Artificial airway suctioning is a key component of airway management and a core skill for clinicians charged with assuring airway patency. Suctioning of the artificial airway is a common procedure ...performed worldwide on a daily basis. As such, it is imperative that clinicians are familiar with the most-effective and efficient methods to perform the procedure. We conducted a systematic review to assist in the development of evidence-based recommendations that pertain to the care of patients with artificial airways. From our systematic review, we developed guidelines and recommendations that addressed questions related to the indications, complications, timing, duration, and methods of artificial airway suctioning. By using a modified version of the RAND/UCLA Appropriateness Method, the following recommendations for suctioning were developed for neonatal, pediatric, and adult patients with an artificial airway: (1) breath sounds, visual secretions in the artificial airway, and a sawtooth pattern on the ventilator waveform are indicators for suctioning pediatric and adult patients, and an acute increase in airway resistance may be an indicator for suctioning in neonates; (2) as-needed only, rather than scheduled, suctioning is sufficient for neonatal and pediatric patients; (3) both closed and open suction systems may be used to safely and effectively remove secretions from the artificial airway of adult patients; (4) preoxygenation should be performed before suctioning in pediatric and adult patients; (5) the use of normal saline solution should generally be avoided during suctioning; (6) during open suctioning, sterile technique should be used; (7) suction catheters should occlude < 70% of the endotracheal tube lumen in neonates and < 50% in pediatric and adult patients, and suction pressure should be kept below -120 mm Hg in neonatal and pediatric patients and -200 mm Hg in adult patients; (8) suction should be applied for a maximum of 15 s per suctioning procedure; (9) deep suctioning should only be used when shallow suctioning is ineffective; (10) routine bronchoscopy for secretion removal is not recommended; and (11) devices used to clear endotracheal tubes may be used when airway resistance is increased due to secretion accumulation.
A molecular test to distinguish between sepsis and systemic inflammation of noninfectious etiology could potentially have clinical utility.
This study evaluated the diagnostic performance of a ...molecular host response assay (SeptiCyte LAB) designed to distinguish between sepsis and noninfectious systemic inflammation in critically ill adults.
The study employed a prospective, observational, noninterventional design and recruited a heterogeneous cohort of adult critical care patients from seven sites in the United States (n = 249). An additional group of 198 patients, recruited in the large MARS (Molecular Diagnosis and Risk Stratification of Sepsis) consortium trial in the Netherlands ( www.clinicaltrials.gov identifier NCT01905033), was also tested and analyzed, making a grand total of 447 patients in our study. The performance of SeptiCyte LAB was compared with retrospective physician diagnosis by a panel of three experts.
In receiver operating characteristic curve analysis, SeptiCyte LAB had an estimated area under the curve of 0.82-0.89 for discriminating sepsis from noninfectious systemic inflammation. The relative likelihood of sepsis versus noninfectious systemic inflammation was found to increase with increasing test score (range, 0-10). In a forward logistic regression analysis, the diagnostic performance of the assay was improved only marginally when used in combination with other clinical and laboratory variables, including procalcitonin. The performance of the assay was not significantly affected by demographic variables, including age, sex, or race/ethnicity.
SeptiCyte LAB appears to be a promising diagnostic tool to complement physician assessment of infection likelihood in critically ill adult patients with systemic inflammation. Clinical trial registered with www.clinicaltrials.gov (NCT01905033 and NCT02127502).
Hospital-acquired pneumonia (HAP) and the need for positive-pressure ventilation (PPV) are significant postoperative pulmonary complications (PPCs) that increase patients' lengths of stay, mortality, ...and costs. Current tools used to predict PPCs use nonmodifiable preoperative factors; thus, they cannot assess provided respiratory therapy effectiveness. The Respiratory Assessment and Allocation of Therapy (RAAT) tool was created to identify HAP and the need for PPV and assist in assigning respiratory therapies. This study aimed to assess the RAAT tool's reliability and validity and determine if allocated respiratory procedures based on scores prevented HAP and the need for PPV.
Electronic medical record data for nonintubated surgical ICU subjects scored with the RAAT tool were pulled from July 1, 2015-January 31, 2016, using a consecutive sampling technique. Sensitivity, specificity, and jackknife analysis were generated based on total RAAT scores. A unit-weighted analysis and mean differences of consecutive RAAT scores were analyzed with RAAT total scores ≥ 10 and the need for PPV.
