Ventilator Weaning in Prolonged Mechanical Ventilation-A Narrative Review.

Patients requiring mechanical ventilation (MV) beyond 21 days, usually referred to as prolonged MV, represent a unique group with significant medical needs and a generally poor prognosis. Research suggests that approximately 10% of all MV patients will need prolonged ventilatory care, and that number will continue to rise. Although we have extensive knowledge of MV in the acute care setting, less is known about care in the post-ICU setting. More than 50% of patients who were deemed unweanable in the ICU will be liberated from MV in the post-acute setting. Prolonged MV also presents a challenge in care for medically complex, elderly, socioeconomically disadvantaged and marginalized individuals, usually at the end of their life. Patients and their families often rely on ventilator weaning facilities and skilled nursing homes for the continuation of care, but home ventilation is becoming more common. The focus of this review is to discuss recent advances in the weaning strategies in prolonged MV, present their outcomes and provide insight into the complexity of care.

Secreted frizzled related-protein 2 is prognostic for human pancreatic cancer patient survival and is associated with fibrosis.

Pancreatic adenocarcinoma (PDAC) is one of the deadliest cancers, with five-year survival rates of 9%. We hypothesized that secreted frizzled-related protein 2 (SFRP2) may influence stromal growth in pancreatic cancer, since it increases fibrosis and collagen production in non-neoplastic pathologies. We assessed SFRP2 value as a biomarker and assessed its function in PDAC. SFRP2 gene expression in patients with PDAC was analyzed using TCGA data. Disease free survival (DFS) was analyzed using Kaplan Meier test. The effect of KRAS inhibition on SFRP2 expression in PDAC cells was assessed. The associations of stromal content with SFPR2 mRNA and protein with fibrosis were analyzed. The role of SFRP2 in mesenchymal transformation was assessed by western blot in fibroblasts. Of all cancers in TCGA, SFRP2 levels were highest in PDAC, and higher in PDAC than normal tissues (n= 234, p= 0.0003). High SFRP2 levels correlated with decreased DFS (p= 0.0097). KRAS inhibition reduced SFRP2 levels. Spearman correlation was 0.81 between stromal RNA and SFRP2 in human PDAC, and 0.75 between fibrosis and SFRP2 levels in PDAC tumors. SFRP2-treated fibroblasts displayed mesenchymal characteristics. SFRP2 is prognostic for PDAC survival, regulated by KRAS, and associated with PDAC fibrosis.

Quantitative image analysis in COVID-19 acute respiratory distress syndrome: a cohort observational study.

Background Acute respiratory distress syndrome (ARDS) is a severe form of acute lung injury commonly associated with pneumonia, including coronavirus disease-19 (COVID-19). The resultant effect can be persistent lung damage, but its extent is not known. We used quantitative high resolution computed tomography (QHR-CT) lung scans to radiographically characterize the lung damage in COVID-19 ARDS (CARDS) survivors. Methods Patients with CARDS (N=20) underwent QHR-CT lung scans 60 to 90 days after initial diagnosis, while hospitalized at a long-term acute care hospital (LTACH). QHR-CT assessed for mixed disease (QMD), ground glass opacities (QGGO), consolidation (QCON) and normal lung tissue (QNL). QMD was correlated with respiratory support on admission, tracheostomy decannulation and supplementary oxygen need on discharge. Results Sixteen patients arrived with tracheostomy requiring invasive mechanical ventilation. Four patients arrived on nasal oxygen support. Of the patients included in this study 10 had the tracheostomy cannula removed, four remained on invasive ventilation, and two died. QHR-CT showed 45% QMD, 28.1% QGGO, 3.0% QCON and QNL=23.9%. Patients with mandatory mechanical ventilation had the highest proportion of QMD when compared to no mechanical ventilation. There was no correlation between QMD and tracheostomy decannulation or need for supplementary oxygen at discharge. Conclusions Our data shows severe ongoing lung injury in patients with CARDS, beyond what is usually expected in ARDS. In this severely ill population, the extent of mixed disease correlates with mechanical ventilation, signaling formation of interstitial lung disease. QHR-CT analysis can be useful in the post-acute setting to evaluate for interstitial changes in ARDS.

Alumina surfaces with nanoscale topography reduce attachment and biofilm formation by Escherichia coli and Listeria spp.

