Blue Protocol Research Articles

The Histopathological Examination of the Degeneration of Menisci in Osteoarthritic Knees Using an Adapted Bonar Score: Does Osteoarthritis Equally Influence the Lateral and Medial Menisci?

This study aimed to investigate the degeneration of the meniscal tissue in osteoarthritic knees and to adapt the Bonar score and its modifications to develop a microscopic examination. This study included consecutive patients who underwent total knee arthroplasty for symptomatic end-stage gonarthrosis. During the surgery, the menisci were completely dissected to preserve their original shapes. The samples were prepared using the hematoxylin and eosin (H&E) staining method and the Alcian blue protocol and were examined under light microscopy. The extent of histopathological changes was assessed based on the classical Bonar score assumptions. Additionally, in the second step of the examination, menisci remnants were evaluated using the modified Bonar score developed by Zabrzyński et al. The study involved 44 patients, from whom 83 samples of knee menisci were obtained. Histological examination of the meniscal specimens under a light microscope revealed tissue degeneration in all cases, in both the medial and lateral menisci. The mean classical Bonar score was 8.3571 and the mean modified Bonar score was 6.9398. There were no statistically significant differences in classical Bonar score assessment between medial and lateral menisci (p = 0.3014). There were no statistically significant differences in the modified-Bonar score assessment between medial and lateral menisci (p = 0.3620). We show that both menisci are implicated in the degenerative process, with high scores in the Bonar system, regardless of knee axial deformity. The Bonar score, along with its modifications, can be readily employed in the microscopic assessment of meniscus pathology.

Экстренное прикроватное ультразвуковое исследование легких в практике интенсивной терапии (BLUE protocol). Первый опыт

An ultrasound examination of the lungs in the intensive care unit is one of the methods for diagnosing acute respiratory failure directly in the patient's bed. Important is the protocol of emergency bedside ultrasound examination of the lungs, Blue Protocol. The use of the protocol in patients with acute respiratory failure for a short time allows you to identify the causes of the latter and decide on the appropriate intensive care. The objective of this study was to identify the causes of acute respiratory failure in patients entered the department of anesthesiology and resuscitation according to emergency indications, according to the Blue protocol.

The Value of BLUE Protocol in the Diagnosis of Acute Onset of Respiratory Distress in Critically Ill Patient

Abstract To detect the value of BLUE protocol in the diagnosis of acute onset of respiratory distress in critically ill patients This cross-sectional study conducted on 60 patients by performing ultrasonography on consecutive patients admitted to the ICU with acute onset of respiratory distress (dyspnea), comparing lung ultrasonography results on initial presentation with the final diagnosis with conventional method of diagnosis by the ICU team. The BLUE protocol proved its importance, availability, easiness of application, accuracy and its ability to reach a final correct diagnosis in 90%of the patients. The lung U/S showed much better results than the CXR, but still the CT chest was more superior to the lung U/S as the sensitivity of the BLUE protocol in the diagnosis of pneumonia, pulmonary edema, pneumothorax, pleural effusion and COPD was 91.4%, 92.8%, 90%, 88.8% and 78.6 respectively. The lung U/S (BLUE protocol) is a bedside, reliable, dynamic, rapid, and noninvasive technique, these results suggest it could have a significant role in the diagnostic workup of acute onset of respiratory distress in the ICU.

Enrichment of Polycyclic Aromatic Hydrocarbon (PAH)-Degrading Strictly Anaerobic Sulfate-Reducing Cultures from Contaminated Soil and Sediment.

Sulfate-reducing bacteria (SRB) are crucial players in global biogeochemical cycling and some have been implicated in the anaerobic biodegradation of organic pollutants, including recalcitrant and hazardous polycyclic aromatic hydrocarbons (PAHs). Obtaining PAH-degrading SRB cultures for laboratories is of paramount importance in the development of the young field of anaerobic biodegradation of PAHs. SRB grow exceptionally slowly on PAH substrates and are highly sensitive to oxygen. Consequently, enrichment and maintenance of PAH-degrading SRB cultures and characterization of the biodegradation process remain a tedious and formidable task, especially for new researchers. To address these technical constraints, we have developed robust and effective protocols for obtaining and characterizing PAH-degrading SRB cultures. In this set of protocols, we describe step-by-step procedures for preparing inocula from contaminated soil or sediment, preparing anoxic medium, establishing enrichment cultures with PAHs as substrates under completely anaerobic sulfate-reducing conditions, successive culture transfers to obtain highly enriched cultures, rapid verification of the viability of SRB in slow-growing cultures, assessment of PAH degradation by extracting residuals using organic solvent and subsequent analysis by gas chromatography-mass spectrometry, and spectrophotometric determination of sulfate and sulfide in miniaturized, medium-throughput format. These protocols are expected to serve as a comprehensive manual for obtaining and characterizing PAH-degrading sulfate-reducing cultures. © 2024 The Author(s). Current Protocols published by Wiley Periodicals LLC. Basic Protocol 1: Obtaining PAH-degrading strictly anaerobic sulfate-reducing enrichment cultures from contaminated soil and sediment Support Protocol 1: Operation and maintenance of an anaerobic workstation Support Protocol 2: Setup of gas purging systems for preparing anoxic solutions Support Protocol 3: Verification of viability in slow-growing SRB enrichment cultures Support Protocol 4: Extraction of genomic DNA from low-biomass cultures Basic Protocol 2: Extraction of residual PAH from liquid culture and analysis by GC-MS Basic Protocol 3: Spectrophotometric determination of sulfate concentration in SRB cultures Basic Protocol 4: Spectrophotometric determination of sulfide concentrations in SRB cultures by the methylene blue method Alternate Protocol: Spectrophotometric determination of sulfide concentrations in SRB cultures by the colloidal copper sulfide method.

