Respiratory Discharge Research Articles

Microbial associations for pneumonia causative agents and level of their resistance to antimicrobial drugs during a new coronavirus infection pandemic

Introduction. Bacterial coinfection and secondary bacterial infection are considered critical risk factors for the severity and mortality of SARS-CoV-2-caused pneumonia. The aim of the study was to analyze a pattern of microbial associations between K. pneumoniae and A. baumannii isolated from the lower respiratory tract discharge and sectional material (lung tissue) of patients diagnosed with pneumonia, and to compare resistance level in monoculture and associations during new coronavirus infection pandemic. Materials and methods. A bacteriological study of 2689 sputum and bronchial washing samples from patients at infectious diseases hospitals, and 1411 lung pathological material samples was carried out. Bacterial isolates were identified by mass spectrometry. Antibiotic sensitivity for isolates was determined by the disk diffusion method. Genetic determinants of resistance to beta-lactam antibiotics were detected by PCR. Statistical data processing was performed using SPSS version 22 software. Results. K. pneumoniae and A. baumannii isolates were predominantly found in two- and three-pathogen associations. It was established that the resistance level of K. pneumoniae isolates in association with A. baumannii is significantly higher compared to that in monoculture for all antimicrobial drugs studied. At the same time, K. pneumoniae in combination with Candida spp. vs monoculture showed significantly lower level of resistance to ciprofloxacin, amikacin, cefotaxime, ceftazidime and amoxicillin/clavulanic acid. K. pneumoniae isolates carried resistance determinants to extended-spectrum beta-lactamases: OXA-48 — (22.5%), OXA-51 — (5.6%), OXA-23 — (4.2%), KPC — 70.9%, NDM — 7%. Of these, 14.1% of strains had the ability to co-produce serine carbapenemases OXA-48 and KPC. Sputum and lung tissue A. baumannii isolates exhibited extremely high multiple resistance regardless of their associations with other microorganisms. Microbiome species similarity in the lower respiratory tract and lung tissue discharge was revealed. The proportion of lung tissue vs sputum resistant strains of K. pneumoniae and A. baumannii was significantly higher. Conclusion. The detection of of multiple drug resistant K. pneumoniae and A. baumannii isolates as well as their associations may indicate aggravated pneumonia severity.

The Age of Older Patients Requiring Prolonged Mechanical Ventilation Is Not the Sole Determinant of Their Long-Term Survival.

Background and Objectives: There are few data on the effects of prolonged mechanical ventilation on elderly patients. Our objective is to investigate the effects of prolonged mechanical ventilation on older patients' successful weaning and long-term survival. Methods: We examined how aging affected the course and results of elderly patients on prolonged mechanical ventilation by contrasting five age groups. Age, sex, cause of acute respiratory failure, comorbidities, discharge status, weaning status, and long-term survival outcomes were among the information we gathered. Results: Patients on prolonged mechanical ventilation who had undergone tracheostomy and had been successfully weaned had a greater one-year survival rate. The 1-year survival rate was poorer for older patients with four or more comorbidities. Regarding the 5-year survival rate, the risk of death was 45% lower in the successfully weaned patients than in the unsuccessfully weaned patients. The risk of death was 46% lower in patients undergoing tracheostomy than in those not undergoing tracheostomy. Older prolonged mechanical ventilation (PMV) patients with four or more comorbidities had an increased risk of death. Conclusions: When it comes to elderly patients on prolonged mechanical ventilation, there are other factors in addition to age that influence long-term survival. Long-term survival is likewise linked to successful weaning and undergoing tracheostomy.

Mapping inpatient care pathways for patients with COPD: an observational study using routinely collected electronic hospital record data.

Respiratory specialist ward care is associated with better outcomes for patients with COPD exacerbations. We assessed patient pathways and associated factors for people admitted to hospital with COPD exacerbations. We analysed routinely collected electronic health data for patients admitted with COPD exacerbation in 2018 to Queen Elizabeth Hospital, Birmingham, UK. We extracted data on demographics, deprivation index, Elixhauser comorbidities, ward moves, length of stay, and in-hospital and 1-year mortality. We compared care pathways with recommended care pathways (transition from initial assessment area to respiratory wards or discharge). We used Markov state transition models to derive probabilities of following recommended pathways for patient subgroups. Of 42 555 patients with unplanned admissions during 2018, 571 patients were admitted at least once with an exacerbation of COPD. The mean±sd age was 51±11 years; 313 (55%) were women, 337 (59%) lived in the most deprived neighbourhoods and 45 (9%) were from non-white ethnic backgrounds. 428 (75.0%) had ≥4 comorbidities. Age >70 years was associated with higher in-hospital and 1-year mortality, more places of care (wards) and longer length of stay; having ≥4 comorbidities was associated with higher mortality and longer length of stay. Older age was associated with a significantly lower probability of following a recommended pathway (>70 years: 0.514, 95% CI 0.458-0.571; ≤70 years: 0.636, 95% CI 0.572-0.696; p=0.004). Only older age was associated with a lower chance of following recommended hospital pathways of care. Such analyses could help refine appropriate care pathways for patients with COPD exacerbations.

