Standard Labs Research Articles

208: Correlation of TEG R time values and standard coagulation labs for pediatric ECMO patients receiving heparin or bivalirudin

208: Correlation of TEG R time values and standard coagulation labs for pediatric ECMO patients receiving heparin or bivalirudin

Software-assisted automated detection and identification of "unknown" analogues of benzodiazepines in liquid chromatography mass spectrometry analysis.

Benzodiazepines (BZDs) construct a large group of psychoactive drugs acting as depressants of the central nervous system (CNS) and used in medicine as sedatives and anxiolytic and antiepileptic agents. The illicit use of these materials is a worldwide problem, and for many years, part of the benzodiazepines have been abused as rape drugs. For example, flunitrazepam (Rohypnol) is most commonly linked by media reports to drug-facilitated sexual assaults, more commonly referred to as "date rape." Furthermore, there are growing concerns for other misuses of these drugs. Over the last few years, there was an increase in the number, type, and availability of new psychoactive substances (NPS) belonging to the benzodiazepine group, challenging standard forensic labs to fully identify the chemical structure of new, unknown benzodiazepines. This work demonstrates a new application of the automated tool for the detection and identification of benzodiazepine analogues using high-resolution-accurate-mass LC-MS analysis, followed by "Compound Discoverer" (CD) software data processing, to automatically detect various benzodiazepine analogues by picking peaks and compare them to in silico calculated modifications made on a predefined basic backbone. Subsequently, a complete structural elucidation for the proposed molecular formula is obtained by MS/MS data analysis of the suspected component. This method was found to be useful for the automated detection and putative identification of a series of nine "unknown" benzodiazepine analogues, at concentrations in the low ng/mL range. We hereby present a general demonstration of this powerful tool for the forensic community in the detection and identification of hazardous unknown compounds.

T staging esophageal tumors with x rays.

With histopathology results typically taking several days, the ability to stage tumors during interventions could provide a step change in various cancer interventions. X-ray technology has advanced significantly in recent years with the introduction of phase-based imaging methods. These have been adapted for use in standard labs rather than specialized facilities such as synchrotrons, and approaches that enable fast 3D scans with conventional x-ray sources have been developed. This opens the possibility to produce 3D images with enhanced soft tissue contrast at a level of detail comparable to histopathology, in times sufficiently short to be compatible with use during surgical interventions. In this paper we discuss the application of one such approach to human esophagi obtained from esophagectomy interventions. We demonstrate that the image quality is sufficiently high to enable tumor staging based on the x-ray datasets alone. Alongside detection of involved margins with potentially life-saving implications, staging tumors intra-operatively has the potential to change patient pathways, facilitating optimization of therapeutic interventions during the procedure itself. Besides a prospective intra-operative use, the availability of high-quality 3D images of entire esophageal tumors can support histopathological characterization, from enabling "right slice first time" approaches to understanding the histopathology in the full 3D context of the surrounding tumor environment.

Discussion of impacts of measurement error in architectural acoustics performance specifications

Customers for acoustic products need manufacturers and professionals to provide performance specifications to allow informed design decisions. Acoustic professionals rely upon standard tests and special labs to quantify products. Data published by the ASTM for E90 shows that an STC rating for a single construction can have a variability range of up to 7 points. Being logarithmic, this equates to a sound pressure range of more than 2×, larger than 100%. The log nature of many acoustical performance metrics hides this from most. This large variability causes challenges for the architectural acoustics community. The primary negative impact: customers do not trust the acoustical ratings manufacturers provide. This is not an issue of the manufacturers providing inaccurate information, it is an issue of under-reported and incomplete understanding of the uncertainty in the metrics themselves. For perspective, NRC measured the Young’s Modulus of OSB material to have a mean of 6.8 × 109 and a standard deviation of 1.5 × 108 (Ref: NRC IR-766, Table 22). This yields a measurement error of 3.8%. It is simple to account for this in the design process. If the metric has an uncertainty as large as the acoustic metrics, the standard paradigm for accounting for error not only breaks down, it incentivizes bad actors: cherry picking, lab shopping, etc. More open acknowledgement of the measurement error in architectural acoustic metrics would increase the confidence customers have in them and would allow designers to make more informed decisions.

Evaluation of Diurnal Changes of Mental Fatigue Using a New Portable Device for Visual Cognitive Evoked Potentials.

