Association between spontaneous breathing trial methods and reintubation in adult critically ill patients: A systematic review and network meta-analysis of randomized controlled trials.

BACKGROUND: Reintubation is associated with higher risk of mortality. There is no clear evidence on the best spontaneous breathing trial (SBT) method to reduce the risk of reintubation. RESEARCH QUESTION: Are different methods of conducting SBT in critically ill patients associated with different risk of reintubation compared to T-tube? STUDY DESIGN AND METHODS: We conducted a systematic review and Bayesian network meta-analysis of randomized controlled trials (RCTs) investigating the effects of different SBT methods on reintubation. We surveyed PubMed, MEDLINE, CINAHL and CENTRAL databases from inception to 26th January 2024. The Surface Under the Cumulative Ranking curve (SUCRA) was used to determine the likelihood that an intervention was ranked as the best. Pairwise comparisons were also investigated by frequentist meta-analysis. Certainty of the evidence was assessed according to the GRADE approach. RESULTS: A total of 22 RCTs were included, for a total of 6196 patients. The network included nine nodes, with 13 direct pairwise comparisons. About 71% of the patients were allocated to T-tube and PSV-ZEEP, with 2135 and 2101 patients, respectively. The only intervention with a significantly lower risk of reintubation compared to T-tube was high flow oxygen (HFO) (RR 0.23, CrI 0.09 to 0.51, moderate quality evidence). HFO was associated with the highest probability of being the best intervention for reducing the risk of reintubation (81.86%, SUCRA 96.42), followed by continuous positive airway pressure (11.8%, SUCRA 76.75). INTERPRETATION: HFO SBT was associated with a lower risk of reintubation in comparison to other SBT methods. The results of our analysis should be considered with caution due to the low number of studies that investigated HFO SBT, and potential clinical heterogeneity related to co-interventions. Further trials should be performed to confirm the results on larger cohorts of patients and assess specific subgroups.

Central venous pressure waveform analysis during sleep/rest: a novel approach to enhance intensive care unit post-extubation monitoring of extubation failure.

This pilot study aimed to investigate the relation between cardio-respiratory parameters derived from Central Venous Pressure (CVP) waveform and Extubation Failure (EF) in mechanically ventilated ICU patients during post-extubation period. This study also proposes a new methodology for analysing these parameters during rest/sleep periods to try to improve the identification of EF. We conducted a prospective observational study, computing CVP-derived parameters including breathing effort, spectral analyses, and entropy in twenty critically ill patients post-extubation. The Dynamic Warping Index (DWi) was calculated from the respiratory component extracted from the CVP signal to identify rest/sleep states. The obtained parameters from EF patients and patients without EF were compared both during arbitrary periods and during reduced DWi (rest/sleep). We have analysed data from twenty patients of which nine experienced EF. Our findings may suggest significantly increased respiratory effort in EF patients compared to those successfully extubated. Our study also suggests the occurrence of significant change in the frequency dispersion of the cardiac signal component. We also identified a possible improvement in the differentiation between the two groups of patients when assessed during rest/sleep states. Although with caveats regarding the sample size, the results of this pilot study may suggest that CVP-derived cardio-respiratory parameters are valuable for monitoring respiratory failure during post-extubation, which could aid in managing non-invasive interventions and possibly reduce the incidence of EF. Our findings also indicate the possible importance of considering sleep/rest state when assessing cardio-respiratory parameters, which could enhance respiratory failure detection/monitoring.

Brief communication: New method for measuring nitrogen isotopes in tooth dentine at high temporal resolution.

OBJECTIVES: Nitrogen isotopes (δ15N) are widely used to study human nursing and weaning ages. Conventional methods involve sampling 1-mm thick sections of tooth dentine-producing an averaging effect that integrates months of formation. We introduce a novel protocol for measuring δ15N by multicollector secondary ion mass spectrometry (SIMS). MATERIALS AND METHODS: We sampled dentine δ15N on a weekly to monthly basis along the developmental axis in two first molars of healthy children from Australia and New Zealand (n = 217 measurements). Nitrogen isotope ratios were determined from measurements of CN- secondary molecular ions in ~35 µm spots. By relating spot position to enamel formation, we identified prenatal dentine, as well as sampling ages over more than 3 years. We also created calcium-normalized barium and strontium maps with laser ablation-inductively coupled plasma-mass spectrometry. RESULTS: We found rapid postnatal δ15N increases of ~2‰-3‰, during which time the children were exclusively breastfed, followed by declines as the breastfeeding frequency decreased. After weaning, δ15N values remained stable for several months, coinciding with diets that did not include meat or cow's milk; values then varied by ~2‰ starting in the third year of life. Barium did not show an immediate postnatal increase, rising after a few months until ~1-1.5 years of age, and falling until or shortly after the cessation of suckling. Initial strontium trends varied but both individuals peaked months after weaning. DISCUSSION: Developmentally informed SIMS measurements of δ15N minimize time averaging and can be precisely related to an individual's early dietary history.

