Respiratory Morbidity and Mortality of Traumatic Cervical Spinal Injury.

BACKGROUND: Traumatic cervical spinal injuries can severely affect respiratory function and cause significant morbidity and mortality. The typical respiratory morbidity in cervical spine injury is Atelectasis, Ventilator-associated pneumonia, acute respiratory distress syndrome and delayed weaning, etc. The study aims to see the prevalence of respiratory morbidity as well as mortality associated with cervical spine injury. METHODS: Cross sectional study based on retrospective data was conducted on the X Sciences with the existing hospital record during the period of 3 years to find out the prevalence respiratory morbidity like Ventilatory Associated Pneumonia, delayed weaning, ARDS, atelectasis of traumatic cervical spine injury, determine the prevalence, type, and impact of respiratory morbidity and mortality in this population. RESULTS: Total no 76 patients data meeting the inclusion criteria included in study. Male patients were more prone to develop traumatic cervical spinal injuries (SCI). The prevalence of respiratory morbidity in term of VAP(57.89), delayed weaning(46.05) and Atelectasis(22.36) was high. Patients with Asia A Neurology has higher association for VAP and delayed weaning, while Asia E Neurology patients had no respiratory morbidity. The study found a significant positive association between respiratory morbidity with hospital stay, and ventilator days (p-value: 0.019 and 0.048). A total of 15 patients died, 28.95% were discharged on request and 40.8% leaving the hospital against medical advice. CONCLUSIONS: The prevalence of respiratory morbidity higher in cervical spine injury. Furthermore, it has associated with prolonged ICU and ventilator days and increase in mortality.

The role of gender differences in the outcome of juvenile social isolation: Emphasis on changes in behavioral, biochemical and expression of nitric oxide synthase genes alteration.

Social isolation can cause serious problem in performance of individuals in community. As gender differences may cause variation results in the severity of depressive behavior and response of patients to therapy, the impact of gender and the interaction of the level of endocrine secretion in depression were investigated in this study. Wistar rats of both sexes were subjected to post-weaning social isolation (PWSI) conditions and, together with the control group, experienced several behavioral tests including open-field Test (OFT), elevated plus maze (EPM), force swimming test (FST), splash test and novel object recognition test (NOR). Hippocampal tissue was isolated to measure biochemical factors such as nitric oxide level, FRAP amount, MDA level. In addition, real-time-PCR test was used to quantify the genes expression level of inducible nitric oxide synthase (iNOS) and neuronal nitric oxide synthase (nNOS). On the other hand, sexual hormone levels in blood were measured. Both cognitive and behavioral f unctions were declined as the result of PWSI induction in male and diestrus female rats. The consequent surge of estradiol during estrous phase seems to suppress the accumulation of reactive oxygen species (ROS), and modulate iNOS and nNOS expression. In conclusion, while the pattern of PWSI in surge cellular antioxidants, raising cellular ROS level is gender-specific, this alleviation was in relation with the drop of estradiol and unrelated with testosterone level.

Comparison of the effects of zinc oxide and zinc aspartic acid chelate on the performance of weaning pigs.

