathy, acidosis, and hypothermia. In this article, we describe this approach to trauma resuscitation and the supporting evidence base.

Resuscitation lacks a place in the hospital to call its own. Specialised intensive care units, though excellent at providing longitudinal critical care, often lack the flexibility to adapt to fluctuating critical care needs. We offer the resuscitative care unit as a potential solution to ensure that patients receive appropriate care during the most critical hours of their illnesses. These units offer an infrastructure for resuscitation and can meet the changing needs of their institutions.

Study Objectives: Delays in intensive care unit (ICU) admission for critically ill patients are associated with worse outcomes, but the effect of “boarding” during the COVID-19 pandemic has not been well characterized. This study describes the emergency department (ED)-based care for patients presenting with COVID-19-related acute hypoxemic respiratory failure (AHRF) to five hospitals in a large, academic health system during the initial surge in New York City, examining both respiratory modality choice and settings. For those managed with noninvasive respiratory support, we also aimed to explore the association between ED boarding time and patient morbidity and mortality. Methods: We conducted a retrospective cohort study of ED patients presenting from 3/1/2020 to 7/10/2020 with COVID-19-related AHRF and requiring ICU admission at any time during their hospitalization. Patient demographics, comorbidities, severity of illness (Mortality Probability Model III on admission), clinical course, including the use, settings (initial and changes), and duration of respiratory support modalities (ie, noninvasive ventilation [NIV], high flow nasal cannula [HFNC], invasive mechanical ventilation [IMV]), as well as hospital site, were collected through validated electronic query and standardized manual chart abstraction. AHRF severity was defined using a PaO2/FiO2 ratio (PF): 200-300 (mild), 100-199 (moderate), and

Coronavirus disease 2019 has been a worldwide pandemic since early 2020 with New York City being the epicenter in the United States during early 2020. Although cases of decreased coronavirus disease 2019 during the summer, cases began to rise once more in the fall-winter period. Little is known about trends in patient characteristics, medical care, and outcome between these time periods. We report initial patient characteristics and outcomes from a large quaternary referral center in New York City between Spring (March to June), Summer (July to September), and Winter (October to December), including prevalence of renal failure, respiratory failure, and mortality; stratified across several key populations of interest including all patients, ICU patients, those requiring of noninvasive positive pressure ventilation and high-flow nasal cannula, and those intubated in each time period.

INTRODUCTION: In early March 2020, COVID-19 spread in New York City This paper shows trends of rising cases of DKA associated with a worsening COVID-19 pandemic in New York City With the potential for such a large number of DKA patients, our institution found a need for revised glycemic management protocol We discuss how a multidisciplinary team designed a protocol to care for patients with COVID-19 infection and DKA METHODS: Five of The Mount Sinai Health System's EDs are on a shared electronic health record system (Epic Systems, Verona, WI) Deidentified visit data extracted for routine quality review was made available for analysis We looked at total visits and select visit diagnoses related to DKA through March, April and May 2019 and compared those counts to the same period in 2020 Our protocol was developed by stakeholders in a multidisciplinary hospital team We focused on the basic tenets of DKA management: insulin therapy, fluid resuscitation, and electrolyte repletion RESULTS: A total of 93,218 visits were recorded across the five EDs from March 1-May 31, 2019 During that period there were 106 diagnoses of DKA made in the EDs (0 114% of visits) Across the same period in 2020 there were 59,009 visits, and 214 diagnoses of DKA (0 363% of visits) This coincides with the height of the Sars-CoV-2 pandemic in New York City To address this surge, our protocol decreased the frequency of fingerstick monitoring, with changes to insulin dosing allowing admission to non-ICU beds We transitioned from a provider-driven protocol to a nurse-driven protocol to avoid treatment delays due to order placement Insulin infusion rate charts were created to provide nurses guidance on dosing modifications To minimize ARDS risk, our protocol's fluid replacement recommendations lowered resuscitation and replacement rate volumes, adjusting based on provider reassessment Lab values were monitored every 3-4 hours CONCLUSIONS: There is a correlation between the rise of the Sars-CoV-2 pandemic in New York City and a net rise in patients diagnosed with diabetic ketoacidosis We believe our DKA protocol will facilitate safe and effective management of patients with COVID-19 and DKA, reducing the healthcare burden associated with protocols that necessitate frequent treatment modifications and ICU-level care