An examination of social relations and concussion management via the blue card.

Initially developed by New Zealand Rugby in 2014, the Blue Card initiative in rugby enables match officials to remove athletes from play if they are suspected to have sustained a concussion. Considerable attention has been paid by sport and health advocates to the possibilities and limitations of this initiative in safeguarding athlete health. However, little if any attention has been paid to the well-being of those responsible for administering the Blue Card (i.e., match officials). The aim of this paper was to examine match officials' experiences with and perspectives on implementing the Blue Card initiative in Ontario, Canada, with focused attention on the tensions around their ability to manage games and participants (e.g., athletes, coaches) while attempting to safeguard athlete well-being. Using Relational Coordination Theory (RCT) as a guiding framework and qualitative research method, we highlight the rich accounts of 19 match officials' perspectives and experiences regarding sport-related concussion (SRC) management and the Blue Card protocol. Four themes were derived from the data, reflecting latent assumptions embedded within the concussion management process, which include: assumptions of trust, respect, and cooperation; assumptions of shared responsibility; assumptions of shared understanding; and assumptions of harassment-free sport. Our findings emphasize the need to attend to social relations in concussion management and provide insight into match officials' fraught experiences on the frontlines of concussion management. We identify factors affecting match official well-being and provide considerations for concussion management initiatives designed to improve athlete safety, such as the Blue Card.

Unlocking the biological potential of transition metal complexes with Thiosemicarbazone ligands: Insights from computational studies

In the previous study, the synthesis and characterization of 4-(3-fluorophenyl)-3-thiosemicarbazide and benzaldehyde derivatives based thiosemicarbazone ligands and their Co(II), Ni(II), Cu(II), Zn(II) complexes were carried out to evaluate their malarial and oxidant and inflammatory inhibition abilities, demonstrating that these compounds have robust efficacy for these ailments. In the present research, to find out a combating agent against breast cancer, tuberculosis, bacterial and fungal ailments, the compounds were tested through MTT, microplate alamar blue and serial dilution protocols. ADMET and DFT investigation were analyzed against highly bioactive compounds (2, 7–10) to give a new insight about compound's reactivity, stability and drug likeness properties. Furthermore, activity results shows that the ligand (2) and its complexes demonstrate greater efficacy compared to ligand (1) and its complexes. The Cu(II) (9) and Zn(II) (10) complexes were observed as highly efficient for breast cancer (MCF-7 cell line), TB (H37Rv strain), bacterial and fungal ailments in comparison of standard drugs with 0.029 ± 0.001 μM IC50 value for (9) in anticancer activity and 0.0034 ± 0.0017 μmol/mL MIC value for (10) in anti-tuberculosis activity. In the molecular docking investigation, the various kind of binding interactions and lowest binding affinity of (9) (against 4RJ3 (−10.0 kcal/mol), 2VCJ (−7.9 kcal/mol)) and (10) (−7.8 and −8.3 kcal/mol for 5V3Y and 3PTY protein) support their bioactivity. This research highlights the pharmaceutical importance of transition metal complexes having thiosemicarbazones, presenting a significant approach for the discovery of potent anti-infectious agent.

Lumbar Intrathecal Injection in Adult and Neonatal Mice.

This article describes a step-by-step process of lumbar intrathecal injection of Evans blue dye and AAV9-EGFP in adult (2-month-old) and neonatal (postnatal day 10) mice. Intrathecal injection is a clinically translatable technique that has already been extensively applied in humans. In mice, intrathecal injection is considered a challenging procedure that requires a trained and experienced researcher. For both adult and neonatal mice, lumbar intrathecal injection is directed into the L5-L6 intervertebral space. Intrathecally injected material enters the cerebrospinal fluid (CSF) within the intrathecal space from where it can directly access the central nervous system (CNS) parenchyma. Simultaneously, intrathecally injected material exits the CSF with pressure gradient and enters the endoneurial fluid and ultimately the peripheral nerves. While in the CSF, the injectable material also enters the bloodstream and systemic circulation through the arachnoid villi. A successful lumbar intrathecal injection results in adequate biodistribution of the injectable material in the CNS, PNS, and peripheral organs. When correctly applied, this technique is considered as minimally invasive and non-disruptive and can be used for the lumbar delivery of any solute. © 2024 Wiley Periodicals LLC. Basic Protocol 1: C57BL/6 adult and P10 mice lumbar intrathecal injection Basic Protocol 2: Tissue collection and preparation for evaluating Evans blue dye diffusion Basic Protocol 3: Tissue collection and preparation for immunohistochemistry staining Basic Protocol 4: Tissue collection and vector genome copy number analysis.

