High-flow nasal oxygen in infants and children for early respiratory management of pneumonia-induced acute hypoxemic respiratory failure: the CENTURI randomized clinical trial

Objective

To compare the effectiveness of early high-flow nasal cannula (HFNC) and low-flow oxygen support (LFOS) in children under 5 years with acute hypoxemic respiratory failure (AHRF) due to severe community-acquired pneumonia in low-middle-income countries.

Methods

An open-label randomized clinical trial enrolled children aged 2-59 months with AHRF due to severe community-acquired pneumonia and randomized into HFNC and LFOS. In the LFOS group, the patient received cold wall oxygen humidified by bubbling through sterile water administered through simple nasal prongs at a fixed flow rate of 2 L/min. In the HFNC group, the patient received humidified, heated (37 °C), high-flow oxygen at a flow rate assigned based on weight range, with a titratable oxygen fraction. The primary outcome was treatment failure in 72 h (escalating the respiratory support method using any modality other than primary intervention).

Results

Data was analyzed intention-to-treat (HFNC = 124; LFOS = 120). Median (IQR) age was 12 (6-20) and 11 (6-27) months, respectively. Treatment failure occurred in a significantly lower proportion in the HFNC group (7.3%, n = 9/124) as compared to the LFOS group (20%, n = 24/120) (relative risk = 0.36, 95% CI 0.18 to 0.75; p = 0.004; adjusted hazard ratio 0.34, 95% CI 0.16 to 0.73; p = 0.006). The intubation rate was significantly lower in the HFNC group (7.3%, n = 9/124 vs. 16.7%, n = 20/120; relative risk = 0.44, 95% CI 0.21 to 0.92, p = 0.023). There were no significant differences noted in other secondary outcomes. No mortality occurred.

Conclusion

High-flow nasal cannula oxygen therapy used as early respiratory support in children under 5 years with acute hypoxemic respiratory failure due to severe community-acquired pneumonia was associated with significantly lower treatment failure compared with standard low-flow oxygen support.

Trial registration

CTRI/2016/04/006788. Registered 01 April 2016, https://ctri.nic.in/Clinicaltrials/advsearch.php.

Supplementary Information

The online version contains supplementary material available at 10.1007/s44253-024-00031-8.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Novel TBXAS1 variants in two Indian children with Ghosal hematodiaphyseal dysplasia: A concise report

Ghosal hematodiaphyseal dysplasia (GHDD) is a rare, autosomal recessive condition characterised by diaphyseal dysplasia of long bones with defective haematopoiesis. We describe 2 such cases with clinical and radiological evidence of GHDD. Molecular analysis revealed novel variants in TBXAS1 gene in both of them. Suspicion and confirmation of this entity is crucial in cases of refractory anemia with bony deformities, as the clinical manifestations in this entity are usually well responsive to corticosteroids.

1063 Incidence, Risk Factors, and Outcomes of ARDS in Patients with SARS-CoV-2 Infection

Introduction

Many asymptomatic patients are diagnosed with SARS-CoV-2 infection on screening, which might alter their expected course of illness. We wanted to study the incidence, risk factors, and ARDS outcomes in these patients admitted to our ITU.

Method

A review of all admissions (medical, surgical, and obstetric) to our ITU from May to October 2020 was done after institutional ethics approval. Age, gender, comorbidities, admission diagnosis, APACHE II score, and in-hospital course were studied. ARDS was defined as PaO2/FiO2 ≤ 300 mmHg (with PEEP or CPAP ≥ 5 cmH2O) in the absence of cardiac failure or fluid overload. Data were analyzed using Statistical Package for Social Services (SPSS) software Version 21.0 (Armonk, NY: IBM Corp).

Results

Of the 832 cases, 119 (14.3%) had SARS-CoV-2 infection. 41 of 119 (34.4%) cases developed ARDS. Among the comorbidities studied, only hypertension (OR 2.6, 95% CI 1.0-6.2) seemed to increase ARDS odds. Patients with Severe Acute Respiratory Illness (SARI) had a higher incidence of ARDS when compared to the asymptomatic ones (P < .05). Patients with sepsis (OR 5.8, 95% CI 2.4-13.7) and APACHE II score ≥10 (OR 5, 95% CI 2.0-12.3) had higher odds of developing ARDS. Age, gender, trauma, and recent surgery did not seem to increase the risk of ARDS.

