The beginnings of cardiac catheterization and the resulting impact on pulmonary medicine

Designing a SARS-CoV-2 T-Cell-Inducing Vaccine for High-Risk Patient Groups

We describe the results of two vaccinations of a self-experimenting healthy volunteer with SARS-CoV-2-derived peptides performed in March and April 2020, respectively. The first set of peptides contained eight peptides predicted to bind to the individual's HLA molecules. The second set consisted of ten peptides predicted to bind promiscuously to several HLA-DR allotypes. The vaccine formulation contained the new TLR 1/2 agonist XS15 and was administered as an emulsion in Montanide as a single subcutaneous injection. Peripheral blood mononuclear cells isolated from blood drawn before and after vaccinations were assessed using Interferon-γ ELISpot assays and intracellular cytokine staining. We detected vaccine-induced CD4 T cell responses against six out of 11 peptides predicted to bind to HLA-DR after 19 days, following vaccination, for one peptide already at day 12. We used these results to support the design of a T-cell-inducing vaccine for application in high-risk patients, with weakened lymphocyte performance. Meanwhile, an according vaccine, incorporating T cell epitopes predominant in convalescents, is undergoing clinical trial testing.

Central venous catheter insertion in adult patients: a best practice implementation project

INTRODUCTION AND AIMS

The central venous catheter (CVC) is an indispensable device in the daily practice of modern medicine. Thus, the implementation of CVC interferes with the care of a large number of patients. This project aimed to implement the best practices in the insertion of CVC in adult hospitals in Brazil.

METHODS

The project had three phases, including forming a team and conducting the baseline audit; identifying problems and developing strategies; and conducting a follow-up audit to assess the impact on compliance with best practices. A baseline audit was conducted at a public Hospital in Minas Gerais, Brazil, in June and July 2019. For data collection, direct observation of the procedure was performed and through the PACES (Practical Application of Clinical Evidence System) audit and feedback tool to check the compliance criteria established in the literature. After implementation, a second audit was conducted in August 2019.

RESULTS

During the baseline audit, the absence of adequate compliance with the criteria for using an ultrasound to insert the catheter and correct hand hygiene before the procedure was identified. Theoretical-practical training was carried out, including the use of ultrasound to perform the procedure, using an adapted mannequin. The follow-up audit showed an improvement in the compliance rate for the following audit criteria: physical assessment before the procedure (92-100%); evaluation of the most suitable vein for insertion of the catheter, avoiding the femoral vein (92-100%); correct hand hygiene before the procedure (58-100%); maintenance of asepsis throughout the procedure (83-91%) and use of ultrasound to guide venous catheterization (17-100%).

CONCLUSION

The current project proved that training the team can be effective in optimizing the implementation of evidence.

Conceptualising Surgical Innovation: An Eliminativist Proposal

Improving surgical interventions is key to improving outcomes. Ensuring the safe and transparent translation of such improvements is essential. Evaluation and governance initiatives, including the IDEAL framework and the Macquarie Surgical Innovation Identification Tool have begun to address this. Yet without a definition of innovation that allows non-surgeons to identify when it is occurring, these initiatives are of limited value. A definition seems elusive, so we undertook a conceptual study of surgical innovation. This indicated common conceptual areas in discussions of (surgical) innovation, that we categorised alliteratively under the themes of "purpose" (about drivers of innovation), "place" (about contexts of innovation), "process" (about differentiating innovation), "product" (about tangible and intangible results of innovation) and "person" (about personal factors and viewpoint). These conceptual areas are used in varying-sometimes contradictory-ways in different discussions. Highlighting these conceptual areas of surgical innovation may be useful in clarifying what should be reported in registries of innovation. However our wider conclusion was that the term "innovation" carries too much conceptual baggage to inform normative inquiry about surgical practice. Instead, we propose elimination of the term "innovation" from serious discourse aimed at evaluation and regulation of surgery. In our view researchers, philosophers and policy-makers should consider what it is about surgical activity that needs attention and develop robust definitions to identify these areas: for our own focus on transparency and safety, this means finding criteria that can objectively identify certain risk profiles during the development of surgery.

In-Vivo Microsystems: A Review

In-vivo sensors yield valuable medical information by measuring directly on the living tissue of a patient. These devices can be surface or implant devices. Electrical activity in the body, from organs or muscles can be measured using surface electrodes. For short term internal devices, catheters are used. These include cardiac catheter (in blood vessels) and bladder catheters. Due to the size and shape of the catheters, silicon devices provided an excellent solution for sensors. Since many cardiac catheters are disposable, the high volume has led to lower prices of the silicon sensors. Many catheters use a single sensor, but silicon offers the opportunity to have multi sensors in a single catheter, while maintaining small size. The cardiac catheter is usually inserted for a maximum of 72 h. Some devices may be used for a short-to-medium period to monitor parameters after an operation or injury (1-4 weeks). Increasingly, sensing, and actuating, devices are being applied to longer term implants for monitoring a range of parameters for chronic conditions. Devices for longer term implantation presented additional challenges due to the harshness of the environment and the stricter regulations for biocompatibility and safety. This paper will examine the three main areas of application for in-vivo devices: surface devices and short/medium-term and long-term implants. The issues of biocompatibility and safety will be discussed.