#2999 Renal venous congestion as a predictor of poor prognosis in patients with acute decompensated heart failure

Abstract Background and Aims Systemic venous congestion in acute decompensated heart failure (ADHF) is associated with a risk of end-organ damage and high in-hospital mortality. We aimed to assess the prevalence and severity of renal venous congestion using venous excess ultrasound (VExUS) protocol in intensive care unit (ICU) patients with ADHF, and to evaluate the association between type of intra-renal venous blood flow, incidence of acute kidney injury (AKI), and in-hospital death. Method A prospective single-center study included 99 patients who were admitted to the ICU with ADHF (mean age 71.1 ± 12.54 years, 56 (56.6%) males). Inclusion criteria: age ≥18 years, ADHF II–IV, signed informed consent. Exclusion criteria: acute coronary syndrome, severe concomitant diseases, refusal to participate in the study. Upon admission, routine clinical, laboratory and instrumental examinations, lung ultrasound using the BLUE protocol, and assessment of venous congestion using the pulse-wave dopplerography were performed. The presence of continuous blood flow was regarded as the absence of renal venous congestion, while intermittent (biphasic and monophasic blood flow) indicated venous congestion. The diagnosis of ADHF and AKI was established based on generally accepted criteria in accordance with modern international recommendations. All patients received optimal drug therapy. The end point was defined as death from cardiovascular causes during hospitalization. Statistical analysis was performed using SPSS Statistics, version 26.0. Results Upon admission, continuous renal venous blood flow was detected in 17 (17.2%) patients, intermittent in 82 (82.8%): biphasic in 47 (47.5%) and monophasic in 35 (35.3%). The patient groups were comparable in gender, age, frequency of coronary heart disease, diabetes mellitus, anemia. Atrial fibrillation was more common in case of monophasic (p < 0.006), and arterial hypertension in patients with continuous venous blood flow (p < 0.001). Patients with renal venous congestion, compared with patients without signs of congestion, had more severe heart failure: swollen neck veins: 5 (29.4%) vs 21 (45%) vs 28 (60%), p < 0.001; hepatomegaly 12 (72.6%) vs 40 (85.1%) vs 31 (88.6%), p < 0.001; edema 8 (47.3%) vs 40 (85.1%) vs 24 (68.6%), p < 0.001; NYHA functional class IV 8 (47.1%) vs 32 (68.1%) vs 26 (74.6%), p < 0.001; more B-lines on lung ultrasound, M+SD 28.82 ± 8.91 vs 34.38 ± 9.64 vs 35.37 ± 8.72, p < 0.001, higher NTproBNP levels, pg/l, Ме(IQR) 2100 (1800;4560) vs 3418 (2300;8434) vs 4100 (2500;9282), p < 0.001, and albuminuria levels mg/g, Ме(IQR) 85 (29;145) vs 127 (49;248) vs 139 (64;245), p < 0.001. The incidence of AKI (4 (23.5%) vs 23 (49%) vs 31 (88.6%), p < 0.001), and in-hospital death (0 (0) vs 11 (23.4%) vs 12 (34.3%), p < 0.003) was also higher in the group of patients with monophasic renal blood flow. The presence of renal venous congestion on admission was associated with an increased risk of death due to heart failure during hospitalization with RR 1.32 (95% CI: 1.16-2.64), p < 0.001, and RR 1.64 (95% CI: 1.48-2.83), p < 0.001 in patients with biphasic and monophasic renal venous blood flow respectively, and with development of AKI RR 3.29 (95% CI: 1.50-7.24), p < 0.003 in patients with monophasic renal venous blood flow. Conclusion In ICU patients with ADHF, the presence of renal venous congestion, assessed on admission with Doppler ultrasound of the intrarenal veins using the VEXUS protocol, is associated with a high risk of developing AKI and in-hospital death.

Elevated level of neuroserpin is an indication for the resistance to gambogic acid-induced apoptosis and oxidative stress in triple-negative breast cancer cells.