The first or second RAAT score of ≤ 5 (unlikely to receive PPV) and ≥ 10 (likely to receive PPV) provided a sensitivity of 0.833 and 0.783 and specificity of 0.761 and 0.804, respectively. Jackknifed sensitivity and specificity for identified cutoffs above were 0.800-0.917 and 0.775-0.739 for the first RAAT score and 0.667-0.889 and 0.815-0.79 for the second RAAT score. The initial RAAT scores of ≥ 10 predicted the need for PPV (
< .001) and was associated with higher in-hospital mortality (
< .001). Mean differences between consecutive RAAT scores revealed decreasing scores did not need PPV.
The RAAT scoring tool demonstrated an association with the need for PPV using modifiable factors and appears to provide a quantitative method of determining if allocated respiratory therapy is effective.
Abstract
Aminoacyl-tRNA synthetases (ARSs) are critical for protein translation. Pathogenic variants of ARSs have been previously associated with peripheral neuropathy and multisystem disease in ...heterozygotes and homozygotes, respectively. We report seven related children homozygous for a novel mutation in tyrosyl-tRNA synthetase (YARS, c.499C > A, p.Pro167Thr) identified by whole exome sequencing. This variant lies within a highly conserved interface required for protein homodimerization, an essential step in YARS catalytic function. Affected children expressed a more severe phenotype than previously reported, including poor growth, developmental delay, brain dysmyelination, sensorineural hearing loss, nystagmus, progressive cholestatic liver disease, pancreatic insufficiency, hypoglycemia, anemia, intermittent proteinuria, recurrent bloodstream infections and chronic pulmonary disease. Related adults heterozygous for YARS p.Pro167Thr showed no evidence of peripheral neuropathy on electromyography, in contrast to previous reports for other YARS variants. Analysis of YARS p.Pro167Thr in yeast complementation assays revealed a loss-of-function, hypomorphic allele that significantly impaired growth. Recombinant YARS p.Pro167Thr demonstrated normal subcellular localization, but greatly diminished ability to homodimerize in human embryonic kidney cells. This work adds to a rapidly growing body of research emphasizing the importance of ARSs in multisystem disease and significantly expands the allelic and clinical heterogeneity of YARS-associated human disease. A deeper understanding of the role of YARS in human disease may inspire innovative therapies and improve care of affected patients.
All instrumented basaltic caldera collapses have generated Mw > 5 very long period earthquakes. However, previous studies of source dynamics have been limited to lumped models treating the caldera ...block as rigid, leaving open questions related to how ruptures initiate and propagate around the ring fault, and the seismic expressions of those dynamics. We present the first 3D numerical model capturing the nucleation and propagation of ring fault rupture, the mechanical coupling to the underlying viscoelastic magma, and the associated seismic wavefield. We demonstrate that seismic radiation, neglected in previous models, acts as a damping mechanism reducing coseismic slip by up to half, with effects most pronounced for large magma chamber volume/ring fault radius or highly compliant crust/compressible magma. Viscosity of basaltic magma has negligible effect on collapse dynamics. In contrast, viscosity of silicic magma significantly reduces ring fault slip. We use the model to simulate the 2018 Kı̄lauea caldera collapse. Three stages of collapse, characterized by ring fault rupture initiation and propagation, deceleration of the downward‐moving caldera block and magma column, and post‐collapse resonant oscillations, in addition to chamber pressurization, are identified in simulated and observed (unfiltered) near‐field seismograms. A detailed comparison of simulated and observed displacement waveforms corresponding to collapse earthquakes with hypocenters at various azimuths of the ring fault reveals a complex nucleation phase for earthquakes initiated on the northwest. Our numerical simulation framework will enhance future efforts to reconcile seismic and geodetic observations of caldera collapse with conceptual models of ring fault and magma chamber dynamics.
Plain Language Summary
Caldera collapse manifests as the rapid subsidence of a kilometer‐scale block of crust circumscribed by a near‐circular fault on top of a volcano. The subsidence of the caldera block is caused by the eruption‐induced withdrawal of magma and reduction in pressure in the underlying magma chamber. All scientifically instrumented caldera collapses at volcanoes with low‐viscosity magma are accompanied by earthquakes of magnitude 5 and above. How do magma viscosity and the seismic wave radiation influence the amount of slip per earthquake on the fault? What can we learn about the dynamics of these earthquakes from seismic records? We address these questions by performing computer simulations of caldera collapse earthquakes and compare the results to the seismic records from the Kı̄lauea caldera collapse of 2018.
