Antibiotic De-Escalation Practices in the Intensive Care Unit: A Multicenter Observational Study.

BACKGROUND: There is little known about antibiotic de-escalation (ADE) practices in the intensive care unit (ICU). OBJECTIVE: The objective was to determine the proportion of patients who received ADE within 24 hours of actionable cultures and identify predictors of timely ADE. METHODS: Multicenter cohort study in ICUs of 15 hospitals in Australia and New Zealand. Adult patients were included if they were started on broad-spectrum antibiotics within 24 hours of ICU admission. The ADE was defined as switching from a broad-spectrum agent to a narrower-spectrum agent or antibiotic cessation. The primary outcome was ADE within 24 hours of an actionable culture, where ADE was possible. RESULTS: The 446 patients included in the study had a mean age of 63 ± 16 years, 60% were male, 32% were mechanically ventilated, and 19% were immunocompromised. Of these, 161 (36.1%) were not eligible for ADE and 37 (8.3%) for whom ADE within 24 hours of actionable culture could not be determined. In the remaining 248 patients, ADE occurred ≤24 hours in 60.5% (n = 150/248) after actionable cultures. In the multivariable logistic regression analysis, ADE was less likely to occur within 24 hours for patients with negative cultures (odds ratio [OR] = 0.48, 95% confidence interval [CI] = 0.25-0.92, P = 0.03). CONCLUSION AND RELEVANCE: Timely ADE may not occur in 40% of patients in the ICU and is less likely to occur in patients with negative cultures. Timely ADE can be improved, and patients with negative cultures should be targeted as part of antimicrobial stewardship efforts.

Left-Sided Intra-thoracic Ectopic Kidney With Symptomatic Bochdalek Hernia: A Case Report.

A congenital defect in the diaphragm, known as a Bochdalek hernia (BH), is a condition that allows herniation of the abdominal viscera into the thorax. BH is the most common type of congenital diaphragmatic hernia (CDH) and is typically detected on the left side. An ectopic kidney is a rare condition. An intra-thoracic ectopic kidney is an extremely uncommon condition. In adult patients, the presence of BH with an intra-thoracic kidney is extremely uncommon and is often a finding discovered unintentionally. A 51-year-old male patient presented to the outpatient unit of the pulmonology department. He stated that he had been suffering symptoms such as coughing, wheezing, and breathing difficulties for one year. A chest X-ray showed a well-defined radio-opaque lesion in the lower left zone. A computed tomography (CT) scan of the chest demonstrated a defect in the posterolateral region of the left hemidiaphragm, as well as herniation of the left kidney and retroperitoneal fat in the left hemithorax. The intra-thoracic ectopic kidney was found to be normal in size and showed normal attenuation and enhancement, with the contrast being promptly excreted into the pelvicalyceal system during CT urography. Due to the hernia's small size and lack of abnormalities on CT urography, the patient was recommended a conservative treatment. A follow-up examination was performed on the patient annually. Throughout the follow-up period, there was not a single episode of kidney-related issues. To avoid unwanted image-guided biopsies and surgical procedures, it is imperative to look for intra-thoracic kidneys in patients presenting with a thoracic mass or an elevated hemi-diaphragm.

Potential Applications and Additive Manufacturing Technology-Based Considerations of Mesoporous Silica: A Review.

Nanoporous materials are categorized as microporous (pore sizes 0.2-2 nm), mesoporous (pore sizes 2-50 nm), and macroporous (pore sizes 50-1000 nm). Mesoporous silica (MS) has gained a significant interest due to its notable characteristics, including organized pore networks, specific surface areas, and the ability to be integrated in a variety of morphologies. Recently, MS has been widely accepted by range of manufacturer and as drug carrier. Moreover, silica nanoparticles containing mesopores, also known as mesoporous silica nanoparticles (MSNs), have attracted widespread attention in additive manufacturing (AM). AM commonly known as three-dimensional printing is the formalized rapid prototyping (RP) technology. AM techniques, in comparison to conventional methods, aid in reducing the necessity for tooling and allow versatility in product and design customization. There are generally several types of AM processes reported including VAT polymerization (VP), powder bed fusion (PBF), sheet lamination (SL), material extrusion (ME), binder jetting (BJ), direct energy deposition (DED), and material jetting (MJ). Furthermore, AM techniques are utilized in fabrication of various classified fields such as architectural modeling, fuel cell manufacturing, lightweight machines, medical, and fabrication of drug delivery systems. The review concisely elaborates on applications of mesoporous silica as versatile material in fabrication of various AM-based pharmaceutical products with an elaboration on various AM techniques to reduce the knowledge gap.

Surgical and Functional Outcomes of the Results of Conventional Two-Screw Proximal Femoral Nail (PFN) Versus Helical-Blade Anti-rotation Proximal Femoral Nail (PFNA2).