Georgia community pharmacies and clinics: An evaluation of health outcomes and care access

BackgroundCare access remains a major social determinant of health. Safety net clinics may not be numerically sufficient to meet the health care demand for vulnerable populations. Community pharmacists remain a trusted health care provider and serve as first-line care access points. To date, Georgia care access points by safety net clinics and community pharmacies have not been compared. ObjectivesThis study sought to evaluate care access across Georgia. County health outcomes and health factor rankings were compared with mortality prevalence of respiratory disease, diabetes mellitus, kidney disease, and a composite of ambulatory care sensitive conditions emergency department (ER) utilization and hospital discharge. In addition, this study sought to determine whether care access points improve if community pharmacies were to provide primary care services. Design and Outcome MeasuresGeographic information systems mapping was used to locate safety net clinics and community pharmacies. Care access difference was analyzed using a 2-sample t test and health outcomes and rankings were evaluated using ordinary least square regression analysis. ResultsA significant difference in care access points was found between safety net clinics and community pharmacies across the state of Georgia (P < 0.05). Mortality prevalence for respiratory disease (P < 0.01), diabetes mellitus (P < 0.1), kidney disease (P < 0.05), ER utilization (P < 0.01), and hospital discharge (P < 0.01) was lower in counties in the top 50% than the bottom 50% health outcome ranking and health factor ranking. Approximately 95% of counties (n = 151) would experience more than a 50% increase in primary care access points by way of community pharmacies. ConclusionCommunity pharmacies are well positioned to address primary care disease states, reduce health care resource strain, and decrease preventable health care resource utilization. Leveraging pharmacists to provide primary care services can address care access issues and may improve care quality and reduce preventable hospitalizations and ER utilization in Georgia.

Applying the Global Leadership Initiative on Malnutrition criteria in patients admitted with SARS-CoV-2 infection using computed tomography imaging.

Patients with low muscle mass and acute SARS-CoV-2 infection meet the Global Leadership Initiative on Malnutrition (GLIM) etiologic and phenotypic criteria to diagnose malnutrition, respectively. However, available cut-points to classify individuals with low muscle mass are not straightforward. Using computed tomography (CT) to determine low muscularity, we assessed the prevalence of malnutrition using the GLIM framework and associations with clinical outcomes. A retrospective cohort was conducted gathering patient data from various clinical resources. Patients admitted to the COVID-19 unit (March 2020 to June 2020) with appropriate/evaluable CT studies (chest or abdomen/pelvis) within the first 5 days of admission were considered eligible. Sex- and vertebral-specific skeletal muscle indices (SMI; cm2 /m2 ) from healthy controls were used to determine low muscle mass. Injury-adjusted SMI were derived, extrapolated from cancer cut-points and explored. Descriptive statistics and mediation analyses were completed. Patients (n = 141) were 58.2 years of age and racially diverse. Obesity (46%), diabetes (40%), and cardiovascular disease (68%) were prevalent. Using healthy controls and injury-adjusted SMI, malnutrition prevalence was 26% (n = 36/141) and 50% (n = 71/141), respectively. Mediation analyses demonstrated a significant reduction in the effect of malnutrition on outcomes in the presence of Acute Physiology and Chronic Health Evaluation II, supporting the mediating effects of severity of illness intensive care unit (ICU) admission, ICU length of stay, mechanical ventilation, complex respiratory support, discharge status (all P values = 0.03), and 28-day mortality (P = 0.04). Future studies involving the GLIM criteria should consider these collective findings in their design, analyses, and implementation.

Burden of Treatments for Respiratory Complications in Extremely Premature Infants: Interviews with Caregivers