Effectiveness of Adaptive Support Ventilation in Facilitating Weaning from Mechanical Ventilation in Postoperative Patients.

OBJECTIVE: This meta-analysis aims to evaluate the effectiveness of adaptive support ventilation (ASV) in facilitating postoperative weaning from mechanical ventilation in cardiac surgery patients. DESIGN: A systematic review and meta-analysis to assess ASV in weaning postoperative cardiac surgery patients. Outcomes included early extubation, reintubation rates, time to extubation, and lengths of intensive care units and hospital stays. SETTING: We searched electronic databases from inception to March 2023 and included randomized controlled trials that compared ASV with conventional ventilation methods in this population. PARTICIPANTS: Postoperative cardiac surgery patients. MEASUREMENTS AND MAIN RESULTS: A random effects model was used for meta-analysis, and trial sequential analysis (TSA) was conducted to assess result robustness. The meta-analysis included 11 randomized controlled trials with a total of 1027 randomized patients. ASV was associated with a shorter time to extubation compared to conventional ventilation (random effects, mean difference -68.30 hours; 95% confidence interval, -115.50 to -21.09) with TSA providing a conclusive finding. While ASV indicated improved early extubation rates, no significant differences were found in reintubation rates or lengths of intensive care unit and hospital stays, with these TSA results being inclusive. CONCLUSIONS: ASV appears to facilitate a shorter time to extubation in postoperative cardiac surgery patients compared to conventional ventilation, suggesting benefits in accelerating the weaning process and reducing mechanical ventilation duration.

Impact of Nutritional Strategies to Prevent Post-Weaning Diarrhoea on Performance, Behaviour, and Microbiota in Piglets from Organic Farming.

Organic livestock farming is committed to high environmental and animal welfare standards, although pathologies such as post-weaning diarrhoea (PWD) may appear. The main objective of this study was to assess nutritional strategies to prevent PWD in organic piglets. A total of 134 weaned piglets were fed one of three diets: high crude protein (17.8%, HCP), low crude protein (16.8%, LCP), and low crude protein supplemented with liquid whey (LCP+W). Piglets were assessed weekly for four weeks on the following parameters: diarrhoea incidence, additional health parameters, average daily gain, and behaviour. Faecal samples were taken to analyse the intestinal microbiota composition. Data were analysed using LMM and GLMM models and Shannon and Whittaker indexes. No significant effect of diet on diarrhoea incidence was found, but the LCP+W diet increased average daily gain. Pigs fed the LCP+W diet presented a lower percentage of drinking and negative social behaviour compared with the HCP diet, and LCP pigs presented higher exploration compared with HCP. In addition, LCP+W piglets showed a higher abundance of the beneficial genus Frisingicoccus. Although liquid whey did not reduce diarrhoea incidence, the benefits found in growth, microbiota composition, and reduced negative social behaviour indicate that it could be an optimal supplement to organic diets.

Extracorporeal Life Support in Myocardial Infarction: New Highlights.

Background and Objectives: Cardiogenic shock (CS) is a potentially severe complication following acute myocardial infarction (AMI). The use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in these patients has risen significantly over the past two decades, especially when conventional treatments fail. Our aim is to provide an overview of the role of VA-ECMO in CS complicating AMI, with the most recent literature highlights. Materials and Methods: We have reviewed the current VA-ECMO practices with a particular focus on CS complicating AMI. The largest studies reporting the most significant results, i.e., overall clinical outcomes and management of the weaning process, were identified in the PubMed database from 2019 to 2024. Results: The literature about the use of VA-ECMO in CS complicating AMI primarily has consisted of observational studies until 2019, generating the need for randomized controlled trials. The EURO-SHOCK trial showed a lower 30-day all-cause mortality rate in patients receiving VA-ECMO compared to those receiving standard therapy. The ECMO-CS trial compared immediate VA-ECMO implementation with early conservative therapy, with a similar mortality rate between the two groups. The ECLS-SHOCK trial, the largest randomized controlled trial in this field, found no significant difference in mortality at 30 days between the ECMO group and the control group. Recent studies suggest the potential benefits of combining left ventricular unloading devices with VA-ECMO, but they also highlight the increased complication rate, such as bleeding and vascular issues. The routine use of VA-ECMO in AMI complicated by CS cannot be universally supported due to limited evidence and associated risks. Ongoing trials like the Danger Shock, Anchor, and Recover IV trials aim to provide further insights into the management of AMI complicated by CS. Conclusions: Standardizing the timing and indications for initiating mechanical circulatory support (MCS) is crucial and should guide future trials. Multidisciplinary approaches tailored to individual patient needs are essential to minimize complications from unnecessary MCS device initiation.

The influence of different spontaneous breathing trials on regional ventilation distribution in patients with prolonged mechanical ventilation.

