A synergistic mindsets intervention protects adolescents from stress.

Social-evaluative stressors-experiences in which people feel they could be judged negatively-pose a major threat to adolescent mental health1-3 and can cause young people to disengage from stressful pursuits, resulting in missed opportunities to acquire valuable skills. Here we show that replicable benefits for the stress responses of adolescents can be achieved with a short (around 30-min), scalable 'synergistic mindsets' intervention. This intervention, which is a self-administered online training module, synergistically targets both growth mindsets4 (the idea that intelligence can be developed) and stress-can-be-enhancing mindsets5 (the idea that one's physiological stress response can fuel optimal performance). In six double-blind, randomized, controlled experiments that were conducted with secondary and post-secondary students in the United States, the synergistic mindsets intervention improved stress-related cognitions (study 1, n = 2,717; study 2, n = 755), cardiovascular reactivity (study 3, n = 160; study 4, n = 200), daily cortisol levels (study 5, n = 118 students, n = 1,213 observations), psychological well-being (studies 4 and 5), academic success (study 5) and anxiety symptoms during the 2020 COVID-19 lockdowns (study 6, n = 341). Heterogeneity analyses (studies 3, 5 and 6) and a four-cell experiment (study 4) showed that the benefits of the intervention depended on addressing both mindsets-growth and stress-synergistically. Confidence in these conclusions comes from a conservative, Bayesian machine-learning statistical method for detecting heterogeneous effects6. Thus, our research has identified a treatment for adolescent stress that could, in principle, be scaled nationally at low cost.

Shock index and pulse pressure as triggers for massive transfusion.

BACKGROUND: Hemorrhage is the most common cause of preventable death in trauma patients. These mortalities might be prevented with prehospital transfusion. We sought to characterize injured patients requiring massive transfusion to determine the potential impact of a prehospital whole blood transfusion program. The primary goal of this analysis was to determine a method to identify patients at risk of massive transfusion in the prehospital environment. Many of the existing predictive models require laboratory values and/or sonographic evaluation of the patient after arrival at the hospital. Development of an algorithm to predict massive transfusion protocol (MTP) activation could lead to an easy-to-use tool for prehospital personnel to determine when a patient needs blood transfusion. METHODS: Using our Level I trauma center's registry, we retrospectively identified all adult trauma patients from January 2015 to August 2017 requiring activation of the MTP. Patients who were younger than 18 years, older than 89 years, prisoners, pregnant women, and/or with nontraumatic hemorrhage were excluded from the study. We retrospectively collected data including demographics, blood utilization, variable outcome data (survival, length of stay, intensive care unit days, ventilator days), prehospital vital signs, prehospital transport times, and Injury Severity Score. The independent-samples t test and χ test were used to compare the group who died to the group who survived. p < 0.05 was considered significant. Based on age and mechanism of injury, relative risk of death was calculated. Graphs were generated using Microsoft Excel software to plot patient variables. RESULTS: Our study population of 102 MTP patients had an average age of 42 years and average Injury Severity Score of 29, consisted of 80% males (82/102), and was 66% blunt trauma (67/102). The all-cause mortality was 67% (68/102). The positive predictive value of death for patients with pulse pressure of less than 45 and shock index of greater than 1 was 0.78 for all patients, but was 0.79 and 0.92 for blunt injury and elderly patients, respectively. CONCLUSIONS: Our data demonstrate a high mortality rate in trauma patients who require MTP despite short transport times, indicating the need for early intervention in the prehospital environment. Given our understanding that the most severely injured patients in hemorrhagic shock require blood resuscitation, this study demonstrates that this subset of trauma patients requiring massive transfusion can be identified in the prehospital setting. We recommend using Emergency Medical Services pulse pressure in combination with shock index to serve as a trigger for initiation of prehospital whole blood transfusion. LEVEL OF EVIDENCE: Therapeutic/care management, level V.

Elevated midline head positioning of extremely low birth weight infants: effects on cardiopulmonary function and the incidence of periventricular-intraventricular hemorrhage.

OBJECTIVE: Changes in cerebrovascular hemodynamics associated with head position may be important in the pathogenesis of periventricular-intraventricular hemorrhage (PIVH) in premature infants. This study evaluated the effect of elevated midline head positioning on cardiopulmonary function and the incidence of PIVH. STUDY DESIGN: ELBW infants were randomized to FLAT (flat, supine) or ELEV (supine, bed elevated 30 degrees) for 96 h. Cardiopulmonary function, complications of prematurity, and the occurrence of PIVH were documented. RESULTS: Infants were randomized into FLAT (n = 90) and ELEV groups (n = 90). No significant differences were seen in the incidence of BPD or other respiratory complications. The ELEV group developed significantly fewer grade 4 hemorrhages (p = 0.036) and survival to discharge was significantly higher in the ELEV group (p = 0.037). CONCLUSIONS: Managing ELBW infants in an elevated midline head position for the first 4 days of life appears safe and may decrease the likelihood of severe PIVH and improve survival.