Introduction: Extremely premature (EP) infants (<28 weeks gestational age) with respiratory conditions after discharge from the neonatal intensive care unit (NICU) impose a significant burden on caregivers. This study explored caregiver burden post-NICU discharge and perceptions of meaningful change in infant chronic respiratory morbidity. Methods: Adult primary caregivers of EP infants 3–14 months corrected age were recruited through patient advocacy organizations or hospital centers in the USA, Northern Ireland, Germany, and Japan and interviewed by phone. Interviews explored caregiver experiences with infants with respiratory conditions, associated treatment burden, and meaningful change in infant respiratory morbidity as measured by treatment use. Qualitative analysis of interview data was performed using MAXQDA software. Sociodemographic data were summarized using descriptive statistics. Results: Forty-five caregivers (95.6% female) of EP infants were interviewed. Respiratory morbidities post-NICU discharge included coughing (78%), breathing difficulties (76%), wheezing (58%), and bronchopulmonary dysplasia/chronic lung disease of prematurity (56%). Respiratory medications were required by 87% of infants, 80% used home respiratory technology support (e.g., supplemental oxygen), 38% were re-hospitalized, and 33% had emergency department visits. Caregivers considered visits to the emergency department to be the most burdensome treatment requirement they experienced, and reduction in the number of emergency department visits was considered the most meaningful change in treatment use. Conclusion: These findings underscore the significant burden faced by caregivers of EP infants with respiratory morbidities. Development of treatments for respiratory complications should take into consideration the concerns and preferences of caregivers in order to provide a meaningful benefit.

Outcomes of Mechanical Thrombectomy Compared With Systemic Thrombolysis in Pulmonary Embolism: A Comprehensive Evaluation From the National Inpatient Sample Database

Background: Systemic thrombolysis (ST) may not be ideal for many patients with acute pulmonary embolism (PE) due to bleeding risk. In this analysis, we evaluated the safety and effectiveness of mechanical thrombectomy (MT) as an alternative to ST for acute PE. Methods: Patients aged ≥18 years who underwent MT and/or ST for PE were identified from the National Inpatient Sample database from 2016 to 2017. Patients who underwent catheter-directed thrombolysis were excluded. We compared in-hospital outcomes of both groups in this retrospective study. Results: Of 16 890 patients who received an intervention for acute PE, 1380 (8.2%) received MT and 15 510 (91.8%) received ST. There was no difference in age between both groups. In-hospital mortality was significantly lower in patients who received MT than that in those who received ST (11.9% vs 20.6%, odds ratio [OR]: 0.52, 95% confidence interval [CI]: 0.29–0.93, p=0.028). There was no statistically significant difference in terms of periprocedural bleeding, intracranial hemorrhage, and acute kidney injury between the 2 groups (p≥0.608 for all). Patients who received MT had a higher rate of respiratory complications (19.0% vs 11.6%, OR: 1.79, 95% CI: 1.06–3.03, p=0.030) and discharge to an outside facility (34.1% vs 19.2%, OR: 2.18, 95% CI: 1.41–3.37, p<0.001) than those who received ST. Conclusion: Mortality was significantly lower with MT than that with ST, but larger randomized studies are needed to validate this. The use of MT should be individualized on the basis of the patients’ clinical presentation, risk profile, and local resources. Clinical Impact In this study, we utilized the National Inpatient Sample database to study the in-hospital outcomes of pulmonary embolism patients who underwent mechanical thrombectomy compared to those who underwent systemic thrombolysis. We found that the patients who were diagnosed with pulmonary embolism and underwent mechanical thrombectomy had significantly lower mortality compared to those who were treated using systemic thrombolysis. This study was the first of its kind, utilizing the national inpatient sample database for evaluation of mechanical thrombectomy in comparison with the standard of care. These result would direct further randomized controlled trials for better evaluation of the utilization of mechanical thrombectomy in the correct clinical context. Furthermore, our study demonstrated comparable peri-operative complications between the mechanical thrombectomy group and the systemic thrombolysis group. These results would direct clinicians to consider mechanical thrombectomy if clinically indicated given the promising results.

124 AN INTERDISCIPLINARY PREHABILITATION PILOT FOR FRAIL ADULTS UNDERGOING ELECTIVE ANTERIOR RESECTION AND HARTMANN’S REVERSAL SURGERIES IN AN IRISH ACUTE HOSPITAL

Abstract Background Frailty affects 21.5% of individuals aged 65 and over in Ireland (TILDA, 2017).Timely interventions can limit or reverse the impacts of frailty. Local HIPE data from 2016-2020 highlighted correlations between increased average Length of Stay (aLOS) and median age (&amp;gt;65 years) for those undergoing elective Anterior Resections and Hartmann’s reversal surgeries. Prehabilitation aims to identify and manage modifiable risk factors that may impact on LOS, as well as optimise patients’ resilience and physiological reserves to reduce postoperative complications. Modifiable factors include pre-operative function, co-morbidities and post-operative delirium. In the Republic of Ireland, surgical interdisciplinary Prehabilitation services exist only in one hospital. Methods An interdisciplinary prehabilitation pilot for individuals undergoing elective colorectal surgeries was developed. Patients are referred from surgical clinics to Physiotherapy, Occupational Therapy or Dietitian preoperatively. Interventions include respiratory optimisation, exercise prescription, discharge planning, equipment provision and pre-operative nutritional reviews. Results Three elective patients have completed the first phase of the pilot. Two underwent anterior resections and one underwent a Hartmann’s reversal. The LOS for each individual was 4 days respectively, 4 days under the KPIs. Patients received virtual assessment and individualised interventions including an interdisciplinary educational booklet. Interventions included: exercise programmes, nutritional support, discharge planning discussion and equipment as indicated. No post-operative complications were identified and no interim beds or home supports were required. Qualitative feedback surveys were completed by all participants. Subjective feedback from patients has been overwhelmingly positive. Conclusion Patients report feeling physically and psychologically better prepared for surgery with better knowledge of post-operative expectations. Patients are more proactive in their postoperative recovery meaning they can return home sooner. This pilot enhances evidence-based ERAS practice, improving the quality and safety of patients journey. Participants also had a 12 day cumulative reduction in aLOS with financial savings of €12000.