Introduction An intertrochanteric (IT) femur fracture is an extra-capsular fracture between greater and lesser trochanters. Unstable IT fractures are those where there is poor contact between fracture fragments (especially medial and posterior cortices), comminution, and fracture pattern, such that the weight-bearing forces tend to displace the fracture further or a reverse oblique type. Proximal femoral nailing (PFN) is one of the modalities for proximal femoral fractures. A newer modality for proximal femoral fracture is PFNA2, i.e., PFN anti-rotation, which makes use of a helical blade for a better compaction of bone. Both nail designs (PFN and PFNA2) are available in short and long sizes (so a total of four variants). Only a few studies have compared the treatment of IT femur fracture concerning fracture geometry, design, and length using either of the two nail types. In our study, we assessed the surgical and functional outcomes of PFN and PFNA2. Materials and methods This prospective observational study was carried out on 30 patients who had sustained IT fractures of the femur. All cases of IT femur fractures more than 18 years of age, closed injuries, and the patients who consented to participate in this program were included in the study. All open injuries, the patients who refused to participate in this program, patients who have associated injuries, patients with a subtrochanteric femur fracture, and patients with less than six months of follow-up were excluded. The patients were randomized into two types of implant groups. All patients were operated with a standard protocol. The study was conducted for 18 months from February 2021 to August 2022. The results were analyzed (of all four variants) by comparing patient demographics, implant size, implant type, locking methods, union time, and other parameters. Results Most of the patients were operated on with a 10 mm nail diameter (17/30 patients), 380 mm length (long-nail group) (five/11 patients), and 250 mm length (short-nail group). With the use of PFNA2, the overall duration of hospital stay was less. The overall operative time (incision to wound closure) with the use of the short PFNA2 was lesser than that with the use of other designs due to the use of the zig for distal screws. The use of a distal dynamic locking screw in a majority of the patients can get better compression at the fracture site once the patient starts weight bearing and decrease the chances of the Z-effect, reverse Z-effect, screw back-out, and screw cut-out. The union time was nearly the same in the majority of the patients, with an early union seen with the use of PFNA2 nails. The overall modified Harris hip score (HHS) at the final follow-up was nearly the same with slightly better results with the use of PFNA2. Conclusions PFNA2 is the implant of choice in elderly patients with osteoporotic bone. It has less operative time, which is required in such patients with medical comorbidities; hence, it has marginal superiority over PFN. Short-nail design results in less operative time and less blood loss.

Biomaterials-based additive manufacturing for customized bioengineering in management of otolaryngology: a comprehensive review.

Three-dimensional (3D)/four-dimensional (4D) printing, also known as additive manufacturing or fast prototyping, is a manufacturing technique that uses a digital model to generate a 3D/4D solid product. The usage of biomaterials with 3D/4D printers in the pharma and healthcare industries is gaining significant popularity. 3D printing has mostly been employed in the domain of otolaryngology to build portable anatomical models, personalized patient-centric implants, biologic tissue scaffolds, surgical planning in individuals with challenging conditions, and surgical training. Although identical to 3D printing technology in this application, 4D printing technology comprises a fourth dimension of time. With the use of 4D printing, a printed structure may alter over time under various stimuli. Smart polymeric materials are also generally denoted as bioinks are frequently employed in tissue engineering applications of 3D/4D printing. In general, 4D printing could significantly improve the safety and efficacy of otolaryngology therapies. The use of bioprinting in otolaryngology has an opportunity to transform the treatment of diseases influencing the ear, nose, and throat as well as the field of tissue regeneration. The present review briefs on polymeric material including biomaterials and cells used in the manufacturing of patient centric 3D/4D bio-printed products utilized in management of otolaryngology.

Enteric glial hub cells coordinate intestinal motility.

Enteric glia are the predominant cell type in the enteric nervous system yet their identities and roles in gastrointestinal function are not well classified. Using our optimized single nucleus RNA-sequencing method, we identified distinct molecular classes of enteric glia and defined their morphological and spatial diversity. Our findings revealed a functionally specialized biosensor subtype of enteric glia that we call "hub cells." Deletion of the mechanosensory ion channel PIEZO2 from adult enteric glial hub cells, but not other subtypes of enteric glia, led to defects in intestinal motility and gastric emptying in mice. These results provide insight into the multifaceted functions of different enteric glial cell subtypes in gut health and emphasize that therapies targeting enteric glia could advance the treatment of gastrointestinal diseases.

Clean fleets, different streets: evaluating the effect of New York City's clean bus program on changes to estimated ambient air pollution.

