Development of a pig wean-quality score using machine-learning algorithms to characterize and classify groups with high mortality risk under field conditions.

Mortality during the post-weaning phase is a critical indicator of swine production system performance, influenced by a complex interaction of multiple factors of the epidemiological triad. This study leveraged retrospective data from 1723 groups of pigs marketed within a US swine production system to develop a Wean-Quality Score (WQS) using machine learning techniques. The study evaluated three machine learning models, Random Forest, Support Vector Machine, and Gradient Boosting Machine, to classify groups having high or low 60-day mortality, where high mortality groups represented 25 % of the groups among the study population with the highest mortality values (n=431; 60-day mortality=9.98 %), and the remaining 75 % of the groups were of low mortality (n=1292; 60-day mortality=2.75 %). The best-performing model, Random Forest (RF), outperformed the other ML models in terms of accuracy (0.90), sensitivity (0.84), and specificity (0.92) metrics, and was then selected for further analysis, which consisted of creating the WQS and ranking the most important factors for classifying groups as high or low mortality. The most important factors ranked through the RF model to classify groups with high mortality were pre-weaning mortality, weaning age, average parity of litters in sow farms, and PRRS status. Additionally, stocking conditions such as stocking density and time to fill the barn were important predictors of high mortality. The WQS was developed and correlated (r = 0.74) with the actual 60-day mortality of the groups, offering a valuable tool for assessing post-weaning survivability in swine production systems before weaning. This study highlights the potential of machine learning and comprehensive data utilization to improve the assessment and management of weaned pig quality in commercial swine production, which producers can utilize to identify and intervene in groups, according to the WQS.

Influence of Diet on Reproducible Corticosterone Levels in a Mouse Model of Maternal Separation with Early Weaning.

Maternal separation with early weaning (MSEW) is a popular early life stress (ELS) model in rodents, which emulates childhood neglect through scheduled mother-offspring separation. Although variations of ELS models, including maternal separation and MSEW, have been published for the mouse species, the reported results are inconsistent. Corticosterone is considered the main stress hormone involved in regulating stress responses in rodents-yet generating a robust and reproducible corticosterone response in mouse models of ELS has been elusive. Considering the current lack of standardization for MSEW protocols, these inconsistent results may be attributed to variations in model methodologies. Here, we compared the effects of select early wean diet sources-which are the non-milk diets used to complete early weaning in MSEW pups-on the immediate stress phenotype of C57BL/6J mice at postnatal day 21. Non-aversive handling was an integral component of our modified MSEW model. The evaluation of body weight and serum corticosterone revealed the early wean diet to be a key variable in the resulting stress phenotype. Interestingly, select non-milk diets facilitated a stress phenotype in which low body weight was accompanied by significant corticosterone elevation. Our data indicate that dietary considerations are critical in MSEW-based studies and provide insight into improving the reproducibility of key stress-associated outcomes as a function of this widely used ELS paradigm.

To wean or not to wean: proton pump inhibitor management after anti-reflux surgery amongst foregut experts.

BACKGROUND: Most patients undergoing anti-reflux surgery (ARS) have a history of preoperative proton pump inhibitor (PPI) use. It is well-established that ARS is effective in restoring the anti-reflux barrier, eliminating the ongoing need for costly PPIs. Current literature lacks objective evidence supporting an optimal postoperative PPI cessation or weaning strategy, leading to wide practice variations. We sought to objectively gauge current practice and opinion surrounding the postoperative management of PPIs among expert foregut surgeons and gastroenterologists in the United States. METHODS: We created a survey of postoperative PPI management protocols, with an emphasis on discontinuation and timing of PPI cessation, and aimed to determine what factors played a role in the decision-making. An electronic survey tool (Qualtrics XM, Qualtrics, Provo, UT) was used to distribute the survey and to record the responses anonymously for a period of three months. RESULTS: The survey was viewed 2658 times by 373 institutions and shared with 644 members. In total, 121 respondents participated in the survey and 111 were surgeons (92%). Fifty respondents (42%) always discontinue PPIs immediately after ARS. Of the remaining 70 respondents (58%), 46% always wean or taper PPIs postoperatively and 47% wean or taper them selectively. The majority (92%) of practitioners taper within a 3-month period postoperatively. Five respondents never discontinue PPIs after ARS. Overall, only 23 respondents (19%) stated their protocol is based on medical literature or evidence-based medicine. Instead, decision-making is primarily based on anecdotal evidence/personal preference (42%, n = 50) or prior training/mentors (39%, n = 47). CONCLUSIONS: There are two major protocols used for PPI discontinuation after ARS: Nearly half of providers abruptly stop PPIs, while just over half gradually tapers them, most often in the early postoperative period. These decisions are primarily driven by institutional practices and personal preferences, underscoring the need for evidence-based recommendations.