Using the Generalized Synthetic Control Method to Estimate the Impact of Extreme Weather Events on Population Health.

Traditional epidemiologic approaches such as time-series or case-crossover designs are often used to estimate the effects of extreme weather events but can be limited by unmeasured confounding. Quasi-experimental methods are a family of methods that leverage natural experiments to adjust for unmeasured confounding indirectly. The recently developed generalized synthetic control method that exploits the timing of an exposure is well suited to estimate the impact of acute environmental events on health outcomes. To demonstrate how this method can be used to study extreme weather events, we examined the impact of the 20-26 October 2007 Southern California wildfire storm on respiratory hospitalizations. We used generalized synthetic control to compare the average number of ZIP code-level respiratory hospitalizations during the wildfire storm between ZIP codes that were classified as exposed versus unexposed to wildfire smoke. We considered wildfire exposure eligibility for each ZIP code using fire perimeters and satellite-based smoke plume data. We retrieved respiratory hospitalization discharge data from the Office of Statewide Health Planning and Development. R code to implement the generalized synthetic control method is included for reproducibility. The analysis included 172 exposed and 578 unexposed ZIP codes. We estimated that the average effect of the wildfire storm among the exposed ZIP codes was an 18% (95% confidence interval: 10% to 29%) increase in respiratory hospitalizations. We illustrate the use of generalized synthetic control to leverage natural experiments to quantify the health impacts of extreme weather events when traditional approaches are unavailable or limited by assumptions.

Etiological structure of infectious complications and microbial colonization in patients of COVID-19 hospital of a multidisciplinary federal medical institution

BACKGROUND: Despite the proven importance of secondary bacterial infections influencing the severity of viral respiratory diseases, their etiology is still not well understood. There is a gap in knowledge about the nature, frequency, and antimicrobial resistance profiles of bacterial pathogens in the current COVID-19 pandemic.&#x0D; AIM: To describe the species spectrum of microorganisms in patients of the COVID-19 Hospital on the basis of a multidisciplinary federal medical institution.&#x0D; MATERIALS AND METHODS: Clinical samples (blood, lower respiratory tract discharge, urine, other biological materials) from patients with COVID-19 who were treated at the COVID-19 Hospital at a multidisciplinary federal medical institution were obtained and processed.&#x0D; RESULTS: The bacteriological laboratory received 1821 samples of biomaterial from 452 patients, microorganisms were isolated from 620 (38.0%) samples. Most of the biomaterial was represented by blood 35.9% and discharge from the lower respiratory tract 31.7%. The structure of microorganisms was dominated by Candida albicans 19.7%, Staphylococcus aureus 10.2%, Klebsiella pneumoniae 10.1%, Enterococcus faecalis 7.9%. At the beginning of the period of operation of the Hospital, the most frequently identified microorganisms were S. aureus and Haemophilus influenzae 19.7% and 7.9%, respectively, while in the final period there was a change in the spectrum of microorganisms to nosocomial ESKAPE -pathogens with multiple drug resistance, the structure was dominated by Acinetobacter baumannii 24.3%. Antibiotic consumption in the hospital increased from 18.3 DDD/100 patient days in 2019 to 28.8 DDD/100 patient days in 2020.&#x0D; CONCLUSION: Significant colonization of various loci of patients with COVID-19 by fungi of the genus Candida was revealed. There has been a change in the microbial spectrum of infectious agents from community-acquired (H. influenzae and S. pneumoniae) to nosocomial ESKAPE pathogens with multiple drug resistance. The consumption of antibiotics has increased significantly.