The triple-negative breast cancer (TNBC) subtype, characterized by loss of HER2, estrogen, and progesterone receptors, displays aggressive phenotype and poor prognosis compared to other BC subtypes. Since the TNBC cells are devoid of receptors, endocrine therapy is an ineffective option for TNBC patients, necessitating canonical chemotherapy strategies to treat TNBC. It is crucial to use alternative and natural agents to support chemotherapy in TNBC. To clarify the molecular mechanism of the tumorigenic effects of gambogic acid (GA) on TNBC cells with different epithelial character since GA has a wide spectrum of anticancer activity for most cancer types. We determined the cytotoxic dose of GA incubation of TNBC cells (MDA-MB-231 and BT-20 cells) for 24 h. We performed the MTT test and toluidine blue (TB) staining protocol for TNBC cells. We analyzed E-cadherin, N-cadherin, Bax, and neuroserpin mRNAs in both cells by qPCR. We evaluated apoptosis using DAPI staining and assessed the ROS using the 2',7'-dichlorofluorescin diacetate (DCFH-DA) method. We determined the IC50 concentrations of GA in MDA-MB-231 and BT-20 cells to be 315.8 nM and 441.8 nM, respectively. TB staining showed that BT-20 cells survive at excessive cytotoxic doses of GA, while most of the MDA-MB-231 cells were killed. Also, we found that BT-20 cells are more resistant to GA-induced apoptosis and oxidative stress than the MDA-MB-231 cells. qPCR results showed that GA upregulated neuroserpin, an oxidative stress-relieving factor in the BT-20 cells, but not in the MDA-MB-231 cells. The elevated level of neuroserpin could be a predictive marker to determine the development of resistance to chemotherapeutic agents.

Monitoring of infusion therapy in patients with reduced cardiac reserve during abdominal operations

Background. In the pathogenesis of many intra- and postoperative complications, the composition, volume and rate of infusion therapy (IT) play a significant role. This problem is especially relevant for patients with concomitant chronic pathology of the cardiovascular, respiratory systems and kidneys. Informative indicators for assessing the correctness of IT and early diagnosis of intraoperative complications associated with errors in its implementation are complex monitoring of functional indicators of the cardiovascular and respiratory systems. Purpose – of the study is to investigate changes in biochemical markers of heart failure and ultrasound signs of venous stasis in two modes of infusion therapy (restrictive and liberal), on the basis of a comparative study, to determine the optimal mode of perioperative IT in patients undergoing elective surgery for diseases of the abdominal cavity and have comorbid pathology in the form of coronary heart disease (CHD) and heart failure (HF). Materials and Methods. 86 patients were included in a single-center, prospective, randomized study. All patients were randomly divided into two groups depending on the mode of intraoperative IT: in the first group (n = 44) – a restrictive mode of 5–8 ml/kg/hour was applied, in the second (n = 42) – a liberal mode. Echocardiography was performed at the stages of the study. Heart contractility, central hemodynamics, and ejection fraction were evaluated. An ultrasound scan of the inferior vena cava (IVC) was performed during breathing as a non-invasive method of assessing the intravascular blood volume. The diameter of the vein during inhalation and exhalation was evaluated. Based on the respiratory change in the diameter of the IVC, the caval index is calculated, which is expressed as a percentage. An index approaching 100% indicates near-complete collapse and probable volume depletion, while an index close to 0% indicates minimal collapse and intravascular overflow. Ultrasound of the lungs was performed according to the BLUE protocol with a convex sensor in 8 zones along the front chest wall. The severity of pulmonary congestion was assessed based on the sum of B-lines: 5 and less – no congestion, 6 to 15 – slight congestion, 15 to 29 – moderate, 30 and more – significant. Results. The conducted study shows the advantage of the restrictive regimen of IT in patients with concomitant coronary artery disease and minimal signs of congestive heart failure during abdominal surgical operations. The regime with restriction of intravenous fluid administration was better, as it reduces venous congestion, reduces the amount of fluid in the interstitial space of the lungs, causes a smaller compensatory reaction of the cardiovascular system to infusion with normal values of NT-proBNP. The task of the anesthesiologist in this case is careful control of daily and cumulative water balance, adequate monitoring of indicators of the cardiovascular system, use of modern ultrasound technologies and protocols for controlling volemic status, assessment of the dynamics of biomarkers of heart failure, which will allow complex abdominal operations to be safely performed in patients with reduced cardiac reserve. Conclusions. As a result of the conducted research, it was established that: the use of a liberal regimen of infusion therapy in the perioperative period in patients with coronary heart disease and HF I, I-II FC compared to a restrictive regimen leads to a statistically significant increase in biomarkers of heart failure and ultrasound signs of volemic overload. The restrictive regimen of IT in a dose of 5–8 ml/kg/hour, in comparison with a liberal one in a dose of 12–15 ml/kg/hour, can be recognized as optimal and safe in patients with coronary heart disease and HF I, I-II FC during surgery on the organs of the abdominal cavity. The use and widespread implementation in practice of complex determination of the level of the amino-terminal prohormone of brain natriuretic peptide (NT-proBNP) NT-proBNP, non-invasive methods of ultrasound of the heart – echocardiography, ultrasound of the lungs and central vessels – assessment of the dynamic filling of the inferior vena cava (IVC) allows significantly supplement clinical information on volemic status, venous stasis, contractility of the heart and fluid retention in the interstitial space of the lungs and may be key in the prevention of cardiac complications in this category of patients.