OBJECTIVE: This study aimed to explore the influence of different spontaneous breathing trials (SBTs) on regional ventilation distribution in patients with prolonged mechanical ventilation (PMV). METHODS: A total of 24 patients with PMV were analyzed retrospectively. They received three different SBT modes which are automatic tube compensation (ATC), continuous positive airway pressure (CPAP), and T-piece (TP), over three days, and every SBT lasted two hours. Electrical impedance tomography (EIT) was used to monitor the SBT process and five-minute EIT data from five periods (pre-SBT which is t0, at the beginning and the end of the first hour SBT are t1 and t2, at the beginning and the end of the second hour SBT are t3 and t4) were analyzed. RESULTS: In all PMV patients, the temporal skew of aeration (TSA) values at t3 were significantly different in three SBTs (ATC: 18.18±22.97; CPAP: 20.42±17.01; TP:11.26±11.79; p=0.05). In the weaning success group, TSA (t1) values were significantly different too (ATC: 11.11±13.88; CPAP: 19.09±15.77; TP: 9.09±12.74; p=0.04). In the weaning failure group, TSA (t4) values were significantly different in three SBTs (ATC: 36.67±18.46; CPAP: 15.38±11.69; TP: 17.65±17.93; p=0.04). The patient's inspiratory effort (Global flow index at t1) in patients with weaning failure under CPAP (3.51±4.31) was significantly higher than that in the ATC (1.15±1.47) and TP (0.89±1.28). The SBT mode with the best ventilation uniformity may be the one that activates the respiratory muscles the most which may be the optimal SBT. The SBT mode of most uniform ventilation distribution settings varies from patient to patient. CONCLUSION: The regional ventilation distribution was different for each individual, making the SBT with the best ventilation distribution of patients need to be personalized. EIT is a tool that can be considered for real-time assessment.

The Relationship of Diaphragmatic Ultrasound-Based and Manometric Indices With Difficult Weaning in Tracheostomized Patients.

BACKGROUND: Patients with a tracheostomy and difficult weaning from invasive mechanical ventilation constitute a challenging problem in critical care. An increased duration of ventilation may lead to diaphragmatic dysfunction and a noninvasive assessment of the diaphragm, such as ultrasound, attracts interest in the clinical practice. We evaluated the relationship of ultrasound-derived indices with weaning outcome and with established indices of respiratory strength and load in subjects who are tracheostomized and undergoing weaning. METHODS: This prospective study was conducted at an academic ICU in Greece. Twenty subjects with tracheostomy and difficult weaning, during a spontaneous breathing trial, underwent time synchronous diaphragmatic sonography and esophageal manometry, to assess diaphragmatic excursion and thickening fraction, esophageal and transdiaphragmatic pressures, pressure-time product of the esophageal pressure, and maximum inspiratory pressure. The primary outcome was liberation from mechanical ventilation at 48 h. The relationship of diaphragmatic ultrasound with esophageal pressure-derived indices was also evaluated. RESULTS: Weaning from invasive ventilation failed in 10 subjects. Diaphragmatic excursion exhibited a significant difference between weaning success and failure (1.34 ± 0.56 versus 0.79 ± 0.44; P = .044), a strong correlation with transdiaphragmatic pressure (r = 0.7, P = .02), and a moderate correlation with the pressure-time product of the esophageal pressure (r = 0.65, P = .02) and the maximum inspiratory pressure (r = 0.66, P = .02). Transdiaphragmatic pressure presented the highest area under the curve (0.97). However, when transdiaphragmatic pressure was compared with diaphragmatic excursion (area under the curve, 0.84) for predictive accuracy, no significant difference was found. CONCLUSIONS: Diaphragmatic excursion is a valuable tool for the assessment of diaphragmatic strength, respiratory load, and weaning prediction.

Normalization of eosinophil count is predictive of oxygen weaning over the course of COVID-19 infection among hospitalized adults during the first wave of 2020 pandemic.

Background: Understanding COVID-19 outcomes remains a challenge. While numerous biomarkers have been proposed for severity at admission, limited exploration exists for markers during the infection course, especially for the requirement of oxygen therapy. This study investigates the potential of eosinophil count normalization as a predictor for oxygen weaning during the initial wave of the pandemic. Methods: A retrospective study was conducted between March and April 2020 (first wave) among adults admitted directly to a medicine ward. Biological abnormalities, including lymphocyte count, eosinophil count, and C-reactive protein (CRP), were gathered daily during the first week of admission according to oxygen level. In case of worsening, oxygen level was censored at 15 L/min. The primary aim was to assess whether eosinophil count normalization predicts a subsequent decrease in oxygen requirements. Results: Overall, 132 patients were admitted, with a mean age of 59.0 ± 16.3 years. Of the patients, 72% required oxygen, and 20.5% were admitted to the intensive care unit after a median delay of 48 hours. The median CRP at admission was 79 (26-130) mg/L, whereas the eosinophil count was 10 (0-60)/mm3. Eosinophil count normalization (≥100/mm3) by day 2 correlated significantly with decreased oxygen needs (<2 L) with hazard ratio (HR) = 3.7 [1.1-12.9] (p = 0.04). Likewise, CRP < 80 mg/L was associated with reduced oxygen requirements (p < 0.001). Predictors, including underlying chronic respiratory disease, exhibited a trend toward a negative association (p = 0.06). Conclusion: The study highlights the relationship between eosinophil count and CRP, with implications for predicting oxygen weaning during COVID-19. Further research is warranted to explore the relevance of these biomarkers in other respiratory infections.

