Evaluation of continuous aspiration of subglottic secretions in prevention of microaspiration during general anesthesia: a randomized controlled pilot study

AimTo assess the difference between endotracheal tubes (ETT) with continuous suction of subglottic secretions (CASS) and standard ETT in preventing secretions movement from the pharynx into the trachea, past the inflated cuff during general anesthesia.MethodsThis randomized, controlled trial enrolled 50 patients who underwent general anesthesia for elective abdominal surgery lasting longer than two hours. They received either ETT with CASS: Teleflex ISIS HVT (GISIS, n = 17) or Mallinckrodt TaperGuard Evac (GEvac, n = 17), or ETT without suction: Mallinckrodt Intermediate Hi-Lo (GStand, n = 16). Methylene blue dye solution (10 mL) was delivered into the hypopharynx every 60 minutes. Subglottic secretions were continuously suctioned. Fiberoptic bronchoscopy was performed every 20 minutes and during tracheal extubation to evaluate the dye location.ResultsThe groups did not differ in age, sex, body mass index, race, American Society of Anesthesiologists status, and surgery type. Dye migrated past the inflated cuff into the distal trachea in no patient with ETT with CASS and in 13% of patients with standard ETT. On tracheal extubation, dye migrated into the distal trachea more often in the GStand group (56%), compared with the GEvac (13%) and GISIS group (29%) (P = 0.045). The GISIS group had 26 ± 19 mL of secretions suctioned from above the inflated cuff, while the GEvac group had 13 ± 10 mL (P = 0.05).ConclusionCompared with standard ETT, ETT with CASS efficiently removed secretions during general anesthesia, prevented secretions from migrating past the inflated cuff, and significantly reduced the amount of secretions that reached the distal airways on tracheal extubation.ClinicalTrial.gov identification number{"type":"clinical-trial","attrs":{"text":"NCT01386879","term_id":"NCT01386879"}}NCT01386879

Postoperative pulmonary complications (PPC) commonly lead to morbidity and mortality in patients managed with general anesthesia for major surgery. In a systematic review of PPC after non-cardiothoracic surgery, the average incidence was 3.4% with a range from 1% to over 40% (1). Elderly and diabetic patients had the highest incidence. The incidence in abdominal surgery was 14.2% (1). A prospective multicenter study with a heterogeneous surgical population of almost 2500 patients revealed a 5.0% incidence of PPC; with a high mortality in patients who developed PPC (2). Patients with evidence of microaspiration have about three times higher incidence of postoperative pneumonia compared with patients without microaspiration (40% vs 12%), with mortality rate of 19.2% if they develop pneumonia (3).Endotracheal tubes (ETT) with continuous aspiration of subglottic secretions (CASS) are recommended in intensive care unit (ICU) patients requiring prolonged mechanical ventilation to prevent ventilator-associated pneumonia (4). A meta-analysis showed almost a 50% reduction of ventilator-associated pneumonia in patients receiving ETT with CASS in the ICU compared with standard ETT (5). It is unknown if using an ETT with CASS intraoperatively reduces the incidence of PPC in patients undergoing prolonged general anesthesia, and are extubated at the end of surgery.We hypothesized that a subglottic suction ETT with CASS would effectively remove secretions that accumulate above the inflated cuff and decrease the volume of secretions aspirated into the distal trachea during general anesthesia with mechanical ventilation and during tracheal extubation. The primary aim of the study was to evaluate whether there is a difference between three types of ETT in preventing the movement of methylene blue dye from the pharynx into the trachea, past the inflated cuff. The secondary objectives were to evaluate whether there is a difference in the volume, pH, and bacterial load of the secretions aspirated from above the subglottic suction ETT cuff.     

Theoretical and Experimental Models to Evaluate the Possibility of Corrosion Resistant Concrete for Coastal Offshore Structures

This study built theoretical and practical models to evaluate the corrosion resistance of concrete for coastal offshore structures in Vietnam. A mathematical model was developed in the form of a system of nonlinear partial differential equations characterizing the diffusion “free calcium hydroxide” in a solid of a concrete structure. The model describes the process of non-stationary mass conductivity observed in the “concrete structure—marine environment” system under non-uniform arbitrary initial conditions, as well as combined boundary conditions of the second and third kind, taking into account the nonlinear nature of the coefficients of mass conductivity k and mass transfer β. It was shown that the solution of the boundary value problem of non-stationary mass conductivity allows us to conclude about the duration of the service life of a concrete structure, which will be determined by the processes occurring at the interface: in concrete—mass conductivity, depending on the structural and mechanical characteristics of hydraulic structures, and in the liquid phase—mass transfer, determined by the conditions of interaction at the interface of the indicated phases.     