In this research, the growth efficiency, nutritional utilization, fecal microbial levels, and fecal score of weaned pigs were evaluated using therapeutic zinc oxide (ZnO) and zinc aspartic acid chelate (Zn-Asp). In a 42-day feeding trial, 60 weaned pigs ([Yorkshire × Landrace] × Duroc) were arbitrarily allotted (age: 21 days; 7.01 ± 0.65 kg preliminary body weight) to 3 different treatment groups with 5 repetitions (2 male and 2 female piglets) in each pen. The trial had 2 different phases, including 1-21 days as phase 1, and 22-42 days as phase 2. The nutritional treatments were: basal diet as control (CON), basal diet incorporated with 3,000 ppm ZnO as TRT1, and basal diet incorporated with 750 ppm Zn-Asp as TRT2. In comparison to the CON group, the pigs in the TRT1 and TRT2 groups had greater (p < 0.05) body weight on day 42; an average daily gain, and an average daily feed intake on days 22-42. Furthermore, during days 1-42, the average daily gain in the treatment groups trended higher (p < 0.05) than in the CON group. Additionally, the fecal score decreased (p < 0.05) at week 6, the lactic acid bacteria count tended to increase (p < 0.05), and coliform bacteria presented a trend in reduction (p < 0.05) in the TRT1 and TRT2 groups compared to the CON group. However, there was no difference in nutrient utilization (p > 0.05) among the dietary treatments. Briefly, the therapeutic ZnO and Zn-Asp nutritional approaches could decrease fecal score and coliform bacteria, increase lactic acid bacteria, and improve growth efficiency; moreover, Zn-Asp (750 ppm) can perform a comparable role to therapeutic ZnO (3,000 ppm). So we can use Zn-Asp (750 ppm) instead of therapeutic ZnO (3,000 ppm) for the better performance of weaning pigs and the reduction of environmental pollution, as therapeutic ZnO is responsible for environmental pollution.

A Simplified Protocol for Tracheostomy Decannulation in Patients Weaned off Prolonged Mechanical Ventilation.

Introduction The criteria for the removal of the tracheostomy tube (decannulation) vary from center to center. Some perform an endoscopic evaluation under anesthesia or computed tomography, which adds to the cost and discomfort. We use a simple two-part protocol to determine the eligibility and carry out the decannulation: part I consists of airway and swallowing assessment through an office-based flexible laryngotracheoscopy, and part II involves a tracheostomy capping trial. Objective The primary objective was to determine the safety and efficacy of the simplified decannulation protocol followed at our center among the patients who were weaned off the mechanical ventilator and exhibited good swallowing function clinically. Methods Of the patients considered for decannulation between November 1st, 2018, and October 31st, 2020, those who had undergone tracheostomy for prolonged mechanical ventilation were included. The efficacy to predict successful decannulation was calculated by the decannulation rate among patients who had been deemed eligible for decannulation in part I of the protocol, and the safety profile was defined by the protocol's ability to correctly predict the chances of risk-free decannulation among those submitted to part II of the protocol. Results Among the 48 patients included (mean age: 46.5 years; male-to-female ratio: 3:1), the efficacy of our protocol in predicting the successful decannulation was of 87.5%, and it was was safe or reliable in 95.45%. Also, in our cohort, the decannulation success and the duration of tracheotomy dependence were significantly affected by the neurological status of the patients. Conclusion The decannulation protocol consisting of office-based flexible laryngotracheoscopy and capping trial of the tracheostomy tube can safely and effectively aid the decannulation process.

Assessment of breast-feeding and weaning practices of under-fives and their associated co-morbidities in urban and rural areas of Ahmedabad City, Gujarat, India.

Introduction: Shaping up the post-2015 development agenda is of crucial importance in the development process around the Globe as 20151 was the last year of milllenium development goals. It is the right time to asses our own progress vis-a-vis the Millennium development goals. Appropriate feeding and weaning practices are the key contributor for decreasing morbidities and mortalities in under-five children. As per national family health survey-5 (NFHS-5), only 55.8% of the Indian infants between 0 and 6 months were exclusively breastfed in Gujarat. Children age 6-8 months receiving solid or semi-solid food and breast milk were only 49.4% in Gujarat. Only 5.8% of breastfeeding infants aged 6-23 months receive an adequate diet in Gujarat. Hence the following study was done to know the practice of breastfeeding and weaning in mothers of urban and rural area of Ahmedabad city, Gujarat. Objective: The primary objective of this study was to describe the breastfeeding and newborn care practices and the factors affecting the initiation and duration of breastfeeding in urban and rural areas of Ahmedabad city, Gujarat and the secondary objective was to describe the comorbidities associated with them. Methods: Cross-sectional study was done in anganwadis of slums of urban and rural field practice area of B.J. Medical College, Ahmedabad. Results: Half of the under-five children were provided jaggery as pre-lacteal feed both in urban (45%) and rural (53%) area. In urban area most common reason for providing pre lacteal feeds was due to family customs (55%) followed by their belief that it leads to help in removal of meconium from gut (22%) followed by as advised from their relatives (23%) as compared to in rural area where there was belief that it leads to help in removal of meconium from gut (52%) followed by family customs (31%) and advise from relatives (17%). There were 7.5% under-five children in urban area in whom breastfeeding was not initiated immediately compared to rural area in which there were 42% under-five children. Conclusion: Frequent occurrence of acute illness among under-fives may have lead to undernutrition.