In the age homogenous group of 13 healthy volunteers, we examined visual evoked potentials (VEP) visually evoked cognitive potentials (event-related potentials - ERP) and choice reaction time (CRT) five times during the day (from 10.00 a.m. up to midnight) to verify whether there are significant changes of the measured parameters of the cortical evoked potentials and CRT which might reflect the level of the mental fatigue. The electrophysiological testing was done with the use of a new portable VEP device named "VEPpeak" enabling to perform the examination outside standard labs in almost any conditions. It was found that the latency of ERP (P300 peak time) and CRT displayed significant prolongation toward midnight while VEP latency and all amplitudes did not change significantly. This pilot study supports our idea that the portable VEP device possibly might be used for the objective examination of mental fatigue that is needed in many situations. This should be confirmed in a larger study also including a comparison with non-electrophysiological fatigue testing.

Review on the Synthesis and Biological Importance of Triazole Ring-containing Structures

Currently, many organic compounds have been synthesized and identified by chemists in chemical laboratories, numbering in the millions. The triazole ring is categorized as a subset of organic heterocyclic compounds. It constitutes a significant and extensive subject matter, and an in-depth examination of triazoles and their derivatives can lead to the development of specialized medical and biological chemical agents aimed at preventing a range of diseases. This article generally has two parts, the first part of the article is dedicated to triazole syntheses, in which the research of different authors is reviewed from 2005 to 2021, and the second part of this article is the biological importance of the triazole ring. Based on the special importance of medicine, we can mention antimicrobial and antifungal drugs that have a high level of medicinal activity. Unfortunately, we don’t have standard chemical labs, to perform experiments. Nowadays, lab researches are replacing one group by another or one atom by another to obtain compound with deferent properties.

Baseline CRP and Ferritin Identify Patients at High Risk of Poor Outcomes after Axicabtagene Ciloleucel Despite Corticosteroid Prophylaxis

Introduction: We and others have reported the role of cytokines and the tumor microenvironment on the development of severe grade >3 toxicities and CAR T resistance in recipients of CD19 targeted therapy. However, these analyses are not readily available outside of research settings. Early intervention and prophylactic strategies with cytokine blocking agents and/or steroids to mitigate severe toxicity have been explored. In a recent analysis of cohort 6 of the ZUMA-1 trial, investigators reported improved rates of severe toxicity with the prophylactic use of dexamethasone (Oluwole OO, Br J Haematol 2021). There is limited data on which patients benefit the most from such strategies. Methods: This is a study to evaluate factors associated with the development of severe immune mediated toxicities and treatment resistance in patients with R/R DLBCL treated with standard of care axicabtagene ciloleucel (axi-cel) at Moffitt Cancer Center. Baseline samples of CRP, LDH and ferritin were collected within one week prior to lymphodepleting chemotherapy. Cytokine analyses were performed as previously described (Faramand R, CCR 2020). Cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) were graded based on ASTCT criteria. Patients were stratified into three risk groups based on baseline CRP and ferritin; low risk (CRP <4gm/dL and ferritin <400ng/dL), intermediate (not meeting criteria for high risk or low risk), and high risk (CRP >4gm/dL and ferritin >400ng/dL). During the study period, institutional clinical standards were revised to administer prophylactic corticosteroids consecutively to all patients meeting high risk criteria. Patient survival outcomes were compared using Kaplan-Meier curves and subsequent log-rank tests. Multivariable Cox proportional hazards regression model with adjustment for clinical covariates was used to estimate hazard ratios for survival outcomes. Results: 136 patients with R/R DLBCL treated with axi-cel (>2 lines of therapy) are included in this study. Baseline patient characteristics and outcomes are summarized in Table 1. Most patients developed CRS (n=126) with 10.3% developing severe (gr. >3) CRS. Eighty-three patients (61%) developed ICANS with 28% having severe gr. >3 toxicity. The median overall survival (OS) was 34.9 months with a median progression free survival (PFS) of 12.2 months. We previously reported association of baseline elevated IL6 levels with poor clinical outcomes. Baseline IL6 levels correlated (p<0.0001, Fig. 1A) with risk category based on CRP and ferritin. Rates of severe CRS (25.9 vs. 1.61%, p=0.001) and ICANS ( 51.9 vs. 16.1%, p=0.002) were significantly higher in the high-risk (HR) group in comparison to the low risk group. Median PFS was 3 months, 7.9 and not reached in the high, intermediate and low risk groups respectively (p=0.0001) (Fig. 1B). The median OS was significantly inferior in the HR group at 6.9 months compared to 14.9 months and not reached in the intermediate and low groups respectively (p<0.0001) (Fig. 1C). Based on the above risk stratification, ten additional patients met HR criteria and were treated with prophylactic dexamethasone for three days starting on the day of CAR T cell infusion. Although most patients (90%) developed CRS, none developed severe CRS in the prophylactic steroids group which compares favorably to 25.9% observed in historical HR patients who did not receive prophylactic steroids (p=0.16). Severe ICANS was lower (30%) in the prophylactic cohort as compared to 52% in historical HR patients (p=0.29). The median PFS and OS were 2.9 and 5.9 months respectively in recipients of prophylactic steroids. Discussion: We establish that baseline elevated levels of CRP and Ferritin are associated with severe toxicity, and significantly inferior PFS and OS. Patients in the low risk group have excellent outcomes in terms of toxicity and efficacy using standard treatment paradigms negating the need for steroid prophylaxis and may be considered for outpatient treatment. In this report, prophylactic steroids were only used in 10 patients meeting high risk criteria. While there were no cases of severe CRS, efficacy outcomes remained poor in this high-risk cohort despite steroid prophylaxis. High risk patients can be easily identified prior to treatment with CAR T using standard labs and are encouraged to enroll on clinical trials to improve outcomes. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Natural history study for children and adults with rare solid tumors.