Occurrence of pendelluft during ventilator weaning with T piece correlated with increased mortality in difficult-to-wean patients.

BACKGROUND: Difficult-to-wean patients, typically identified as those failing the initial spontaneous breathing trial (SBT), face elevated mortality rates. Pendelluft, frequently observed in patients experiencing SBT failure, can be conveniently detected through bedside monitoring with electrical impedance tomography (EIT). This study aimed to explore the impact of pendelluft during SBT on difficult-to-wean patients. METHODS: This retrospective observational study included difficult-to-wean patients undergoing spontaneous T piece breathing, during which EIT data were collected. Pendelluft occurrence was defined when its amplitude exceeded 2.5% of global tidal impedance variation. Physiological parameters during SBT were retrospectively retrieved from the EIT Examination Report Form. Other clinical data including mechanical ventilation duration, length of ICU stay, length of hospital stay, and 28-day mortality were retrieved from patient records in the hospital information system for each subject. RESULTS: Pendelluft was observed in 72 (70.4%) of the 108 included patients, with 16 (14.8%) experiencing mortality by day 28. The pendelluft group exhibited significantly higher mortality (19.7% vs. 3.1%, p = 0.035), longer median mechanical ventilation duration [9 (5-15) vs. 7 (5-11) days, p = 0.041] and shorter ventilator-free days at day 28 [18 (4-22) vs. 20 (16-23) days, p = 0.043]. The presence of pendellfut was independently associated with increased mortality at day 28 (OR = 10.50, 95% confidence interval 1.21-90.99, p = 0.033). CONCLUSIONS: Pendelluft occurred in 70.4% of difficult-to-wean patients undergoing T piece spontaneous breathing. Pendelluft was associated with worse clinical outcomes, including prolonged mechanical ventilation and increased mortality in this population. Our findings underscore the significance of monitoring pendelluft using EIT during SBT for difficult-to-wean patients.

Experiences in Tube Weaning Children with Congenital Heart Disease and Oral Feeding Aversion.

Infants and children with congenital heart disease (CHD) often require supplemental nutrition via tube feeding before and after surgery. Tube feeding may be required due to poor weight gain, inadequate oral-motor skills, and/or reduced endurance for oral feeding. Our team has described a successful approach to weaning this population (Horsley et al. (2022) Pediatr Cardiol 43:1429-1437). A subgroup of tube-fed patients with CHD who demonstrate oral feeding aversion (OA) presents unique challenges to the tube weaning process. We discuss our team's experience with tube weaning orally averse children with CHD. Of 36 patients enrolled in the Cincinnati Children's Heart Institute Cardiology Feeding Tube Wean Clinic, 11 (31%) were determined to have oral feeding aversion (OA) by a speech-language pathologist (SLP). Descriptive data comparing the OA group to the non-averse group was gathered prior to and during the wean. Both groups had the ability to tube wean successfully, although the OA group had lower median oral intake (9 vs 24%) and higher age at start of the wean (9 vs 4 months). Those with OA also had a longer median duration of wean in days (17 vs 12 days) and higher likelihood of return to tube feeds within six-month post-wean (22 vs 0%). Additionally, the OA group had a higher percentage of genetic syndromes (36 vs 16%), although this was not found to be statistically significant in this study. Children with OA present with unique challenges for tube weaning. The results of this study show that weaning children with CHD and OA is possible with a multidisciplinary team who is knowledgeable about this population.

Evaluation of bovine colostrum replacer supplementation to improve weaning transition in Holstein dairy calves.