Effects of supplementing direct-fed microbials on health and growth of pre-weaning Gyr × Holstein dairy calves.

This study aimed to evaluate the effects of direct-fed microbials (DFM) on health and growth responses of pre-weaning Bos indicus × B. taurus (Gyr × Holstein) crossbred calves. Ninety newborn heifer calves [initial body weight (BW) 35 ± 4.0 kg] were used. At birth, calves were ranked by initial BW and parity of the dam and assigned to: 1) whole milk without DFM supplementation (CON; n = 30), 2) whole milk with the addition of 1.0 g/calf per day of a Bacillus-based DFM (BAC; n = 30), or 3) whole milk with the addition of 1.0 g/calf per day of BAC and 1.2 g/calf per day of Enterococcus faecium 669 (MIX; n = 30). Milk was fed individually during the study (77 d) and the BAC and MIX treatments were offered daily throughout the 77-d pre-weaning period. All calves were offered a starter supplement and corn silage starting on d 1 and 60 of age, respectively. Milk and starter supplement intake were evaluated daily, and BW was recorded on d 0 and at weaning (d 77). Diarrhea and pneumonia were assessed daily, and fecal samples were collected on d 0, 7, 14, 21, and at weaning (d 77) for assessment of the presence of bacterial and protozoal pathogens via qPCR. All data were analyzed using SAS (v. 9.4) with calf as the experimental unit and using single-df orthogonal contrasts (BAC + MIX vs. CON; BAC vs. MIX). Daily feeding of DFM, regardless of type, improved weaning BW. Odds ratio for occurrence of pneumonia was lower for DFM-supplemented calves, but occurrence of both did not differ between BAC and MIX calves. No Salmonella spp. or E. coli F41 were detected in any of the calves. The proportion of calves positive for E. coli F17 was greater for DFM calves on d 7 (92 and 96% vs. 81% for BAC, MIX, and CON, respectively), 21 (13 and 26% vs. 7% for BAC, MIX, and CON, respectively), and at weaning (48 and 35% vs. 22% for BAC, MIX, and CON, respectively). For C. difficile, more DFM calves were positive on d 7 (65 and 30% vs. 35% for BAC, MIX, and CON, respectively) and 14 (20 and 28% vs. 7% for BAC, MIX, and CON, respectively), but also greater for BAC vs. MIX on d 7. More CON calves were positive for C. perfringens on d 14 (14% vs. 3 and 8% for CON, BAC, and MIX, respectively) compared with DFM-fed calves. Incidence of calves positive for C. perfringens was greater in BAC vs. MIX on d 7 (50 vs. 18%), and greater for MIX vs. BAC at weaning (9 vs. 0%). For protozoa occurrence, a lower proportion of DFM calves were positive for Cryptosporidium spp. on d 7 (58 and 48% vs. 76% for BAC, MIX, and CON, respectively), but opposite results were observed on d 21 for Cryptosporidium spp. (3 and 11% vs. 0% for BAC, MIX, and CON, respectively) and Eimeria spp. on d 14 (7 and 8% vs. 0% for BAC, MIX, and CON, respectively) and 21 (50 and 59% vs. 38% for BAC, MIX, and CON, respectively). In summary, DFM feeding alleviated the occurrence of pneumonia, improved growth rates, while also modulating the prevalence of bacteria and protozoa in pre-weaning Gyr × Holstein calves.