TPS1600 Background: Rare cancers is defined as fewer than 15 cases per 100,000 people per year and account for 27% cancers diagnosed and lead to 25% of cancer-related deaths. Nearly 13% (1 in 8) of all cancers diagnosed in adults ages 20 and older are rare. All pediatric cancers are rare and approximately 12,600 children under the age of 20 years are diagnosed with cancer each year. Rarity of these diseases has caused a stagnation in understanding the tumor biology and developing newer therapies. Initiatives like Orphan Drug Act (1983) and Rare Disease Act (2002) has led to improvement in funding and research about these rare tumors. The Cancer Moonshot Research Initiative funded My Pediatric and Adult Rare Tumor (MyPART) network (cancer.gov/mypart) in the NCI Pediatric Oncology Branch and launched a longitudinal Natural History Study for Children and Adults with Rare Solid Tumors (NCT03739827). Methods: A prospective study to evaluate the natural history of rare pediatric and adult solid tumors comprehensively and longitudinally. Patients of any age with a rare solid tumor (&lt;15 cases per 100,000 people per year) are eligible. Patients with germline mutation who are at risk of developing these tumors or relatives of participants are also eligible. Patients can participate from home or are are invited to NIH for annual evaluations. Participants complete individual medical history, family history, patient related-outcomes measurements (PROs) and provide samples (blood, saliva) for DNA analysis. Tumors are analyzed using a 500+ gene panel (TruSight500, Illumina Panel) and undergo a comprehensive genomic and epigenomic analysis. Participants invited to NIH undergo a clinical evaluation, genetic counseling, blood collection (standard clinical labs, germline DNA/RNA, immune phenotypes, cytokines, exosomes), and imaging studies, as indicated. The goals of this study are to 1) Estimate and define the clinical spectrum of rare cancers 2) Evaluate and follow biological relatives of patients with rare tumors or carriers of germline genetic variants that predispose to development of rare tumors 3) Develop a better understanding of these diseases in an effort to develop a) Novel therapeutic interventions, b) Preventive/screening guidelines, c) Endpoints for future clinical trials, and d) Relevant patient reported outcomes that can improve our understanding of patients psychosocial and functional needs. Subprotocols under this protocol for children and adults include adrenocortical cancer (NCT04447014), neuroendocrine neoplasms (NCT04488263) and Chordoma (NCT0391046) to gather tumor specific data. Study accrual is ongoing. Clinical trial information: NCT03739827.

