Insights and Opinions of Critical Care Healthcare Professionals in the Management of Carbapenem-resistant Enterobacteriaceae Cases and Antibiotic-Resistant Infections in the Intensive Care Unit Setting: A Survey-Based Approach.

INTRODUCTION: A survey-based approach to managing antibiotic-resistant infections in the intensive care unit (ICU) setting, with a focus on carbapenem-resistant Enterobacteriaceae (CRE) cases, was conducted. Among CRE, New Delhi metallo-ß-lactamase 1 (NDM-1) is a carbapenemase that is resistant to ß-lactam antibiotics and has a broader spectrum of antimicrobial resistance than other carbapenemase types. The article explains that healthcare-associated infections (HAIs) are a significant problem, particularly in low- and middle-income countries, and that carbapenem in combination with other antibiotics are the most potent class of antimicrobial agents effective in treating life-threatening bacterial infections, including those caused by resistant strains. AIM: The survey aimed to gather critical care healthcare professionals (HCPs') opinions on their current practices in managing infections acquired in the hospital and ICU settings, with a focus on CRE cases, specifically NDM-1 and other antibiotic-resistant infections. METHODS: Responses from critical care healthcare professionals, including online surveys and in-person interviews, to gain insights into the management of infections caused by multidrug-resistant bacteria. The findings related to the insights on the prevalence of bacterial flora, clinical experiences on efficacy and safety of meropenem sulbactam ethylenediaminetetraacetic acid (EDTA) (MSE) in CRE cases, and various combination therapies of antibiotics used to treat antibiotic-resistant infections in ICU setting were evaluated. RESULTS: Klebsiella pneumoniae bacteria were the most common bacteria in cultures, followed by Escherichia coli, Pseudomonas aeruginosa, and Acinetobacter baumannii. NDM-1 was the type of carbapenemase found in around 50% of CRE patients. MSE is among the most preferred antibiotics besides colistin, polymyxin B, and ceftazidime avibactum for CRE cases and specifically for NDM-1 cases due to its high rate of efficacy and safety. CONCLUSION: The article concludes with a discussion on the antibiotics used in response to CRE cases, reporting that critical care HCP considers MSE with high efficacy and safe antibiotic combination and was used as both monotherapy and in combination with other antibiotics. The survey highlights the need for exploring and better understanding the role of MSE in the management of CRE infections, especially in NDM-1.

Dynamics of Drop Formation in the Presence of Interfacial Mass Transfer.

The dynamics of drop formation have been investigated in the presence of interfacial mass transfer through controlled flow visualization experiments. The mixtures of n-hexane (solvent) and acetone (solute) were used as a dispersed phase, having different initial compositions varying over a broad range. Drops were formed at the submerged position in the continuous phase (water) at the same operating flow conditions. The unsteady force balance model is developed to analyze the implications of the simultaneously occurring interfacial transfer of the solute on the formation dynamics in real time, and predictions are validated with experimental results. Based on initial compositions, the analysis of the transient drop shape shows a sharp transition in the drop formation regime. At lower initial solute concentrations, i.e., ϕ0 < 0.2, axisymmetric drop formation occurs and the interfacial solute transfer has negligible effects on the formation dynamics. Over an intermediate range of solute concentrations, i.e., 0.2 < ϕ0 < 0.5, Marangoni instability is triggered along the evolving interface, and therefore, the interface deformations and contractions occur during the drop formation. At ϕ0 = 0.5, the drop takes highly nonaxisymmetric shapes and remains away from equilibrium until its detachment from an orifice. For ϕ0 > 0.5, the spontaneous ejection of plumes of the solute results in the rapid generation of multiple droplets of smaller size. This work shows that higher solute concentration gradients not only lead to faster solute transport but also induce strong interfacial instability simultaneously. Thus, the coupled effects of transient change in composition and fluid properties govern the drop size and its formation time in such systems under non-equilibrium.

Insights into the Synthesis and Kinetics of Silver-on-Silica Core-Shell Particles.