Outcomes of different pulmonary rehabilitation protocols in patients under mechanical ventilation with difficult weaning: a retrospective cohort study.

BACKGROUND: The endeavor of liberating patients from ventilator dependence within respiratory care centers (RCCs) poses considerable challenges. Multiple factors contribute to this process, yet establishing an effective regimen for pulmonary rehabilitation (PR) remains uncertain. This retrospective study aimed to evaluate existing rehabilitation protocols, ascertain associations between clinical factors and patient outcomes, and explore the influence of these protocols on the outcomes of the patients to shape suitable rehabilitation programs. METHODS: Conducted at a medical center in northern Taiwan, the retrospective study examined 320 newly admitted RCC patients between January 1, 2015, and December 31, 2017. Each patient received a tailored PR protocol, following which researchers evaluated weaning rates, RCC survival, and 3-month survival as outcome variables. Analyses scrutinized differences in baseline characteristics and prognoses among three PR protocols: protocol 1 (routine care), protocol 2 (routine care plus breathing training), and protocol 3 (routine care plus breathing and limb muscle training). RESULTS: Among the patients, 28.75% followed protocol 1, 59.37% protocol 2, and 11.88% protocol 3. Variances in age, body-mass index, pneumonia diagnosis, do-not-resuscitate orders, Glasgow Coma Scale scores (≤ 14), and Acute Physiology and Chronic Health Evaluation II (APACHE) scores were notable across these protocols. Age, APACHE scores, and abnormal blood urea nitrogen levels (> 20 mg/dL) significantly correlated with outcomes-such as weaning, RCC survival, and 3-month survival. Elevated mean hemoglobin levels linked to increased weaning rates (p = 0.0065) and 3-month survival (p = 0.0102). Four adjusted models clarified the impact of rehabilitation protocols. Notably, the PR protocol 3 group exhibited significantly higher 3-month survival rates compared to protocol 1, with odds ratios (ORs) ranging from 3.87 to 3.97 across models. This association persisted when comparing with protocol 2, with ORs between 3.92 and 4.22. CONCLUSION: Our study showed that distinct PR protocols significantly affected the outcomes of ventilator-dependent patients within RCCs. The study underlines the importance of tailored rehabilitation programs and identifies key clinical factors influencing patient outcomes. Recommendations advocate prospective studies with larger cohorts to comprehensively assess PR effects on RCC patients.

Prebiotic galactooligosaccharide improves piglet growth performance and intestinal health associated with alterations of the hindgut microbiota during the peri-weaning period.

BACKGROUND: Weaning stress reduces growth performance and health of young pigs due in part to an abrupt change in diets from highly digestible milk to fibrous plant-based feedstuffs. This study investigated whether dietary galactooligosaccharide (GOS), supplemented both pre- and post-weaning, could improve growth performance and intestinal health via alterations in the hindgut microbial community. METHODS: Using a 3 × 2 factorial design, during farrowing 288 piglets from 24 litters received either no creep feed (FC), creep without GOS (FG-) or creep with 5% GOS (FG+) followed by a phase 1 nursery diet without (NG-) or with 3.8% GOS (NG+). Pigs were sampled pre- (D22) and post-weaning (D31) to assess intestinal measures. RESULTS: Creep fed pigs grew 19% faster than controls (P < 0.01) prior to weaning, and by the end of the nursery phase (D58), pigs fed GOS pre-farrowing (FG+) were 1.85 kg heavier than controls (P < 0.05). Furthermore, pigs fed GOS in phase 1 of the nursery grew 34% faster (P < 0.04), with greater feed intake and efficiency. Cecal microbial communities clustered distinctly in pre- vs. post-weaned pigs, based on principal coordinate analysis (P < 0.01). No effects of GOS were detected pre-weaning, but gruel creep feeding increased Chao1 α-diversity and altered several genera in the cecal microbiota (P < 0.05). Post-weaning, GOS supplementation increased some genera such as Fusicatenibacter and Collinsella, whereas others decreased such as Campylobacter and Frisingicoccus (P < 0.05). Changes were accompanied by higher molar proportions of butyrate in the cecum of GOS-fed pigs (P < 0.05). CONCLUSIONS: Gruel creep feeding effectively improves suckling pig growth regardless of GOS treatment. When supplemented post-weaning, prebiotic GOS improves piglet growth performance associated with changes in hindgut microbial composition.