Unlocking Diagnostic Precision: FATE Protocol Integration with BLUE and eFAST Protocols for Enhanced Pre-Hospital Differential Diagnosis of Pleural Effusion Manifested as Dyspnea in Adults-A Pilot Study.

Background: Dyspnea commonly stems from combined myocardial and pulmonary dysfunction, posing challenges for accurate pre-hospital diagnosis. Limited diagnostic capabilities hinder the differentiation of cardiac and pulmonary issues. This study assesses the efficacy of combined cardiac and pulmonary ultrasound using the BLUE, eFAST, and FATE protocols. Methods: Participants were consecutively enrolled from dyspnea-related emergency calls in Warsaw, Poland, from 4 April 2022, to 15 June 2023. Patients with pleural effusion were identified through pre-hospital and in-hospital radiological assessments. Pre-hospital thoracic ultrasonography followed the BLUE, eFAST, and FATE protocols, alongside comprehensive clinical assessments. The pre-hospital diagnoses were juxtaposed with the with hospital discharge diagnoses. Results: Sixteen patients (8 men, 8 women; median age: 76 years) were enrolled. Inter-rater agreement for the BLUE protocol was substantial (κ = 0.78), as was agreement for eFAST (κ = 0.75), with almost perfect agreement for combined protocol assessment (κ = 0.83). Left ventricle hypokinesis, identified via the FATE protocol, significantly correlated with hospital-diagnosed decompensated heart failure as the primary cause of dyspnea. Sensitivity and specificity were 1.0 (95%CI: 0.62-1.0) and 0.6 (95%CI: 0.15-0.95), respectively. Positive predictive value was 0.85 (95%CI: 0.55-0.98), and diagnostic accuracy was 0.86 (95%CI: 0.62-0.98). Conclusions: Integrating the FATE protocol into BLUE and eFAST enhances pre-hospital differential diagnosis accuracy of pleural effusion in adults. This synergistic approach streamlines diagnostic processes and facilitates informed clinical decision-making. Larger-scale validation studies are needed for broader applicability.

Impact of a COVID-19 code blue protocol on resuscitation care and CPR quality during in-hospital cardiac arrest

ObjectiveWe sought to evaluate the impact of a COVID-19 Code Blue policy on in-hospital cardiac arrest (IHCA) processes of care, cardiopulmonary resuscitation (CPR) quality metrics, and survival to hospital discharge. MethodsWe completed a health record review of consecutive IHCA for which resuscitation was attempted. We report Utstein outcomes and CPR quality metrics 33 months before (July,2017-March,2020) and after (April,2020-December,2022) the implementation of a COVID-19 Code Blue policy requiring all team members to don personal protective equipment including gown, gloves, mask, and eye protection for all IHCA. ResultsThere were 800 IHCA with the following characteristics (Before n = 396; After n = 404): mean age 66, 62.9% male, 81.3% witnessed, 31.3% in the emergency department, 25.6% cardiac cause, and initial shockable rhythm in 16.7%. Among all 404 patients screened for COVID-19, 25 of 288 available test results before IHCA occurred were positive. Comparing the before and after periods: there were relevant time delays (min:sec) in start of chest compressions (0:17vs.0:37;p = 0.005), team arrival (0:43vs.1:21;p = 0.002), 1st rhythm analysis (1:15vs.3:16;p < 0.0001), 1st epinephrine (3:44vs.4:34;p = 0.02), and airway insertion (8:38vs. 10:18;p = 0.02). Resuscitation duration was similar (18:28vs.19:35;p = 0.34). Exception of peri-shock pause which appeared longer (0:06vs.0:14;p = 0.07), chest compression fraction, rate and depth were identical and good. Factors independently associated with survival were age (adjOR 0.98;p < 0.001), male sex (adjOR 1.51;p = 0.048), witnessed (adjOR 2.35;p = 0.02), shockable rhythm (adjOR 3.31;p < 0.0001), hospital location (p = 0.0002), and COVID-19 period (adjOR 0.68;p = 0.052). ConclusionsThe COVID-19 Code Blue policy was associated with delayed processes of care but similarly good CPR quality. The COVID-19 period appeared associated with decreased survival.

Albuminuria as a marker of systemic congestion and a predictor of poor long-term prognosis in acute decompensated heart failure