Epidemiology, genetic diversity, and association of canine circovirus infection in dogs with respiratory disease

Although canine circovirus (CanineCV)-associated with gastroenteritis has been well documented, the virus is also detectable in the respiratory discharge of dogs with respiratory disease. In this study, an epidemiological approach was used to explore the association between the presence of CanineCV and respiratory symptoms in dogs. Respiratory swabs were collected from 76 healthy dogs and 114 dogs with respiratory illness and tested for CanineCV using conventional PCR (cPCR). Furthermore, lung tissues collected from 15 necropsied dogs showing pneumonia were tested using the real-time PCR (qPCR) and in situ hybridization (ISH) technique. A total of 8.95% (17/190) of dogs were CanineCV positive, with a significant association (p = 0.013) in dogs with respiratory signs. Four necropsied dogs were qPCR positive with the CanineCV-DNA labeling localized in tracheobronchial lymphoid cells (3/4), pulmonary parenchyma, capillary endothelia, and mononuclear cells harboring in alveoli (2/4). Full-length genome sequences of seven CanineCV strains were analyzed, indicating that the detected CanineCV genome clustered in the CanineCV-4 genotype. Genetic recombination was also evident in the replicase (Rep) gene. Although the role of CanineCV primarily affecting lung lesions could not be determined from this study, the presence of CanineCV DNA in pulmonary-associated cells indicated the potential association of the virus with canine respiratory disease; thus, linking causality must be examined in further studies.

The Effect of Alfentanil on Emergence Delirium Following General Anesthesia in Children: A Randomized Clinical Trial.

BackgroundEmergence delirium can occur after general anesthesia in children. An intravenous infusion of alfentanil may reduce the incidence or severity of emergence delirium after sevoflurane anesthesia.ObjectiveThe study aimed to investigate the effects of alfentanil intravenous infusion on emergence delirium and other perioperative complications.MethodThis was a single-center, randomized, placebo-controlled, double-blind clinical trial. A total of 172 children undergoing ambulatory dental treatment were randomized into three groups. Alfentanil group Alf2 received 0.2 μg/kg/min of alfentanil for continuous infusion, alfentanil group Alf4 received 0.4 μg/kg/min alfentanil, and the saline group (group Sal) received a continuous infusion of normal saline, with the same volume as the two other groups, as a placebo. The incidence of emergence delirium (assessed by the Paediatric Anaesthesia Emergence Delirium [PAED] scale), hemodynamic parameters, and recovery characteristics were recorded during the recovery period. The Aono scale was also used to assess for emergence delirium. A WeChat applet was designed to facilitate a caregiver teleconsultation and to provide feedback on postoperative nausea and vomiting and any other complications after discharge.ResultsThe incidence of emergence delirium in group Alf2 (22.9%) and group Alf4 (21.1%) was significantly lower than that observed in the Sal group (48.3%). The PAED scores in group Alf2 (6.4 ± 3.5) and group Alf4 (5.8 ± 3.8) were significantly lower than those for group Sal (9.6 ± 5.1) (p < 0.01). Ten children in the Alf4 group needed manual ventilatory assistance to maintain end-tidal carbon dioxide (ETCO2) < 55 mm; children in group Alf2 did not. There was no significant difference between the discharge time of groups Alf2 and Sal (31.2 ± 4.64 vs 30.5 ± 2.82 min; 0.659 [95% confidence interval {CI} −1.052 to 2.369], p = 0.643); the time to discharge of group Alf4 (35.16 ± 3.97 min) was significantly longer than that of groups Alf2 and Sal (p < 0.01). The incidence of nausea and vomiting was similar in the three groups. No other clinically relevant adverse events were observed.ConclusionsIntravenous infusion of 0.2 μg/kg/min and 0.4 μg/kg/min alfentanil decreased the incidence of emergence delirium in the post-anesthesia care unit. The 0.2 μg/kg/min dose of alfentanil resulted in less respiratory depression and discharge delay than the 0.4 μg/kg/min alfentanil dose.Trial registrationChinese Clinical Trial Registry (ChiCTR2100043320)Supplementary InformationThe online version contains supplementary material available at 10.1007/s40272-022-00510-5.

Gender Differences in Prolonged Mechanical Ventilation Patients - A Retrospective Observational Study.