Single-Stage Bronchoscopy-Guided Protocol for Tracheostomy Decannulation in Adult Patients.

INTRODUCTION: Tracheostomy decannulation is a routine procedure in airway management. There is no standard decannulation method; however, the two commonly practiced approaches are tracheostomy downsizing and intermittent capping, which are both accompanied by multiple visits to the clinic and increase patient discomfort. Herein, we explore fiberoptic bronchoscopy application in a novel single-stage decannulation protocol. METHODS: We conducted a retrospective study on tracheostomy patients eligible for decannulation. Fiberoptic bronchoscopy was performed on patients with spontaneous ventilation for ≥48 h, age ≥18, hemodynamic stability, normal chest X-ray, adequate swallowing, effective cough, adequate consciousness, patent speaking valve, and absent history of recurrent aspiration. Tracheostomy removal occurred after evaluating the airway and ruling out tracheomalacia, tracheitis with stenosis, obstructive granulation tissue, and moderate-to-severe stenosis. We documented patients' demographic and clinical information, along with details of their post-decannulation course. RESULTS: Out of 58 patients admitted for tracheostomy removal, we excluded six patients (10.3%) from the study because, despite clinical indications for successful weaning, they exhibited abnormalities that interrupted the decannulation process. Of the remaining 52 patients, 50 (96.1%) were successfully weaned off, while two needed reinsertion during their hospital course. Bronchoscopy findings were unremarkable in 33 (63.5%) patients, and the most frequently observed abnormalities were paucity of vocal cord movement in 5 (9.6%) patients and granulation tissue formation in 5 (9.6%) patients. No further airway management was necessary after discharge. CONCLUSIONS: Our study introduces the innovative approach of single-stage bronchoscopic decannulation as a potentially beneficial tool for immediate decannulation. Based on our experience, we achieved a relatively satisfactory outcome following single-stage tracheostomy decannulation with bronchoscopy. The approach shows promise in providing valuable airway insights and predicting possible decannulation failures. Further research is needed to evaluate its impact on stress reduction for patients and surgeons, its superiority compared to traditional techniques, its long-term effects on healthcare, and its potential cost-effectiveness.

The respiratory and fecal microbiota of beef calves from birth to weaning.

The development and growth of animals coincide with the establishment and maturation of their microbiotas. To evaluate the respiratory and fecal microbiotas of beef calves from birth to weaning, a total of 30 pregnant cows, and their calves at birth, were enrolled in this study. Deep nasal swabs and feces were collected from calves longitudinally, starting on the day of birth and ending on the day of weaning. Nasopharyngeal, vaginal, and fecal samples were also collected from cows, and the microbiotas of all samples were analyzed. The fecal microbiota of calves was enriched with Lactobacillus during the first 8 weeks of life, before being displaced by genera associated with fiber digestion, and then increasing in diversity across time. In contrast, the diversity of calf respiratory microbiota generally decreased with age. At birth, the calf and cow nasal microbiotas were highly similar, indicating colonization from dam contact. This was supported by microbial source-tracking analysis. The structure of the calf nasal microbiota remained similar to that of the cows, until weaning, when it diverged. The changes were driven by a decrease in Lactobacillus and an increase in genera typically associated with bovine respiratory disease, including Mannheimia, Pasteurella, and Mycoplasma. These three genera colonized calves early in life, though Mannheimia was initially transferred from the cow reproductive tract. Path analysis was used to model the interrelationships of calf respiratory and fecal microbiotas. It was observed that respiratory Lactobacillus and fecal Oscillospiraceae UCG-005 negatively affected the abundance of Mannheimia or Pasteurella.IMPORTANCEIn beef cattle production, bovine respiratory disease (BRD) accounts for most of the feedlot morbidities and mortalities. Metaphylaxis is a common management tool to mitigate BRD, however its use has led to increased antimicrobial resistance. Novel methods to mitigate BRD are needed, including microbiota-based strategies. However, information on the respiratory bacteria of beef calves prior to weaning was limited. In this study, it was shown that the microbiota of cows influenced the initial composition of both respiratory and fecal microbiotas in calves. While colonization of the respiratory tract of calves by BRD-associated genera occurred early in life, their relative abundances increased at weaning, and were negatively correlated with respiratory and gut bacteria. Thus, microbiotas of both the respiratory and gastrointestinal tracts have important roles in antagonism of respiratory pathogens and are potential targets for enhancing calf respiratory health. Modulation may be most beneficial, if done prior to weaning, before opportunistic pathogens establish colonization.

The Impact of Abrupt and Fenceline-Weaning Methods on Cattle Stress Response, Live Weight Gain, and Behaviour.