Correction Factors for the LSDG Free-Air Ionization Chamber for Low and Medium-Energy X-Rays with Monte Carlo Calculations

Advances in radiation dosimetry continue to improve the accuracy of calibrating photon and electron beams of radiotherapy. This accuracy in the dose delivery to the patient in radiotherapy depends to a large extent on the absolute dosimetry of the irradiation unit. This necessitates the use of an ionization chamber such as Free air ionization chambers (FAC), calibrated in a recognised Standard Dosimetry Laboratory [1]. FACs are widely used by Primary Standard Dosimetry Labs (PSDL) as primary standard for absolute measurement of air kerma in beam of low and medium energy x-rays. It can accurately measure air kerma of x-ray beams of energy up to about 300kV. The purpose of this investigation, was to determine the correction factors of the Free Air Chamber (FAC) using the Monte Carlo calculations.

CNV analysis in a diagnostic setting using target panel.

Copy-number variation (CNV) is an important source of genetic diversity in humans. It can cause Mendelian or sporadic traits or be associated with complex diseases by various molecular mechanisms, including gene dosage, gene disruption, gene fusion and position effects. In clinical diagnostics, it is therefore fundamental to be able to identify such variations. The preferred techniques for CNV detection are MLPA, aCGH and qPCR, which have proven to be valuable, and they are complex, costly and require prior knowledge of the region to analyze. CNV calling from NGS data still suffers from data variability. Coverage can vary greatly from one region of the genome to another, depending on many factors like complexity, GC content, repeated regions and many others. In this paper, we describe how we developed a method for CNV detection. Our method exploits CoNVaDING to detect single- and multiple-exon CNVs in targeted NGS data. We demonstrated that our CNV analysis has 100% specificity and 99.998% sensitivity. We also show how we evaluated the performance of this method based on internal analysis. The results indicate that the method can be used to screen prior to standard labs technologies, thus reducing the number of analyses, as well as costs, and increasing test conclusiveness.

Insurance Design and Out-of-Pocket (OOP) Costs: a Comparison of Oral and Intravenous (IV) Treatment Plans for Chronic Lymphocytic Leukemia (CLL) in the Era of the Affordable Care Act (ACA)

BackgroundPatients on treatment for CLL can incur significant OOP costs, but little is known about length of time to reach OOP maximums, and variance of cost-sharing between IV and oral medications, especially among privately-insured patients. These issues have both practice and policy implications. First, from a practice perspective, insurance plans can vary their cost-sharing for IV versus oral chemotherapy, and cost-sharing can impact adherence and outcomes. Second, from a policy perspective, 43 states have enacted laws to ensure cost-sharing parity between oral and IV chemotherapy, but there is little evidence that these laws actually lower costs for patients. Thus, our objective was to determine, for both oral and IV drugs, how quickly patients reach their annual OOP maximums.MethodsUsing Health Insurance Marketplace Public Use Files that contain cost-sharing data for all private insurance plans participating in the Affordable Care Act's (ACA) Federally Facilitated Marketplace, we determined the relative impact on OOP cost of oral (ibrutinib) vs. IV (bendamustine/rituximab; BR) chemotherapy on time to reaching OOP maximums. With this data, we created a model of guideline-based, first-line CLL treatment regimens for ibrutinib and BR. We used Current Procedural Terminology (CPT) codes for procedures, and Healthcare Common Procedure Coding System (HCPCS) J-codes for drugs. We used a patient weight of 70kg and body surface area of 1.8m2 for dosing. Ibrutinib was dosed at 420mg. BR was dosed at bendamustine 70mg/m2 and rituximab 375mg/m2 for the first dose and bendamustine 500mg/m2 for all subsequent doses. We accounted for billing of professional fees, facility fees, infusional drugs, oral specialty drugs, supportive care medications, imaging, and blood tests. The average bill for each visit was applied to ACA Marketplace plans at 100% of Medicare fee schedule. As a sensitivity analysis, we varied costs to 120% and 150% of the Medicare Fee schedule based on an evidence-based multiplier for estimation of private insurance fees. Descriptive statistics and t-tests for comparison were calculated for number of days to reach OOP maximum for each insurance plan. We assessed variation according to metal tier (Catastrophic, Bronze, Silver, Gold, Platinum).ResultsOf the nearly 55,000 ACA plans nationally, 3092 unique insurance plan designs were identified on the ACA Marketplace for 2017. The average OOP maximum of these plans by metal tier was $7150 for catastrophic (maximum allowed by the ACA in 2017), $6883 for bronze, $6463 for silver, $4931 for gold, and $2284 for platinum. On average, patients on 95% of plans will reach the OOP maximum for the year for both BR and ibrutinib. A patient on BR will reach the OOP maximum in a mean of 3 clinic visits (29 days) for 100%, 120% and 150% of Medicare pricing. Using the 100% Medicare pricing estimate, a patient on ibrutinib will reach the OOP maximum in a mean of 3 visits (36 days) based on the typical timing of office visits. For the 120% and 150% of Medicare pricing estimates, the maximum OOP costs for ibrutinib are reached after only 2 visits (8 days). Metal tier also impacted time to maximum. For a patient on BR at 100% of Medicare, the maximum OOP expense was reached after 1 visit (1 day) for catastrophic, 2 visits (2 days) for bronze, 3 visits (28 days) for silver, 4 visits (29 days) for gold, 10 visits (113 days) for platinum. For a patient receiving ibrutinib at 100% of Medicare, the maximum OOP expense was reached after 1 visit (1 day) for catastrophic, 2 visits (8 days) for bronze, and 3 visits (28 days) for silver, gold, and platinum.ConclusionsFirst, using standard Medicare pricing, we found that patients receiving BR or ibrutinib quickly reached their maximum annual OOP caps within an average of 29 days (3 clinic visits) for BR and 36 days (3 visits) for ibrutinib. Using pricing schedules more reflective of private insurance, patients are likely to reach their cap even faster. Second, drug costs contributed most to reaching the maximums despite accounting for standard professional fees, labs, and imaging. These data suggest a limited benefit of state parity laws since the underlying costs of these drugs remain high, and patients reach OOP caps very quickly with either oral or IV drugs. Methods for reducing the financial burden to the patient and health care system from these novel yet expensive therapies need to be explored. DisclosuresZafar:Novartis: Other: Spouse's Employment.