Conclusions

Even though COVID-19 patients admitted with SARI and sepsis are at a higher risk of developing ARDS, further research will be needed to predict the extent to which SARS-CoV-2 infection will influence the course of their illness.

744 A Quality Improvement Project on Timely Removal of Central Venous Catheters

Introduction

Central Line-Associated Blood Stream Infections are associated with high morbidity and mortality. It is essential to ensure quality in insertion, maintenance, and timely removal of central lines. Our ICU follows a protocol to remove unused lines after five days. We have an electronic alert system to monitor these lines, and we wanted to audit its usage and improve its efficacy.

Method

This project was designed using QI methodology and was carried out in a Level III Surgical ICU. We implemented two PDSA cycles in August and December 2020. After the first cycle, an online survey was performed among ICU doctors to gauge their knowledge of the alert system and local protocols. Based on the above results, an educational session was carried out, showing a step-by-step guide to using the alert system, and a re-audit was done in December.

Results

The first cycle showed that alerts were created for only 17 (25%) of 68 lines. Also, the survey revealed that about 30% of doctors were unfamiliar with the alert system. After the intervention, adherence to the alert system increased to 65% (alerts for 41 of 63 lines). There was also a significant improvement in the mean number of central line days from 6.4 (SD = 3.1) to 4.2 (SD = 2.8) [P <  .05].

Conclusions

It is crucial to monitor central lines, and simple educational sessions about local protocols can bring success in implementing sustainable change in quality. We suggest hospitals have systems to monitor the central lines and regularly audit their effectiveness.

Reduced rotavirus vaccine efficacy in protein malnourished human-faecal-microbiota-transplanted gnotobiotic pig model is in part attributed to the gut microbiota

The low efficacy of human rotavirus (HRV) vaccines in low- and middle-income countries (LMIC) remains a major challenge for global health. Protein-calorie malnutrition (kwashiorkor) affects the gut microbiota and compromises immune development, leading to environmental enteropathy, vaccine failures, and increased susceptibility to enteric diseases in young children. Relationship between diet and reduced vaccine efficacy in developing countries is not well established; therefore, we investigated the interconnections between the host-microbiota-nutrition-HRV vaccine using HRV-vaccinated, human infant faecal microbiota (HIFM)-transplanted neonatal gnotobiotic pigs fed with a protein deficient or sufficient diet. The microbiota from faecal, intestinal (duodenum, ileum, jejunum, and colon), and systemic tissue (liver, spleen, and mesenteric lymph node [MLN]) samples was analysed before and after HRV challenge using MiSeq 16S rRNA sequencing. Overall, microbiota from deficient fed HIFM pigs displayed, compared to the sufficient group, significantly higher Shannon index, especially in the faeces and lower intestines; higher level of Proteus and Enterococcus, and lower level of Bifidobacterium, Clostridium, and Streptococcus in the three types of samples collected (P<0.05); and higher unique operational taxonomic units (OTUs), especially in the systemic tissues. Further, the multivariate analysis between microbiota and immunologic data showed that 38 OTUs at the genus level correlated (r²≤0.5 or ≥-0.5; P<0.05) with at least one host immune response parameter (regulatory [Tregs and transforming growth factor-β], effectors [interferon (IFN)-γ⁺ CD4⁺ and CD8⁺ T cells, IFN-γ and interleukin (IL)-12], and inflammatory [tumour necrosis factor-α, IL-17 and IL-22]) and with opposite trends between diet groups. Differences described above were increased after HRV challenge. We demonstrated that a protein deficient diet affects the composition of the gut microbiota and those changes may further correlate with immune responses induced by HRV and perturbed by the deficient diet. Thus, our findings suggest that the reduced efficacy of HRV vaccine observed in Gn pig model is in part attributed to the altered microbiota composition.

