Impact of a national collaborative project to improve the care of mechanically ventilated patients

This prospective quasi-experimental study from the NASAM (National Approach to Standardize and Improve Mechanical Ventilation) collaborative assessed the impact of evidence-based practices including subglottic suctioning, daily assessment for spontaneous awakening trial (SAT), spontaneous breathing trial (SBT), head of bed elevation, and avoidance of neuromuscular blockers unless otherwise indicated. The study outcomes included VAE (primary) and intensive care unit (ICU) mortality. Changes in daily care process measures and outcomes were evaluated using repeated measures mixed modeling. The results were reported as incident rate ratio (IRR) for each additional month with 95% confidence interval (CI). A comprehensive program that included education on evidence-based practices for optimal care of mechanically ventilated patients with real-time benchmarking of daily care process measures to drive improvement in forty-two ICUs from 26 hospitals in Saudi Arabia (>27,000 days of observation). Compliance with subglottic suctioning, SAT and SBT increased monthly during the project by 3.5%, 2.1% and 1.9%, respectively (IRR 1.035, 95%CI 1.007-1.064, p = 0.0148; 1.021, 95% CI 1.010-1.032, p = 0.0003; and 1.019, 95%CI 1.009-1.029, p = 0.0001, respectively). The use of neuromuscular blockers decreased monthly by 2.5% (IRR 0.975, 95%CI 0.953-0.998, p = 0.0341). The compliance with head of bed elevation was high at baseline and did not change over time. Based on data for 83153 ventilator days, VAE rate was 15.2/1000 ventilator day (95%CI 12.6-18.1) at baseline and did not change during the project (IRR 1.019, 95%CI 0.985-1.053, p = 0.2812). Based on data for 8523 patients; the mortality was 30.4% (95%CI 27.4-33.6) at baseline, and decreased monthly during the project by 1.6% (IRR 0.984, 95%CI 0.973-0.996, p = 0.0067). A national quality improvement collaborative was associated with improvements in daily care processes. These changes were associated with a reduction in mortality but not VAEs. Registration The study is registered in clinicaltrials.gov (NCT03790150).

Impact of single and mixed infections with Escherichia coli and Mycoplasma gallisepticum on Newcastle disease virus vaccine performance in broiler chickens: an in vivo perspective

AIMS

This study was designed to investigate, in an in vivo setting, the effects of single and combined infections with either Mycoplasma gallisepticum (MG) and/or Escherichia coli on the chicken immune response induced by Newcastle disease virus (NDV) vaccine.

METHODS AND RESULTS

Humoral immunity was measured through detection of NDV antibody and anti-NDV IgG titres using haemagglutination-inhibition test and enzyme-linked immunosorbent assay, respectively. In addition, the expression levels of pro-inflammatory cytokines' genes (interleukin (IL) 6, IL4 and interferon (IFN) γ) were analysed using quantitative reverse transcription PCR. Significant (P < 0·05) results in all immunological parameters were detected in the vaccinated noninfected chicken group in comparison with those in groups exposed to bacterial infections. Bacterial infection along with vaccination hampered the NDV antibodies production and reduced the vaccine upregulated cytokine genes. The vaccinated mixed infection group reported lower antibody titres and cytokines expression levels compared to those in the single infection groups. All the previously enhanced immunological parameters reflected the maximum protection post challenge with velogenic viscerotropic NDV in the vaccinated noninfected chicken group.

CONCLUSIONS

These findings provide novel insights into the immunosuppression activities of MG and E. coli infection in chickens vaccinated against NDV.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study hopes to provide a better insight to the immunosuppressive action of bacterial pathogens in chickens. This will help to improve biosecurity strategies during NDV vaccination in the future.