Antimicrobial stewardship for sepsis in the intensive care unit: Survey of critical care and infectious diseases physicians

OBJECTIVE: To evaluate the attitudes of infectious diseases (ID) and critical care physicians toward antimicrobial stewardship in the intensive care unit (ICU). DESIGN: Anonymous, cross-sectional, web-based surveys. SETTING: Surveys were completed in March-November 2017, and data were analyzed from December 2017 to December 2019. PARTICIPANTS: ID and critical care fellows and attending physicians. METHODS: We included 10 demographic and 17 newly developed, 5-point, Likert-scaled items measuring attitudes toward ICU antimicrobial stewardship and transdisciplinary collaboration. Exploratory principal components analysis (PCA) was used for data reduction. Multivariable linear regression models explored demographic and attitudinal variables. RESULTS: Of 372 respondents, 315 physicians had complete data (72% attendings, 28% fellows; 63% ID specialists, and 37% critical care specialists). Our PCA yielded a 3-item factor measuring which specialty should assume ICU antimicrobial stewardship (Cronbach standardized α = 0.71; higher scores indicate that ID physicians should be stewards), and a 4-item factor measuring value of ICU transdisciplinary collaborations (α = 0.62; higher scores indicate higher value). In regression models, ID physicians (vs critical care physicians), placed higher value on ICU collaborations and expressed discomfort with uncertain diagnoses. These factors were independently associated with stronger agreement that ID physicians should be ICU antimicrobial stewards. The following factors were independently associated with higher value of transdisciplinary collaboration: female sex, less discomfort with uncertain diagnoses, and stronger agreement with ID physicians as ICU antimicrobial stewards. CONCLUSIONS: ID and critical care physicians endorsed their own group for antimicrobial stewardship, but both groups placed high value on ICU transdisciplinary collaborations. Physicians who were more uncomfortable with uncertain diagnoses reported preference for ID physicians to coordinate ICU antimicrobial stewardship; however, physicians who were less uncomfortable with uncertain diagnoses placed greater value on ICU collaborations

Assessment of antibodies in the upper and lower human respiratory tract at steady state and after respiratory viral infection

OBJECTIVES: There is an increasing appreciation for the need to study mucosal antibody responses in humans. Our aim was to determine the utility of different types of samples from the human respiratory tract, specifically nasopharyngeal (NP) swabs obtained for diagnostic purposes and bronchoalveolar lavage (BAL) obtained in outpatient and inpatient settings. METHODS: We analysed antibody levels in plasma and NP swabs from 67 individuals with acute influenza as well as plasma and BAL from individuals undergoing bronchoscopy, including five control subjects as well as seven moderately and seven severely ill subjects with a respiratory viral infection. Levels of α2-macroglobulin were determined in BAL and plasma to assess plasma exudation. RESULTS: IgG and IgA were readily detectable in BAL and NP swabs, albeit at different ratios, while IgM levels were low. The total amount of antibody recovered from NP swabs varied greatly between study participants. Accordingly, the levels of influenza HA-specific antibodies varied, and individuals with lower amounts of total Ig in NP swabs had undetectable levels of HA-specific Ig. Similarly, the total amount of antibody recovered from BAL varied between study participants. However, severely ill patients showed evidence of increased plasma exudation, which may confound analysis of their BAL samples for mucosal antibodies. CONCLUSION: Nasopharyngeal swabs collected for diagnostic purposes may have utility in assessing antibodies from the human nasal mucosa, but variability in sampling should be accounted for. BAL samples can be utilised to study antibodies from the lower respiratory tract, but the possibility of plasma exudation should be excluded

Bleeding and thrombotic complications associated with anticoagulation prior to lung transplantation: A case series

Background: Scarce data is available on therapeutic anticoagulation (AC) in patients undergoing pulmonary transplantation. We describe our institutional experience with AC-induced coagulopathy in recipients at the time of transplantation and evaluate its impact on posttransplant outcomes. Methods: Records of adult patients on therapeutic AC at the time of lung transplantation from January 2014 to July 2021 were reviewed. Administration of preoperative pharmacologic reversal was assessed, with adequate reversal defined as international normalized ratio (INR) ≤1.5. We evaluated the incidence of major bleeding complications [delayed sternal closure, reoperation due to bleeding, chest tube output ≥1,500 cc, ≥4 units of packed red blood cells, ≥4 units of platelets, or ≥5 units of fresh frozen plasma (FFP)], major thrombotic complications [venous thromboembolism (VTE) or other major thrombosis on imaging], and inpatient mortality. Results: Of 602 lung transplant recipients, 10 patients taking preoperative warfarin were included in the study. While most patients received pharmacologic reversal preoperatively (n=9, 90%), successful reversal was rarely achieved (n=3, 30%). Inadequate INR reversal was associated with major bleeding events (n=6, 60%). Major thrombotic complications were more frequent (n=7, 70%) than bleeding events. Notably, all fatalities within the cohort (n=2, 20%) were associated with thrombotic, but not bleeding, complications. Conclusions: This is the first known report on the incidence and impact of AC-induced coagulopathy in patients undergoing lung transplantation. Major thrombotic events are frequent and associated with high mortality. Routine surveillance and treatment may be warranted