Cardiolipin, conformation, and respiratory complex-dependent oligomerization of the major mitochondrial ADP/ATP carrier in yeast

The phospholipid cardiolipin has pleiotropic structural and functional roles that are collectively essential for mitochondrial biology. Yet, the molecular details of how this lipid supports the structure and function of proteins and protein complexes are poorly understood. To address this property of cardiolipin, we use the mitochondrial adenosine 5'-diphosphate/adenosine 5'-triphosphate carrier (Aac) as a model. Here, we have determined that cardiolipin is critical for both the tertiary and quaternary assembly of the major yeast Aac isoform Aac2 as well as its conformation. Notably, these cardiolipin-provided structural roles are separable. In addition, we show that multiple copies of Aac2 engage in shared complexes that are largely dependent on the presence of assembled respiratory complexes III and IV or respiratory supercomplexes. Intriguingly, the assembly state of Aac2 is sensitive to its transport-related conformation. Together, these results expand our understanding of the numerous structural roles provided by cardiolipin for mitochondrial membrane proteins.

Retention and relapse in clinical practice

Maintaining teeth in their corrected positions following orthodontic treatment can be extremely challenging. Teeth have a tendency to move back towards the original malocclusion as a result of periodontal, gingival, occlusal and growth related factors. However, tooth movement can also occur as a result of normal age changes. Because orthodontics is unable to predict which patients are at risk of relapse, those which will remain stable and the extent of relapse that will occur in the long-term, clinicians need to treat all patients as if they have a high potential to relapse. To reduce this risk, long term retention is advocated. This can be a significant commitment for patients, and so retention and the potential for relapse must form a key part of the informed consent process prior to orthodontic treatment. It is vital that patients are made fully aware of their responsibilities in committing to wear retainers as prescribed in order to reduce the chance of relapse. If patients are unable or unwilling to comply as prescribed, they must be prepared to accept that there will be tooth positional changes following treatment. There is currently insufficient high quality evidence regarding the best type of retention or retention regimen, and so each clinician's approach will be affected by their personal, clinical experience and expertise, and guided by their patients' expectations and circumstances.

Effect of antibiotic, probiotic, and human rotavirus infection on colonisation dynamics of defined commensal microbiota in a gnotobiotic pig model

We developed a gnotobiotic (Gn) pig model colonised with defined commensal microbiota (DMF) to provide a simplified and controlled system to study the interactions between intestinal commensals, antibiotics (ciprofloxacin, CIP), probiotics (Escherichia coli Nissle 1917, EcN) and virulent human rotavirus (VirHRV). The DMF included seven gut commensal species of porcine origin that mimic the predominant species in the infant gut. Gn piglets were divided into four groups: DMF control (non-treated), DMF+CIP (CIP treated), DMF+CIP+EcN (CIP/EcN treated), DMF+EcN (EcN treated) and inoculated orally with 10⁵ cfu of each DMF strain. The pig gut was successfully colonised by all DMF species and established a simplified bacterial community by post-bacteria colonisation day (PBCD) 14/post-VirHRV challenge day (PCD) 0. Overall, Bifidobacterium adolescentis was commonly observed in faeces in all groups and time points. At PCD0, after six days of CIP treatment (DMF+CIP), we observed significantly decreased aerobic and anaerobic bacteria counts especially in jejunum (P<0.001), where no DMF species were detected in jejunum by T-RFLP. Following HRV challenge, 100% of pigs in DMF+CIP group developed diarrhoea with higher diarrhoea scores and duration as compared to all other groups. However, only 33% of pigs treated with EcN plus CIP developed diarrhoea. EcN treatment also enhanced the bacterial diversity and all seven DMF species were detected with a higher proportion of Bifidobacterium longum in jejunum in the DMF+CIP+EcN group on PBCD14/PCD0. Our results suggest that EcN increased the proportion of B. longum especially in jejunum and mitigated adverse impacts of antibiotic use during acute-infectious diarrhoea. The DMF model with a simplified gut commensal community can further our knowledge of how commensals and probiotics promote intestinal homeostasis and contribute to host health.

Psychosocial Needs of Patient's Relatives and Health Care Providers in a Pediatric Critical Care Unit

OBJECTIVE

To describe the needs of relatives of children admitted to an Intensive Care Unit and compare their needs with the perspectives of doctors, nurses and administrators.

METHODS

This is a descriptive comparative study done at a tertiary care PICU from South India. A modified Critical Care Family Needs Inventory (CCFNI) (internal consistency reliability =0.93) was used to assess the needs of 35 family members, 30 nurses, 30 doctors and 30 administrators. Four needs pertaining to developing countries were included. Their responses were ranked by means and analysed by multivariate analysis of variance.