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.

Contextual design requirements for decision-support tools involved in weaning patients from mechanical ventilation in intensive care units.

Weaning patients from ventilation in intensive care units (ICU) is a complex task. There is a growing desire to build decision-support tools to help clinicians during this process, especially those employing Artificial Intelligence (AI). However, tools built for this purpose should fit within and ideally improve the current work environment, to ensure they can successfully integrate into clinical practice. To do so, it is important to identify areas where decision-support tools may aid clinicians, and associated design requirements for such tools. This study analysed the work context surrounding the weaning process from mechanical ventilation in ICU environments, via cognitive task and work domain analyses. In doing so, both what cognitive processes clinicians perform during weaning, and the constraints and affordances of the work environment itself, were described. This study found a number of weaning process tasks where decision-support tools may prove beneficial, and from these a set of contextual design requirements were created. This work benefits researchers interested in creating human-centred decision-support tools for mechanical ventilation that are sensitive to the wider work system.

Dietary tryptophan improves growth and intestinal health by promoting the secretion of intestinal ß-defensins against enterotoxigenic E. coli F4 in weaned piglets.

Adequate dietary L-tryptophan (Trp) governs intestinal homeostasis in piglets. However, the defensive role of Trp in the diet against enterotoxigenic E. coli F4 (K88) in pigs is still poorly understood. Here, sixty (6.15 ± 1.52 kg, 24-day-old, Duroc × Landrace × Yorkshire) weaned piglets were used for an E. coli F4 attack test in a 2 × 2 factorial design. The growth (ADG, ADFI, GH), immune factors (IL-10, IgA, IgG, IgM), Trp metabolite 5-HT, intestinal morphology (jejunal and colonic VH), mRNA expression of ß-defensins (jejunal BD-127, BD-119, ileal BD-1, BD-127), and abundance of beneficial microorganisms in the colon (Prevotella 9, Lactobacillus, Phascolarctobacterium, Faecalibacterium) were higher in the piglets in the HT (High Trp) and HTK (High Trp, K88) groups than in the LT (Low Trp) and LTK (Low Trp, K88) groups (P < 0.05), while FCR, diarrhea rate, diarrhea index, serum Trp, Kyn, IDO, D-LA, ET, and abundance of harmful microorganisms in the colon (Spirochaetes, Fusobacteria, Prevotella, Christensenellaceae R7) were lower in the HT and HTK groups than in the LT and LTK groups (P < 0.05). High Trp reduced the expression of virulence genes (K88 and LT) after E. coli F4 attack (P < 0.05). The IL-6, TNF-α was lower in the HTK group than in the LT, LTK group (P < 0.05). In short, a diet containing 0.35% Trp protected piglets from enterotoxigenic E. coli F4 (K88) via Trp metabolism promoting BD expression in the intestinal mucosa, which improved growth and intestinal health.

[Curriculum "Tracheostomy management in dysphagia therapy"]. / Curriculum "Trachealkanülenmanagement in der Dysphagietherapie".

The number of tracheotomized patients with dysphagia and their need for treatment are continuously increasing in clinical and community settings. The revised version of the directive on home care and community-based intensive care of the Federal Joint Committee (G-BA) requires that tracheotomized patients are regularly evaluated with the aim of identifying and promoting the therapeutic potential after hospital discharge. Dysphagia treatment plays a crucial role as without improvement of severe dysphagia there is practically no possibility for decannulation. Tracheotomized patients with dysphagia are treated by speech and language therapists (SLT); however, the contents of tracheostomy management (TM) are not obligatory in the speech and language therapeutic training curricula, so that there is a need for further education and treatment standards must be secured. Therefore, the German Interdisciplinary Society for Dysphagia (DGD) in cooperation with the participating German medical and therapeutic societies developed a postgraduate curriculum for TM. This should serve as the basis for contents in TM and qualification of therapists within the framework of the delegation of medical services. The goals of the TM curriculum are the definition of theoretical and practical contents of TM, the qualification to perform TM according to current standards of care and quality assurance. The curriculum defines two qualification levels (user and trainer), entry requirements, curricular contents, examination and qualification criteria as well as transitional regulations for SLTs already experienced in TM.