The impact of abrupt (AB) and fenceline (FL) weaning methods on cattle stress response, live weight gain, and behaviour were determined across 14 days. Thirty-two cow-calf pairs were fitted with ear tag sensors (to continuously record behaviour) and allocated to two weaning treatments. After separation, FL calves were maintained in a pen adjacent to the FL cow paddock. The AB calves were transported to a pen removing all contact with the cows. After 7 d, FL cows were transported away from all calf pens. Body weights and salivary samples were collected for all animals on experimental days 0, 7, and 14. Fenceline-weaned calves had a greater duration of rest and rumination with reduced high activity across the first 3 days after separation as compared to abruptly weaned calves in line with the greater occurrences of pacing observed for AB calves. Fenceline-separated cows had greater levels of rest across the first 7 days but similar levels of rumination compared to abruptly separated cows. Fenceline-separated cow activity levels tended to be greater and eating levels were similar across the first three days. Body weight (BW) and cortisol concentrations were similar for AB and FL cattle, but FL cows had lower overall weight gain than the abrupt cows likely due to reduced eating time on days four to seven. Together, these results suggest that calves be fenceline-weaned for three days followed by total separation.

Effects of Defatted and Hydrolyzed Black Soldier Fly Larvae Meal as an Alternative Fish Meal in Weaning Pigs.

In Experiment 1, a total of eighteen crossbred ([Landrace × Yorkshire] × Duroc) barrows with an initial body weight of 6.74 ± 0.68 kg were randomly divided into three dietary treatments (one pig per cage and six replicates per treatment) and housed in metabolic cages that were equipped with a feeder and slatted floor to collect urine and feces. In Experiment 2, a total of 96 crossbred ([Landrace × Yorkshire] × Duroc) barrows with an initial body weight of 8.25 ± 0.42 kg were used in the 6-week trial. The pigs were randomly divided into three dietary treatments (three pigs per pen and eight replicates per treatment). In Experiment 1, nutrient composition of defatted black soldier fly larvae meal (BLM) was superior to that of hydrolyzed BLM but lower than that of fish meal (FM). Also, defatted BLM and FM had better apparent total track digestibility (ATTD) of crude protein (CP) and better nitrogen retention (p < 0.05) than hydrolyzed BLM, but there was no significant difference (p > 0.05) between defatted BLM and FM. In Experiment 2, defatted BLM improved (p < 0.05) average daily gain (ADG), feed conversion ratio (FCR), and feed cost per kg gain (FCG) compared with FM. Defatted BLM could replace soybean meal and fish meal as an alternative protein source for weaning pigs.

The Value of Ischemic Cardiac Biomarkers to Predict Spontaneous Breathing Trial or Extubation Failure: A Systematic Review.

Background: It is unclear whether other cardiac biomarkers than NT-proBNP can be useful in the risk stratification of patients weaning from mechanical ventilation. The aim of this study is to summarize the role of ischemic cardiac biomarkers in predicting spontaneous breathing trial (SBT) or extubation failure. Methods: We systematically searched Embase, MEDLINE, Web of Science, and Cochrane Central for studies published before January 2024 that reported the association between ischemic cardiac biomarkers and SBT or extubation failure. Data were extracted using a standardized form and methodological assessment was performed using the QUIPS tool. Results: Seven observational studies investigating four ischemic cardiac biomarkers (Troponin-T, Troponin-I, CK-MB, Myoglobin) were included. One study reported a higher peak Troponin-I in patients with extubation failure compared to extubation success (50 ng/L [IQR, 20-215] versus 30 ng/L [IQR, 10-86], p = 0.01). A second study found that Troponin-I measured before the SBT was higher in patients with SBT failure in comparison to patients with SBT success (100 ± 80 ng/L versus 70 ± 130 ng/L, p = 0.03). A third study reported a higher CK-MB measured at the end of the SBT in patients with weaning failure (SBT or extubation failure) in comparison to weaning success (8.77 ± 20.5 ng/mL versus 1.52 ± 1.42 ng/mL, p = 0.047). Troponin-T and Myoglobin as well as Troponin-I and CK-MB measured at other time points were not found to be related to SBT or extubation failure. However, most studies were underpowered and with high risk of bias. Conclusions: The association with SBT or extubation failure is limited for Troponin-I and CK-MB and appears absent for Troponin-T and Myoglobin, but available studies are hampered by significant methodological drawbacks. To more definitively determine the role of ischemic cardiac biomarkers, future studies should prioritize larger sample sizes, including patients at risk of cardiac disease, using stringent SBTs and structured timing of laboratory measurements before and after SBT.

Hypophosphatemia in Chronic Obstructive Pulmonary Disease Patients Requiring Mechanical Ventilation and Its Impact on Weaning in an Intensive Care Unit of a Tertiary Care Hospital in Eastern India.

