Protocolized reduction of non-resuscitation fluids versus usual care in septic shock patients (REDUSE): a randomized multicentre feasibility trial.

BACKGROUND/PURPOSE: Non-resuscitation fluids constitute the majority of fluid administered for septic shock patients in the intensive care unit (ICU). This multicentre, randomized, feasibility trial was conducted to test the hypothesis that a restrictive protocol targeting non-resuscitation fluids reduces the overall volume administered compared with usual care. METHODS: Adults with septic shock in six Swedish ICUs were randomized within 12 h of ICU admission to receive either protocolized reduction of non-resuscitation fluids or usual care. The primary outcome was the total volume of fluid administered within three days of inclusion. RESULTS: Median (IQR) total volume of fluid in the first three days, was 6008 ml (interquartile range [IQR] 3960-8123) in the restrictive fluid group (n = 44), and 9765 ml (IQR 6804-12,401) in the control group (n = 48); corresponding to a Hodges-Lehmann median difference of 3560 ml [95% confidence interval 1614-5302]; p < 0.001). Outcome data on all-cause mortality, days alive and free of mechanical ventilation and acute kidney injury or ischemic events in the ICU within 90 days of inclusion were recorded in 98/98 (100%), 95/98 (98%) and 95/98 (98%) of participants respectively. Cognition and health-related quality of life at six months were recorded in 39/52 (75%) and 41/52 (79%) of surviving participants, respectively. Ninety out of 134 patients (67%) of eligible patients were randomized, and 15/98 (15%) of the participants experienced at least one protocol violation. CONCLUSION: Protocolized reduction of non-resuscitation fluids in patients with septic shock resulted in a large decrease in fluid administration compared with usual care. A trial using this design to test if reducing non-resuscitation fluids improves outcomes is feasible. TRIAL REGISTRATION: Clinicaltrials.gov, NCT05249088, 18 February 2022. https://clinicaltrials.gov/ct2/show/NCT05249088.

Is there consistency in cephalometric landmark identification amongst oral and maxillofacial surgeons?

There may be significant variation amongst oral and maxillofacial surgeons (OMFS) in the identification and placement of cephalometric landmarks for orthognathic surgery, and this could impact upon the surgical plan and final treatment outcome. In an effort to assess this variability, 10 lateral cephalometric radiographs were selected for evaluation by 16 OMFS with different levels of surgical knowledge and experience, and the position of 21 commonly used cephalometric landmarks were identified on radiographs displayed on a computer screen using a computer mouse on a pen tablet. The database consisted of real position measurements (x, y) to determine the consistency of landmark identification between surgeons and within individual surgeons. Inter-examiner analysis demonstrated that most landmark points had excellent reliability (intra-class correlation coefficient >0.90). Regardless of the level of surgeon experience, certain landmarks presented consistently poor reliability, and intra-examiner reliability analysis demonstrated that some locations had a higher average difference for both x and y axes. In particular, porion, condylion, and gonion showed poor agreement and reliability between examiners. The identification of most landmarks showed some inconsistencies within different parameters of evaluation. Such variability among surgeons may be addressed by the consistent use of high-quality images, and also by periodic surgeon education of the definition of the specific landmarks.

Rosuvastatin in experimental brain trauma: improved capillary patency but no effect on edema or cerebral blood flow.

BACKGROUND: Microvascular dysfunction, characterized by edema formation secondary to increased blood-brain barrier (BBB) permeability and decreased blood flow, contributes to poor outcome following brain trauma. Recent studies have indicated that statins may counteract edema formation following brain trauma but little is known about other circulatory effects of statins in this setting. The objective of this study was to investigate whether statin treatment improves brain microcirculation early after traumatic brain injury, and whether microvascular effects are associated with altered production of nitric oxide and prostacyclin. METHODS: After fluid percussion injury, rats were randomized to intravenous treatment with 20mg/kg of rosuvastatin or vehicle. Brain edema (wet/dry weight), BBB integrity ((51)Cr-EDTA blood to brain transfer), cerebral blood flow ((14)C-iodoantipyrine autoradiography), and number of perfused cortical capillaries (FITC-albumin fluorescence microscopy), were measured at 4 and 24h. NO and prostacyclin production was estimated from plasma concentration of the degradation products NO2- and NO3- (NOx) and 6-keto-PGF1-alpha, respectively. Sham injured animals were treated with vehicle and analyzed at 4h. RESULTS: Trauma resulted in brain edema, BBB dysfunction, and reduced cortical blood flow, with no effect of statin treatment. Trauma also induced a reduction in the number of perfused capillaries, which was improved by statin treatment. Statin treatment led to increased NOx levels and reduced mean arterial blood pressure. 6-Keto-PGF1-alpha levels tended to increase after trauma, and were significantly reduced by rosuvastatin. CONCLUSIONS: Rosuvastatin treatment may improve microcirculation after traumatic brain injury by preserved patency of cerebral capillaries. This effect is associated with increased NO and reduced prostacyclin production. No effect on brain edema or BBB integrity was found.