Aim. To identify the relationship of different albuminuria levels with paraclinical signs of congestion on admission and discharge and with the prognosis of acute decompensated heart failure (ADHF).Material and methods. Patients hospitalized with ADHF were included. Albuminu­ria level was assessed on admission and discharge. Patients were divided into groups according to albuminuria level (A1, A2, A3) according to KDIGO guidelines. Among the congestion parameters, the following were assessed: N-terminal pro-brain natriuretic peptide (NT-proBNP), lung ultrasound examination (BLUE protocol), venous congestion according to the VExUS ultrasound protocol (inferior vena cava, portal, hepatic and renal veins). The primary endpoint was a composite of all-cause death and rehospitalization for ADHF within 180 days of discharge.Results. The final analysis included 180 patients. The prevalence of A1, A2 and A3 albuminuria at admission was 50%, 39%, 11%, respectively. A greater degree of albu­minuria was associated with worse renal function at admission and discharge. Pati­ents with increased albuminuria on admission had higher NT-proBNP and a greater number of B-lines on pulmonary ultrasound in on admission and discharge, and a higher degree of complex venous congestion and renal vein congestion on VExUS on admission. A3 albuminuria at admission and discharge was associated with an increased risk of poor long-term prognosis (hazard ratio (HR) 3,551; 95% confidence interval (CI) 1,593-7,914; p=0,002), (HR 4,362; 95% CI 1,623-11,726; p=0,004).Conclusion. In patients with ADHF, the albuminuria level on admission is associated with the severity of congestion upon admission and discharge. A3 albuminuria at admission and at discharge is a predictor of long-term poor prognosis within 180 days after discharge.

Diagnostic role of thoracic ultrasound in patients with acute respiratory failure at emergency service.

This study aimed to elucidate the effectiveness of bedside thoracic ultrasound according to BLUE protocol and to investigate its superiority over other imaging methods in the emergency service. A total of 120 patients admitted to our institution's emergency care department due to respiratory distress have been enrolled in this prospective research. Thorax USG has been performed in the right and left hemithorax at the points specified in the BLUE protocol for each patient. Pleural sliding motion, A-lines, B-lines, consolidation, effusion, and the presence of barcode signs were evaluated individually. Age, sex, comorbid diseases, other radiological examination findings, laboratory findings, final clinical diagnosis, and hospitalization-discharge status of the patients were recorded. When a correct diagnosis of pneumonia has been analyzed for imaging techniques, the diagnostic rate of chest radiography was 83.3%, CT was 100.0%, and USG was 66.6%. The correct diagnostic rate of chest radiography was 94.5%; CT and USG were 100.0%. The correct diagnosis of pulmonary edema on chest radiography was 94.5%; CT and USG were 100.0%. While the correct diagnosis of pleural effusion on chest radiography and CT was 100.0%, it was 92.3% in USG imaging. Finally, CT and USG imaging performed better than chest radiography in patients with pneumothorax (chest radiography 80.0%, CT and USG 100%). USG imaging could be preferred in the diagnosis of pneumonia, pulmonary edema, pleural effusion, pneumothorax, pulmonary embolism, and differential diagnosis at the emergency service.

Match official experiences with the Blue Card protocol in amateur rugby: implementing Rowan’s Law for concussion management

ABSTRACT The Blue Card protocol was introduced to domestic amateur rugby competitions to bring Rugby Canada into compliance with provincial concussion legislation. The Blue Card protocol formalises how match officials can remove an athlete with a suspected concussion from play and prevents athletes from returning to sport without medical clearance. This exploratory study examined the experiences of Canadian rugby match officials with the novel Blue Card process. Semi-structured interviews conducted with six Canadian rugby match officials were subjected to Interpretive Phenomenological Analysis. Findings revealed interpersonal (e.g. stakeholder collaboration and peer support) and intrapersonal (e.g. concerns about personal liability and comfort with the administration of the Blue Card) factors related to the successful implementation of concussion management protocols. Match officials distinguished actions from members of the rugby community as either supporting (e.g. information sharing) or actively resisting (e.g. questioning match official decisions regarding the Blue Card) efforts to implement the Blue Card protocol. Those who had personal experience removing an athlete from play due to a suspected concussion or who administered a Blue Card during the 2019 season reported feeling more comfortable with the process than less experienced peers. However, in this early policy implementation phase, 50% of participants expressed concerns about their personal liability associated with the Blue Card process. Implications for the design and implementation of sport-related concussion research and policy at the amateur level are discussed.

Discriminating Between Apoptosis, Necrosis, Necroptosis, and Ferroptosis by Microscopy and Flow Cytometry.