The objective of this randomized controlled trial was to evaluate the efficacy of supplementing bovine colostrum replacer during weaning to reduce intestinal permeability and improve gain. For this experiment, 65 calves were enrolled and housed individually until 70 d of age. Calves were fed milk replacer (150 g/L) 3 times daily with 9, 10.5, 11.25, and 12 L/d offered from d 1 to 7, 8 to 14, 15 to 21, 22 to 56, respectively. Calves were weaned over 8 d from d 57 to 64, receiving a total of 7.8 L in 2 meals per day from d 57 to 60 and 3.8 L/d in 1 feeding from d 61 to 64. At d 57, calves were blocked by birth weight and randomly assigned to 1 of 2 treatments, equal in ME, which were fed once daily during weaning from d 57 to 64: control (CON; n = 31 calves): 3.8 L of milk replacer (150 g/L) fed by nipple bottle, or colostrum supplementation (COL; n = 34): a mixture of 1 L of bovine colostrum replacer (125 g/L) and 3 L of milk replacer (150 g/L) with 3.8 L of of the mixture fed by nipple bottle. Serum IgG was measured within 48 h of birth and BW was taken at d 0, 57, 60, 64, 70, 77, and 84. Starter intake and bovine respiratory disease (BRD) score were measured daily from d 50 to 70, and fecal consistency was examined daily from d 56 to 70. Serum BHB and lung consolidation were evaluated at d 57, 64, and 70, and intestinal permeability was assessed by recovery of chromium-EDTA, lactulose, and d-mannitol from plasma after oral administration at d 56 and 65. Body weight had no difference between treatment groups at the start of weaning, but COL were 2.79 kg (95% CI: 0.90-4.68) and 2.76 kg (95% CI: 0.86-4.65) heavier than CON at d 77 and 84, respectively. Additionally, COL tended to gain 100.00 g/d more than CON calves (95% CI: -10.41-207.13) from d 57 to 84. No differences were observed in any of the other variables measured. Supplementation of bovine colostrum replacer during weaning may improve weight gain, but the mechanism of action is not clear.

Effect of creep feeding pelleted starter diet, liquid milk replacer and a liquid mixture of starter diet and milk replacer to suckling pigs on their growth and medication usage.

The aim of this study was to assess the effect of creep-feeding solid starter diet, liquid milk replacer, and a liquid mixture of starter diet and milk replacer to suckling pigs on their growth and medication usage up to target slaughter weight (approximately 120 kg). Ninety-one sows and their litters were randomly assigned to one of four post-farrowing treatments at day 107 of gestation; (1) no creep feed provided to weaning at day 28 of age (CONTROL; n = 20), (2) dry pelleted starter diet provided as creep feed from day 10 of age to weaning (DPS; n = 25), (3) liquid milk replacer provided as creep feed from day 3 of age to weaning (LMR; n = 23), and (4) liquid milk replacer provided from days 3 to 6 of age followed by a mixture of liquid milk replacer with an increasing proportion of liquid starter diet to weaning provided as creep feed (LMR + S; n = 23). Pig weight and dry matter disappearance (DMd) were recorded during lactation and postweaning until pigs reached target slaughter weight (approximately 120 kg). At target slaughter weight, carcass weight and quality were recorded. Medication (antibiotic and anti-inflammatory) usage per pig on a litter basis, and number of injections and clinical cases of disease per litter were recorded from birth to slaughter. At day 5 postweaning, a subset of pigs (n = 40) were sacrificed and intestinal samples were collected for histological analysis. Piglets supplemented with DPS had higher DMd of creep feed than those supplemented with LMR or LMR + S (P < 0.001). Providing LMR + S to suckling piglets reduced the coefficient of variation (CV) for within-litter piglet weaning weight (P < 0.01) compared to DPS and LMR, but the CV of LMR + S was similar to that of CONTROL. Providing DPS or LMR to suckling piglets increased piglet weaning weight compared to CONTROL (P < 0.001) but pig weight was not significantly different from CONTROL at time points thereafter. Gain to feed ratio from weaning to day 6 postweaning was less for LMR pigs compared to all other treatments (P < 0.001). Providing DPS or LMR + S to suckling piglets tended to increase postweaning ileal villus height (P = 0.07). Diarrhea incidence, as well as the number of clinical cases of disease and injections per litter and volume of antibiotic and anti-inflammatory administered per pig pre- and postweaning, were not affected by treatment (P > 0.05). In conclusion, supplementing suckling pigs with liquid milk replacer or dry pelleted starter diet improved growth at weaning, but the benefit did not persist to slaughter.

Weaning buprenorphine in pregnant patients.

