The Profile of Early Sedation Depth and Clinical Outcomes of Mechanically Ventilated Patients in Korea.

BACKGROUND: Current international guidelines recommend against deep sedation as it is associated with worse outcomes in the intensive care unit (ICU). However, in Korea the prevalence of deep sedation and its impact on patients in the ICU are not well known. METHODS: From April 2020 to July 2021, a multicenter, prospective, longitudinal, noninterventional cohort study was performed in 20 Korean ICUs. Sedation depth extent was divided into light and deep using a mean Richmond Agitation-Sedation Scale value within the first 48 hours. Propensity score matching was used to balance covariables; the outcomes were compared between the two groups. RESULTS: Overall, 631 patients (418 [66.2%] and 213 [33.8%] in the deep and light sedation groups, respectively) were included. Mortality rates were 14.1% and 8.4% in the deep and light sedation groups (P = 0.039), respectively. Kaplan-Meier estimates showed that time to extubation (P < 0.001), ICU length of stay (P = 0.005), and death (P = 0.041) differed between the groups. After adjusting for confounders, early deep sedation was only associated with delayed time to extubation (hazard ratio [HR], 0.66; 95% confidence interval [CI], 0.55-0.80; P < 0.001). In the matched cohort, deep sedation remained significantly associated with delayed time to extubation (HR, 0.68; 95% CI, 0.56-0.83; P < 0.001) but was not associated with ICU length of stay (HR, 0.94; 95% CI, 0.79-1.13; P = 0.500) and in-hospital mortality (HR, 1.19; 95% CI, 0.65-2.17; P = 0.582). CONCLUSION: In many Korean ICUs, early deep sedation was highly prevalent in mechanically ventilated patients and was associated with delayed extubation, but not prolonged ICU stay or in-hospital death.

A shared mechanism of multidrug resistance in laboratory-evolved uropathogenic Escherichia coli.

The emergence of multidrug-resistant bacteria poses a significant threat to human health, necessitating a comprehensive understanding of their underlying mechanisms. Uropathogenic Escherichia coli (UPEC), the primary causative agent of urinary tract infections, is frequently associated with multidrug resistance and recurrent infections. To elucidate the mechanism of resistance of UPEC to beta-lactam antibiotics, we generated ampicillin-resistant UPEC strains through continuous exposure to low and high levels of ampicillin in the laboratory, referred to as Low AmpR and High AmpR, respectively. Whole-genome sequencing revealed that both Low and High AmpR strains contained mutations in the marR, acrR, and envZ genes. The High AmpR strain exhibited a single additional mutation in the nlpD gene. Using protein modeling and qRT-PCR analyses, we validated the contributions of each mutation in the identified genes to antibiotic resistance in the AmpR strains, including a decrease in membrane permeability, increased expression of multidrug efflux pump, and inhibition of cell lysis. Furthermore, the AmpR strain does not decrease the bacterial burden in the mouse bladder even after continuous antibiotic treatment in vivo, implicating the increasing difficulty in treating host infections caused by the AmpR strain. Interestingly, ampicillin-induced mutations also result in multidrug resistance in UPEC, suggesting a common mechanism by which bacteria acquire cross-resistance to other classes of antibiotics.

ClC Chloride Channels in Gram-Negative Bacteria and Its Role in the Acid Resistance Systems.

Pathogenic bacteria that colonize the human intestinal tract have evolved strategies to overcome acidic conditions when they pass through the gastrointestinal tract. Amino acid-mediated acid resistance systems are effective survival strategies in a stomach that is full of amino acid substrate. The amino acid antiporter, amino acid decarboxylase, and ClC chloride antiporter are all engaged in these systems, and each one plays a role in protecting against or adapting to the acidic environment. The ClC chloride antiporter, a member of the ClC channel family, eliminates negatively charged intracellular chloride ions to avoid inner membrane hyperpolarization as an electrical shunt of the acid resistance system. In this review, we will discuss the structure and function of the prokaryotic ClC chloride antiporter of amino acid-mediated acid resistance system.