BackgroundThe gender differences in patients requiring prolonged mechanical ventilation are not understood. We investigated the effects of gender differences in terms of age, causes of respiratory failure, discharge status, successful weaning, mortality rate and long-term survival outcomes in patients receiving prolonged mechanical ventilation.MethodsWe conducted a six-year retrospective study of patients requiring prolonged mechanical ventilation. Survival curves for all patients requiring prolonged mechanical ventilation and those who were very old (aged ≥ 80 years) were compared based on gender.ResultsAmong the 574 patients enrolled. There was no statistically significant difference between male and female patients regarding successful weaning, ventilator dependence, or in-hospital mortality. We gathered long-term follow-up data on 296 patients, including 70 very old male patients and 41 very old female patients. The 6-month, 3-year, and 5-year mortality rates for the 189 male patients were 75.1%, 85.2%, and 89.9%, respectively; the corresponding rates for the 107 female patients were 66.4%, 86.0%, and 88.8%, respectively. There was no statistically significant difference between two groups regarding mortality rates. The five-year survival curve of male patients was similar to that of female patients. The 6-month, 1-year, and 5-year mortality rates for the 70 very old male patients were 90.0%, 95.7%, and 97.1%, respectively; the corresponding rates for the 41 very old female patients were 63.4%, 90.2%, and 95.1%, respectively. There was a statistically significant difference between very old male and very old female patients in the 6-month mortality rate and the five-year survival curve.ConclusionThere were no gender differences in weaning status, ventilator dependence, in-hospital mortality, or survival outcomes among patients requiring prolonged mechanical ventilation. Among very old patients requiring prolonged mechanical ventilation, the risk of death was 34% lower in very old female patients than in very old male patients for a period of five years.

Identifying the vagal bronchopulmonary afferents responsible for eliciting the cough response to inhaled sulfur dioxide in mice

Among the three major types of vagal sensory nerves innervating the lung and airways, C‐fibers and rapidly adapting receptors (RARs or irritant receptors) are known to possess the properties and functions of “cough receptors”, but their relative roles in regulating cough reflex responses to inhaled irritants are not yet clearly defined. To address this question, we have recently carried out a series of studies in a mouse cough model, in which the intra‐pleural pressure was continuously recorded by a surgically implanted telemetry sensor. Sulfur dioxide (SO2), a common irritant gas, was chosen for the study because its widespread use as a chemical agent in various industrial operations has led to severe lung injuries in workers in numerous incidences resulting from accidental release of high concentrations of SO2 in industrial facilities. Inhalation of SO2 (300 and 600 ppm) consistently and reproducibly elicited coughs in a concentration‐dependent manner in awake mice moving freely in a recording chamber. The cough frequency increased rapidly after the onset of the SO2 inhalation challenge, which continued for the remaining duration of 8‐min exposure. In the current study, single‐fiber electrophysiological recording of vagal afferent activity in anesthetized mice showed that the high concentration of SO2 (600 ppm) evoked a sustained stimulatory effect on C‐fibers for the entire duration (8 min) of the inhalation challenge. However, in sharp contrast, inhalation of SO2 at the same concentration and duration generated a distinct and consistent inhibitory effect on both phasic RARs and slowly adapting receptors. Their respiratory cycle‐related phasic discharge declined progressively and/or ceased completely within 1‐3 min after the onset of the SO2 inhalation challenge, which gradually recovered after &gt;15 min following the termination of the SO2 inhalation. In a small percentage of RARs that displayed no phasic activity during eupneic breathing and often exhibited sensitivity to certain inhaled irritants, the same SO2 inhalation challenge did not evoke any significant stimulatory effect. Taken together, these observations suggest that stimulation of bronchopulmonary C‐fibers is primarily responsible for triggering airway irritation and coughing in response to the SO2 inhalation challenge.

Association of Acute Respiratory Failure in Early Childhood With Long-term Neurocognitive Outcomes

Approximately 23 700 US children undergo invasive mechanical ventilation for acute respiratory failure annually, with unknown long-term effects on neurocognitive function. To evaluate neurocognitive outcomes of children who survive pediatric intensive care unit (PICU) hospitalization for acute respiratory failure compared with their biological siblings. Prospective sibling-matched cohort study conducted at 31 US PICUs and associated neuropsychology testing centers. Patients were 8 years or younger with a Pediatric Cerebral Performance Category score of 1 (normal) before PICU admission and less than or equal to 3 (no worse than moderate neurocognitive dysfunction) at PICU discharge, excluding patients with a history of neurocognitive deficits or who were readmitted and underwent mechanical ventilation. Biological siblings were aged 4 to 16 years at testing, with Pediatric Cerebral Performance Category score of 1 and no history of mechanical ventilation or general anesthesia. A total of 121 sibling pairs were enrolled from September 2, 2014, to December 13, 2017, and underwent neurocognitive testing starting March 14, 2015. The date of the final follow-up was November 6, 2018. Critical illness and PICU treatment for acute respiratory failure. The primary outcome was IQ, estimated by the age-appropriate Vocabulary and Block Design subtests of the Wechsler Intelligence Scale. Secondary outcomes included measures of attention, processing speed, learning and memory, visuospatial skills, motor skills, language, and executive function. Evaluations occurred 3 to 8 years after hospital discharge. Patients (n = 121; 55 [45%] female patients) underwent PICU care at a median (IQR) age of 1.0 (0.2-3.2) years, received a median (IQR) of 5.5 (3.1-7.7) days of invasive mechanical ventilation, and were tested at a median (IQR) age of 6.6 (5.4-9.1) years. Matched siblings (n = 121; 72 [60%] female siblings) were tested at a median (IQR) age of 8.4 (7.0-10.2) years. Patients had a lower mean estimated IQ than matched siblings (101.5 vs 104.3; mean difference, -2.8 [95% CI, -5.4 to -0.2]). Among secondary outcomes, patients had significantly lower scores than matched siblings on nonverbal memory (mean difference, -0.9 [95% CI, -1.6 to -0.3]), visuospatial skills (mean difference, -0.9 [95% CI, -1.8 to -0.1]), and fine motor control (mean difference, -3.1 [95% CI, -4.9 to -1.4]) and significantly higher scores on processing speed (mean difference, 4.4 [95% CI, 0.2-8.5]). There were no significant differences in the remaining secondary outcomes, including attention, verbal memory, expressive language, and executive function. Among children, survival of PICU hospitalization for respiratory failure and discharge without severe cognitive dysfunction was associated with significantly lower subsequent IQ scores compared with matched siblings. However, the magnitude of the difference was small and of uncertain clinical importance.