Gaps and opportunities in the treatment of relapsed-refractory multiple myeloma: Consensus recommendations of the NCI Multiple Myeloma Steering Committee

A wide variety of new therapeutic options for Multiple Myeloma (MM) have recently become available, extending progression-free and overall survival for patients in meaningful ways. However, these treatments are not curative, and patients eventually relapse, necessitating decisions on the appropriate choice of treatment(s) for the next phase of the disease. Additionally, an important subset of MM patients will prove to be refractory to the majority of the available treatments, requiring selection of effective therapies from the remaining options. Immunomodulatory agents (IMiDs), proteasome inhibitors, monoclonal antibodies, and alkylating agents are the major classes of MM therapies, with several options in each class. Patients who are refractory to one agent in a class may be responsive to a related compound or to a drug from a different class. However, rules for selection of alternative treatments in these situations are somewhat empirical and later phase clinical trials to inform those choices are ongoing. To address these issues the NCI Multiple Myeloma Steering Committee formed a relapsed/refractory working group to review optimal treatment choices, timing, and sequencing and provide recommendations. Additional issues considered include the role of salvage autologous stem cell transplantation, risk stratification, targeted approaches for genetic subsets of MM, appropriate clinical trial endpoints, and promising investigational agents. This report summarizes the deliberations of the working group and suggests potential avenues of research to improve the precision, timing, and durability of treatments for Myeloma.Subject terms: Combination drug therapy, Cancer therapeutic resistance, Targeted therapies     

Formation and Thermal Stability of the ω-Phase in Ti–Nb and Ti–Mo Alloys Subjected to HPT

This paper discusses the features of ω-phase formation and its thermal stability depending on the phase composition, alloying element and the grain size of the initial microstructure of Ti–Nb and Ti–Mo alloys subjected to high-pressure torsion (HPT) deformation. In the case of two-phase Ti–3wt.% Nb and Ti–20wt.% Nb alloys with different volume fractions of α- and β-phases, a complete β→ω phase transformation and partial α→ω transformation were found. The dependence of the α→ω transformation on the concentration of the alloying element was determined: the greater content of Nb in the α-phase, the lower the amount of ω-phase that was formed from it. In the case of single-phase Ti–Mo alloys, it was found that the amount of ω-phase formed from the coarse-grained β-phase of the Ti–18wt.% Mo alloy was less than the amount of the ω-phase formed from the fine α′-martensite of the Ti–2wt.% Mo alloy. This was despite the fact that the ω-phase is easier to form from the β-phase than from the α- or α′-phase. It is possible that the grain size of the microstructure also affected the phase transformation, namely, the fine martensitic plates more easily gain deformation and overcome the critical shear stresses necessary for the phase transformation. It was also found that the thermal stability of the ω-phase in the Ti–Nb and Ti–Mo alloys increased with the increasing concentration of Nb or Mo.     

Prolonging Bacterial Viability in Biological Concrete: Coated Expanded Clay Particles

One of the biggest challenges in the development of a biological self-healing concrete is to ensure the long-term viability of bacteria that are embedded in the concrete. In the present study, a coated expanded clay (EC) is investigated for its potential use as a bacterial carrier in biological concrete. Eight different materials for coatings were selected considering cost, workability and accessibility in the construction industry. Long-term (56 days) viability analysis was conducted with a final evaluation of each coating performance. Our results indicate that healing efficiency in biological concrete specimens is strongly related to viable bacteria present in the healing agent. More viable bacteria-containing specimens exhibited a higher crack closure ratio. Our data suggest that the additional coating of EC particles improves long-term bacterial viability and, consequently, provides efficient crack healing in biological concrete.     