Transposition of insertion sequences by dielectric barrier discharge plasma and gamma irradiation in the radiation-resistant bacterium Deinococcus geothermalis.

Insertion sequences (ISs) of the radiation-resistant bacterium Deinococcus geothermalis are transposed into other loci by oxidative stress through hydrogen peroxide treatment. Gamma irradiation and dielectric barrier discharge (DBD) plasma radiation are known to produce a variety of oxidative stress agents such as reactive oxygen species and reactive nitrogen species. Therefore, to determine whether the transposition of ISs was induced in D. geothermalis by both gamma irradiation and DBD plasma radiation, we selected non-pigmented mutants with disrupted target genes encoding carotenoid biosynthesis enzymes such as a phytoene synthase (dgeo_0523) and a phytoene desaturase (dgeo_0524). Different DNA-binding protein-deficient mutants exhibited novel transposition of ISs. Dps (dgeo_0257), OxyR (dgeo_1888), and the LysR (dgeo_2840) family regulator, in addition to cystine importer-disrupted and -overexpressed mutants (dgeo_1986-87 and dgeo_1985R) and wild-type D. geothermalis were tested in this study. Active IS transposition was not detected in two wild-type control species (Deinococcus radiodurans and Deinococcus radiopugnans) after phenotypic selection in gamma irradiation. Our finding demonstrated that gamma irradiation triggers the transposition of particular IS elements, especially ISDge2 and ISDge3 of the IS1 family, ISDge5 of the IS701 family, and ISDge6 of the IS5 family in wild-type strain and the Δdgeo_0257, Δdgeo_1986-87, Δdgeo_1985R, and Δdgeo_2840 mutants. Furthermore, DBD plasma radiation triggered the transposition of ISDge11 of the IS4 family in the wild-type strain; ISDge6 of the IS5 family on Δdgeo_0257, Δdgeo_1888 and Δdgeo_2840; ISDge5 of the IS701 family on Δdgeo_0257 strain.

Genome Plasticity by Insertion Sequences Learned From a Case of Radiation-Resistant Bacterium Deinococcus geothermalis.

The genome of the radiation-resistant bacterium Deinococcus geothermalis contains 19 types of insertion sequences (ISs), including 93 total transposases (Tpases) in 73 full-length ISs from the main chromosome and 2 mega plasmids. In this study, 68 ISs from the D. geothermalis genome were extracted to implicate the earlier genome before its mutation by transposition of ISs. The total size of eliminated ISs from genome was 78.85 kb. From these in silico corrections of mutation by the ISs, we have become aware of some bioinformatics factualness as follows: (1) can reassemble the disrupted genes if the exact IS region was eliminated, (2) can configure the schematic clustering of major DDE type Tpases, (3) can determine IS integration order across multiple hot spots, and (4) can compare genetic relativeness by the partial synteny analysis between D. geothermalis and Deinococcus strain S9. Recently, we found that several IS elements actively transferred to other genomic sites under hydrogen peroxide-induced oxidative stress conditions, resulting in the inactivation of functional genes. Therefore, the single species genome's mobilome study provides significant support to define bacterial genome plasticity and molecular evolution from past and present progressive transposition events.

Simplified Diagnosis of Critical Illness Polyneuropathy in Patients with Prolonged Mechanical Ventilation: A Prospective Observational Cohort Study.