Background Hypophosphatemia, defined as a serum phosphate level less than 2.5 mg/dL, is a frequent finding in patients with chronic obstructive pulmonary disease (COPD) and has been speculated to negatively affect weaning outcomes. This study aimed to determine the incidence of hypophosphatemia in COPD patients requiring mechanical ventilation and evaluate the predictive role of hypophosphatemia as an indicator of successful weaning from mechanical ventilation in such patients admitted to the intensive care unit (ICU) in a tertiary care hospital in eastern India. Methodology This prospective observational study included 60 adult patients aged 18 to 75 years with acute exacerbations of COPD on mechanical ventilation in the ICU who were planned to undergo a weaning trial. Serum phosphate levels were assessed at the time of admission and before each weaning attempt. Weaning outcomes at each attempt, length of ventilator and ICU stay, and mortality were recorded. Data collection was initiated after approval of the Institutional Ethics Committee. Receiver operating curve (ROC) analysis was done to identify the cut-off value of serum phosphate which predicted successful weaning. Results Of 60 participants, hypophosphatemia on admission was present in 15 (25%) patients. Despite the correction, 13 (21.7%) patients had hypophosphatemia before the first weaning attempt. Only 22 patients out of 60 were successfully weaned off from mechanical ventilation in the first trial, accounting for a success rate of 36.7%, of whom 20 were normophosphatemic (90.9%). In the second and third weaning trials, hypophosphatemia was significantly associated with weaning failure. Overall differences in mean serum phosphate levels among those who failed to wean in each weaning trial and the successful attempt were statistically significant (p < 0.001). On ROC analysis of serum phosphate level before the first weaning trial, a cut-off value of ≥3.0 mg/dL was identified to have 86.4% sensitivity, 55.3% specificity, 52.8% positive predictive value, 87.5% negative predictive value, and 66.7% diagnostic accuracy in predicting weaning success. Five patients died, accounting for a mortality rate of 8.3%. Lower mean serum phosphate levels before the first weaning trial, higher mean age, and longer ventilator and ICU days were significantly associated with mortality among our study participants (p < 0.05). Conclusions Our findings suggest that maintaining normal serum phosphate levels is critical to successfully weaning off patients with COPD from ventilator support.

Comparative effectiveness of alternative spontaneous breathing trial techniques: a systematic review and network meta-analysis of randomized trials.

BACKGROUND: The spontaneous breathing trial (SBT) technique that best balance successful extubation with the risk for reintubation is unknown. We sought to determine the comparative efficacy and safety of alternative SBT techniques. METHODS: We searched Medline, EMBASE, and the Cochrane Central Register of Controlled Trials from inception to February 2023 for randomized or quasi-randomized trials comparing SBT techniques in critically ill adults and children and reported initial SBT success, successful extubation, reintubation (primary outcomes) and mortality (ICU, hospital, most protracted; secondary outcome) rates. Two reviewers screened, reviewed full-texts, and abstracted data. We performed frequentist random-effects network meta-analysis. RESULTS: We included 40 RCTs (6716 patients). Pressure Support (PS) versus T-piece SBTs was the most common comparison. Initial successful SBT rates were increased with PS [risk ratio (RR) 1.08, 95% confidence interval (CI) (1.05-1.11)], PS/automatic tube compensation (ATC) [1.12 (1.01 -1.25), high flow nasal cannulae (HFNC) [1.07 (1.00-1.13) (all moderate certainty), and ATC [RR 1.11, (1.03-1.20); low certainty] SBTs compared to T-piece SBTs. Similarly, initial successful SBT rates were increased with PS, ATC, and PS/ATC SBTs compared to continuous positive airway pressure (CPAP) SBTs. Successful extubation rates were increased with PS [RR 1.06, (1.03-1.09); high certainty], ATC [RR 1.13, (1.05-1.21); moderate certainty], and HFNC [RR 1.06, (1.02-1.11); high certainty] SBTs, compared to T-piece SBTs. There was little to no difference in reintubation rates with PS (vs. T-piece) SBTs [RR 1.05, (0.91-1.21); low certainty], but increased reintubation rates with PS [RR 2.84, (1.61-5.03); moderate certainty] and ATC [RR 2.95 (1.57-5.56); moderate certainty] SBTs compared to HFNC SBTs. CONCLUSIONS: SBTs conducted with pressure augmentation (PS, ATC, PS/ATC) versus without (T-piece, CPAP) increased initial successful SBT and successful extubation rates. Although SBTs conducted with PS or ATC versus HFNC increased reintubation rates, this was not the case for PS versus T-piece SBTs.

The ratio of parasternal intercostal muscle-thickening fraction-to-diaphragm thickening fraction for predicting weaning failure.