OBJECTIVE: Evaluate maternal and neonatal outcomes after buprenorphine wean compared to patients maintained on buprenorphine throughout pregnancy. METHODS: Prospective cohort study of pregnant patients with opioid use disorder enrolled in a multidisciplinary treatment program between 2015 and 2022. All patients were offered Medications to treat Opioid Use Disorder (MOUD) primarily with buprenorphine. Patients had at least 2 prenatal visits and negative urine drug tests (UDT) prior to weaning. The experimental group underwent a buprenorphine wean greater than 20% of their baseline dose. The control group was maintained on buprenorphine throughout the pregnancy. Relapse was defined as patient reported use or positive UDT during weekly assessments. Mass spectrophotometer was used for detection of drugs in samples. Fisher's exact tests were used to compare outcomes in weaned and control groups. RESULTS: 334 of 456 (73%) patients were treated with buprenorphine during pregnancy, with 39 in the experimental group and 295 in the control group. The mean dose for buprenorphine was similar between the groups (wean: 10.6 mg ± 5.6 vs. control: 10.3 mg ± 4.6, p = 0.76) but was significantly lower at delivery (wean: 4.4 ± 4.6 mg vs. control: 13.0 ± 4.7, p < 0.0001). Mean gestational age at initiation of the buprenorphine wean was 22.7 weeks. 10 of 39 (26%) who weaned were able to completely discontinue buprenorphine prior to delivery. Demographic data was similar between the groups, including overdose history. Overdose history at time of enrollment had a higher trend in the non-weaning group. neonatal opioid withdrawal syndrome (NOWS) treatment was significantly lower in the wean group (23 vs. 47%, p = 0.006), as was highest Finnegan score (9.6 ± 4.5 vs. 12.3 ± 4.0, p = 0.0003). Birthweight percentile was significantly higher in the wean group (44.3 ± 29.9 vs. 34.8 ± 24.4, p = 0.03). Gestational age at delivery, mode of delivery, and complications (HTN, DM, preterm labor, or short cervix) at delivery did not significantly differ between the groups. CONCLUSION: Despite counseling to stay on buprenorphine, there are patients who desire to wean. The NOWS rate in the weaned cohort was significantly lower than the controls with no observed increase in maternal or neonatal morbidity. There were no maternal overdoses or deaths during the pregnancy. Larger studies are needed to evaluate this approach.

Propofol Sedation Washouts in Critically Ill Infants: A Case Series.

Medically complex infants are experiencing longer hospital stays, more invasive procedures, and increasingly involved therapeutic interventions that often require long-term analgesia and sedation. This is most commonly achieved with continuous intravenous infusions of opioids and benzodiazepines. There are times when patients develop a tolerance for these medications or the clinical scenario necessitates a rapid wean of them. A rapid wean of either class of medication can lead to increased signs of pain and agitation or withdrawal symptoms. As a result, when a rapid wean is needed or there has been a failure to control symptoms with conventional measures, alternative therapies are considered. Propofol, a sedative hypnotic typically used for general anesthesia and procedural sedation, is one such medication. It has effectively been used for short-term sedation in adults and children to facilitate weaning benzodiazepines and opioids. There is a paucity of data on the use of propofol in infants for this purpose. Here we describe the use of propofol to rapidly wean high-dose sedation and analgesia medications, a propofol sedation washout, in 3 infants. The washouts proved to be safe and efficacious. Based on institutional experience and a literature review, considerations and recommendations are made for propofol sedation washouts in infants.

Development and application of a scoring system for septum injuries in beef calves with and without a nose flap.

The weaning period is a stressful time for beef calves because they must quickly gain independence from their dam. Gradual methods of weaning, such as when the calf is fitted with a nose flap to prevent suckling, are known to reduce the behavioral and physiological indicators of stress. Nose flaps are held in place by the nasal septum and are worn for 4 to 7 d. In the present study, the objectives were to 1) identify if a plastic nose flap worn for 7 d caused nasal injuries, (2) identify if factors like calf body weight or septum size predict injuries or flap loss, and (3) create a scoring system that could reliably score wound characteristics. Eighty-two (N = 82) Angus and Angus-Hereford crossbred beef calves were randomly assigned to 'Flap' or 'No Flap' treatments. Calves weighed 247 ±â€…29 kg and those with a flap had septums that were 39 ±â€…2 mm (mean ±â€…SD). Images were taken of each nostril before flap insertion, on the day of removal, and 6 d after removal. Wounds were scored for the presence/absence of three characteristics in either nostril: damage (tissue where the flap rested was a different color than surrounding nostril), impression (edges of the wound were clearly raised or sunken), and blood. One trained observer scored a subset of photos (N = 64) twice, in a consistent manner for all three characteristics (damage, impression, and blood; 97%, 91%, and 100% agreement between 1st and 2nd evaluations, respectively), indicating that our system is repeatable. Thirty-two percent of calves in the Flap treatment lost their flap before the day of removal. No calves in the No Flap treatment were injured. All animals that kept their flap in for 7 d had damage and impressions in at least one nostril and 86% of calves had blood present immediately after nose flap removal (P ≤ 0.001 compared to No Flap) indicating that the flaps altered the nasal tissue and created open wounds. Six d after flap removal, 100% still had visible damage, 64% had impressions, and 29% had blood, indicating that while damage is longer lasting, wounds can start to repair after the flap is removed. Injuries were prevalent in all calves, thus there was no relationship between calf size (body weight or septum width) on these wounds (P ≥ 0.374). Body weight or septum size did not differ (P ≥ 0.489) between calves that kept or lost their flap. Injuries inflicted from a nose flap may counteract the previously documented benefits of this method of weaning, making it less advantageous than alternatives and raise concerns about other uses of these devices in other contexts.