Apoptosis is a mode of programmed cell death that plays important roles in tissue sculpting during development, in the maintenance of tissue homeostasis in the adult, and in the eradication of injured or infected cells during pathological processes. Numerous physiological as well as pathological stimuli trigger apoptosis, such as engagement of plasma-membrane-associated Fas, TRAIL, or TNF receptors, growth factor deprivation, hypoxia, radiation, and exposure to diverse cytotoxic drugs. Apoptosis is coordinated by members of the caspase family of cysteine proteases, which, upon activation, trigger a series of dramatic morphological and biochemical changes including retraction from the substratum, cell shrinkage, extensive and protracted plasma membrane blebbing, chromatin condensation, DNA hydrolysis, nuclear fragmentation, and proteolytic cleavage of numerous caspase substrates. These dramatic structural and biochemical alterations result not only in the controlled dismantling of the cell, but also in the rapid recognition and removal of apoptotic cells by phagocytes through the cell surface display of phagocytotic triggers such as phosphatidylserine. Necrosis, which is typically nonprogrammed or imposed upon the cell by overwhelming membrane or organelle damage, is characterized by high-amplitude cell swelling, followed by rapid plasma membrane rupture and release of cellular contents into the extracellular space. Necrosis is often provoked by infectious agents or severe departure from physiological conditions due to toxins, temperature extremes, or physical injury. However, forms of programmed necrosis (necroptosis, pyroptosis, ferroptosis) can also occur in specific circumstances. Nonprogrammed and programmed necrosis can be distinguished from apoptosis by morphological features, based on the rapid uptake of vital dyes, and through the application of specific inhibitors of key molecules associated with the latter modes of cell death. This unit describes protocols for the measurement of apoptosis and necrosis and for distinguishing apoptosis from programmed as well as conventional necrosis. © 2023 The Authors. Current Protocols published by Wiley Periodicals LLC. Basic Protocol 1: Analysis of cell morphology by phase-contrast microscopy Alternative Protocol 1: Assessment of morphological changes using eosin-methylene blue staining Alternative Protocol 2: Analysis of nuclear morphology by fluorescence microscopy Support Protocol: Preparation of cytospins Basic Protocol 2: Measurement of plasma membrane composition with annexin V and propidium iodide Basic Protocol 3: Measurement of DNA fragmentation by flow cytometry Alternative Protocol 3: Analysis of DNA fragmentation by the TUNEL assay Basic Protocol 4: Measurement of caspase activation by flow cytometry Basic Protocol 5: Discriminating between apoptosis, necrosis, necroptosis, and ferroptosis.

A Discourse Analysis Of Students-Teacher Pattern Interaction In Elt Classroom

This study aims to find patterns of interaction between students and teachers in ELT classes. Participants involved in this study were 32 students and one English teacher. This research is a qualitative research with a descriptive design. This relates to the use of language in a social context, namely interaction or dialogue between students and teachers. The author uses 2 types of instruments, namely observation using the blue print protocol and also recording all English learning activities in the ninth grade of SMP N Toboali. Then after making observations and obtaining all the required data, the authors conducted an analysis using FIAS (Flanders Interaction System Analysis) which consisted of 3 parts, namely the teacher's indirect influence, the teacher's direct influence and students' speech responses. The teacher's indirect influence consists of 3 kinds of interactions such as receiving feelings, praising encouragement, accepting or using student ideas, and asking questions. Then, the teacher's direct influence consists of lecturing or explaining, giving directions, and criticizing or justifying authority. The last is the student's response which consists of the student's speech response, student initiation, and silence. According to the research results, there are four types of classroom interaction research: content traffic, teacher control, teacher support, and student participation. Based on the results of the data found, it shows that the dominant pattern used in this study is student participation, with a total of 54 or 45% of utterances. Hence, it can be concluded that the students of ninth grade students at SMPN 3 Toboali were active during the teaching and learning process in class.

Pro: Does Every Anesthesiologist Need to Learn Point-of-Care Ultrasound?

THE APPLICATIONS OF ULTRASOUND for the anesthesiologist are diverse and expanding rapidly. Although national society guidelines governing the appropriate use of ultrasound in anesthesiology have been available only for transesophageal echocardiography (TEE) and vascular access imaging, clinical guidance has more recently been published describing the use of focused cardiac ultrasound in multiple clinical contexts. 1 Troianos CA Hartman GS Glas KE et al. Guidelines for performing ultrasound guided vascular cannulation: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr. 2011; 24: 1291-1318 Abstract Full Text Full Text PDF PubMed Scopus (257) Google Scholar , 2 American Society of Anesthesiologists and Society of Cardiovascular Anesthesiologists Task Force on Transesophageal EchocardiographyPractice guidelines for perioperative transesophageal echocardiography. An updated report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Anesthesiology. 2010; 112: 1084-1096 Crossref PubMed Scopus (391) Google Scholar , 3 Spencer KT Kimura BJ Korcarz CE et al. Focused cardiac ultrasound: Recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr. 2013; 26: 567-581 Abstract Full Text Full Text PDF PubMed Scopus (398) Google Scholar , 4 Via G Hussain A Wells M et al. International evidence-based recommendations for focused cardiac ultrasound. J Am Soc Echocardiogr. 2014; 27 (683.e1-683.e33) Abstract Full Text Full Text PDF PubMed Scopus (368) Google Scholar Additionally, numerous point-of-care ultrasound (POCUS) protocols now exist to guide the examination of nearly every organ system and area, including cardiac, pulmonary and/or pleural, abdominal, genitourinary, ocular, and airway. 4 Via G Hussain A Wells M et al. International evidence-based recommendations for focused cardiac ultrasound. J Am Soc Echocardiogr. 2014; 27 (683.e1-683.e33) Abstract Full Text Full Text PDF PubMed Scopus (368) Google Scholar , 5 Haskins SC Bronshteyn Y Perlas A et al. American Society of Regional Anesthesia and Pain Medicine expert panel recommendations on point-of-care ultrasound education and training for regional anesthesiologists and pain physicians-part I: Clinical indications. Reg Anesth Pain Med. 2021; 46: 1031-1047 Crossref PubMed Scopus (15) Google Scholar , 6 Haskins SC Bronshteyn Y Perlas A et al. American Society of Regional Anesthesia and Pain Medicine expert panel recommendations on point-of-care ultrasound education and training for regional anesthesiologists and pain physicians-part II: Recommendations. Reg Anesth Pain Med. 2021; 46: 1048-1060 Crossref PubMed Scopus (14) Google Scholar , 7 Holm JH Frederiksen CA Johl-Olsen P et al. Perioperative use of focus assessed transthoracic echocardiography (FATE). Anesth Analg. 2012; 115: 1029-1032 Crossref PubMed Scopus (71) Google Scholar , 8 Lichtenstein DA Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: The BLUE protocol. Chest. 2008; 134: 117-125 Abstract Full Text Full Text PDF PubMed Scopus (1146) Google Scholar , 9 Volpicelli G Elbarbary M Blaivas M et al. International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med. 2012; 38: 577-591 Crossref PubMed Scopus (1758) Google Scholar , 10 Scalea TM Rodriguez A Chiu WC et al. Focused Assessment with Sonography for Trauma (FAST): Results from an international consensus conference. J Trauma. 1999; 46: 466-472 Crossref PubMed Google Scholar , 11 Perlas A Van de Putte P Van Houwe P et al. I-AIM framework for point-of-care gastric ultrasound. Br J Anaesth. 2016; 116: 7-11 Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar

