Reversibly paralysing and heavily sedating hospitalized patients with severe breathing problems do not improve outcomes in most cases, according to a National Institutes of Health-funded clinical trial conducted at dozens of North American hospitals and led by clinician-scientists at the University of Pittsburgh and University of Colorado schools of medicine.
The trial—which was stopped early due to futility—settles a long-standing debate in the critical care medicine community about whether it is better to paralyse and sedate patients in acute respiratory distress to aid mechanical ventilation or avoid heavy sedation to improve recovery.
“It’s been a conundrum—on the one hand, really well-done studies have shown that temporarily paralysing the patient to improve mechanical breathing saves lives. But you can’t paralyse without heavy sedation, and studies also show heavy sedation results in worse recovery. You can’t have both—so what’s a clinician to do?” said senior author Derek Angus, M.D., M.P.H., who holds the Mitchell P. Fink Endowed Chair of the Pitt School of Medicine’s Department of Critical Care Medicine. “Our trial finally settles it—light sedation with intermittent, short-term paralysis if necessary is as good as deep sedation with continuous paralysis.”
The Re-evaluation Of Systemic Early neuromuscular blockade (ROSE) trial is the first of the new National Heart, Lung, and Blood Institute’s (NHLBI) Prevention & Early Treatment of Acute Lung Injury (PETAL) Network. PETAL develops and conducts randomized controlled clinical trials to prevent or treat patients who have, or who are at risk for, acute lung injury or acute respiratory distress syndrome. The trial network places particular emphasis on early detection by requiring every network member institute include both critical care and emergency medicine, acute care or trauma principal investigators to ensure that critical health issues are recognized and triaged as fast as possible to improve patients’ odds of recovery before they are even transferred to the intensive care unit.
Angus, who also directs Pitt’s Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, said the trial results make him confident when he says that avoiding paralysis and deep sedation is the best practice for most patients hospitalized with breathing problems. However, he notes that future trials will be needed to tease out whether there is a subpopulation of patients with acute respiratory distress syndrome who still benefit from neuromuscular blockade.
UPMChttps://tinyurl.com/yxc95rrl
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Without timely intervention, privacy curtains in hospitals can become breeding grounds for resistant bacteria, posing a threat to patient safety, according to new research published.
The longitudinal, prospective, pilot study tracked the contamination rate of ten freshly laundered privacy curtains in the Regional Burns/Plastics Unit of the Health Services Center in Winnipeg, Canada. While the curtains had minimal contamination when they were first hung, the curtains that were hung in patient rooms became increasingly contaminated over time — and by day 14, 87.5 percent of the curtains tested positive for methicillin-resistant Staphylococcus aureus (MRSA), a pathogen associated with significant morbidity and mortality. In contrast, control curtains that were not placed in patient rooms stayed clean the entire 21 days.
None of the rooms where the curtains were placed were occupied by patients with MRSA. Four curtains were placed in a four-bed room; four were placed in two double rooms; and two controls were placed in areas without direct patient or caregiver contact. Researchers took samples from areas where people hold curtains, suggesting that the increasing contamination resulted from direct contact.
"We know that privacy curtains pose a high risk for cross-contamination because they are frequently touched but infrequently changed," said Kevin Shek, BSc, the study’s lead author in the article. "The high rate of contamination that we saw by the fourteenth day may represent an opportune time to intervene, either by cleaning or replacing the curtains."
By day 21, almost all curtains exceeded 2.5 CFU/cm, the requirement for food processing equipment cleanliness in some locations, such as the United Kingdom.
"Keeping the patient’s environment clean is a critical component in preventing healthcare-associated infections," said 2018 APIC President Janet Haas, PhD, RN, CIC, FSHEA, FAPIC. "Because privacy curtains could be a mode of disease transmission, maintaining a schedule of regular cleaning offers another potential way to protect patients from harm while they are in our care."
ScienceDaily
https://tinyurl.com/y3kbgpxu
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Bacteria that develop resistance to antibiotic drugs – superbugs – pose a major global health threat to humanity. In a concerted effort to stave off this threat, several global programmes have been established and numerous new research initiatives are being carried out. Whether they are successful is yet to be seen. International Hospital reports.
Antimicrobial or antibiotic resistance is a major emerging global health threat which continues to escalate around the world. In the EU it is responsible for around 33,000 deaths each year according to the European Commission [1] and is estimated to cost the EU EUR 1.5 billion per year in healthcare costs and productivity losses.
In the United States, the Centers for Disease Control and Prevention (CDC) estimates that more than 2.8 million antibiotic-resistant infections occur in the country each year, and more than 35,000 people die as a result [2].
In the CDC’s 2019 Antimicrobial Resistance Threats Report, Robert R. Redfield, M.D., Director of the CDC, emphasises that we should stop referring to a coming post-antibiotic era. “It’s already here,” he says. “You and I are living in a time when some miracle drugs no longer perform miracles and families are being ripped apart by a microscopic enemy. The time for action is now and we can be part of the solution.”
So, what exactly is antimicrobial resistance (AMR)? Simply put, antimicrobial resistance occurs when microorganisms – such as bacteria, viruses, fungi, protozoa and helminths (worm-like parasites) – mutate or develop a resistance gene when they are exposed to antimicrobial drugs, such as antibiotics, antifungals, antivirals, antimalarials, and antihelminthics. As a result, the drugs become ineffective and infections persist in the body, increasing the risk of morbidity and mortality as well as the spread of the disease to others.