887 Universal hemoglobin a1c in the early diagnosis of gestational diabetes

To compare ACOG’s suggested risk-based early screening protocol with universal hemoglobin A1c screening to identify gestational diabetes before 20 weeks. Retrospective cohort of women who delivered at Crozer Chester Medical Center in 2017. In June 2017, we implemented universal hemoglobin A1c screening for pregnant women. This screening strategy recommended universal hemoglobin A1c, followed by glucose challenge test (GCT) in women whose A1c level was ≥ 5.7%. "Risk-based screening" was based on ACOG's recommendation for early pregnancy screening with 1 hour GCT for overweight/obese women with one additional risk factor (physical inactivity, first-degree relative with DM, high-risk race or ethnicity, prior delivery of infant ≥ 4000g, history of GDM, hypertension, dyslipidemia, PCOS, A1c≥5.7, pre-pregnancy BMI≥40, history of CVD). We compared the incidence of early diagnosis of gestational diabetes between women undergoing "risk-based screening" with women undergoing "universal A1c screening", see figure. 671 women met inclusion criteria. 326 underwent risk-based screening, and 345 underwent universal A1c screening. There was no difference in incidence of women with gestational diabetes diagnosed early in pregnancy using the A1c protocol versus the risk-based protocol (15.15% vs. 16%, p=1), see table. Fewer women screened positive and underwent early glucose screening with the A1c protocol versus risk-based protocol (14.2% vs 28.5%, p <0.001). Women who screened positive with the A1c protocol compared to the risk-based protocol were more likely to develop gestational diabetes (PPV = 32.6% vs PPV = 15%). Universal hemoglobin A1c is an effective screening tool in the early diagnosis of gestational diabetes. There was no difference in diagnosing gestational diabetes before 20 weeks gestation between universal hemoglobin A1c screening and risk-based screening. However, universal A1c screening may be appealing to both providers and patients, as it can be easily included in standard prenatal labs and may lead to fewer early glucose challenge tests.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Approach to the Poisoned Patient.