HUBUNGAN PERILAKU DAN LINGKUNGAN RUMAH DENGAN TB PARU DI WILAYAH KERJA PUSKESMAS PANYABUNGAN JAE

ABSTRACT&#x0D; Pulmonary tuberculosis or pulmonary tuberculosis is a contagious infectious disease that attacks the lungs and bronchi. This disease is caused by mycobacterium tuberculosis which spreads through the air of human respiratory discharges. In 2017, the figure of Case Notification Rate / CNR (new case) of pulmonary TB (+) in North Sumatra was 104.3 / 100,000 population and Mandailing Natal District became an area second place with CNR of 187 / 100,000 population. One of the factors that can affect the recovery of pulmonary TB include behaviors such as knowledge, attitudes and actions as well as the environment such as ventilation area and occupancy density. The purpose of this study was to determine the relationship of behavior and home environment to the incidence of pulmonary TB in Panyabungan Jae Public Health Center in 2019. This type of research uses analytic survey method with cross sectional approach. The sample in this study were 56 people taken by total sampling technique. The results showed that the majority of respondents have less knowledge, negative attitudes, actions are not good, the area of ​​ventilation of the house does not meet the requirements and the density of dense occupancy with the majority of the occurrence of pulmonary TB. Bivariate test results found that there is a relationship between knowledge (p = 0.003), attitude (p = 0.010), actions (p = 0.013), ventilation area (p = 0.003) and density (p = 0.017) with the incidence of pulmonary TB in the Panyabungan Jae Public Health Center. It is expected that the community in the Panyabungan Jae Puskesmas area will be more active in carrying out the examination and treatment of new TB and following the management of pulmonary TB provided by health care workers. The next researcher is expected to be able to develop research on the factors that cause pulmonary TB in a region

A Bayesian Multi-Outcome Analysis of Fine Particulate Matter and Cardiorespiratory Hospitalizations.

Short-term fine particulate matter (PM2.5) exposure is positively associated with acute cardiovascular and respiratory events. Understanding whether this association varies across specific cardiovascular and respiratory conditions has important biologic, clinical, and public health implications. We conducted a time-stratified case-crossover study of hospitalizations from 2000 through 2014 among United States Medicare beneficiaries aged 65+. The outcomes were hospitalizations with any of 57 cardiovascular and 32 respiratory discharge diagnoses. We estimated associations with two-day moving average PM2.5 as a piecewise linear term with a knot at PM2.5 = 25 g/m3. We used Multi-Outcome Regression with Tree-structured Shrinkage (MOReTreeS) to identify de novo groups of related diseases such that PM2.5 associations are: (1) similar within outcome groups; but (2) different between outcome groups. We adjusted for temperature, humidity, and individual-level characteristics. We introduce an R package, moretrees. Our dataset included 16,007,293 cardiovascular and 8,690,837 respiratory hospitalizations. Of 57 cardiovascular diseases, 51 were grouped and positively associated with PM2.5. We observed a stronger positive association for heart failure, which formed a separate group. We observed negative associations for groups containing the outcomes other aneurysm and intracranial hemorrhage. Of 32 respiratory outcomes, 31 were grouped and were positively associated with PM2.5. Influenza formed a separate group with a negative association. We used a new statistical approach, MOReTreeS, to uncover variation in the association between short-term PM2.5 exposure and hospitalizations for cardiovascular and respiratory causes controlling for patient characteristics, time trends, and environmental confounders.