The changing face of pulmonary hypertension diagnosis: a historical perspective on the influence of diagnostics and biomarkers

Pulmonary hypertension is a complex, multifactorial disease that results in right heart failure and premature death. Since the initial reports of pulmonary hypertension in the late 1800s, the diagnosis of pulmonary hypertension has evolved with respect to its definition, screening tools, and diagnostic techniques. This historical perspective traces the earliest roots of pulmonary hypertension detection and diagnosis through to the current recommendations for classification. We highlight the diagnostic tools used in the past and present, and end with a focus on the future directions of early detection. Early detection of pulmonary hypertension and pulmonary arterial hypertension and the proper determination of etiology are vital for the early therapeutic intervention that can prolong life expectancy and improve quality of life. The search for a non-invasive screening tool for the identification and classification of pulmonary hypertension is ongoing, and we discuss the role of animal models of the disease in this search.

A new synthetic toll-like receptor 1/2 ligand is an efficient adjuvant for peptide vaccination in a human volunteer

BACKGROUND

We previously showed that the bacterial lipopeptide Pam₃Cys-Ser-Ser, meanwhile established as a toll-like receptor (TLR) 1/2 ligand, acts as a strong adjuvant for the induction of virus specific CD8⁺ T cells in mice, when covalently coupled to a synthetic peptide.

CASE PRESENTATION

We now designed a new water-soluble synthetic Pam₃Cys-derivative, named XS15 and characterized it in vitro by a TLR2 NF-κB luciferase reporter assay. Further, the capacity of XS15 to activate immune cells and stimulate peptide-specific CD8⁺ T and NK cells by 6-sulfo LacNAc⁺ monocytes was assessed by flow cytometry as well as cytokine induction using immunoassays. The induction of a functional immune response after vaccination of a volunteer with viral peptides was assessed by ELISpot assay and flow cytometry in peripheral blood cells and infiltrating cells at the vaccination site, as well as by immunohistochemistry and imaging. XS15 induced strong ex vivo CD8⁺ and T_H1 CD4⁺ responses in a human volunteer upon a single injection of XS15 mixed to uncoupled peptides in a water-in-oil emulsion (Montanide™ ISA51 VG). A granuloma formed locally at the injection site containing highly activated functional CD4⁺ and CD8⁺ effector memory T cells. The total number of vaccine peptide-specific functional T cells was experimentally assessed and estimated to be 3.0 × 10⁵ in the granuloma and 20.5 × 10⁶ in peripheral blood.

CONCLUSION

Thus, in one volunteer we show a granuloma forming by peptides combined with an efficient adjuvant in a water-in-oil-emulsion, inducing antigen specific T cells detectable in circulation and at the vaccination site, after one single vaccination only. The ex vivo T cell responses in peripheral blood were detectable for more than one year and could be strongly boosted by a second vaccination. Hence, XS15 is a promising adjuvant candidate for peptide vaccination, in particular for tumor peptide vaccines in a personalized setting.

Ultrasound Guidance for Central Venous Access: Current Evidence and Clinical Recommendations

Ultrasound-guided central line placement has been shown to decrease the number of needle puncture attempts, complication, and failure rates. In order to obtain successful central access, it is important to have adequate cognitive knowledge, workflow understanding, and manual dexterity to safely execute this invasive procedure. The operator should also be familiar with the anatomical variations, equipment operations, and potential complications and their prevention. In this article, we present a detailed review of ultrasound-guided central venous access. It includes a description of anatomy, operative technique, equipment operation, and techniques for specific situations. We describe the use of ultrasound guidance to avoid and identify various complications associated with this procedure. We have also reviewed recent recommendations and guidelines for the use of ultrasound for central venous access and the current evidence pertaining to the recommendations for the expected level of training, methodology, and metrics for establishing competency.

Accepting the challenge: maintaining AJP-Lung as the best place to publish basic and translational studies in lung biology and pathophysiology

Rory E. Morty takes over from Sadis Matalon as Editor in Chief of the American Journal of Physiology-Lung Cellular and Molecular Physiology in January 2018. Here, key achievements and new and noteworthy additions to the editorial portfolio of the journal will be reviewed. Additionally, selected recent reports will be highlighted and used to illustrate how the broad spectrum of the journal's editorial content promotes methodological innovation and scientific advances in lung biology and pathophysiology.