Pharmacology of the urotensin-II receptor antagonist palosuran (ACT-058362; 1-[2-(4-benzyl-4-hydroxy-piperidin-1-yl)-ethyl]-3-(2-methyl-quinolin-4-yl)-urea sulfate salt): first demonstration of a pathophysiological role of the urotensin System

Urotensin-II (U-II) is a cyclic peptide now described as the most potent vasoconstrictor known. U-II binds to a specific G protein-coupled receptor, formerly the orphan receptor GPR14, now renamed urotensin receptor (UT receptor), and present in mammalian species. Palosuran (ACT-058362; 1-[2-(4-benzyl-4-hydroxy-piperidin-1-yl)-ethyl]-3-(2-methyl-quinolin-4-yl)-urea sulfate salt) is a new potent and specific antagonist of the human UT receptor. ACT-058362 antagonizes the specific binding of (125)I-labeled U-II on natural and recombinant cells carrying the human UT receptor with a high affinity in the low nanomolar range and a competitive mode of antagonism, revealed only with prolonged incubation times. ACT-058362 also inhibits U-II-induced calcium mobilization and mitogen-activated protein kinase phosphorylation. The binding inhibitory potency of ACT-058362 is more than 100-fold less on the rat than on the human UT receptor, which is reflected in a pD'(2) value of 5.2 for inhibiting contraction of isolated rat aortic rings induced by U-II. In functional assays of short incubation times, ACT-058362 behaves as an apparent noncompetitive inhibitor. In vivo, intravenous ACT-058362 prevents the no-reflow phenomenon, which follows renal artery clamping in rats, without decreasing blood pressure and prevents the subsequent development of acute renal failure and the histological consequences of ischemia. In conclusion, the in vivo efficacy of the specific UT receptor antagonist ACT-058362 reveals a role of endogenous U-II in renal ischemia. As a selective renal vasodilator, ACT-058362 may be effective in other renal diseases.     

Serum-Mediated Inhibition of Enzyme Replacement Therapy in Fabry Disease

Fabry disease (FD) is a progressive multisystemic disorder, treatable with recombinant enzyme replacement therapy (agalsidase). However, recent studies suggest an endogenous inhibition of agalsidase in patients with FD, as reported for other lysosomal storage diseases. To assess the clinical consequences of serum-mediated agalsidase inhibition in affected patients, we determined the agalsidase inhibition status of 168 patients (68 male) with FD and compared outcomes of inhibition-positive patients with those of inhibition-negative patients. The assessment included clinical events during time on agalsidase, determination of renal and cardiac function, and evaluation of FD-related symptoms. The frequency of serum-mediated agalsidase inhibition was 40% in agalsidase-treated males. Inhibition did not depend on the compound initially used (agalsidase-α or -β). Agalsidase inhibition was associated with higher lyso-globotriaosylceramide levels and worse disease severity scores in patients. Compared with agalsidase inhibition-negative men, agalsidase inhibition-positive men showed greater left ventricular mass (P=0.02) and substantially lower renal function (difference in eGFR of about –30 ml/min per 1.73 m²; P=0.04), which was confirmed by a longitudinal 5-year retrospective analysis. Additionally, affected patients presented more often with FD-typical symptoms, such as diarrhea, fatigue, and neuropathic pain, among others. Therefore, patients with poor clinical outcome on agalsidase should be tested for agalsidase inhibition. Future studies are warranted to determine if affected patients with FD benefit from acute reduction of anti-agalsidase antibodies or long-term immune modulation therapies to suppress agalsidase inhibition and to identify mechanisms that minimize antibody generation against agalsidase.     

Patupilone (epothilone B) inhibits growth and survival of multiple myeloma cells in vitro and in vivo

In this study, we investigated the in vitro and in vivo efficacy of patupilone (epothilone B, EPO906), a novel nontaxane microtubule stabilizing agent, in treatment of multiple myeloma (MM). Patupilone directly inhibited growth and survival of MM cells, including those resistant to conventional chemotherapies, such as the taxane paclitaxel. Patupilone induced G2M arrest of MM cells, with subsequent apoptosis. Interleukin-6 (IL-6) and insulin-like growth factor-1 (IGF-1), 2 known growth and survival factors for MM, did not protect MM.1S cells against patupilone-induced cell death. Proliferation of MM cells induced by adherence to bone marrow stromal cells (BMSCs) was also inhibited by patupilone and was paralleled by down-regulation of vascular endothelial growth factor (VEGF) secretion. Importantly, stimulation of cells from patients with MM, either with IL-6 or by adherence to BMSCs, enhanced the anti-proliferative and proapoptotic effects of patupilone. Moreover, patupilone was effective against MM cell lines that overexpress the MDR1/P-glycoprotein multidrug efflux pump. In addition, patupilone was effective in slowing tumor growth and prolonging median survival of mice that received orthotopical transplants with MM tumor cells. Taken together, these preclinical findings suggest that patupilone may be a safe and effective drug in the treatment of MM, providing the framework for clinical studies to improve patient outcome in MM.