BACKGROUND: Diaphragm dysfunction is associated with weaning outcomes in mechanical ventilation patients, in the case of diaphragm dysfunction, the accessory respiratory muscles would be recruited. The main purpose of this study is to explore the performance of parasternal intercostal muscle thickening fraction in relation to diaphragmatic thickening fraction ratio (TFic1/TFdi2) for predicting weaning outcomes, and compare its accuracy with D-RSBI in predicting weaning failure. MATERIALS AND METHODS: We prospectively enrolled consecutive patients from 7/2022-5/2023. We measured TFic, TFdi, and diaphragmatic excursion (DE3) by ultrasound and calculated the TFic/TFdi ratio and diaphragmatic rapid shallow breathing index (D-RSBI4). Receiver-operator characteristic (ROC5) curves evaluated the accuracy of the TFic/TFdi ratio and D-RSBI in predicting weaning failure. RESULTS: 161 were included in the final analysis, 114 patients (70.8%) were successfully weaned from mechanical ventilation. The TFic/TFdi ratio (AUROC = 0.887 (95% CI: 0.821-0.953)) was superior to the D-RSBI (AUROC = 0.875 (95% CI: 0.807-0.944)) for predicting weaning failure. CONCLUSIONS: The TFic/TFdi ratio predicted weaning failure with high accuracy and outperformed the D-RSBI.

[Prevalence and determinants of continued breastfeeding beyond 6 months among Algerian women. Evidence for Multiple Indicators Cluster Surveys]. / Prévalence et déterminants de l'allaitement maternel poursuivi au-delà de 6 mois chez les femmes algériennes. Analyse à partir des données de l'enquête par grappes à indicateurs multiples.

Background and rationale: Breastfeeding is considered the best nutrition for infants and plays a significant role in a child's growth and development. In this regard, the World Health Organization (WHO) strongly recommends exclusive breastfeeding for the first 6 months of life, as well as continued breastfeeding when safe and appropriate complementary foods are introduced, up to 2 years of age or beyond. Nonetheless, breastfeeding practices remain sub-optimal in many parts of the world. In this respect, many children have shown not to be breastfed up to 6 months of age or are not breastfed during their first hours of life or are weaned too early. This allows for the use of infant formula, which can be life threatening due to poor hygiene, storage conditions or inappropriate foods. Likewise, breastfeeding rates in the Middle East and North Africa (MENA) region are lower than the global average. In Algeria, the breastfeeding rate up to 6 months of age is among the lowest in the world according to previous Multiple Indicators Cluster Surveys (MICS) reports. In addition, by the end of the sixth month, the percentage of children exclusively breastfed is less than 3% and only 23% of children receive breast milk at 22-23 months. The median duration of breast-feeding is 12 weeks. However, the socio-demographic factors associated with this sub-optimal breastfeeding practice are not explored in these reports, as studies and research conducted in this context using other data are few and mostly conducted in limited geographical areas. Materials and methods: This stands for a descriptive cross-sectional study of all children who were breastfed in the MICS database, carried out in 2019, 8 709 children, including 4 471 boys and 4 238 girls, registered in the database. To explore factors associated with the duration of breastfeeding, we only included weaned children to minimize bias related to children who were still breastfeeding. This allowed to analyze data from 3 761 children, including 1 930 boys (5.4%) and 1,831 girls (48.6%). Through using a logistic regression model, we could attain the assessment of the role of different socio-demographic, economic and geographical factors in the maintenance of breastfeeding beyond 6 months. Results: The prevalence of breastfeeding is 81.1%; the rate of exclusive breastfeeding of children aged 0-6 months is 28.7%. The factors associated with breastfeeding beyond six months are area of residence, mother's occupational status and wealth quintile. In fact, rural area appears to be a factor favoring the continuation of breastfeeding beyond six months, compared with urban area (OR = 1.29; CI [1.032-1.369]). Mothers living in the Eastern Highlands geographic region appear to be 1.56 times more likely to maintain breastfeeding for more than six months compared to those living in the Southern region (OR = 1.56; CI [1.123 - 1.677]). Children of non-working mothers are almost 1.5 times more likely to be breastfed after 6 months than those of working mothers (OR = 1.489; CI [1.107 - 1.947]). Parents belonging to the "richest" wealth quintiles appear to increase the chance of continued breastfeeding after 6 months with a 1.24-fold increase compared to those belonging to the "poorest" quintile (OR = 1.24; CI [1.086 - 1.812]). Factors such as the child's gender, maternal education level, and functional difficulties do not appear to be determining factors for the continuation of breastfeeding after six months. Discussion and conclusion: The prevalence and factors associated with the initiation and continuation of breastfeeding vary from one country to another. Notwithstanding the numerous studies to better comprehend mothers' breastfeeding behaviour and various initiatives for promotion thereof, many countries have low rates. In consequence, the downward trend in breastfeeding is directly linked to advances in the production and marketing of industrial milks, the lack of information and awareness among mothers and the lack of training of health professionals. In this respect, it is highly recommended to encourage behavioural changes, to improve communication about the duration of breastfeeding, to increase the use of postnatal counselling and training of paramedical staff according to the recommendations with support for mothers.This study is of great interest in developing countries like Algeria, in order to adopt preventive interventions, and to organise communication and pre- and post-natal counselling in the breastfeeding project. Clearly, this study should be enhanced with supplementary qualitative studies concerning the factors contributing to early discontinuation of breastfeeding.