BACKGROUND: Although early identification of critical illness polyneuropathy (CIP) is necessary, the established diagnostic criteria have several limitations in the intensive care unit (ICU) setting. The purpose of this study was to define simplified diagnostic criteria of CIP that best predict clinical outcomes. METHODS: This prospective, single-center study included 41 ICU patients with prolonged mechanical ventilation (≥21 days). We applied three different sets of diagnostic criteria (combining the results of the Medical Research Council (MRC) sum score and nerve conduction studies (NCS)) for CIP in order to identify the criteria with the best predictive power for clinical outcomes. RESULTS: The simplified diagnosis of CIP meeting the criteria, i.e., that the MRC sum score < 48 and amplitudes of the tibial and sural nerve < 80% of the lower limit of normal, showed the strongest association with 0 ventilator-free days at day 60 (odds ratio, 6.222; p = 0.029). CONCLUSIONS: The diagnostic criteria combining the MRC sum score and the tibial and the sural NCS were identified as the simplified criteria of CIP that best predicted the clinical outcomes. The implementation of these simplified criteria may allow for early identification of CIP in the ICU, thereby contributing to prompt interventions for patients with a poor prognosis.

Transposition of Insertion Sequences was Triggered by Oxidative Stress in Radiation-Resistant Bacterium Deinococcus geothermalis.

During an oxidative stress-response assay on a putative Dps-like gene-disrupted Δdgeo_0257 mutant strain of radiation-resistant bacterium Deinococcus geothermalis, a non-pigmented colony was observed among the normal reddish color colonies. This non-pigmented mutant cell subsequently displayed higher sensitivity to H2O2. While carotenoid has a role in protecting as scavenger of reactive oxygen species the reddish wild-type strain from radiation and oxidative stresses, it is hypothesized that the carotenoid biosynthesis pathway has been disrupted in the mutant D. geothermalis cell. Here, we show that, in the non-pigmented mutant cell of interest, phytoene desaturase (Dgeo_0524, crtI), a key enzyme in carotenoid biosynthesis, was interrupted by transposition of an ISDge7 family member insertion sequence (IS) element. RNA-Seq analysis between wild-type and Δdgeo_0257 mutant strains revealed that the expression level of ISDge5 family transposases, but not ISDge7 family members, were substantially up-regulated in the Δdgeo_0257 mutant strain. We revealed that the non-pigmented strain resulted from the genomic integration of ISDge7 family member IS elements, which were also highly up-regulated, particularly following oxidative stress. The transposition path for both transposases is a replicative mode. When exposed to oxidative stress in the absence of the putative DNA binding protein Dgeo_0257, a reddish D. geothermalis strain became non-pigmented. This transformation was facilitated by transposition of an ISDge7 family IS element into a gene encoding a key enzyme of carotenoid biosynthesis. Further, we present evidence of additional active transposition by the ISDge5 family IS elements, a gene that was up-regulated during the stationary phase regardless of the presence of oxidative stress.

Feasibility of Percutaneous Dilatational Tracheostomy with a Light Source in the Surgical Intensive Care Unit.

BACKGROUND: Although percutaneous dilatational tracheostomy (PDT) under bronchoscopic guidance is feasible in the intensive care unit (ICU), it requires extensive equipment and specialists. The present study evaluated the feasibility of performing PDT with a light source in the surgical ICU. METHODS: The study involved a retrospective review of the outcomes of patients who underwent PDT with a light source performed by a surgery resident under the supervision of a surgical intensivist in the surgical ICU from October 2015 through September 2016. During the procedure, a light wand was inserted into the endotracheal tube after skin incision. Then, the light wand and the endotracheal tube were pulled out slightly, the passage of light through the airway was confirmed, and the relevant point was punctured. RESULTS: Fifty patients underwent PDT with a light source. The average procedural duration was 14.0 ± 7.0 minutes. There were no procedure-associated deaths. Intraoperative complications included minor bleeding in three patients (6%) and paratracheal placement of the tracheostomy tube in one patient (2%); these were immediately resolved by the surgical intensivist. Two patients required conversion to surgical tracheostomy because of the difficulty in light wand insertion into the endotracheal tube and a very narrow trachea, respectively. CONCLUSIONS: PDT with a light source can be performed without bronchoscopy and does not require expensive equipment and specialist intervention in the surgical ICU. It can be safely performed by a surgical intensivist with experience in surgical tracheostomy.