In this study, a heterogeneous nucleation and growth model has been developed to explore the formation mechanism of silver-deposited silica core-shell particles based on the reaction kinetics. To validate the core-shell model, the time-dependent experimental data were quantitatively examined and in situ reduction, nucleation, and growth rates were estimated by optimizing the concentration profiles of reactants and deposited silver particles. Using this model, we also attempted to predict the change in the surface area and diameter of core-shell particles. The concentration of the reducing agent, metal precursor, and reaction temperature were found to have a strong influence on the rate constants and morphology of core-shell particles. Higher rates of nucleation and growth often produced thick, asymmetric patches that covered the entire surface, whereas lower rates produced sparsely deposited silver particles with a spherical shape. The result revealed that by simply tuning the process parameters and controlling the relative rates, the morphology of deposited silver particles and the surface coverage can be controlled while retaining the spherical shape of the core. The present study aims to offer comprehensive data pertaining to the nucleation, growth, and coalescence processes of core-shell nanostructures which will aid in the development and understanding of the principles that govern the formation of nanoparticle-coated materials.

Leveraging Active Learning for Failure Mode Acquisition.

Identifying failure modes is an important task to improve the design and reliability of a product and can also serve as a key input in sensor selection for predictive maintenance. Failure mode acquisition typically relies on experts or simulations which require significant computing resources. With the recent advances in Natural Language Processing (NLP), efforts have been made to automate this process. However, it is not only time consuming, but extremely challenging to obtain maintenance records that list failure modes. Unsupervised learning methods such as topic modeling, clustering, and community detection are promising approaches for automatic processing of maintenance records to identify failure modes. However, the nascent state of NLP tools combined with incompleteness and inaccuracies of typical maintenance records pose significant technical challenges. As a step towards addressing these challenges, this paper proposes a framework in which online active learning is used to identify failure modes from maintenance records. Active learning provides a semi-supervised machine learning approach, allowing for a human in the training stage of the model. The hypothesis of this paper is that the use of a human to annotate part of the data and train a machine learning model to annotate the rest is more efficient than training unsupervised learning models. Results demonstrate that the model is trained with annotating less than ten percent of the total available data. The framework is able to achieve ninety percent (90%) accuracy in the identification of failure modes in test cases with an F-1 score of 0.89. This paper also demonstrates the effectiveness of the proposed framework with both qualitative and quantitative measures.

Targeting NLRP3 signaling by a novel-designed sulfonylurea compound for inhibition of microglial inflammation.

The nucleotide-binding oligomerization domain (NOD)-like receptor protein 3 (NLRP3) inflammasome plays an important role in microglia-mediated inflammation. Dysregulation of NLRP3 signaling results in microglial activation and triggers inflammatory responses contributing to the development of neurological disorders including ischemic stroke, schizophrenia, Alzheimer's disease (AD), Parkinson's disease (PD), and amyotrophic lateral sclerosis (ALS). Inhibition of the NLRP3-linked inflammatory pathways reduces microglia-induced inflammation and is considered as a promising therapeutic approach for neuro-inflammatory diseases. In the present study, we report the development of AMS-17, a rationally-designed tertiary sulfonylurea compound for inhibition of inflammation in microglia. AMS-17 inhibited expression of the NLRP3, and its downstream components and cytokines such as caspase-1, tumor necrosis factor-α (TNF-α), IL-1ß and inducible nitric oxide synthase (iNOS). It also suppressed lipopolysaccharide (LPS)-induced N9 microglial cell phagocytosis in vitro and activation of the microglia in mouse brain in vivo. Together, these results provide promising evidences for the inhibitory effects of AMS-17 in inflammation. This proof-of-concept study provides a new chemical scaffold, designed with the aid of pharmacophore modeling, with NLRP3 inhibitory activity which can be further developed for the treatment of inflammation-associated neurological disorders.

Multi-Step Synthesis of Miltefosine: Integration of Flow Chemistry with Continuous Mechanochemistry.

Herein we report for the first time, an advanced continuous flow synthesis of the blockbuster Leishmaniasis drug miltefosine from simple starting materials by a sequence involving four steps of chemical transformation including a continuous mechanochemical step. First three reaction steps were performed in simple tubular reactors in a telescopic mode, while in the last step the product precipitated from the 3rd step was used for a continuous mechanochemical synthesis of miltefosine. When compared to a typical batch protocol that takes 15 h, miltefosine was obtained in 58 % overall yield in flow synthesis mode at the laboratory scale in a total residence time 34 min at synthesis rate of 10 g/hr, which is sufficient to treat 4800 patients per day.