The long-term ICU patient: Which definition?

AIMS AND OBJECTIVES: To offer a review of the differing terminologies used by clinicians and researchers to describe the long-term intensive care unit (ICU) patient and the underlying propositions that align with this terminology. BACKGROUND: Ongoing medical and technological advances in emergency and intensive care have resulted in improved survival of critically ill patients in recent decades. In addition, these advancements have also resulted in improved survival of complex critically ill patients who progress to a trajectory of prolonged critical illness, having protracted stays in the ICU. There is great variability in terminology used to define the long-term ICU patient. This lack of a common definition for long-term ICU patients is problematic, increasing their vulnerability and risk of care not being centred about their unique needs. DESIGN: In this discursive article, we explore the terminology used to define the long-term ICU patient. An initial broad search of the literature across four electronic databases was conducted to identify common terminology used to define the long-term ICU patient. From here, seven definitions were identified and chosen for inclusion in the review as they meet inclusion criteria and clearly described a group of patients who have an extended ICU stay. The seven selected terms are as follows: prolonged mechanical ventilation; failure to wean; insertion of tracheostomy; chronically critically ill; persistent critical illness; persistent inflammatory-immunosuppressive and catabolic syndrome; and frailty. Following this a focused review of the literature with the selected terms was conducted to explore in greater detail the terminology. DISCUSSION: The lack of clear definition for this patient group can potentiate their care needs being unmet. Acknowledgement of the need to clearly define this patient group is the first step to improve outcomes. Nursing is well positioned to recognise the different terminologies use to describe this group of patients and implement care to suit their unique clinical characteristics. CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE: Recognition and standardisation of these terms are an important priority to pave the way to improve care pathways and outcomes for this group of patients and their family.

Utilizing productivity and health breeding-to-market information along with disease diagnostic data to identify pig mortality risk factors in a U.S. swine production system.

Aggregated diagnostic data collected over time from swine production systems is an important data source to investigate swine productivity and health, especially when combined with records concerning the pre-weaning and post-weaning phases of production. The combination of multiple data streams collected over the lifetime of the pigs is the essence of the whole-herd epidemiological investigation. This approach is particularly valuable for investigating the multifaceted and ever-changing factors contributing to wean-to-finish (W2F) swine mortality. The objective of this study was to use a retrospective dataset ("master table") containing information on 1,742 groups of pigs marketed over time to identify the major risk factors associated with W2F mortality. The master table was built by combining historical breed-to-market performance and health data with disease diagnostic records (Dx Codes) from marketed groups of growing pigs. After building the master table, univariate analyses were conducted to screen for risk factors to be included in the initial multivariable model. After a stepwise backward model selection approach, 5 variables and 2 interactions remained in the final model. Notably, the diagnosis variable significantly associated with W2F mortality was porcine reproductive and respiratory syndrome virus (PRRSV). Closeouts with clinical signs suggestive of Salmonella spp. or Escherichia coli infection were also associated with higher W2F mortality. Source sow farm factors that remained significantly associated with W2F mortality were the sow farm PRRS status, average weaning age, and the average pre-weaning mortality. After testing for the possible interactions in the final model, two interactions were significantly associated with wean-to-finish pig mortality: (1) sow farm PRRS status and a laboratory diagnosis of PRRSV and (2) average weaning age and a laboratory diagnosis of PRRS. Closeouts originating from PRRS epidemic or PRRS negative sow farms, when diagnosed with PRRS in the growing phase, had the highest W2F mortality rates. Likewise, PRRS diagnosis in the growing phase was an important factor in mortality, regardless of the average weaning age of the closeouts. Overall, this study demonstrated the utility of a whole-herd approach when analyzing diagnostic information along with breeding-to-market productivity and health information, to measure the major risk factors associated with W2F mortality in specified time frames and pig populations.

Endovascular Perfusion Augmentation After Resuscitative Endovascular Balloon Occlusion of the Aorta Improves Renal Perfusion and Decreases Vasopressors.