This video lecture is appropriate for emergency medical providers who are not comfortable with initial assessment of poisoned patients. Ideal learners include medical students and residents. Poisoning is the leading cause of injury-related mortality in the United States, with more than 40,000 deaths annually.1 Of all ED injury-related visits, 2.4% are related to poisoning.2 While providers may have access to support services (poison control center, medical toxicology consulting service), they are often responsible for the initial evaluation of poisoned patients. While a large portion of poisoned patients have good outcomes regardless of the care they receive, inappropriate risk assessment and lack of knowledge about basic interventions can put patients at risk. A standardized approach as outlined in the video will help evaluate and treat the vast majority of poisoned patients. By the end of the lecture, learners should be able to: 1) initiate the evaluation of a poisoned patient, 2) identify key interventions to support airway, breathing, and circulation, 3) identify the three components of risk assessment in the poisoned patient, 4) list the four options for gastric decontamination, and 5) select standard diagnostic labs and tests commonly used in evaluating poisoned patients. This is an enhanced live action greenscreen recording with video animation. This video has been made available for a variety of learners on social medial (Facebook and YouTube) and written feedback has been collected on YouTube. The video has been seen over three thousand times and has received positive comments on social media (Facebook, YouTube). Comments include "dropping some tox knowledge bombs, proving yet again that #ToxRocks," and "This is an excellent talk, thank you very much, but I think it would be worth mentioning antidotes." The goal is to expose learners to basic concepts in approaching poisoned patients and focusses on cognitive knowledge and diagnostic frameworks. The learner may watch the on-demand video as part of a flipped classroom experience with clinical cases, or as a just-in-time resource before seeing a patient who has been poisoned. Poisoning, resuscitation, risk assessment, gastric decontamination, occult ingestion, supportive care.

Viral transport media for COVID-19 testing

Precautionary measures of physical isolation, social distancing, and masks have all aided in controlling the spread of COVID-19. However, detection of the virus is crucial to implement isolation of infected individuals. This paper presents the innovative repurposing of lab materials, workspace, and personnel in response to the COVID-19-induced shutdown and consequential shortage of commercially made virus transport media (VTM). This method for VTM production highlights the ability of standard research labs to fulfill the needs of those affected by the pandemic and potential recurrence of outbreaks. Further, the collaboration of the various entities at The Ohio State University Wexner Medical Center (OSUWMC) allowed for efficient production and distribution of VTM tubes to facilitate mass COVID-19 testing. We propose that implementation of this process by university research labs would enable quicker interventions, potentially better outcomes, and prevention of further spread of disease.

A manual multiplex immunofluorescence method for investigating neurodegenerative diseases

BackgroundNeurodegenerative diseases feature stereotypical deposits of protein aggregates that selectively accumulate in vulnerable cells. The ability to simultaneously localize multiple targets in situ is critical to facilitate discovery and validation of pathogenic molecular pathways. Immunostaining methods enable in situ detection of specific targets. Effective stripping of antibodies, allowing successive rounds of staining while maintaining tissue adhesion and antigen integrity, is the main roadblock for enabling multiplex immunostaining in standard labs. Furthermore, stripping techniques require antibody-specific optimization, validation, and quality control steps. New methodAiming to create protocols for multiplex localization of neurodegenerative-related processes, without the need for specialized equipment, we evaluated several antibody stripping techniques. We also recommend quality control steps to validate stripping efficacy and ameliorate concerns of cross-reactivity and false positives based on extensive testing. ResultsA protocol using β-mercaptoethanol and SDS consistently enables reliable antibody stripping across multiple rounds of staining and minimizes the odds of cross-reactivity while preserving tissue adhesion and antigen integrity in human postmortem tissue. Comparison with existing methodsOur proposed method is optimal for standard lab settings and shows consistent efficacy despite the intricacies of suboptimal human postmortem tissue and the need to strip markers bound to highly aggregated proteins. Additionally, it incorporates quality control steps to validate antibody stripping. ConclusionsMultiplex immunofluorescence methods for studying neurodegenerative diseases in human postmortem tissue are feasible even in standard laboratories. Nevertheless, evaluation of stripping parameters during optimization and validation phases of experiments is prudent.