Sensor Selection Framework for Designing Fault Diagnostics System.

In a world of rapidly changing technologies, reliance on complex engineered systems has become substantial. Interactions associated with such systems as well as associated manufacturing processes also continue to evolve and grow in complexity. Consider how the complexity of manufacturing processes makes engineered systems vulnerable to cascading and escalating failures; truly a highly complex and evolving system of systems. Maintaining quality and reliability requires considerations during product development, manufacturing processes, and more. Monitoring the health of the complex system while in operation/use is imperative. These considerations have compelled designers to explore fault-mechanism models and to develop corresponding countermeasures. Increasingly, there has been a reliance on embedded sensors to aid in prognosticating failures, to reduce downtime, during manufacture and system operation. However, the accuracy of estimating the remaining useful life of the system is highly dependent on the quality of the data obtained. This can be enhanced by increasing the number of sensors used, according to information theory. However, adding sensors increases total costs with the cost of the sensors and the costs associated with information-gathering procedures. Determining the optimal number of sensors, associated operating and data acquisition costs, and sensor-configuration are nontrivial. It is also imperative to avoid redundant information due to the presence of additional sensors and the efficient display of information to the decision-maker. Therefore, it is necessary to select a subset of sensors that not only reduce the cost but are also informative. While progress has been made in the sensor selection process, it is limited to either the type of the sensor, number of sensors or both. Such approaches do not address specifications of the required sensors which are integral to the sensor selection process. This paper addresses these shortcomings through a new method, OFCCaTS, to avoid the increased cost associated with health monitoring and to improve its accuracy. The proposed method utilizes a scalable multi-objective framework for sensor selection to maximize fault detection rate while minimizing the total cost of sensors. A wind turbine gearbox is considered to demonstrate the efficacy of the proposed framework.

In Situ Tremor in Vitreoretinal Surgery.

OBJECTIVE: Surgeon tremor was measured during vitreoretinal microscopic surgeries under different hand support conditions. BACKGROUND: While the ophthalmic surgeon's forearm is supported using a standard symmetric wrist rest when operating on the patient's same side as the dominant hand (SSD), the surgeon's hand is placed directly on the patient's forehead when operating on the contralateral side of the dominant hand (CSD). It was hypothesized that more tremor is associated with CSD surgeries than SSD surgeries and that, using an experimental asymmetric wrist rest where the contralateral wrist bar gradually rises and curves toward the patient's operative eye, there is no difference in tremor associated with CSD and SSD surgeries. METHODS: Seventy-six microscope videos, recorded from three surgeons performing macular membrane peeling operations, were analyzed using marker-less motion tracking, and movement data (instrument path length and acceleration) were recorded. Tremor acceleration frequency and magnitude were measured using spectral analysis. Following 47 surgeries using a conventional symmetric wrist support, surgeons incorporated the experimental asymmetric wrist rest into their surgical routine. RESULTS: There was 0.11 mm/s2 (22%) greater (p = .05) average tremor acceleration magnitude for CSD surgeries (0.62 mm/s2, SD = 0.08) than SSD surgeries (0.51 mm/s2, SD = 0.09) for the symmetric wrist rest, while no significant (p > .05) differences were observed (0.57 mm, SD = 0.13 for SSD and 0.58 mm, SD = 0.11 for CSD surgeries) for the experimental asymmetric wrist rest. CONCLUSION: The asymmetric wrist support reduced the difference in tremor acceleration between CSD and SSD surgeries.

Design, synthesis, and screening of sulfonylurea-derived NLRP3 inflammasome inhibitors.