INTRODUCTION: COVID-19 2020 pandemic with New York City (NYC) as the epicenter necessitated an unprecedented increase in critical care capacity and development of institutional guidelines for care We describe our drastic increased ICU capacity and how we created and disseminated our guidelines We hope our experiences help others manage their COVID-19 peaks METHODS: Mount Sinai Hospital System includes a medical school and eight campuses, the largest being Mount Sinai Hospital (MSH) Since 2013, MSH had system-wide staffing models, cross credentialed staff, and combined leadership MSH has and Institute for Critical Care Medicine (ICCM) that includes seven adult ICUs, 45 critical care faculty, rapid response team (RRT), vascular access team (VAS), difficult airway team (DART), patient safety quality team (PSQ), clinical research team, and post-ICU recovery clinic ICCM coordinated COVID-19 critical care response within MSHS ICCM, Emergency Medicine, Anesthesiology, and Infection Prevention helped develop systemwide guidelines on our COVID-19 website accessible to all hospital employees RESULTS: MSH expanded from 1139-beds, 104 ICU beds, to 1453 beds, 235 ICU beds during the COVID-19 peak CONCLUSIONS: MSH's response to COVID-19 surge by expanding critical care bed capacity from 104 to over 200 ICU beds required teamwork across disciplines We developed new guidelines for airway management, cardiac arrest, anticoagulation, vascular access, and proning that helped streamline workflow and accommodate the surge in critically ill patients Non-ICU services and staff were deployed to augment the critical care work force and open new critical care units by leveraging a tiered staffing model This approach to rapidly expanding bed availability and staffing across the system was made possible by the collaboration between ICCM, emergency department, anesthesia department, and infection prevention, and helped to provide the best care for our patients and saved lives

INTRODUCTION: The COVID-19 pandemic mandated rapid, flexible solutions to meet the anticipated surge in both patient acuity and volume This paper describes one institution's Emergency Department innovation at the center of the COVID crisis, including the creation of a temporary ED-ICU and development of interdisciplinary COVID-specific care delivery models to care for critically ill patients METHODS: Mount Sinai Hospital, an urban quaternary academic medical center, had an existing five-bed resuscitation area insufficiently resourced due to its size and lack of negative pressure (NP) rooms The ED-based Observation Unit, which has four NP rooms, was deemed to be the ideal spot for a new ED-ICU An interdisciplinary and intradepartmental task force was critical to this development This task force worked to ensure the physical supplies, medications, staffing, and clinical protocols were appropriate to allow for the proper functioning of the ED-ICU RESULTS: Within one week, the ED-based Observation Unit was quickly converted into a COVID-specific unit, split between a 14-bed stepdown unit and a 13-bed ED-ICU unit The ED-ICU had all the functional and staffing capacities of an ICU, and was able to efficiently care for large numbers of critically ill patients All critically ill patients in the ED were treated in the ED-ICU Further, all intubations and non-invasive ventilation were able to occur in the negative pressure rooms CONCLUSIONS: The Mount Sinai Hospital Emergency Department rapidly adapted the delivery of care and treatment models to meet the challenges of the COVID-19 pandemic An ED-ICU was rapidly built by converting the prior observation area (a 27-bed zone) A redesign of a new space in a large U S academic hospital often requires months, if not years, of planning and negotiations with the varying hospital interests involved With the pressure of high COVID demand, this conversion was executed in approximately 1 week, from the initial decision to full activation Moreover, the unit functioned during the peak of the NYC COVID-19 epidemic largely as envisioned and required surprisingly few space or workflow modifications mid-course Its success was due to the hard work of the leadership team and front-line providers and the collaboration across the institution

