Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK Randomized Clinical Trial.

Importance: Abnormal peripheral perfusion after septic shock resuscitation has been associated with organ dysfunction and mortality. The potential role of the clinical assessment of peripheral perfusion as a target during resuscitation in early septic shock has not been established. Objective: To determine if a peripheral perfusion-targeted resuscitation during early septic shock in adults is more effective than a lactate level-targeted resuscitation for reducing mortality. Design, Setting, and Participants: Multicenter, randomized trial conducted at 28 intensive care units in 5 countries. Four-hundred twenty-four patients with septic shock were included between March 2017 and March 2018. The last date of follow-up was June 12, 2018. Interventions: Patients were randomized to a step-by-step resuscitation protocol aimed at either normalizing capillary refill time (n = 212) or normalizing or decreasing lactate levels at rates greater than 20% per 2 hours (n = 212), during an 8-hour intervention period. Main Outcomes and Measures: The primary outcome was all-cause mortality at 28 days. Secondary outcomes were organ dysfunction at 72 hours after randomization, as assessed by Sequential Organ Failure Assessment (SOFA) score (range, 0 [best] to 24 [worst]); death within 90 days; mechanical ventilation-, renal replacement therapy-, and vasopressor-free days within 28 days; intensive care unit and hospital length of stay. Results: Among 424 patients randomized (mean age, 63 years; 226 [53%] women), 416 (98%) completed the trial. By day 28, 74 patients (34.9%) in the peripheral perfusion group and 92 patients (43.4%) in the lactate group had died (hazard ratio, 0.75 [95% CI, 0.55 to 1.02]; P = .06; risk difference, -8.5% [95% CI, -18.2% to 1.2%]). Peripheral perfusion-targeted resuscitation was associated with less organ dysfunction at 72 hours (mean SOFA score, 5.6 [SD, 4.3] vs 6.6 [SD, 4.7]; mean difference, -1.00 [95% CI, -1.97 to -0.02]; P = .045). There were no significant differences in the other 6 secondary outcomes. No protocol-related serious adverse reactions were confirmed. Conclusions and Relevance: Among patients with septic shock, a resuscitation strategy targeting normalization of capillary refill time, compared with a strategy targeting serum lactate levels, did not reduce all-cause 28-day mortality. Trial Registration: ClinicalTrials.gov Identifier: NCT03078712.

Raspberry Ketone Trifluoroacetate Trapping of Zeugodacus cucurbitae (Diptera: Tephritidae)in Hawaii.

Melon fly, Zeugodacus cucurbitae (Coquillett), is a serious pest of tropical horticulture, causing damage to cucurbits, other fruiting vegetables, and certain tree fruits. The deployment of male lures comprises an important component of several detection and control strategies for this pest, with the main male attractant currently in use being cuelure (CL). A novel fluorinated analog of CL, raspberry ketone trifluoroacetate (RKTA), has been developed for the control of Bactrocera tryoni, a related pest; here, we test this compound for attraction to Z. cucurbitae. In outdoor screen cage testing, observations showed both more flies on filter papers, and a higher percentage of flies feeding, on papers treated with RKTA than on those with CL or melolure (ML). Field trapping with both yellow sticky traps and bucket traps found that RKTA captured more flies during the first 6 h of trapping than CL, while trap captures in the subsequent 18 h did not differ between the two lures. When comparing combined 24 h trap captures, yellow sticky traps containing RKTA captured more flies than those with CL, while bucket trap captures did not vary by lure. Analysis of lures weathered on filter paper found that nearly all applied RKTA hydrolyzed to RK within 6 h. Fine-scale melon fly behaviors digitally recorded in the field showed median resting distances from the lure of responding flies were shorter for RKTA than for CL. This study demonstrates the inherent attractiveness of RKTA while also highlighting the instability of this compound due to hydrolysis.

In vitro evaluation of aerosol delivery of aztreonam lysine (AZLI): an adult mechanical ventilation model.

BACKGROUND: The delivery profile of Aztreonam lysine (AZLI) during mechanical ventilation (MV) is unknown. We evaluated the amount of AZLI drug delivered using an in vitro model of adult MV. METHODS: An adult lung model designed to mimic current clinical practice was used. Both nebulizers were placed before a Y-piece and 4 settings were tested: A) Aeroneb solo® [AS] with a t-piece; B) AS with the spacer; C) M-Neb® [MN] with a t-piece and D) MN with the spacer. Performance was evaluated in terms of: 1) Mass median aerodynamic diameter (MMAD); 2) Geometric standard deviation (GSD), 3) Fine particle dose (FPD), 4) Fine particle fraction (FPF), 5) Inhalable mass (IM), and 6) Recovery rate (RR). RESULTS: Both devices showed an adequate delivery of AZLI during MV, with MMAD between 2.4-2.5 µm and 87% of FPF. The FPD (38.8 and 31.7), IM (44.8 and 36.1) and RR (30 and 24) were similar for AS and MN respectively. Nebulizer aerosol delivery increased (50 and 70% respectively) for both nebulizers when using the spacer. CONCLUSION: Both AS and MN showed a good aerosol delivery profile for AZLI during in vitro mechanical ventilation. Better aerosol delivery performance was obtained using the spacer.