14 Do Calorie Counts Alter Care or Outcomes in Burn Patients?

Abstract Introduction Calorie counts are often used as a monitoring tool for burn nutrition and require accurate documentation by staff for the nutritionist to properly evaluate and treat the patient. The objective of this project was to determine if completion of calorie counts positively impacts patient outcomes. Methods A quality improvement project was conducted on adult burn patients at a large academic medical center from June 2018 to March 2019. All burn patients with calorie count orders and an admission weight were included. The total number of meal trays with completed calorie count documentation was calculated on a weekly basis, generating a total weekly calorie count compliance rate (CCCR). Data collected included weight change from admission to discharge, standard nutrition labs, and if nutritional interventions were changed. Results A total of 76 adult burn patients with a documented admission weight were included. The average total body surface area (TBSA) burn injury was 10.9%. Average length of stay was 1.3 days/ %TBSA. Of the 9.2% of patients with admission and discharge weights, 14% had increased discharge weight (mean CCCR 43%) and 86% had a decrease in weight (mean CCCR 48%). Weekly total protein levels were obtained in 24 patients with 46% having decreased total protein levels (0.1 to 1.1 g/dL) and a mean CCCR of 74.4%. Eight percent had no change in protein levels with a mean CCCR of 74.3% and 46% had increased total protein levels (0.1 and 0.7 g/dL) with a mean CCCR of 70%. Weekly albumin levels were obtained in 25 patients. Fifty-two percent had decreased albumin levels (0.1 to 0.9 g/dL) with a mean CCCR of 72.1%. Twenty percent had no change in albumin level, with a mean CCCR of 75.1% and 28% of patients had increased albumin levels (0.1 to 0.6 g/dL) with a mean CCCR of 69%. Weekly prealbumin serum levels were obtained in 27 patients. Fifty-six percent had decreased levels (1 to 19 mg/dL) with a mean CCCR of 74.1%. Four percent had no change in serum prealbumin, with a mean CCCR of 69%, and 41% had increased prealbumin levels (1 to 21 mg/dL) with a mean CCCR of 68%. Nutritional therapy was altered in 6% of patients by addition of oral supplementation, dietary modifications, or initiation of tube feeding. Conclusions A very small number of patients on calorie counts had any change in nutritional therapy and calorie count compliance showed no relationship with nutrition labs. However, calorie counts are labor-intensive for nursing staff. Further research should be conducted to identify which patients would benefit from daily calorie counts in the burn patient. Applicability of Research to Practice Use of evidence-based outcome measures can drive clinical practice.

Is major burn injury associated with coagulopathy? The value of thrombelastometry in the detection of coagulopathy in major burn injury: A prospective observational study.

The coagulation status of burn patients is generally impaired and is a major factor of the deteriorating burn patients' overall situation. In trauma and other patient groups, the differential diagnosis of coagulation impairment has been largely improved by the use of rotational thromboelastometry (ROTEM®). The aim of this prospective observational study was the differentiated observation of coagulopathy in severely burned patients using standard parameters and ROTEM® thrombelastometry during the relevant stages of burn disease. Twelve patients that sustained at least 20% third degree burns of total body surface area (TBSA) were included in the study. Standard and ROTEM® coagulation analyses were performed on admission and then twice daily during the first 14 days following burn trauma. Although the initial assessment of DIC was similar for both standard labs and ROTEM® measurements, more patients were detected to be in a state of worsening coagulation status for a longer time in ROTEM® than in standard measurements. In addition, one patient was rated in to be in decompensated DIC for 3 days according to ROTEM® measurements, while no patient was rated to be in a decompensated DIC based on standard parameters. This study points towards a more complex picture and higher occurrence of DIC in burn patients when thrombelastometric measurements like ROTEM® are taken into account in addition to standard coagulation parameters.