SESSION TITLE: Lessons from the ICU: What have We Learned about the Management of COVID-19 SESSION TYPE: Original Investigations PRESENTED ON: October 18-21, 2020 PURPOSE: Benefits of early tracheostomy (2-10 days after intubation) include decreased sedation, days on ventilator, ICU length of stay and long-term mortality In addition, it helps improve patient’s comfort level, tracheal suctioning, oral hygiene and facilitates early mobility in comparison to delayed tracheostomy (7-14 days after intubation) With the recent COVID-19 pandemic, an unprecedented surge in patients requiring prolonged mechanical ventilation led to an increase in the need for tracheostomies Tracheostomy is an aerosol-generating procedure that raises potential risk to the proceduralists Therefore, international professional otolaryngology and surgical organizations published guidelines, which recommended delaying tracheostomy to after 21 intubation days in order to ensure viral clearance prior to the procedure In the setting of these well-intended practice guidelines, intensivists are faced with a new dilemma;following the standard of care for tracheostomy planning vs delaying the procedure without evidence to support the new recommended guidelines METHODS: We utilized our previously established Institute for Critical Care Medicine Tracheostomy Team (ICCM-TT), with its multidisciplinary departments, which include Critical Care, General Surgery, Cardiac and Thoracic Surgery and Otolaryngology In April 2020, throughout the nine ICUs dedicated to the management of COVID-19 patients, the ICCM-TT performed 111 tracheostomy procedures Case selection involved a multidisciplinary team evaluation of patient’s clinical status and wishes after goals of care discussion Median time from translaryngeal intubation to tracheostomy was 11 days All cases were performed at bedside, using percutaneous dilatational technique with bronchoscopic guidance Additionally, real-time ultrasound guidance was utilized in cases identified to have difficult anatomical landmarks All of the 111 procedures were performed within 1 day of the tracheostomy request, unless medical instability deferred the procedure or revisiting goals of care was needed RESULTS: Of the patients who received tracheostomy for COVID-19 prolonged respiratory failure: 35 (31 5 %) patients discharged home alive, 23 (20 7 %) weaned from mechanical ventilation (no ventilator support, downsized or decannulated) but remain hospitalized on non-ICU floors, 33 (29 7 %) expired and the remaining 20 (18 %) are either in the ICUs or undergoing active weaning in a designated weaning unit Of note, none of the ICCM-TT proceduralists acquired COVID-19 infection, all have been tested negative for antibodies This may be due to the thorough pre-procedural planning, adherence to ICCM-TT protocols and vigilance in maintaining infection control guidelines CONCLUSIONS: Developing a dedicated tracheostomy team and following standard of care in timing of tracheostomy for COVID-19 patients avoided unnecessary delay of patient’s care without risk of viral transmission to the staff This facilitated patient’s ventilator weaning and discharges, which improved ICU throughput CLINICAL IMPLICATIONS: Our results support creating a dedicated tracheostomy team and following standard of care without the need to delay a necessary procedure for COVID-19 pneumonia patients Furthermore, this deemed safe when infection control protocols were strictly followed DISCLOSURES: No relevant relationships by Adel Bassily-Marcus, source=Web Response No relevant relationships by Ella Illuzzi, source=Web Response No relevant relationships by Roopa Kohli-Seth, source=Web Response No relevant relationships by Evan Leibner, source=Web Response No relevant relationships by Ahmed Mohammed, source=Web Response

The majority of blunt chest injuries are minor contusions or abrasions; however, life-threatening injuries, including tension pneumothorax, hemothorax, and aortic rupture can occur and must be recognized early. This review focuses on the diagnosis, management, and disposition of patients with blunt injuries to the ribs and lung. Utilization of decision rules for chest x-ray and computed tomography are discussed, along with the emerging role of bedside lung ultrasonography. Management controversies presented include the limitations of needle thoracostomy us¬ing standard needle, chest tube placement, and chest tube size. Finally, a discussion is provided related to airway and ventilation management to assist in the timing and type of interventions needed to maintain oxygenation.