Inflammasomes are multiprotein assemblies that produce robust inflammatory responses upon stimulation with pathogen- and/or danger-associated molecular patterns. Uncontrolled inflammasome activation has been linked to the pathophysiology of a wide array of disorders including life-threatening pathogenic infections, e.g., Francisella tularensis. There has been a great deal of interest in the development of small molecule inflammasome inhibitors. Using computational modeling based on chalcone derivatives, we have developed novel tertiary sulfonylurea compounds as inhibitors of the NLRP3 inflammasome. The polar enone functional alert of chalcone was replaced with a sulfonylurea scaffold while maintaining the relative positions of the two aromatic rings. These compounds were evaluated for their ability to inhibit NLRP3 and AIM2 inflammasome activation triggered by Francisella tularensis infection.

In Vivo Pharmacokinetic/Pharmacodynamic Targets of Levonadifloxacin against Staphylococcus aureus in a Neutropenic Murine Lung Infection Model.

Levonadifloxacin is a novel benzoquinolizine subclass of fluoroquinolone, active against quinolone-resistant Staphylococcus aureus A phase 3 trial for levonadifloxacin and its oral prodrug was recently completed. The present study identified area under the concentration-time curve for the free, unbound fraction of a drug divided by the MIC (fAUC/MIC) as an efficacy determinant for levonadifloxacin in a neutropenic murine lung infection model. Mean plasma fAUC/MIC requirement for static and 1 log10 kill effects against 9 S. aureus were 8.1 ± 6.0 and 25.8 ± 12.3, respectively. These targets were employed in the selection of phase 3 doses.

Protein Phosphatase 1-Targeting Small-Molecule C31 Inhibits Ebola Virus Replication.

Background: Ebola virus (EBOV) infection causes severe hemorrhagic fever. EBOV transcription is controlled by host protein phosphatase 1 (PP1), which dephosphorylates VP30 protein. We previously developed 1E7-03, a compound targeting a noncatalytic site of PP1 that induced VP30 phosphorylation and inhibited EBOV transcription. Here, we attempted to further improve 1E7-03, which was not stable in murine serum. Results: High-throughput screening with EBOV-green fluorescent protein was conducted on 72 1E7-03 analogs and identified 6 best inhibitory and the least toxic compounds. A parallel in silico screening of compounds from the ZINC database by docking to PP1 identified the best-binding compound C31, which was also present among the top 6 compounds found in the viral screen. C31 showed the best EBOV inhibitory activity among the top 6 compounds and also inhibited EBOV minigenome. C31 bound to the PP1 C-terminal groove in vitro and increased VP30 phosphorylation in cultured cells. C31 demonstrated improved stability in mouse plasma and cell permeability, compared with 1E7-03. It was also detected for 24 hours after injection in mice. Conclusion: C31 represents a novel PP1-targeting EBOV inhibitor with improved pharmacological properties that can be further evaluated for future antifiloviral therapy.

Design, synthesis, and biological evaluation of inhibitors of the NADPH oxidase, Nox4.

NADPH oxidases (Nox enzymes) are critical mediators of both physiologic and pathophysiologic processes. Nox enzymes catalyze NADPH-dependent generation of reactive oxygen species (ROS), including superoxide and hydrogen peroxide. Until recently, Nox4 was proposed to be involved exclusively in normal physiologic functions. Compelling evidence, however, suggests that Nox4 plays a critical role in fibrosis, as well as a host of pathologies and diseases. These considerations led to a search for novel, small molecule inhibitors of this important enzyme. Ultimately, a series of novel tertiary sulfonylureas (23-25) was designed using pharmacophore modeling, synthesized, and evaluated for inhibition of Nox4-dependent signaling.

Assessing the possibilities of designing a unified multistep continuous flow synthesis platform.

The multistep flow synthesis of complex molecules has gained momentum over the last few years. A wide range of reaction types and conditions have been integrated seamlessly on a single platform including in-line separation as well as monitoring. Beyond merely getting considered as 'flow version' of conventional 'one-pot synthesis', multistep flow synthesis has become the next generation tool for creating libraries of new molecules. Here we give a more 'engineering' look at the possibility of developing a 'unified multistep flow synthesis platform'. A detailed analysis of various scenarios is presented considering 4 different classes of drugs already reported in the literature. The possible complexities that an automated and controlled platform needs to handle are also discussed in detail. Three different design approaches are proposed: (i) one molecule at a time, (ii) many molecules at a time and (iii) cybernetic approach. Each approach would lead to the effortless integration of different synthesis stages and also at different synthesis scales. While one may expect such a platform to operate like a 'driverless car' or a 'robo chemist' or a 'transformer', in reality, such an envisaged system would be much more complex than these examples.