Key Points
Seismic wave radiation through ring fault and magma, as well as high magma viscosity, reduce fault slip by up to half during collapse
Rupture propagation, downward momentum transfer via magma pressure waves, and chamber pressurization are identified in unfiltered seismograms
Comparison between simulated and observed near‐field seismograms from Kı̄lauea 2018 reveals complex nucleation phase on the ring fault
The spatial distribution of aftershocks following major earthquakes has received significant attention due to the shaking hazard these events pose for structures and populations in the affected ...region. Forecasting the spatial distribution of aftershock events is an important part of the estimation of future seismic hazard. A simple spatial shape for the zone of activity has often been assumed in the form of an ellipse having semimajor axis to semiminor axis ratio of 2.0. However, since an important application of these calculations is the estimation of ground shaking hazard, an effective criterion for forecasting future aftershock impacts is to use ground motion prediction equations (GMPEs) in addition to the more usual approach of using epicentral or hypocentral locations. Based on these ideas, we present an aftershock model that uses self-similarity and scaling relations to constrain parameters as an option for such hazard assessment. We fit the spatial aspect ratio to previous earthquake sequences in the studied regions, and demonstrate the effect of the fitting on the likelihood of post-disaster ground motion forecasts for eighteen recent large earthquakes. We find that the forecasts in most geographic regions studied benefit from this optimization technique, while some are better suited to the use of the a priori aspect ratio.
The recent findings of the National Lung Screening Trial showed 24.2% of individuals at high risk for lung cancer having one or more indeterminate nodules detected by low-dose computed ...tomography–based screening, 96.4% of which were eventually confirmed as false positives. These positive scans necessitate additional diagnostic procedures to establish a definitive diagnosis that adds cost and risk to the paradigm. A plasma test able to assign benign versus malignant pathology in high-risk patients would be an invaluable tool to complement low-dose computed tomography–based screening and promote its rapid implementation.
We evaluated 17 biomarkers, previously shown to have value in detecting lung cancer, against a discovery cohort, comprising benign (n = 67) cases and lung cancer (n = 69) cases. A Random Forest method based analysis was used to identify the optimal biomarker panel for assigning disease status, which was then validated against a cohort from the Mayo Clinic, comprising patients with benign (n = 61) or malignant (n = 20) indeterminate lung nodules.
Our discovery efforts produced a seven-analyte plasma biomarker panel consisting of interleukin 6 (IL-6), IL-10, IL-1ra, sIL-2Rα, stromal cell-derived factor-1α+β, tumor necrosis factor α, and macrophage inflammatory protein 1 α. The sensitivity and specificity of our panel in our validation cohort is 95.0% and 23.3%, respectively. The validated negative predictive value of our panel was 93.8%.
We developed a seven-analyte plasma biomarker panel able to identify benign nodules, otherwise deemed indeterminate, with a high degree of accuracy. This panel may have clinical utility in risk-stratifying screen-detected lung nodules, decrease unnecessary follow-up imaging or invasive procedures, and potentially avoid unnecessary morbidity, mortality, and health care costs.
In this paper, we address the problem of verifying earthquake simulators with observed data. Earthquake simulators are a class of computational simulations which attempt to mirror the topological ...complexity of fault systems on which earthquakes occur. In addition, the physics of friction and elastic interactions between fault elements are included in these simulations. Simulation parameters are adjusted so that natural earthquake sequences are matched in their scaling properties. Physically based earthquake simulators can generate many thousands of years of simulated seismicity, allowing for a robust capture of the statistical properties of large, damaging earthquakes that have long recurrence time scales. Verification of simulations against current observed earthquake seismicity is necessary, and following past simulator and forecast model verification methods, we approach the challenges in spatial forecast verification to simulators; namely, that simulator outputs are confined to the modeled faults, while observed earthquake epicenters often occur off of known faults. We present two methods for addressing this discrepancy: a simplistic approach whereby observed earthquakes are shifted to the nearest fault element and a smoothing method based on the power laws of the epidemic-type aftershock (ETAS) model, which distributes the seismicity of each simulated earthquake over the entire test region at a decaying rate with epicentral distance. To test these methods, a receiver operating characteristic plot was produced by comparing the rate maps to observed
m
>
6.0
earthquakes in California since 1980. We found that the nearest-neighbor mapping produced poor forecasts, while the ETAS power-law method produced rate maps that agreed reasonably well with observations.
PDF