INTRODUCTION: Resuscitative endovascular balloon occlusion of the aorta (REBOA) causes a severe ischemia-reperfusion injury. Endovascular Perfusion Augmentation for Critical Care (EPACC) has emerged as a hemodynamic/mechanical adjunct to vasopressors and crystalloid for the treatment of post-REBOA ischemia-reperfusion injury. The objective of the study is to examine the impact of EPACC as a tool for a wean from complete REBOA compared to standard resuscitation techniques. METHODS: Nine swine underwent anesthesia and then a controlled 30% blood volume hemorrhage with 30 min of supraceliac total aortic occlusion to create an ischemia-reperfusion injury. Animals were randomized to standardized critical care (SCC) or 90 min of EPACC followed by SCC. The critical care phase lasted 270 min after injury. Hemodynamic markers and laboratory values of ischemia were recorded. RESULTS: During the first 90 min the intervention phase SCC spent 60% (54%-73%) and EPACC spent 91% (88%-92%) of the time avoiding proximal hypotension (<60 mm Hg), P = 0.03. There was also a statistically significant decrease in cumulative norepinephrine dose at the end of the experiment between SCC (80.89 mcg/kg) versus EPACC (22.03 mcg/kg), P = 0.03. Renal artery flow during EPACC was similar compared to SCC during EPACC, P = 0.19. But during the last hour of the experiment (after removal of aortic balloon) the renal artery flow in EPACC (2.9 mL/kg/min) was statistically significantly increased compared to SCC (1.57 mL/min/kg), P = 0.03. There was a statistically significant decrease in terminal creatinine in the EPACC (1.7 mg/dL) compared to SCC (2.1 mg/dL), P = 0.03. CONCLUSIONS: The 90 min of EPACC as a weaning adjunct in the setting of a severe ischemia-reperfusion injury after complete supraceliac REBOA provides improved renal flow with improvement in terminal creatinine compared to SCC with stabilized proximal hemodynamics and decreased vasopressor dose.

Microbiome, Transcriptome, and Metabolomic Analyses Revealed the Mechanism of Immune Response to Diarrhea in Rabbits Fed Antibiotic-Free Diets.

In this study, diarrhea was induced in rabbits by feeding them antibiotic-free feed. The gut provides important defense against the barriers of the body, of which the duodenum is an important part to help digest food and absorb nutrients. However, the mechanisms underlying the roles of the gut microbiome and fecal metabolome in rabbit diarrhea caused by feeding an antibiotic-free diet have not been characterized. Recently, only a single study has been conducted to further characterize the antibiotic-free feed additives that caused diarrhea in weaned rabbits. The multi-omics techniques, including 16S rRNA sequencing, transcriptome sequencing, and LC-MS analysis, were combined to analyze the gut microbial compositions and functions. They also determined the fecal metabolomic profiles of diarrhea in rabbits caused by feeding antibiotic-free feed. The results showed that the liver, duodenal, and sacculus rotundus tissues of diarrhea rabbits were diseased, the composition of intestinal microbes was significantly changed, the diversity of intestinal microbes was decreased, and the distribution of intestinal microbe groups was changed. Functional analysis based on the cluster of GO and KEGG annotations suggested that two functional GO categories belonged to the metabolism cluster, and five KEGG pathways related to the metabolic pathways were significantly enriched in diarrhea rabbits. Moreover, real-time quantitative PCR (RT-qPCR) was used to verify the significant expression of genes related to diarrhea. Metabolomics profiling identified 432 significantly differently abundant metabolites in diarrhea rabbits, including amino acids and their derivatives. These amino acids were enriched in the tryptophan metabolic pathway. In addition, the functional correlation analysis showed that some altered gut microbiota families, such as Parasutterella, significantly correlated with alterations in fecal metabolites. Collectively, the results suggested that altered gut microbiota was associated with diarrhea caused by antibiotic-free feed additives in weaned rabbit pathogenesis.

Left Atrial Decompression in Pediatric Patients Supported With Extracorporeal Membrane Oxygenation for Failure to Wean From Cardiopulmonary Bypass: A Propensity-Weighted Analysis.