Insights in the Diffusion Controlled Interfacial Flow Synthesis of Au Nanostructures in a Microfluidic System.

Continuous segmented flow interfacial synthesis of Au nanostructures is demonstrated in a microchannel reactor. This study brings new insights into the growth of nanostructures at continuous interfaces. The size as well as the shape of the nanostructures showed significant dependence on the reactant concentrations, reaction time, temperature, and surface tension, which actually controlled the interfacial mass transfer. The microchannel reactor assisted in achieving a high interfacial area, as well as uniformity in mass transfer effects. Hexagonal nanostructures were seen to be formed in synthesis times as short as 10 min. The wettability of the channel showed significant effect on the particle size as well as the actual shape. The hydrophobic channel yielded hexagonal structures of relatively smaller size than the hydrophilic microchannel, which yielded sharp hexagonal bipyramidal particles (diagonal distance of 30 nm). The evolution of particle size and shape for the case of hydrophilic microchannel is also shown as a function of the residence time. The interfacial synthesis approach based on a stable segmented flow promoted an excellent control on the reaction extent, reduction in axial dispersion as well as the particle size distribution.

Automating multistep flow synthesis: approach and challenges in integrating chemistry, machines and logic.

The implementation of automation in the multistep flow synthesis is essential for transforming laboratory-scale chemistry into a reliable industrial process. In this review, we briefly introduce the role of automation based on its application in synthesis viz. auto sampling and inline monitoring, optimization and process control. Subsequently, we have critically reviewed a few multistep flow synthesis and suggested a possible control strategy to be implemented so that it helps to reliably transfer the laboratory-scale synthesis strategy to a pilot scale at its optimum conditions. Due to the vast literature in multistep synthesis, we have classified the literature and have identified the case studies based on few criteria viz. type of reaction, heating methods, processes involving in-line separation units, telescopic synthesis, processes involving in-line quenching and process with the smallest time scale of operation. This classification will cover the broader range in the multistep synthesis literature.

Metamorphic enzyme assembly in polyketide diversification.

Natural product chemical diversity is fuelled by the emergence and ongoing evolution of biosynthetic pathways in secondary metabolism. However, co-evolution of enzymes for metabolic diversification is not well understood, especially at the biochemical level. Here, two parallel assemblies with an extraordinarily high sequence identity from Lyngbya majuscula form a beta-branched cyclopropane in the curacin A pathway (Cur), and a vinyl chloride group in the jamaicamide pathway (Jam). The components include a halogenase, a 3-hydroxy-3-methylglutaryl enzyme cassette for polyketide beta-branching, and an enoyl reductase domain. The halogenase from CurA, and the dehydratases (ECH(1)s), decarboxylases (ECH(2)s) and enoyl reductase domains from both Cur and Jam, were assessed biochemically to determine the mechanisms of cyclopropane and vinyl chloride formation. Unexpectedly, the polyketide beta-branching pathway was modified by introduction of a gamma-chlorination step on (S)-3-hydroxy-3-methylglutaryl mediated by Cur halogenase, a non-haem Fe(ii), alpha-ketoglutarate-dependent enzyme. In a divergent scheme, Cur ECH(2) was found to catalyse formation of the alpha,beta enoyl thioester, whereas Jam ECH(2) formed a vinyl chloride moiety by selectively generating the corresponding beta,gamma enoyl thioester of the 3-methyl-4-chloroglutaconyl decarboxylation product. Finally, the enoyl reductase domain of CurF specifically catalysed an unprecedented cyclopropanation on the chlorinated product of Cur ECH(2) instead of the canonical alpha,beta C = C saturation reaction. Thus, the combination of chlorination and polyketide beta-branching, coupled with mechanistic diversification of ECH(2) and enoyl reductase, leads to the formation of cyclopropane and vinyl chloride moieties. These results reveal a parallel interplay of evolutionary events in multienzyme systems leading to functional group diversity in secondary metabolites.