Exploring the Efficacy of Midodrine for Tapering Off Vasopressors.

Sepsis and septic shock represent critical conditions, often necessitating vasopressor support in the intensive care unit (ICU). Midodrine, an oral vasopressor, has gathered attention as a potential adjunct to vasopressor therapy, aiming to facilitate weaning and improve clinical outcomes. However, the efficacy of midodrine remains questionable, with conflicting evidence from clinical trials and meta-analyses. This article provides a comprehensive review of the literature on midodrine's role in ICU settings by gathering evidence from multicenter trials, retrospective studies, and meta-analyses. While some studies suggest a limited benefit of midodrine in expediting vasopressor weaning and reducing ICU/hospital stays, others report potential advantages, particularly in reducing mortality rates among septic shock patients. Ongoing efforts aim to address knowledge gaps surrounding midodrine's efficacy and safety.

Development and validation of a clinical prediction model for early ventilator weaning in post-cardiac surgery.

Background: Weaning patients from mechanical ventilation is a critical clinical challenge post cardiac surgery. The effective liberation of patients from the ventilator significantly improves their recovery and survival rates. This study aimed to develop and validate a clinical prediction model to evaluate the likelihood of successful extubation in post-cardiac surgery patients. Method: A predictive nomogram was constructed for extubation success in individual patients, and receiver operating characteristic (ROC) and calibration curves were generated to assess its predictive capability. The superior performance of the model was confirmed using Delong's test in the ROC analysis. A decision curve analysis (DCA) was conducted to evaluate the clinical utility of the nomogram. Results: Among 270 adults included in our study, 107 (28.84%) experienced delayed extubation. A predictive nomogram system was derived based on five identified risk factors, including the proportion of male patients, EuroSCORE II, operation time, pump time, bleeding during operation, and brain natriuretic peptide (BNP) level. Based on the predictive system, five independent predictors were used to construct a full nomogram. The area under the curve values of the nomogram were 0.880 and 0.753 for the training and validation cohorts, respectively. The DCA and clinical impact curves showed good clinical utility of this model. Conclusion: Delayed extubation and weaning failure, common and potentially hazardous complications following cardiac surgery, vary in timing based on factors such as sex, EuroSCORE II, pump duration, bleeding, and postoperative BNP reduction. The nomogram developed and validated in this study can accurately predict when extubation should occur in these patients. This tool is vital for assessing risks on an individual basis and making well-informed clinical decisions.

Reducing Airway Occlusion Time Without Losing Accuracy to Predict Successful Mechanical Ventilator Liberation During the Measurement of the Timed Inspiratory Effort Index.