Interfacial regulation of bacterial sphingomyelinase activity.

The objective of this study was to define how the quality of the buffer/membrane interface influences the activity of bacterial sphingomyelinase acting at the interface. The enzyme reaction was carried out in a zero-order trough using a surface barostat. This approach allowed for proper control of the physico-chemical properties of the substrate molecules. Since the molecular area of ceramide is smaller than that of sphingomyelin, the hydrolysis reaction could be followed 'on-line' from the monolayer area decrease at constant surface pressure. The hydrolysis reaction could be divided into two separate phases, the first being the lag-phase (time between enzyme addition and commencement of the monolayer area change), and the second phase being the actual hydrolysis reaction (from which a maximal degradation rate could be determined). The activity of sphingomyelinase (Staphylococcus aureus) toward bovine brain sphingomyelin (bb-SM) was markedly enhanced by Mg2+ (maximal activation at 5 mM). Mg2+ also influenced the lag-phase of the reaction (the lag-time increased markedly when the Mg2+ concentration decreased below 1 mM). Saturated sphingomyelins (bb-SM and N-palmitoyl sphingomyelin [N-P-SM]) were more slowly degraded than the mono-unsaturated N-oleoyl sphingomyelin (N-O-SM). Both bb-SM and N-P-SM monolayers underwent a phase-transition at room temperature, whereas the N-O-SM monolayer did not. The phase-transition (liquid-expanded to liquid-condensed) was observed to greatly increase the lag-time of the hydrolysis reaction. The activity of sphingomyelinase was also sensitive to the lateral surface pressure of the monolayer membrane. Maximal degradation rate was achieved at 20 mN/m (with bb-SM, 30 degrees C); above this pressure the lag-time of the reaction increased sharply. The inclusion of 4 mol% of cholesterol into a [3H]sphingomyelin monolayer markedly increased the extent of [3H]sphingomyelin degradation, and shortened the lag-time of the reaction. The inclusion of 10 mol% of zwitterionic or negatively charged phospholipids to the [3H]sphingomyelin monolayer did not affect the sphingomyelinase reaction significantly. In conclusion, this study has demonstrated that the physico-chemical properties of the substrate molecules have a dominating influence on the activity of a bacterial sphingomyelinase acting at the buffer/membrane interface.

Effect of sterol side-chain structure on sterol-phosphatidylcholine interactions in monolayers and small unilamellar vesicles.

In this study we have characterized the monolayer behavior of analogues of cholesterol having different side-chain structures and their interaction with phosphatidylcholines in mixed monolayers and small unilamellar vesicles (SUVs). Two series of side-chain analogues of cholesterol were synthesized, one with an unbranched side chain (the n-series, from 3 to 7 carbons in length), and the other with a single methyl-branched side chain (the iso-series, from 5 to 10 carbons in length). The length and conformation of the sterol side chain markedly influenced both the mean molecular area of the pure sterols and their monolayer stability (i.e., collapse pressure). Shorter side chains gave smaller mean molecular areas and decreased monolayer stability. The sterols from the n-series also had smaller mean molecular areas than the corresponding sterols in the iso-series. In mixed 1,2-dipalmitoyl-sn-glycero-3-phosphocholine (DPPC)/sterol monolayers (equimolar ratio; at 22 degrees C), all of the sterols tested decreased the monolayer stability as judged by the lower collapse pressure with sterol than without sterol. A similar trend was observed in mixed monolayers containing 1-stearoyl-2-oleoyl-sn-glycero-3-phosphocholine (SOPC), except that sterols from the iso-series with a chain length of 8 or 10 carbon atoms actually stabilized the monolayer compared with the sterol-free SOPC monolayer. The ability of the sterols to condense the molecular packing of DPPC was similar with all sterols (3-5% condensation at 10 mN/m), irrespective of the length or structure of the side chain. 5-Androsten-3 beta-ol, however, which lacks the side chain, did not at all condense the monolayer packing of DPPC. With SOPC mixed monolayers, all side chain containing sterols caused a 18-20% condensation (at 10 mN/m) of monolayer packing. The condensing effect of 5-androsten-3 beta-ol on SOPC packing was again much smaller (about 10%) compared with that of the side-chain sterols. The rate of sterol oxidation by cholesterol oxidase (at 37 degrees C) in DPPC-containing SUVs increased as a function of increasing the side-chain length (iso-series). With sterols from the n-series, the same trend was seen, except that the n-C7 analogue was oxidized much slower than the n-C4, n-C5, and n-C6 analogues. With SOPC SUVs, a similar side-chain dependent oxidation pattern was observed. Our results support and extend previous knowledge about the importance of the sterol side chain in determining sterol-sterol and sterol-phospholipid interactions, both in mono- and bilayers.