Point-of-care ultrasound (POCUS) protocol for systematic assessment of the crashing neonate—expert consensus statement of the international crashing neonate working group

Sudden unexpected clinical deterioration or cardiorespiratory instability is common in neonates and is often referred as a “crashing” neonate. The established resuscitation guidelines provide an excellent framework to stabilize and evaluate these infants, but it is primarily based upon clinical assessment only. However, clinical assessment in sick neonates is limited in identifying underlying pathophysiology. The Crashing Neonate Protocol (CNP), utilizing point-of-care ultrasound (POCUS), is specifically designed for use in neonatal emergencies. It can be applied both in term and pre-term neonates in the neonatal intensive care unit (NICU). The proposed protocol involves a stepwise systematic assessment with basic ultrasound views which can be easily learnt and reproduced with focused structured training on the use of portable ultrasonography (similar to the FAST and BLUE protocols in adult clinical practice). We conducted a literature review of the evidence-based use of POCUS in neonatal practice. We then applied stepwise voting process with a modified DELPHI strategy (electronic voting) utilizing an international expert group to prioritize recommendations. We also conducted an international survey among a group of neonatologists practicing POCUS. The lead expert authors identified a specific list of recommendations to be included in the proposed CNP. This protocol involves pre-defined steps focused on identifying the underlying etiology of clinical instability and assessing the response to intervention.Conclusion: To conclude, the newly proposed POCUS-based CNP should be used as an adjunct to the current recommendations for neonatal resuscitation and not replace them, especially in infants unresponsive to standard resuscitation steps, or where the underlying cause of deterioration remains unclear.What is known?• Point-of-care ultrasound (POCUS) is helpful in evaluation of the underlying pathophysiologic mechanisms in sick infants.What is new?• The Crashing Neonate Protocol (CNP) is proposed as an adjunct to the current recommendations for neonatal resuscitation, with pre-defined steps focused on gaining information regarding the underlying pathophysiology in unexplained “crashing” neonates.• The proposed CNP can help in targeting specific and early therapy based upon the underlying pathophysiology, and it allows assessment of the response to intervention(s) in a timely fashion.

Ultrasound of Lung

Ultrasound (US) is a very common tool in today’s clinical practice. Lung ultrasound was popularized by Daniel Lichtenstein, a French intensivist. He noted that sonographic artifacts during lung ultrasound could differentiate between various lung diseases and subsequently noted the ultrasound’s ability to differentiate various diseases. He also popularized the points of probe placement and various signs and lines in lung ultrasound, which includes the A line, B-lines, Lung sliding sign, seashore sign etc. based upon which the BLUE protocol was introduced. Lung ultrasound has rapidly gained popularity over the past 10 years, mainly due to its wide availability in emergency and trauma settings, lack of radiation exposure, easy availability and cost effectiveness. Although there are limitation to Lung ultrasound, like being user dependent, limited role in surgical emphysema, in severely obese patients, and CT still remains a gold standard for diagnosis of lung pathologies, ultrasound has shown to be equally effective or even better in diagnosis and management of patients in critically ill patients, where obtaining CT scan or other imaging technique is not feasible. Hence, lung ultrasound is a must have tool and knowledge and skills related to lung ultrasound should not only be limited to Radiologist, but also to all thoracic surgeons and physicians involved in managing critically ill patients.