Emergency Department Airway Management Responsibilities in the United States.

BACKGROUND: In the 1990s, emergency medicine (EM) physicians were responsible for intubating about half of the patients requiring airway management in emergency rooms. Since then, no studies have characterized the airway management responsibilities in the emergency room. METHODS: A survey was sent via the Eastern Association for Surgery and Trauma and the Trauma Anesthesiology Society listservs, as well as by direct solicitation. Information was collected on trauma center level, geographical location, department responsible for intubation in the emergency room, department responsible for intubation in the trauma bay, whether these roles differed for pediatrics, whether an anesthesiologist was available "in-house" 24 hours a day, and whether there was a protocol for anesthesiologists to assist as backup during intubations. Responses were collected, reviewed, linked by city, and mapped using Python. RESULTS: The majority of the responses came from the Eastern Association for Surgery of Trauma (84.6%). Of the respondents, 72.6% were from level-1 trauma centers, and most were located in the eastern half of the United States. In the emergency room, EM physicians were primarily responsible for intubations at 81% of the surveyed institutions. In trauma bays, EM physicians were primarily responsible for 61.4% of intubations. There did not appear to be a geographical pattern for personnel responsible for managing the airway at the institutions surveyed. CONCLUSIONS: The majority of institutions have EM physicians managing their airways in both emergency rooms and trauma bays. This may support the observations of an increased percentage of airway management in the emergency room and trauma bay setting by EM physicians compared to 20 years ago.

Prehospital low-titer cold-stored whole blood: Philosophy for ubiquitous utilization of O-positive product for emergency use in hemorrhage due to injury.

The mortality from hemorrhage in trauma patients remains high. Early balanced resuscitation improves survival. These truths, balanced with the availability of local resources and our goals for positive regional impact, were the foundation for the development of our prehospital whole blood initiative-using low-titer cold-stored O RhD-positive whole blood. The main concern with use of RhD-positive blood is the potential development of isoimmunization in RhD-negative patients. We used our retrospective massive transfusion protocol (MTP) data to analyze the anticipated risk of this change in practice. In 30 months, of 124 total MTP patients, only one female of childbearing age that received an MTP was RhD-negative. With the risk of isoimmunization very low and the benefit of increased resources for the early administration of balanced resuscitation high, we determined that the utilization of low-titer cold-stored O RhD-positive whole blood would be safe and best serve our community.

End-of-life discussions: Who's doing the talking?

PURPOSE: To determine, in a tertiary academic medical center, the reported frequency of end-of-life discussions among nurses and the influence of demographic factors on these discussions. METHODS: Survey of nurses on frequency of end-of-life discussions in two urban academic medical centers. Chi-square tests were used to separately assess the relationship between age, gender, specialty, and experience with responses to the question, "Do you regularly talk with your patients about end-of-life wishes?" RESULTS: Overall, more than one-third of respondents reported rarely or never discussing end-of-life wishes with their patients. Only specialty expertise (p<0.001) was statistically significantly associated with discussing end-of-life issues with patients. Over half of nurses specializing in critical care responded that they have these discussion "always" or "most of the time." However, for the specialties of surgery (59%) and anesthesiology (56%), the majority of respondents reported rarely or never having end-of-life discussions with patients. CONCLUSIONS: In a survey conducted in two tertiary care institutions, more than one-third of nurses from all disciplines responded that they never or almost never discuss end-of-life issues with their patients. Specialty influenced the likelihood of discussing end-of-life issues with patients.

Serial time-resolved crystallography of photosystem II using a femtosecond X-ray laser.

Photosynthesis, a process catalysed by plants, algae and cyanobacteria converts sunlight to energy thus sustaining all higher life on Earth. Two large membrane protein complexes, photosystem I and II (PSI and PSII), act in series to catalyse the light-driven reactions in photosynthesis. PSII catalyses the light-driven water splitting process, which maintains the Earth's oxygenic atmosphere. In this process, the oxygen-evolving complex (OEC) of PSII cycles through five states, S0 to S4, in which four electrons are sequentially extracted from the OEC in four light-driven charge-separation events. Here we describe time resolved experiments on PSII nano/microcrystals from Thermosynechococcus elongatus performed with the recently developed technique of serial femtosecond crystallography. Structures have been determined from PSII in the dark S1 state and after double laser excitation (putative S3 state) at 5 and 5.5 Å resolution, respectively. The results provide evidence that PSII undergoes significant conformational changes at the electron acceptor side and at the Mn4CaO5 core of the OEC. These include an elongation of the metal cluster, accompanied by changes in the protein environment, which could allow for binding of the second substrate water molecule between the more distant protruding Mn (referred to as the 'dangler' Mn) and the Mn3CaOx cubane in the S2 to S3 transition, as predicted by spectroscopic and computational studies. This work shows the great potential for time-resolved serial femtosecond crystallography for investigation of catalytic processes in biomolecules.