BACKGROUND: In 2013, a new predictor of successful mechanical ventilation liberation named timed inspiratory effort (TIE) index was devised with the normalization of the maximum inspiratory pressure (obtained within 60 s of unidirectional airway occlusion) with the time at which the value was reached. The aim of this study was to verify whether the presence of a sequence of a certain number of inspiratory effort values between 30-60 s > 1.0 cm H2O/s could predict weaning success in a performance comparable to the TIE index. METHODS: This was a retrospective observational study using 4 databases of previous studies on the TIE index. All patients receiving mechanical ventilation for ≤ 24 h were eligible. Liberation from mechanical ventilation-extubation decisions was made based on performance with spontaneous breathing trials. P < .05 was considered significant. The performance of the TIE index was evaluated by calculating the area under the receiver operating characteristics (AUROC) curve. RESULTS: From 349 eligible patients, 165 subjects were selected for analysis. The AUROC for the TIE index in the studied sample was 0.92 (95% CI 0.87-0.97, P < .001). A sequence of ≤ 4 inspiratory efforts > 1.0 cm H2O/s was found in 51.5% of the subjects, with successful ventilatory liberation occurring in 95.3%. The highest specificity values belonged to the sequence of ≤ 4 and ≤ 5 inspiratory efforts > 1.0 cm H2O/s; the highest positive predictive value and positive likelihood ratio belonged to the sequence of ≤ 4 inspiratory efforts > 1.0 cm H2O/s. The mean time that could have been spared if the procedure were interrupted after the first sequence of 4 inspiratory efforts > 1.0 cm H2O/s was 23 ± 3 s. CONCLUSIONS: The presence of a sequence of ≤ 4 inspiratory efforts > 1.0 cm H2O/s during the TIE index measurement was a reliable predictor of weaning success, which could allow timely interruption of the procedure and entail a substantial reduction in airway occlusion time.

Weaning strategies for children on home invasive mechanical ventilation.

Children who require home mechanical ventilation (HMV) with an artificial airway or invasive mechanical ventilation (HMV) have a possibility of successful weaning due to the potential of compensatory lung growth. Internationally accepted guidelines on how to wean from HMV in children is not available, we summarize the weaning strategies from the literature reviews combined with our 27-year experience in the Pediatric Home Respiratory Care program at the tertiary care center in Thailand. The readiness to wean is considered in patients with hemodynamic stability, having effective cough measured by maximal inspiratory pressure, requiring a fraction of inspired oxygen (FiO2) < 40%, positive end expiratory pressure <5 cmH2O, and acceptable arterial blood gases. The strategies of weaning is start weaning during the daytime while the child is awake and close monitoring is feasible. Disconnect time is gradually increased through naps and sleeping hours. Weaning from the conventional mechanical ventilator to Bilevel PAP or CPAP are optional. Factors affected the successful weaning are mainly the underlying diseases, complications, growth and development, caregivers, and resources. Weaning should be stopped during acute illness or increased work of breathing. The readiness for decannulation could be determined by using the speaking devices, tracheostomy capping, and measurement of end-expiratory pressure. Polysomnography and airway evaluation by bronchoscopy are recommended before decannulation. Weaning when the child is ready is crucial because living with HMV can be challenging and stressful. Failure to remove a tracheostomy when indicated can result in delayed speech, social problems as well as risk for infection.

Author Response.

How to cite this article: Ramaswamy A, Kumar R, Ish P, Gupta N. Author Response. Indian J Crit Care Med 2024;28(4):405.

Evaluation of the Effectiveness of Teduglutide Treatment in Patients with Short Bowel Syndrome in Slovakia-Multicenter Real-World Study.

(1) Background: We present the first real-world-data study on teduglutide-treated SBS patients in the Slovak Republic and the first study to enable the comparison of the effects of teduglutide treatment between the adult and pediatric populations. (2) Methods: This was a non-interventional retrospective cohort study of adult and pediatric SBS patients treated with teduglutide. Primary and secondary endpoints were the results of teduglutide use at 12 weeks and 6 months after the initiation of treatment, compared to baseline. (3) Results: Teduglutide treatment led to a statistically significant reduction in the volume of intravenous hydration, HPN caloric intake, HPN and intravenous hydration applications per week and to increased urine output in adult patients. The results in the pediatric population were similar, but not statistically significant. A complete weaning off HPN was achieved in 57.14% of all patients (50.00% of children; 62.50% of adults) after a median of 0.99 years of teduglutide treatment (1.07 and 0.98 years for children and adults, respectively). (4) Conclusions: Teduglutide treatment in SBS patients leads to considerable reduction in or even weaning off PN in both pediatric and adult patients.

Using Artificial Intelligence to Predict Mechanical Ventilation Weaning Success in Patients with Respiratory Failure, Including Those with Acute Respiratory Distress Syndrome.