Breathing coordinates cortico-hippocampal dynamics in mice during offline states

Network dynamics have been proposed as a mechanistic substrate for the information transfer across cortical and hippocampal circuits. However, little is known about the mechanisms that synchronize and coordinate these processes across widespread brain regions during offline states. Here we address the hypothesis that breathing acts as an oscillatory pacemaker, persistently coupling distributed brain circuit dynamics. Using large-scale recordings from a number of cortical and subcortical brain regions in behaving mice, we uncover the presence of an intracerebral respiratory corollary discharge, that modulates neural activity across these circuits. During offline states, the respiratory modulation underlies the coupling of hippocampal sharp-wave ripples and cortical DOWN/UP state transitions, which mediates systems memory consolidation. These results highlight breathing, a perennial brain rhythm, as an oscillatory scaffold for the functional coordination of the limbic circuit that supports the segregation and integration of information flow across neuronal networks during offline states.

The Influence of Traumatic Injuries Early Diagnosis on the Development of Pulmonary Complications in Patients With Multisystem Chest Trauma

Despite the existing progress in providing care to patients with severe multisystem chest injury using advanced diagnostic methods, a high mortality rate still reaches 20–30%.Aim of study.To assess the impact of early diagnosis and correction of chest injuries on the development of complications in patients with multisystem trauma.Material and methods.The results of diagnosis and treatment of 89 patients with severe multisystem closed chest injury were studied. According to the time of admission to the Institute, the patients were divided into two groups: Group I, who were admitted to the Institute within the first hours after the injury (51 patients), and Group II, who were transferred from other medical institutions on the 3rd–7th day (38). CT was performed as a standard method of diagnosis and monitoring the dynamics of the process. With the development of purulent-inflammatory pulmonary complications, the bacteriological test of bronchoalveolar lavage was performed. Treatment included complex intensive therapy, drainage of the pleural cavity and emergency surgical interventions, if necessary.Results.In Group I, lung contusion occurred in 43 (84%) patients, and after 7-10 days, the contusion foci partially regressed in 20 (46.5%) patients. In 8 (16%) patients with lung rupture, infiltrative changes in the lung were resolved on the 18th-30th day, while 4 (50%) of them had pneumonia outside the contusion zones. In Group II, patients were put on a ventilator and inflammatory changes in the lungs were revealed in 30 patients (79%). Lung rupture associated with the contusion was revealed in 2 (5.2%). When comparing the groups by the composition of the isolated microflora, it was found that in patients of group II, Acinetobacter spp was more often found (46.7% vs. 17.1% in group I patients, p=0.021) and Enterococcus spp. (30.0% and 8.6%, respectively, p=0.058), as well as Klebsiella pneumoniae (46.7% and 37.1%, p=0.6). At the same time, Staphylococcus aureus was not found in these patients, while it was detected in 14.3% of patients from Group I (p=0.09). Medical care in Group I was carried out according to the principles of the “golden hour”: within the first hour from the moment of admission to the patients with the presence of pneumothorax and hemothorax, the pleural cavity was drained. In Group II, this procedure was performed in other medical institutions and in 5 additional patients at the Institute.Conclusions.Early computed tomography diagnosis of multisystem trauma makes it possible to assess the severity of injuries to the chest organs and other areas of the body and determine the treatment tactics. A comprehensive approach to the management of patients, including early diagnosis of trauma, drainage of the pleural cavity, determination of management tactics, bacterial test of the lower respiratory tract discharge, helps reduce infectious complications by an average of 45.46%.

Influence of Pharmaceutical Copayment on Emergency Hospital Admissions: A 1978-2018 Time Series Analysis in Spain.

No studies have evaluated the influence of pharmaceutical copayment on hospital admission rates using time series analysis. Therefore, we aimed to analyze the relationship between hospital admission rates and the influence of the introduction of a pharmaceutical copayment system (PCS). In July 2012, a PCS was implemented in Spain, and we designed a time series analysis (1978–2018) to assess its impact on emergency hospital admissions. Hospital admission rates were estimated between 1978 and 2018 each month using the Hospital Morbidity Survey in Spain (the number of urgent hospital admissions per 100,000 inhabitants). This was conducted for men, women and both and for all-cause, cardiovascular and respiratory hospital discharges. Life expectancy was obtained from the National Institute of Statistics. The copayment variable took a value of 0 before its implementation (pre-PCS: January 1978–June 2012) and 1 after that (post-PCS: July 2012–December 2018). ARIMA (Autoregressive Integrated Moving Average) (2,0,0)(1,0,0) models were estimated with two predictors (life expectancy and copayment implementation). Pharmaceutical copayment did not influence hospital admission rates (with p-values between 0.448 and 0.925) and there was even a reduction in the rates for most of the analyses performed. In conclusion, the PCS did not influence hospital admission rates. More studies are needed to design health policies that strike a balance between the amount contributed by the taxpayer and hospital admission rates.