Background Left atrial (LA) decompression on extracorporeal membrane oxygenation (ECMO) can reduce left ventricular distension, allowing myocardial rest and recovery, and protect from lung injury secondary to cardiogenic pulmonary edema. However, clinical benefits remain unknown. We sought to evaluate the association between LA decompression and in-hospital adverse outcome (mortality, transplant on ECMO, or conversion to ventricular assist device) in patients who failed to wean from cardiopulmonary bypass using a propensity score to adjust for baseline differences. Methods and Results Children (aged <18 years) with biventricular physiology supported with ECMO for failure to wean from cardiopulmonary bypass after cardiac surgery from 2000 through 2016, reported to the ELSO (Extracorporeal Life Support Organization) Registry, were included. Inverse probability of treatment weighted logistic regression was used to test the association between LA decompression and in-hospital adverse outcomes. Of the 2915 patients supported with venoarterial ECMO for failure to wean from cardiopulmonary bypass, 1508 had biventricular physiology and 279 (18%) underwent LA decompression (LA+). Genetic and congenital abnormalities (P=0.001) and pulmonary hypertension (P=0.010) were less frequent and baseline arrhythmias (P=0.022) were more frequent in LA+ patients. LA+ patients had longer pre-ECMO mechanical ventilation and CBP time (P<0.001), and used aortic cross-clamp (P=0.001) more frequently. Covariates were well balanced between the propensity-weighted cohorts. In-hospital adverse outcomes occurred in 47% of LA+ patients and 51% of the others. Weighted multivariate logistic regression showed LA decompression to be protective for in-hospital adverse outcomes (adjusted odds ratio, 0.775 [95% CI, 0.644-0.932]). Conclusions LA decompression independently decreased the risk of in-hospital adverse outcome in pediatric venoarterial ECMO patients who failed to wean from cardiopulmonary bypass, suggesting that these patients may benefit from LA decompression.

Cause of In-Hospital Death After Weaning from Venoarterial-Extracorporeal Membrane Oxygenation.

PURPOSE: A survival gap between weaning from venoarterial-extracorporeal membrane oxygenation (VA-ECMO) and the hospital discharge has been consistently reported. The aim of this study is to investigate the clinical features of patients who underwent successful VA-ECMO decannulation at our institution and to identify the major contributors responsible for adverse outcomes. METHODS: We retrospectively reviewed all patients supported with VA-ECMO in our institution between January 2013 and June 2020. Only patients that survived VA-ECMO and underwent successful decannulation were included and dichotomized based on survival to hospital discharge: non-survivors versus survivors. The primary study outcome was the cause of death after successful VA-ECMO decannulation. RESULTS: Of the 262 adult patients who underwent VA-ECMO decannulation, 72 (27.5%) patients did not survive to hospital discharge. Non-survivors were older (62 vs. 54 years, p < 0.001) and suffering from many pre-existing comorbidities. Pneumonia and sepsis were the most frequent infectious complication and almost twice as likely in non-survivors. Major causes of death were: cardiovascular (31.9%), infections (25.0%) and neurological (20.8%). The survival curve demonstrated that 51.4% of our patients died within 8 days after decannulation. Multivariate analysis identified older age, central venous cannulation, pulmonary bleeding and infection, dialysis after VA-ECMO, sepsis, and ischemic stroke (OR = 7.86, 95% CI: 2.76-2.43, p < 0.001) as factors significantly predisposing to patients' death. CONCLUSION: In our study, one-third of patients decannulated off VA-ECMO did not survive to hospital discharge due to end-stage heart failure, infections or neurological injury. The first 8 post-decannulation days were recognized as a critical period where thorough strategies to prevent acquired infections and cautious support of end-organ function should be warranted. Future large-scale trials are needed to confirm our results.

Palliative Care and Population Management Compassionate Extubation of the ICU Patient and the Use of the Respiratory Distress Observation Scale.

End of life (EOL) can be an extremely stressful experience for patients, their families, and health care staff. Critical care nurses are trained to help patients survive acute episodes and assist in restoring their health. Unfortunately, not all ICU patients are able to fully recover or obtain previous quality of life before hospitalization. In these situations, the focus moves to transitioning patients from restorative care to palliative care. This article will explain EOL care guidelines for critical care nurses using the Respiratory Distress Observation Scale to ensure patient comfort during compassionate extubation.

Whole-herd risk factors associated with wean-to-finish mortality under the conditions of a Midwestern USA swine production system.