22 Thromboelastography Detects Coagulopathy Faster than Standard Coagulation Studies in Simulated Pit Viper Envenomation

Venomous snakebites pose a significant risk of morbidity and mortality in rural and austere environments, so it is not surprising that the World Health Organization recently set a goal of reducing snakebite deaths by half by 2030. Many of these envenomations are due to pit vipers, leading to severe hematologic derangements, such as venom-induced consumptive coagulopathy (VICC). Immediacy in detection of envenomations is crucial for ameliorating morbidity and mortality, but diagnosis of envenomization can be challenging, requiring access to clinical laboratory facilities. Further, the laboratory-based evaluations of coagulation function take more than an hour to conduct. In contrast, thromboelastography (TEG) is promising as a rapid, portable, bedside test of coagulation that produces meaningful results in less than 15 minutes. Therefore, the primary objective of this study was to assess the efficacy of TEG compared to standard lab tests in detecting pit viper venom at increasing concentrations. Blood samples drawn from 19 healthy adult volunteers were mixed with varying concentrations of western diamond back rattlesnake (Crotalus atrox) venom (none, 0.5%, 1%, 2%, 33%, 66%, and 100% of LD50), then assessed with standard laboratory-based tests of coagulation function (labs), including prothrombin time (PT), partial thromboplastin time (PTT), international normalized ratio (INR), D-dimer, and Fibrinogen, as well as with TEG measures of reaction time (R), amplification (K), rate of clot formation (Angle), and clot strength (MA). Data were analyzed as changes from baseline and categorized as percent of samples out of normal physiologic range, then analyzed using ANOVA and binomial statistics at the p<.05 threshold for statistical significance. TEG and standard labs were both excellent (100%) at detecting higher concentrations of venom (33%, 66%, 100%), save D-dimer. Importantly, at low venom concentration levels (0.5%, 1%, 2%), the TEG measures of R, K, alpha, and MA were similar to laboratory-based evaluations of PT and INR at detecting venom, and were significantly superior to PTT, D-dimer, and Fibrinogen. TEG provides a sensitive, real-time quantitative evaluation of coagulation derangements during simulated pit viper envenomation that is faster than standard laboratory tests. TEG was sensitive at low venom concentrations, outperforming multiple traditional laboratory evaluations of VICC. While the present study was limited to in vitro analyses, our findings suggest that TEG is a fast, effective, and portable point-of-care testing modality to assist the emergency physician community to rapidly and accurately diagnose patients stricken with venomous snake bites.

Rolling Labs – Teaching Vehicle Electronics from the Beginning

This paper describes the pedagogical approach to teach vehicle electronics at the University of Applied Science Aachen. As vehicle electronics is getting more and more complex, in particular with regard to Advanced Driver Assistance Systems and autonomous driving, a dedicated concept is needed to integrate the require-ments of vehicle electronics into the studies of electrical engineering. The con-cept of rolling labs is established during the last years for the studies of electrical engineering. The rolling labs cover different levels of complexity and integration of the electronics and components used in modern applications and hence under-graduate students can start working with interesting and close to reality systems rather early. The rolling labs enable several different possibilities of teaching and learning, either for standard labs, for team works in terms of problem-based learning (PBL) or for individual works like bachelor or master thesis. In addi-tion, the systems can be used as research platforms and for demonstration and marketing purpose to introduce the challenging topic of vehicle electronics to other people.

Screen Circuits: Fear and Paranoia in the Sprawl (circa 1995)

The 1990s was a strange time to be alive: a saxophone playing U.S. president waltzed into a Cold War vacuum left behind by the crumbling of the Soviet Eastern Bloc, while Gulf War 1.0 was the first mediated war, yet one lacking any meaningful optics - Baudrillard's so-called weak event. Meanwhile, technology, culture and information was rapidly beginning to coalesce in unexpected ways. The 1990s was more of a feeling than a knowing, there was certainly change afoot and the clock was ticking on a century of acceleration and shrinking horizons. Zygmunt Bauman (Liquid Modernity, 2000) and Paul Virilio (Open Sky, 1997) capture this time from the perspective of the machine's lens and big data's gathering torrents. We were only just beginning to stockpile our algorithmic future. There is of course a strong human element to all of this as well, as domesticity was about to be transformed in ways not seen since the automation of white goods in the 1950s. Installing a telephone line in a new rental was a priority as this was not just a communication device but a gateway to a new digital epoch (chat rooms, conspiracy theories, gaming mods and a seemingly limitless archive of music). Australians, who would become the new suitors of the boom in computer peripherals and digital gadgetry, turned the latent ability to send short text messages from their mobile phones into a new form of digital dialectics. Meanwhile, the cinema was signalling a grave warning of what all of this might mean if we could indeed become virtual, if the machine was in fact alive and information networks consciousness itself. From James Bond confronting a Rupert Murdock/Conrad Black-type media demigod in Tomorrow Never Dies (1997), to the digital psychedelics of the millennial rush in Strange Days (1995) to Henry Rollins raging against reality in the William Gibson penned Johnny Mnemonic (1995). These mid-nineties films tapped a rich vein of paranoia around the new vanguard of networked information and computer-generated image making while also expressing - in often garish terms - a deep anxiety about a not-to-distant future crackling into view beyond the millennial divide.