This work reports on a simple, robust and scientifically sound method to develop surfaces able to reduce microbial attachment and biofilm development, with possible applications in medicine, dentistry, food processing, or water treatment. Anodic surfaces with cylindrical nanopores 15 to 100 nm in diameter were manufactured and incubated with Escherichia coli ATCC 25922 and Listeria innocua. Surfaces with 15 and 25 nm pore diameters significantly repressed attachment and biofilm formation. Surface-bacteria interaction forces calculated using the extended Derjaguin Landau Verwey-Overbeek (XDLVO) theory indicate that reduction in attachment and biofilm formation is due to a synergy between electrostatic repulsion and surface effective free energy. An attachment study using E. coli K12 strains unable to express appendages also suggests that the small-pore surfaces may inhibit flagella-dependent attachment. These results can have immediate, far-reaching implications and commercial applications, with substantial benefits for human health and life.

Effect of pulsed light treatments on the growth and resistance behavior of Listeria monocytogenes 10403S, Listeria innocua, and Escherichia coli ATCC 25922 in a liquid substrate.

Pulsed light (PL) treatment can effectively inactivate a large proportion of contaminating bacteria on surfaces and in clear solutions. An important issue that needs to be investigated is whether repeated exposure to PL treatment causes any changes to the growth and resistance behavior of the bacteria surviving the treatment. To test this, three challenge microorganisms were used: Listeria monocytogenes, Listeria innocua, and Escherichia coli. Cells of the challenge bacteria were treated with either low or high PL doses. Survivors of the PL treatment were enumerated, isolated, regrown, and exposed again to PL treatment. PL inactivation curves were generated for the survivors of each exposure cycle (as well as controls) to examine possible differences induced by repeated treatments. Growth curves of L. monocytogenes, L. innocua, and E. coli isolates recovered from exposure to either 1.1 or 10.1 J/cm(2) were not significantly different from the growth curves of untreated cells. Reduction levels of up to 4 and up to 6 log CFU were obtained after exposure to 1.1 and 10.1 J/cm(2), respectively, both for the controls and the repeatedly treated and recovered isolates. These results show that PL did not significantly change the growth kinetics or resistance to PL of the target microorganisms after up to 10 exposures. These findings have significance for the practical application of PL treatment, as they indicate that this technology does not select for microorganisms with increased resistance.

Effect of micro- and nanoscale topography on the adhesion of bacterial cells to solid surfaces.

Attachment and biofilm formation by bacterial pathogens on surfaces in natural, industrial, and hospital settings lead to infections and illnesses and even death. Minimizing bacterial attachment to surfaces using controlled topography could reduce the spreading of pathogens and, thus, the incidence of illnesses and subsequent human and financial losses. In this context, the attachment of key microorganisms, including Escherichia coli, Listeria innocua, and Pseudomonas fluorescens, to silica and alumina surfaces with micron and nanoscale topography was investigated. The results suggest that orientation of the attached cells occurs preferentially such as to maximize their contact area with the surface. Moreover, the bacterial cells exhibited different morphologies, including different number and size of cellular appendages, depending on the topographical details of the surface to which they attached. This suggests that bacteria may utilize different mechanisms of attachment in response to surface topography. These results are important for the design of novel microbe-repellant materials.

Amplification of oral streptococcal DNA from human incisors and bite marks.

Challenges to the evidentiary value of morphometric determinations have led to a requirement for scientifically substantiated approaches to the forensic analysis of bite marks. Human teeth support genotypically distinctive populations of bacteria that could be exploited for forensic purposes. This study explored the feasibility of directly amplifying bacterial DNA from bite marks for comparison with that from teeth. Samples from self-inflicted experimental bite marks (n = 24) and human incisors were amplified by PCR using primers specific for streptococcal 16S ribosomal DNA. Amplicon profiles (resolved by denaturing gradient gel electrophoresis) from bite mark samples aligned significantly more closely with profiles generated from the teeth responsible than with those from other teeth. Streptococcal amplicons were generated from dental samples applied to excised porcine skin for up to 48 h. These findings indicate that streptococcal DNA can be amplified directly from bite marks, and have potential application in bite mark analysis.

Molecular basis of ChvE function in sugar binding, sugar utilization, and virulence in Agrobacterium tumefaciens.