Swine wean-to-finish (W2F) mortality is a multifactorial, dynamic process and a key performance indicator of commercial swine production. Although swine producers typically capture the relevant data, analysis of W2F mortality risk factors is often hindered by the fact that, even if data is available, they are typically in different formats, non-uniform, and dispersed among multiple unconnected databases. In this study, an automated framework was created to link multiple data streams to specific cohorts of market animals, including sow farm productivity parameters, sow farm and growing pig health factors, facilities, management factors, and closeout data from a Midwestern USA production system. The final dataset (master-table) contained breeding-to-market data for 1,316 cohorts of pigs marketed between July 2018 and June 2019. Following integration into a master-table, continuous explanatory variables were categorized into quartiles averages, and the W2F mortality was log-transformed, reporting geometric mean mortality of 8.69 % for the study population. Further, univariate analyses were performed to identify individual variables associated with W2F mortality (p < 0.10) for further inclusion in a multivariable model, where model selection was applied. The final multivariable model consisted of 13 risk factors and accounted for 68.2 % (R2) of the variability of the W2F mortality, demonstrating that sow farm health and performance are closely linked to downstream W2F mortality. Higher sow farm productivity was associated with lower subsequent W2F mortality and, conversely, lower sow farm productivity with higher W2F mortality e.g., groups weaned in the highest quartiles for pre-weaning mortality and abortion rate had 13.5 %, and 12.5 %, respectively, which was statistically lower than the lowest quartiles for the same variables (10.5 %, and 10.6 %). Moreover, better sow farm health status was also associated with lower subsequent W2F mortality. A significant difference was detected in W2F mortality between epidemic versus negative groups for porcine reproductive and respiratory syndrome virus (15.4 % vs 8.7 %), and Mycoplasma hyopneumoniae epidemic versus negative groups (13.7 % vs 9.9 %). Overall, this study demonstrated the application of a whole-herd analysis by aggregating information of the pre-weaning phase with the post-weaning phase (breeding-to-market) to identify and measure the major risk factors of W2F mortality.

Turnover events of animal caretakers and its impact on productivity in swine farms.

Attracting and retaining quality animal caretaking personnel is one of most pressing issues the US swine industry currently faces. On-farm employee turnover can be costly and have an impact on productivity. The primary objectives of this study were to describe the amount of animal caretaker turnover events that occurred in a single year in eleven swine farms, and to investigate associations between employee turnover events and two subsequent production parameters of interest: number of pigs weaned per sow (PWS) and pre-weaning mortality (PWM). A retrospective cohort study was conducted with eleven commercial farrow-to-wean swine farms belonging to two vertically integrated multi-site production systems within two swine production companies. Human resources and production data for the year of 2019 were obtained monthly from each farm. The primary predictor of interest was the occurrence of an employee turnover event, defined as 'voluntary' (employee decided to leave or quit) or 'involuntary' (employee was terminated by company decision). The primary outcomes of interest included the monthly average PWS and PWM. These associations were assessed with 1-, 2-, 3-, and 6-months between the turnover events and the outcome. Linear mixed effects models were fit in STATA 15, with system and farm included as random effects. To account for temporal and seasonal trends of production, season and the monthly production were included in the models. There were a total of 152 turnover events, with 4 and 148 turnover events in systems 1 and 2, respectively. The average turnover, calculated as a percent of total turnover among full time employee positions, was 92 % (SD = 62 %; Range = 8-217 %). Improved production efficiency in both monthly PWS (p = 0.01) and PWM (p = 0.02) was observed with the occurrence of an involuntary turnover event two months prior, after controlling for season, previous month production, farm, and system. For the PWS outcome, there was a significant interaction between an involuntary turnover event two months prior and monthly county-level unemployment rate (p = 0.02), indicative of the improved performance being most profound at the lowest levels of unemployment rate and diminishing at the highest levels. Turnover of animal caretaking personnel in farrow-to-wean farms was confirmed to be highly variable and high for the majority of farms in this study. Furthermore, animal caretaker turnover was associated with subsequent trends of production efficiency, warranting closer consideration of prioritizing managerial efforts in worker recruitment, training and retention.

Intracranial Hypertension Recurrence Risk After Wean of Intracranial Pressure-Lowering Medication.

BACKGROUND: The proportion of children with recurrent signs and symptoms of intracranial hypertension after medication wean has been reported to be between 18% and 50%. Few studies have reported intracranial hypertension recurrence risk in children while adjusting for each individual's observed follow-up time after medication wean. In addition, the role of intracranial hypertension etiology on the risk of disease recurrence has not been widely studied. METHODS: The medical charts of patients with intracranial hypertension treated with intracranial pressure-lowering medication were analyzed retrospectively for disease recurrence. Baseline characteristics from diagnosis were recorded in addition to information regarding duration of therapy, medication wean, and recurrence. Survival analyses as well as Poisson regression models with time under observation as an offset were performed. RESULTS: One hundred and thirty-three patients were included in the study. The cumulative risk of intracranial hypertension recurrence increased rapidly within the first six months after medication wean and was 1.5% at one month, 9.5% at three months, and 20% at six months. This risk leveled off near 12 to 18 months. CONCLUSIONS: While the cumulative risk of intracranial hypertension recurrence increases most dramatically within the first six months after medication wean, it does not appear to taper until 12 to 18 months. Given the possibility of delayed or asymptomatic recurrences, long-term follow-up is ideal, although patients can likely be seen less frequently after the first 12 to 18 months after medication wean.