Utilizing computed tomography volumetry for size matching prior to lung transplantation: A case series

BACKGROUND: Appropriate size matching between donor and recipient is critical for successful pulmonary transplantation. Although surrogate measurements such as height and gender are often utilized to approximate predicted lung volume, these methods provide only a gross estimation with wide variability and poor predictive value. CASE DESCRIPTION: A single center exploratory study was conducted in which four patients underwent lung transplantation (LT) with pre-operative computed tomography (CT) volumetry obtained in both the donor and recipient to facilitate decision making regarding organ size and suitability. In four cases in which CT volumetry was used, the lung volumes calculated using surrogate measurements significantly overestimated both donor and recipient lung volumes quantified by CT volumetric analysis. All recipients underwent successful LT without necessary graft downsizing. CONCLUSIONS: This is an initial report of prospectively utilizing CT volumetry as an adjunct to decision-making regarding suitability of donor lungs. In these cases, CT volumetry facilitated the confident acceptance of donor lungs that were initially predicted to be oversized based on other clinical measures

Assessment of the genetic risks of a metallic alloy used in medical implants

The use of artificial implants provides a palliative or permanent solution for individuals who have lost some bodily function through disease, an accident or natural wear. This functional loss can be compensated for by the use of medical devices produced from special biomaterials. Titanium alloy (Ti-6Al-4V) is a well-established primary metallic biomaterial for orthopedic implants, but the toxicity of the chemical components of this alloy has become an issue of concern. In this work, we used the MTT assay and micronucleus assay to examine the cytotoxicity and genotoxicity, respectively, of an extract obtained from this alloy. The MTT assay indicated that the mitochondrial activity and cell viability of CHO-K1 cells were unaffected by exposure to the extract. However, the micronucleus assay revealed DNA damage and an increase in micronucleus frequency at all of the concentrations tested. These results show that ions released from Ti-6Al-4V alloy can cause DNA and nuclear damage and reinforce the importance of assessing the safety of metallic medical devices constructed from biomaterials

Comparative genomic analyses identify common molecular pathways modulated upon exposure to low doses of arsenic and cadmium

<p>Abstract</p> <p>Background</p> <p>Exposure to the toxic metals arsenic and cadmium is associated with detrimental health effects including cancers of various organs. While arsenic and cadmium are well known to cause adverse health effects at high doses, the molecular impact resulting from exposure to environmentally relevant doses of these metals remains largely unexplored.</p> <p>Results</p> <p>In this study, we examined the effects of <it>in vitro </it>exposure to either arsenic or cadmium in human TK6 lymphoblastoid cells using genomics and systems level pathway mapping approaches. A total of 167 genes with differential expression were identified following exposure to either metal with surprisingly no overlap between the two. Real-time PCR was used to confirm target gene expression changes. The gene sets were overlaid onto protein-protein interaction maps to identify metal-induced transcriptional networks. Interestingly, both metal-induced networks were significantly enriched for proteins involved in common biological processes such as tumorigenesis, inflammation, and cell signaling. These findings were further supported by gene set enrichment analysis.</p> <p>Conclusions</p> <p>This study is the first to compare the transcriptional responses induced by low dose exposure to cadmium and arsenic in human lymphoblastoid cells. These results highlight that even at low levels of exposure both metals can dramatically influence the expression of important cellular pathways.</p

El entrenamiento basado en la simulación como innovación imprescindible en la formación médica Simulation-based training as an indispensable innovation in medical training

El entrenamiento basado en la simulación consiste en sustituir la realidad por un escenario simulado en el que estudiantes de medicina y profesionales pueden entrenar para adquirir habilidades de comunicación, psicomotrices o de trabajo en equipo. Dichos escenarios, y las metodologías que se aplican en ellos, varían según las habilidades a entrenar. Este tipo de entrenamiento va siempre asociado a una sesión de retroalimentación en el que participantes y tutores analizan la actividad realizada, sus puntos fuertes y los aspectos a mejorar; esta sesión se debe acompañar de una fase de pensamiento reflexivo y crítico, para profundizar en las ciencias básicas y clínicas del proceso entrenado. El empleo secuencial de diversos tipo de simulaciones puede utilizarse como circuito de entrenamiento o como prueba tipo examen clínico objetivo estructurado. En ambos casos, la evaluación es la última fase imprescindible de simulación aplicada a medicina. La simulación tiene una curva de aprendizaje excelente por su efectividad y rapidez, a la vez que aporta seguridad a los pacientes.<br>Simulation-based training consists in replacing reality with a simulated scenario in which medical students and professionals can train in order to acquire communication, psychomotor or teamwork skills. Such scenarios, and the methodologies that are applied in them, vary according to the skills that are to be trained. This type of training is always linked to a feedback session in which participants and tutors analyse the activity that has been carried out, and discuss its strong points and other aspects that need improving. This session must be accompanied by a phase of reflective critical thinking in order to gain a deeper understanding of both the basic and the clinical sciences involved in the process being trained. The sequential utilisation of different types of simulations can be used as a training circuit or as an objective structured clinical examination-type test. In both cases, evaluation is the last essential phase of simulation applied to medicine. Simulation has an excellent learning curve due to its effectiveness and speed, while also increasing the level of safety for patients