ChvE is a chromosomally encoded protein in Agrobacterium tumefaciens that mediates a sugar-induced increase in virulence (vir) gene expression through the activities of the VirA/VirG two-component system and has also been suggested to be involved in sugar utilization. The ChvE protein has homology to several bacterial periplasmic sugar-binding proteins, such as the ribose-binding protein and the galactose/glucose-binding protein of Escherichia coli. In this study, we provide direct evidence that ChvE specifically binds the vir gene-inducing sugar d-glucose with high affinity. Furthermore, ChvE mutations resulting in altered vir gene expression phenotypes have been isolated and characterized. Three distinct categories of mutants have been identified. Strains expressing the first class are defective in both virulence and d-glucose utilization as a result of mutations to residues lining the sugar-binding cleft. Strains expressing a second class of mutants are not adversely affected in sugar binding but are defective in virulence, presumably due to impaired interactions with the sensor kinase VirA. A subset of this second class of mutants includes variants of ChvE that also result in defective sugar utilization. We propose that these mutations affect not only interactions with VirA but also interactions with a sugar transport system. Examination of a homology model of ChvE shows that the mutated residues associated with the latter two phenotypes lie in two overlapping solvent-exposed sites adjacent to the sugar-binding cleft where conformational changes associated with the binding of sugar might have a maximal effect on ChvE's interactions with its distinct protein partners.

Bridging the partisan divide: Self-affirmation reduces ideological closed-mindedness and inflexibility in negotiation.

Three studies link resistance to probative information and intransigence in negotiation to concerns of identity maintenance. Each shows that affirmations of personal integrity (vs. nonaffirmation or threat) can reduce resistance and intransigence but that this effect occurs only when individuals' partisan identity and/or identity-related convictions are made salient. Affirmation made participants' assessment of a report critical of U.S. foreign policy less dependent on their political views, but only when the identity relevance of the issue rather than the goal of rationality was salient (Study 1). Affirmation increased concession making in a negotiation over abortion policy, but again this effect was moderated by identity salience (Studies 2 and 3). Indeed, although affirmed negotiators proved relatively more open to compromise when either the salience of their true convictions or the importance of remaining faithful to those convictions was heightened, the reverse was true when the salient goal was compromise. The theoretical and applied significance of these findings are discussed.

Altered orbitofrontal sulcogyral pattern in schizophrenia.

Orbitofrontal alteration in schizophrenia has not been well characterized, likely due to marked anatomical variability. To investigate the presence of such alterations, we evaluated the sulcogyral pattern of this 'H-shaped' sulcus. Fifty patients with schizophrenia (100 hemispheres) and 50 age- and gender-matched control subjects (100 hemispheres) were evaluated using 3D high-spatial resolution MRI. Based on a previous study by Chiavaras and Petrides (2000), the sulcogyral pattern of the 'H-shaped' sulcus, which forms the boundaries of major orbitofrontal gyri, was classified into three types (Type I, II and III, in order of frequency) within each hemisphere. Chi-square analysis was performed to compare the sulcogyral pattern, and categorical regression was applied to investigate clinical/cognitive associations. The control data replicated the orbitofrontal sulcogyral pattern reported by Chiavaras and Petrides (P = 0.90-0.95), where the distribution was significantly different between the left and right hemisphere (Type I: right > left, Type II, III: left > right, chi2 = 6.41, P = 0.041). For schizophrenics, the distribution differed significantly from controls (chi2 = 11.90, P = 0.003), especially in the right hemisphere (chi2 = 13.67, P = 0.001). Moreover, the asymmetry observed in controls was not present in schizophrenia (chi2 = 0.13, P = 0.94). Specifically, the most frequent Type I expression was decreased and the rarest Type III expression was increased in schizophrenia, relative to controls. Furthermore, patients with Type III expression in any hemisphere evinced poorer socioeconomic status, poorer cognitive function, more severe symptoms and impulsivity, compared to patients without Type III expression. In contrast, patients with Type I in any hemisphere showed better cognitive function and milder symptoms compared to patients without Type I. Structurally, patients with Type III had significantly smaller intra-cranial contents (ICC) volumes than did patients without Type III (t(40) = 2.29, P = 0.027). The present study provides evidence of altered distribution of orbitofrontal sulcogyral pattern in schizophrenia, possibly reflecting a neurodevelopmental aberration in schizophrenia. Such altered sulcogyral pattern is unlikely to be due to secondary effects of the illness such as medication. Moreover, the structural association between Type III and small ICC volume, observed in the patient group, may suggest that Type III expression could be part of a systematic neurodevelopmental alteration, given that the small ICC volume could reflect early reduction of cranial growth driven by brain growth. The observed contrasting association of Type III expression with poorer outcome, and that of Type I expression with better outcome, further suggests clinical heterogeneity, and possible differences in treatment responsiveness in schizophrenia.