BACKGROUND: Motor vehicles, including public transit buses, are a major source of air pollution in New York City (NYC) and worldwide. To address this problem, governments and transit agencies have implemented policies to introduce cleaner vehicles into transit fleets. Beginning in 2000, the Metropolitan Transit Agency began deploying compressed natural gas, hybrid electric, and low-sulfur diesel buses to reduce urban air pollution. OBJECTIVE: We hypothesized that bus fleet changes incorporating cleaner vehicles would have detectable effects on air pollution concentrations between 2009 and 2014, as measured by the New York City Community Air Survey (NYCCAS). METHODS: Depot- and route-specific information allowed identification of areas with larger or smaller changes in the proportion of distance traveled by clean buses. Data were assembled for 9670 300 m × 300 m grid cell areas with annual concentration estimates for nitrogen oxide (NO), nitrogen dioxide (NO2), and black carbon (BC) from NYCCAS. Spatial error models adjusted for truck route presence and total traffic volume. RESULTS: While concentrations of all three pollutants declined between 2009 and 2014 even in the 39.7% of cells without bus service, the decline in concentrations of NO and NO2 was greater in areas with more bus service and with higher proportional shifts toward clean buses. Conversely, the decline in BC concentration was slower in areas with more bus service and higher proportional clean bus shifts. SIGNIFICANCE: These results provide evidence that the NYC clean bus program impacted concentrations of air pollution, particularly in reductions of NO2. Further work can investigate the potential impact of these changes on health outcomes in NYC residents. IMPACT STATEMENT: Urban air pollution from diesel-burning buses is an important health exposure. The New York Metropolitan Transit Agency has worked to deploy cleaner buses into their fleet, but the impact of this policy has not been evaluated. Successful reductions in air pollution are critical for public health.

Side effects of messenger RNA vaccines and prior history of COVID-19, a cross-sectional study.

BACKGROUND: There are concerns regarding immunogenicity with coronavirus disease 2019 (COVID-19) mRNA vaccines among persons with prior history of COVID-19 (PHC). This study was to analyze the short-term side effects of mRNA vaccines among health care workers (HCWs) with and without PHC. METHODS: A cross-sectional study was performed using an independent online survey questionnaire that gathered responses from HCWs. RESULTS: Among 1,475 HCWs, 1268 (85.97%) completed the survey, 102/1268 (44/447 in Moderna group and 58/821 in Pfizer-BioNTech group) reported PHC during pre-vaccination period. Symptoms of flushing/P = .05, brain fogging/P= .005, vertigo/P= .041, numbness/P= .023, diarrhea/P= .047, hives/P= .028, itching/P= .028, swelling of lips/mouth/P= .001, shortness of breath/P= .022, and anxiety/P= .048 have greater occurrence among Pfizer-BioNtech group with PHC when compared to Pfizer-BioNtech group with no PHC. Symptoms of chills/P= .027, flushing/P= .045, tremor/P= .05, muscle spasm/P= .039, vomiting/P= .031, diarrhea/P= .015, and cough/P= .011 have higher occurrence among Moderna group with PHC when compared to Moderna group with no PHC. CONCLUSIONS: Few short-term side effects among mRNA vaccine recipients with PHC may have necessitated transient time-off from work. The PHC can be considered as a predictor for severity of side effects. While the vaccination program continues in the United States, a future COVID legislation that mandates vaccination among employees along with paid time off provision may help with higher compliance and acceptance.

Prescription Opioid Use Among Patients With Acute Gout Discharged From the Emergency Department.

OBJECTIVE: Acute gout is among the most painful inflammatory arthritides and a frequent cause of emergency department (ED) visits. Prescription opioids are the leading contributor to the ongoing opioid epidemic; EDs are often the source of the index prescription. Our aim was to assess the burden of opioid use and factors associated with its use among gout patients discharged from the ED. METHODS: In the electronic health records system of Lifespan Healthcare System (currently contains 2.2 million records), adult gout patients discharged from the ED or hospital were identified using International Classification of Diseases, Ninth Revision or Tenth Revision diagnostic codes. The study period was March 2015 to September 2017, and only patients with a primary diagnosis of gout were included. If a patient was seen multiple times, only the first encounter was included. For these patients, we estimated the frequency, dose, and duration of opioids prescribed. Using multivariable logistic regression, we ascertained the factors associated with increased odds of opioid prescription at discharge among patients with acute gout. RESULTS: Of the 456 patients, 129 (28.3%) received opioids at discharge (~80% were new patients). The average dose of prescription was mean ± SD 37.9 ± 17.2 mg of morphine equivalent for a median duration of 8 days (interquartile range 5-14). We noted that patients with polyarticular gout attack and diabetes mellitus and those taking opioids prior to admission had higher odds of receiving opioids at discharge. CONCLUSION: Despite the availability of effective treatments, opioids are commonly used for the management of acute gout. This study highlights an opportunity to curb the opioid epidemic among gout patients.