RESULTS

The responses were significantly different between the groups for 13 needs (28%) and two domain items of proximity and support. Needs of relatives correlated with doctors more strongly than with nurses (r_s = 0.80 vs. 0.68; p < 0.001). No significant difference was found between the perceived needs of family members and hospital staff for assurance, information and comfort. Both doctors and administrators underestimated the proximity needs but overestimated the support needs of relatives.

CONCLUSIONS

The CCFNI with minor modifications can be used in developing countries for assessing the needs of families of children in ICU. Making sure that the relative feels assured about the care given to the child and timely information regarding the child's condition, are the two most important domains from the perspective of family members and hospital staff. Meeting these needs might help family members to cope better and be more supportive to their critically ill child.

Awareness and practice concerning oral cancer among Ayurveda and Homeopathy practitioners in Davangere District: A speciality-wise analysis

Context:

In India, oral cancer accounts for one-third of all cancers. Early detection and immediate intervention can lead to marked reduction in the morbidity and mortality. In India, Ayurveda and homeopathy practitioners are distributed widely in rural and urban areas and are easily accessible. Until date, no assessment on their oral cancer knowledge and practice has been done.

Aims:

The present study was undertaken to evaluate the knowledge, awareness, and practice concerning oral cancer.

Subjects and Methods:

Questionnaire comprising 15 questions was distributed to 42 Ayurveda and 38 homeopathy doctors in Davangere District, Karnataka, India, assessing their oral examination habits, knowledge on the risk factors, patient education, clinical signs of the disease and its treatment.

Statistical Analysis Used:

The results were analyzed using Chi-square test.

Results:

Lesser number of the practitioners routinely examined oral mucosa (16.7% and 5.3%, respectively). Fewer advised their patients about the risk factors (2.4% and 2.6%). Less positive response was obtained for the correct method for confirmation of diagnosis (28.6% and 15.8%). Many doctors agreed that they had not undergone training in cancer institute (P = 0.29). Twenty-three (54.8%) Ayurveda and 28 (73.7%) homeopathy doctors opined that they did not have sufficient knowledge regarding early detection and prevention of oral cancer and many were desirous of receiving further information (97.6% and 84.2% respectively).

Conclusions:

This study attempts to highlight the need for improving the oral cancer knowledge and awareness among practicing Ayurveda and homeopathy doctors.

Molecular characterization and expression profile of ghrelin gene during different reproductive phases in buffalo (Bubalus bubalis)

Ghrelin, a novel motilin-related endogenous ligand for growth hormone secretagouge receptor, is implicated in various biological functions, including regulation of female reproduction. But the presence of ghrelin and its role in reproductive functions in buffalo, a species with poor reproductive efficiency, is not known. In the present study full-length ghrelin cDNA was isolated from bubaline abomasum, which encodes the entire prepropeptide of 116 amino acids. The deduced amino acid sequence of ghrelin of buffalo showed >95% and 31% identity with that of ruminants (cattle, sheep, and goat) and humans, respectively. Analysis of synonymous and nonsynonymous nucleotide substitutions in the coding region of ghrelin indicated that these sequences of different species have been under purifying selection. The 3995-bp amplicon of ghrelin gene consisting of 4 exons and 3 introns was cloned with genomic DNA from buffalo. Further, ghrelin expression was determined by quantitative real-time PCR, in situ hybridization, and immunohistochemistry in bubaline endometrial tissues at different stages of the estrous cycle and early pregnancy. Our results indicated the persistent expression of ghrelin mRNA and protein in the endometrium during stage I (day 3-5), stage II (day 6-15), and stage III (day 16-21) of the estrous cycle and also during early (~day 30-40) pregnancy. Immunohistochemistry and quantitative real-time PCR experiments indicated the relatively higher expression of ghrelin in the endometrium during stage II (day 6-15) of the estrous cycle and early pregnancy than during stage I (day 3-5) and stage III (day 16-21) of the estrous cycle, but no statistically significant difference in ghrelin expression was observed among stages. To conclude, the results of the present study indicate the persistent expression of ghrelin in the uterine endometrium throughout the estrous cycle and in early pregnancy which might be helpful in determining its role in buffalo reproduction.