Laponite films provide versatile inorganic scaffolds with materials architectures that direct the self-assembly of CdSe quantum dots (QDs or EviTags) and catalytic surfaces that promote the in situ polymerization of polyaniline (PANI) to yield novel nanocomposites for light emitting diodes (LEDs) and solar cell applications. Water-soluble CdSe EviTags with varying, overlapping emission wavelengths in the visible spectrum were incorporated using soft chemistry routes within Na-Laponite host film platforms to achieve broadband emission in the visible spectrum. QD concentrations, composition and synthesis approach were varied to optimize photophysical properties of the films and to mediate self-assembly, optical cascading and energy transfer. In addition, aniline tetramers coupled to CdSe (QD-AT) surfaces using a dithioate linker were embedded within Cu-Laponite nanoscaffolds and electronically coupled to PANI via vapor phase exposure. Nanotethering and specific host-guest and guest-guest interactions that mediate nanocomposite photophysical behavior were probed using electronic absorption and fluorescence spectroscopies, optical microscopy, AFM, SEM, powder XRD, NMR and ATR-FTIR. Morphology studies indicated that Lap/QD-AT films synthesized using mixed solvent, layer by layer (LbL) methods exhibited anisotropic supramolecular structures with unique mesoscopic ordering that affords bifunctional networks to optimize charge transport.

Time-dependent energetics of blood-protein adsorption are interpreted in terms of a slowly-concentrating three-dimensional interphase volume initially formed by rapid diffusion of protein molecules into an interfacial region spontaneously formed by bringing a protein solution into contact with a physical surface. This modification of standard adsorption theory is motivated by the experimental observation that interfacial tensions of protein-containing solutions decrease slowly over the first hour to a steady-state value while, over this same period, the total adsorbed protein mass is constant (for lysozyme, 15 kDa; alpha-amylase, 51 KDa; albumin, 66 kDa; prothrombin, 72 kDa; IgG, 160 kDa; fibrinogen, 341 kDa studied in this work). These seemingly divergent observations are rationalized by the fact that interfacial energetics (tensions) are explicit functions of solute chemical potential (concentration), not adsorbed mass. Hence, rates of interfacial tension change parallel a slow interphase-concentration effect whereas solution depletion detects a constant interphase composition within the timeframe of experiment. A straightforward mathematical model approximating the perceived physical situation leads to an analytic formulation that is used to compute time-varying interphase volume and protein concentration from experimentally-measured interfacial tensions. Derivation from the fundamental thermodynamic adsorption equation verifies that protein adsorption from dilute solution is controlled by a partition coefficient at equilibrium, as is observed experimentally at steady state. Implications of the alternative interpretation of adsorption kinetics on biomaterials and biocompatibility are discussed.

Author(s): Zaver, MD, Fareen; Hansen, MD, Michael; Leibner, MD, PhD, Evan; Little, DO, Andrew; Lin, MD, Michelle | Abstract: Introduction: By critically appraising open access, educational blogs and podcasts in emergency medicine (EM) using an objective scoring instrument, this installment of the ALiEM (Academic Life in Emergency Medicine) Blog and Podcast Watch series curated and scored relevant posts in the specific areas of pediatric EM. Methods: The Approved Instructional Resources – Professional (AIR-Pro) series is a continuously building curriculum covering a new subject area every two months. For each area, six EM chief residents identify 3-5 advanced clinical questions. Using FOAMsearch.net to search blogs and podcasts, relevant posts are scored by eight reviewers from the AIR-Pro Board, which is comprised of EM faculty and chief residents at various institutions. The scoring instrument contains five measurement outcomes based on 7-point Likert scales: recency, accuracy, educational utility, evidence based, and references. The AIR-Pro label is awarded to posts with a score of ≥26 (out of 35) points. An “Honorable Mention” label is awarded if Board members collectively felt that the posts were valuable and the scores were g 20. Results: We included a total of 41 blog posts and podcasts. Key educational pearls from the 10 high quality AIR-Pro posts and four Honorable Mentions are summarized. Conclusion: The WestJEM ALiEM Blog and Podcast Watch series is based on the AIR and AIR-Pro series, which attempts to identify high quality educational content on open-access blogs and podcasts. Until more objective quality indicators are developed for learners and educators, this series provides an expert-based, crowdsourced approach towards critically appraising educational social media content for EM clinicians. [West J Emerg Med. 2016;17(5)513-518.]