The management of mechanical ventilation (MV) remains a challenge in intensive care units (ICUs). The digitalization of healthcare and the implementation of artificial intelligence (AI) and machine learning (ML) has significantly influenced medical decision-making capabilities, potentially enhancing patient outcomes. Acute respiratory distress syndrome, an overwhelming inflammatory lung disease, is common in ICUs. Most patients require MV. Prolonged MV is associated with an increased length of stay, morbidity, and mortality. Shortening the MV duration has both clinical and economic benefits and emphasizes the need for better MV weaning management. AI and ML models can assist the physician in weaning patients from MV by providing predictive tools based on big data. Many ML models have been developed in recent years, dealing with this unmet need. Such models provide an important prediction regarding the success of the individual patient's MV weaning. Some AI models have shown a notable impact on clinical outcomes. However, there are challenges in integrating AI models into clinical practice due to the unfamiliar nature of AI for many physicians and the complexity of some AI models. Our review explores the evolution of weaning methods up to and including AI and ML as weaning aids.

Incidence of Weaning Failure in Obese Patients in Intensive Care Unit.

Background The escalating prevalence of obesity worldwide presents unique challenges in critical care management, especially in the context of mechanical ventilation and weaning processes in intensive care units (ICUs). The present study aimed to determine the incidence of weaning failure in obese patients in an ICU. Methods A prospective observational study was carried out to gather data on patients in the ICU of Shifa International Hospital located in Islamabad, Pakistan. The target population consisted of adult patients who were both male and female, ages 18 years and above. These individuals required intubation procedures as well as mechanical ventilation during their hospitalization. The researchers followed these patients prospectively and observed their medical conditions closely to gather data about how obesity might impact critical care interventions and outcomes. Results The sample size was 288 bearing a median age of 61.0 with an interquartile range of 19 years. Older age manifested a significantly higher frequency of failed extubation (p=0.065). Higher body mass index (BMI) was significantly associated with failed extubation among the study population. It was found that a higher significant difference was associated with BMI > 30 kg/m2 (obese) in failed and successful extubation. One-half of the patients with failed extubation and only 16 (5.9%) patients with successful extubation had end-stage renal disease (p<0.001). It was found that patients who underwent failed extubation had notably increased ICU mortality (p=0.108), 28-day mortality (p=0.067), as well as mean ICU (p<0.001) and hospital stay (p=0.007). Conclusion Our study revealed some insightful correlations between obesity, age, comorbidities, length of hospitalization, ICU stay, and mortality rate in terms of weaning failure among the study population.

Effects of milk replacer powder added to pasteurized whole milk over different durations on dairy calves fed ground starter diet with alfalfa hay.