Response to aflibercept as secondary therapy in patients with persistent retinal edema due to central retinal vein occlusion initially treated with bevacizumab or ranibizumab.

BACKGROUND: Recent advances have given practitioners options for the treatment of macular edema secondary to central retinal vein occlusion. These options include steroid injections and implants as well as anti-vascular endothelial growth factor medications. However, there is little in the medical literature to guide secondary therapy when an initial treatment strategy is insufficient. The authors present encouraging results from the treatment of six consecutive cases of central retinal vein occlusion treated with aflibercept as a secondary therapy for macular edema refractory to repeated intravitreal bevacizumab or ranibizumab injections. METHODS: A retrospective review of six consecutive cases of central retinal vein occlusion with persistent macular edema despite regular anti-vascular endothelial growth factor injections that were transitioned to aflibercept was conducted. Optical coherence tomography and visual acuity data were examined. RESULTS: All six eyes from the six patients included showed either complete or near complete resolution of macular edema with one or two injections of aflibercept. The improvement in edema was accompanied by lasting modest visual gains in three of the six patients and in subjective visual improvement in four of the six patients. CONCLUSION: The six eyes in this series all responded favorably to aflibercept as a secondary therapy. Although the sample size is too small to draw definitive conclusions, the results are encouraging.

Continuous flow nitration in miniaturized devices.

This review highlights the state of the art in the field of continuous flow nitration with miniaturized devices. Although nitration has been one of the oldest and most important unit reactions, the advent of miniaturized devices has paved the way for new opportunities to reconsider the conventional approach for exothermic and selectivity sensitive nitration reactions. Four different approaches to flow nitration with microreactors are presented herein and discussed in view of their advantages, limitations and applicability of the information towards scale-up. Selected recent patents that disclose scale-up methodologies for continuous flow nitration are also briefly reviewed.

Synthesis and biological evaluation of 2-(5-substituted-1-((diethylamino)methyl)-2-oxoindolin-3-ylidene)-N-substituted-hydrazinecarbothioamides.

ABSTRACT: Various 5-substituted-2-(1-((diethylamino)methyl)-2-oxoindolin-3-ylidene)hydrazinecarbothioamide (4a, b) and 5-substituted-2-(1-((diethylamino)methyl)-2-oxoindolin-3-ylidene)-N-(phenyl-4-substituted)hydrazinecarbothioamide (5a-h) derivatives were synthesized. The compounds were screened for cytotoxicity against human HeLa and CEM T-lymphocytes as well as murine L1210 cells. The compounds were also screened for ß-lactamase inhibitory activity, antiviral, antibacterial, and antifungal activity against various strains of microorganisms. Several of these compounds were endowed with low micromolar 50 %-cytostatic concentration (IC50) values, and some were virtually equally potent as melphalan. The most potent inhibitors against the murine leukemia cells (L1210) were also the most inhibitory against human T-lymphocyte (CEM) tumor cells. Derivative 2-(1-((diethylamino)methyl)-2-oxoindolin-3-ylidene)-N-(4-methoxyphenyl)hydrazinecarbothioamide 5c emerged as the most potent cytostatic compound among the tested compounds. Derivatives 4b, 5a, 5b, and 5d showed antiviral activity against HEL cell cultures (IC50 11-20 µM). Moderate antimicrobial activity was observed for all derivatives. The encouraging cytostatic and antiviral activity data provide an adequate rationale for further modification of these molecular scaffolds. GRAPHICAL ABSTRACT: Derivative 5c (1.9-4.4 µM) emerged as the most potent cytostatic compound among the tested compounds. Derivatives 4b, 5a, 5b, and 5d showed antiviral activity against HEL cell cultures (IC50 11-20 µM).

Methyl 2-bromo-3-(4-chloro-benzene-sulfonamido)-benzoate.

In the crystal structure of the title compound, C(14)H(11)BrClNO(4)S, the mol-ecules form inversion dimers with R(2) (2)(8) motifs through pairs of N-H⋯O hydrogen bonds. The benzene rings are not coplanar and subtend a dihedral angle of 66.27 (8)°. The carbomethoxy group makes a dihedral angle of 75.1 (1)° with the ring to which it is attached.