Genomic analysis of between-cow variation in dermal fibroblast response to lipopolysaccharide

The innate immune response plays a major role in defense against mastitis-causing pathogens. Identification of existing variation in innate immune signaling among cows and the underlying molecular causes for the variation may help in design of new mastitis control strategies. The dermal fibroblast has been used as a model cell type to explore between-cow variation in the ability of cells to produce IL-8 in response to lipopolysaccharide (LPS) treatment, and this response appears related to an animal's ability to respond to in vivo challenge with LPS or Escherichia coli mastitis. In this study, primary dermal fibroblast cultures of cows and microarray-based genomic analysis were used to investigate the cause(s) for the variable response to LPS. Fibroblast cultures from 2 cows, one with a low response phenotype (LR(array)) and another with a high response phenotype (HR(array)), were selected from our collection of fibroblast cultures established from 88 cows. The LR(array) fibroblast culture produced approximately 5-fold less IL-8 and IL-6 protein in response to 24-h LPS treatment than the HR(array) fibroblast culture. Genomic analysis of RNA obtained from 3 replicates of the 2 cultures before and after 8-h LPS treatment revealed a combined LPS-induced differential expression of 321 transcripts, indicating the robust response capability of the fibroblast cell. Under basal conditions, the microarray analysis revealed 2-fold less expression of toll-like receptor 4 (TLR4) in the LR(array) fibroblasts compared with the HR(array) fibroblasts, and this was associated with a marked reduction in expression of genes regulated by the TLR4-MyD88-dependent and TLR4-TRIF-dependent pathways (IL-8, IL-6, SAA3, CCL20, MX1, IRF1, and ISG20). The between-culture differential expression of TLR4 was confirmed and extended by quantitative PCR analysis (QPCR) that revealed a 33-fold lower expression of TLR4 in the LR(array) fibroblast culture. After LPS treatment, the difference in TLR4 expression increased to almost 50-fold and was associated with more than 8-fold lower expression of IL-8 and IL-6. No DNA sequence variations were identified in the proximal 1,300-bp promoter region of the TLR4 gene, and microarray analysis did not reveal a molecular explanation for the reduced TLR4 expression under either basal conditions or following exposure to LPS. The attenuated innate immune response of the LR(array) fibroblast culture to LPS may be caused by reduced TLR4 receptor expression. Also, the primary dermal fibroblast cells can be used to examine underlying causes for between-cow variations in key immune response pathways.

Is orthodontic treatment without premolar extractions always non-extraction treatment?

While it is common in contemporary orthodontic and orthopaedic treatment to commence treatment for many growing patients during the mixed-dentition, the creation of anterior space, often involving the attempted distalization or holding-back of the upper and lower permanent molar teeth has been shown to commonly result in posterior space deficiencies. Although the extractions of permanent premolar teeth may have been avoided, the developing second and third permanent molars are often affected, so that third molar impaction results in many cases. This is not to say that orthodontic treatment carried-out without premolar extractions is not ideal in many cases, but on the available evidence, so-called absolute 'non-extraction' protocols should be questioned, so that both the dental profession and the public at large are not misled.

Reductions of 56Fe heavy-particle irradiation-induced deficits in striatal muscarinic receptor sensitivity by selective cross-activation/inhibition of second-messenger systems

Recent experiments have revealed radiation-induced (600 MeV/u 56Fe energetic particles) losses of sensitivity of rodent neostriatal muscarinic receptors to stimulation by cholinergic agonists that appears as reductions in oxotremorine enhancement of K(+)-evoked dopamine release. These losses were postulated to be the result of radiation-induced alterations early in phosphoinositide-mediated signal transduction. Additional findings indicated that if the ligand-receptor-G protein interface was by passed no radiation deficits were seen. In the present study, radiation-induced deficits in K(+)-evoked dopamine release were examined in perifused striatal tissue obtained from rats exposed to 0, 0.1 or 1.0 Gy of 56Fe particles (600 MeV/u). Results showed that these deficits could be reduced by co-applying combinations of various pharmacological agents that were known to have differential effects on various second messengers such as 1,4,5-inositol-trisphosphate (IP3). Combinations included oxotremorine-carbachol, and either oxotremorine or carbachol with arginine vasopressin or arachidonic acid. These results are discussed in terms of putative radiation-induced changes in receptor-containing membranes which alter receptor-G protein coupling/uncoupling.