Adding milk replacer powder (MRP) to whole milk during the entire preweaning period can increase growth but raises concern because of low starter feed intake and slumps in average daily gain (ADG) at weaning and postweaning. In the current study, effects of adding MRP to pasteurized whole milk (PWM) during d 10-41 or d 10-59 of age were investigated in comparison with PWM. Calves [24 females and 21 males; 39.8 ± 1.85 kg body weight (BW)] were randomly allocated to 1 of 3 treatments: 1) conventional protocol, 5 L/d PWM from d 3-56, and 2.5 L/d from d 57-59 of age (CONV; TS intake = 31.9 kg), 2) short duration of adding MRP to PWM protocol, 5 L/d PWM from d 3-9, 5 L/d PWM + MRP (18% TS) from d 10-41, 5 L/d PWM from d 42-56, and 2.5 L/d PWM from d 57-59 (SD; TS intake = 42.3 kg), 3) long duration of adding MRP to PWM protocol, 5 L/d PWM from d 3-9, 5 L/d PWM + MRP from d 10-56, 2.5 L/d PWM + MRP form d 57-59 (LD; TS intake = 47.7 kg). The osmolality of PWM and PWM + MRP was 278 and 519 mOsm/L, respectively. Calves were weaned on d 60, and the study terminated on d 75. There was a treatment × time interaction for starter intake, where intake was greater for CONV than other treatments from d 14-41 and was greater in CONV than LD during d 42-48 and d 56-62 of age. Final BW was lower in CONV calves than LD calves. Weaning BW and overall hip height were lower in CONV calves than other treatments. The CONV calves had lower ADG at d 14-27 and 35-41 and SD calves had lower ADG at d 42-48 than other treatments. Calves fed CONV treatment had lower ruminal acetate and greater propionate than SD calves during preweaning. Calves fed LD treatment had lower total volatile fatty acids and tended to have greater ruminal pH than other treatments. Calves fed CONV had greater neutrophils and neutrophils/lymphocytes ratio and lower lymphocytes than other treatments. Glucose concentration was greater for LD versus other treatments at d 56, and lower for SD versus other treatments at d 70 of study. Insulin concentration and homeostatic model assessment of insulin resistance index were greater in LD compared with other treatments during preweaning but were not different postweaning. Serum BHB was greater in CONV than other treatments. Albumin was greater for CONV versus other treatments at d 56, however, it was greater in LD-fed calves at d 70 of study. Results indicate that feeding a PWM + MRP to the calves during the entire preweaning period resulted in lower starter feed intake around weaning, but overall starter intake was similar with a greater final BW and fewer health related issues throughout the study. Shifting a PWM + MRP to the conventional whole milk at d 40 of age decreased the ADG of calves.

Spontaneous breathing trial with pressure support on positive end-expiratory pressure and extensive use of non-invasive ventilation versus T-piece in difficult-to-wean patients from mechanical ventilation: a randomized controlled trial.

BACKGROUND: The aim of this study is to assess whether a strategy combining spontaneous breathing trial (SBT) with both pressure support (PS) and positive end-expiratory pressure (PEEP) and extended use of post-extubation non-invasive ventilation (NIV) (extensively-assisted weaning) would shorten the time until successful extubation as compared with SBT with T-piece (TP) and post-extubation NIV performed in selected patients as advocated by guidelines (standard weaning), in difficult-to-wean patients from mechanical ventilation. METHODS: The study is a single-center prospective open label, randomized controlled superiority trial with two parallel groups and balanced randomization with a 1:1 ratio. Eligible patients were intubated patients mechanically ventilated for more than 24 h who failed their first SBT using TP. In the extensively-assisted weaning group, SBT was performed with PS (7 cmH2O) and PEEP (5 cmH2O). In case of SBT success, an additional SBT with TP was performed. Failure of this SBT-TP was an additional criterion for post-extubation NIV in this group in addition to other recommended criteria. In the standard weaning group, SBT was performed with TP, and NIV was performed according to international guidelines. The primary outcome criterion was the time between inclusion and successful extubation evaluated with a Cox model with adjustment on randomization strata. RESULTS: From May 2019 to March 2023, 98 patients were included and randomized in the study (49 in each group). Four patients were excluded from the intention-to-treat population (2 in both groups); therefore, 47 patients were analyzed in each group. The extensively-assisted weaning group had a higher median age (68 [58-73] vs. 62 [55-71] yrs.) and similar sex ratio (62% male vs. 57%). Time until successful extubation was not significantly different between extensively-assisted and standard weaning groups (median, 172 [50-436] vs. 95 [47-232] hours, Cox hazard ratio for successful extubation, 0.88 [95% confidence interval: 0.55-1.42] using the standard weaning group as a reference; p = 0.60). All secondary outcomes were not significantly different between groups. CONCLUSION: An extensively-assisted weaning strategy did not lead to a shorter time to successful extubation than a standard weaning strategy. Trial registration The trial was registered on ClinicalTrials.gov (NCT03861117), on March 1, 2019, before the inclusion of the first patient. https://clinicaltrials.gov/study/NCT03861117 .