Study objective: Annually, 38 million people are evaluated for trauma, the leading cause of death in persons younger than 45 years. The primary objective is to assess whether using a protocol inclusive of point-of-care, limited ultrasonography (PLUS), compared to usual care (control), among patients presenting to the emergency department (ED) with suspected torso trauma decreased time to operative care. Methods: The study was a randomized controlled clinical trial conducted during a 6-month period at 2 Level I trauma centers. The intervention was PLUS conducted by verified clinician sonographers. The primary outcome measure was time from ED arrival to transfer to operative care; secondary outcomes included computed tomography (CT) use, length of stay, complications, and charges. Regression models controlled for confounders and analyzed physician-to-physician variability. All analyses were conducted on an intention-to-treat basis. Results are presented as mean, first-quartile, median, and third-quartile, with multiplicative change and 95% confidence intervals (CIs), or percentage with odds ratio and 95% CIs. Results: Four hundred forty-four patients with suspected torso trauma were eligible; 136 patients lacked consent, and attending physicians refused enrollment of 46 patients. Two hundred sixty-two patients were enrolled: 135 PLUS patients and 127 controls. There were no important differences between groups. Time to operative care was 64% (48, 76) less for PLUS compared to control patients. PLUS patients underwent fewer CTs (odds ratio 0.16) (0.07, 0.32), spent 27% (1, 46) fewer days in hospital, and had fewer complications (odds ratio 0.16) (0.07, 0.32), and charges were 35% (19, 48) less compared to control. Conclusion: A PLUS-inclusive protocol significantly decreased time to operative care in patients with suspected torso trauma, with improved resource use and lower charges. [Ann Emerg Med. 2006;48: 227-235.]

Continuous-flow left ventricular assist devices (cfLVADs) have been proven safe and effective for bridge-to-transplant and destination therapy (DT) in patients with advanced heart failure. However, the fixed pump speed of these devices may lack response to activity and oxygen demand, thereby limiting exercise tolerance. The objective of this observational study was to describe exercise capacity as measured by peak oxygen consumption (peak VO2) that may be expected during support with a cfLVAD. Peak VO2 was measured in patients (mean age: 58.3 ± 11.7 years; 66.7% ischemic and 33.3% DT) before cfLVAD support (11.2 ± 3.0 ml/kg/min, n = 25), between 3 and 6 months (12.7 ± 3.5 ml/kg/min, n = 31), at 1 year (10.7 ± 2.6 ml/kg/min, n = 16), and longer than 1 year (11.2 ± 1.7 ml/kg/min, n = 10). There was no statistical improvement in peak VO2 at any time point after implantation. In addition, ventilatory efficiency remained poor after LVAD implantation at all time points. Although studies have shown an increase in survival and patient's quality of life, exercise capacity as measured by cardiopulmonary exercise testing remains low during cfLVAD support.

Analytical protocol greatly influences the measurement of human serum albumin (HSA) adsorption to commercial expanded polytetrafluororethylene (ePTFE) exhibiting superhydrophobic wetting properties. Degassing of buffer solutions and evacuation of ePTFE adsorbent to remove trapped air immediately prior to contact with protein solutions are shown to be essential. Results obtained with ePTFE as a prototypical superhydrophobic test material suggest that vacuum degassing should be applied in the measurement of protein adsorption to any surface exhibiting superhydrophobicity. Solution depletion quantified using radiometry (125I-labeled HSA) or electrophoresis yield different measures of adsorption, with nearly 4-fold higher surface concentrations of unlabeled HSA measured by the electrophoresis method. This outcome is attributed to the influence of the radiolabel on HSA hydrophilicity which decreases radiolabeled-HSA affinity for a hydrophobic adsorbent in comparison to unlabeled HSA. These results indicate that radiometry underestimates the actual amount of protein adsorbed to a particular material. Removal of radiolabeled HSA adsorbed to ePTFE by 3× serial buffer rinses also shows that the remaining “bound fraction” was about 35% lower than the amount measured by radiometric depletion. This observation implies that measurement of protein bound after surface rinsing significantly underestimates the actual amount of protein concentrated by adsorption into the surface region of a protein-contacting material.

from 10-14% in 2002-2004 down to 2-4% by 2008-2010. Median waiting times have increased since 2005 for medically bridged patients listed status 1A and blood groups O, A, and B. Conclusions: Increased use of LVAD since 2005 as bridge to transplant is associated with increased waiting times of medically bridged patients. The mortality rate of LVAD bridged patients is now significantly lower, but increased waiting time for medically bridged patients who do not qualify for an LVAD may result in increased mortality.