The issue is of such global importance that a political declaration was endorsed by Heads of State at the United Nations General Assembly in New York in September 2016 signalling the world’s commitment to taking a broad, coordinated approach to address the root causes of antimicrobial resistance across multiple sectors, especially human health, animal health and agriculture.
In 2015, the World Health Organization (WHO) established the Global Antimicrobial Resistance and Use Surveillance System (GLASS) [3]. The system calls on countries to monitor and report on antibiotic resistance. The WHO noted in a report published June 1 this year, that in the past three years, participation has grown exponentially. GLASS now aggregates data from more than 64,000 surveillance sites with more than 2 million patients enrolled from 66 countries across the world. In 2018 the number of surveillance sites was 729 across 22 countries.
Hanan Balkhy, Assistant Director-General for antimicrobial resistance at WHO, explained: “The enormous expansion of countries, facilities and patients covered by the new AMR surveillance system allows us to better document the emerging public health threat of AMR.”
On the back of this data, the Organization notes that high rates of resistance among antimicrobials frequently used to treat common infections, such as urinary tract infections or some forms of diarrhoea, indicate that the world is running out of effective ways to tackle these diseases. For instance, the rate of resistance to ciprofloxacin, an antimicrobial frequently used to treat urinary tract infections, varied from 8.4% to 92.9% in 33 reporting countries.
In addition, the WHO expressed concern that the trend will further be fuelled by the inappropriate use of antibiotics during the COVID-19 pandemic. The Organization points out that evidence shows that only a small proportion of COVID-19 patients need antibiotics to treat subsequent bacterial infections and, as such, has issued guidance [4] not to provide antibiotic therapy or prophylaxis to patients with mild COVID-19 or to patients with suspected or confirmed moderate COVID-19 illness unless there is a clinical indication to do so. Solutions
What can be done to counter AMR? Although antimicrobial resistance occurs naturally over time, usually through genetic changes, there are a number of countermeasures. Primarily, healthcare practitioners should reduce the misuse and overuse of antimicrobials which are accelerating AMR. The WHO notes, for example, that in many places, antibiotics are overused and misused in people and animals, and often given without professional oversight. Examples of misuse include when they are taken by people with viral infections like colds and flu, and when they are given as growth promoters in animals or used to prevent diseases in healthy animals.
CDC’s 2019 Antimicrobial Resistant Threats Report
The CDC’s 2019 AR Threats Report lists 18 antibiotic-resistant bacteria and fungi in three categories based on the level of concern to human health – urgent, serious, and concerning. The ‘urgent’ list includes the following five threats: Carbapenem-resistant Acinetobacter Carbapenem-resistant Acinetobacter cause pneumonia and wound, bloodstream, and urinary tract infections. Nearly all these infections happen in patients who recently received care in a healthcare facility. They are estimated to have caused 700 deaths in the US in 2017. Candida auris C. auris is an emerging multidrug-resistant yeast. It can cause severe infections and spreads easily between hospitalized patients and nursing home residents. Clostridioides difficile C. difficile causes life-threatening diarrhoea and colitis (an inflammation of the colon), mostly in people who have had both recent medical care and antibiotics. Estimated death per year in the US: 12,800. Carbapenem-resistant Enterobacteriaceae (CRE) CRE are a major concern for patients in healthcare facilities. Some Enterobacteriaceae are resistant to nearly all antibiotics, leaving more toxic or less effective treatment options. Estimated deaths in the US in 2017: 1,100. Drug-resistant Neisseria gonorrhoeae N. gonorrhoeae causes the sexually transmitted disease gonorrhoeae that can result in life-threatening ectopic pregnancy and infertility, and can increase the risk of getting and giving HIV.
See the report for the complete list. https://www.cdc.gov/drugresistance/pdf/threats-report/2019-ar-threats-report-508.pdf
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Chinese researchers have for the first time shown in a pilot study that the use of convalescent plasma from cured COVID-19 patients provides promising results in the treatment of others with more severe disease.
In the preprint study at medRxiv (http://doi.org/dqrs; 2020), K. Duan et al. report that the administration of a single, high-dose of neutralizing antibodies is safe and provides encouraging results with regards to the reduction of viral load and improvement of clinical outcomes.
In the study, ten severe patients confirmed by real-time viral RNA test were enrolled prospectively. One dose of 200 mL convalescent plasma (CP) derived from recently recovered donors with the neutralizing antibody titers above 1:640 was transfused to the patients as an addition to maximal supportive care and antiviral agents.
After CP transfusion, the level of neutralizing antibody increased rapidly up to 1:640 in five cases, while that of the other four cases maintained at a high level (1:640). All patients showed significant improvement in or complete disappearance of clinical symptoms – including fever, cough, shortness of breath, and chest pain – within 3 days.
The authors state that along with increased oxyhaemoglobin saturation – indicative of recuperating lung function – several parameters also improved, including increased lymphocyte counts and decreased C-reactive protein. Radiological examinations showed varying degrees of absorption of lung lesions within 7 days. The viral load was undetectable after transfusion in seven patients who had previous viremia. No severe adverse effects were observed.
The study shows that CP therapy could potentially improve clinical outcomes through neutralizing viremia in severe COVID-19 cases, however, the authors note that further investigation is needed in larger well-controlled trials to assess the optimal dose and time point.
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New research has shown how surgical gowns used in hospitals are retaining superbug Clostridium difficile (C. difficile), even after being treated with the recommended amount of disinfectant. The research, led by the University of Plymouth, tested single-use hospital surgical gowns (made of polypropylene) that had been infected with three different strains of C. difficile, a bacteria that can cause severe diarrhea, bowel complications and even death. After treating infected items for ten minutes with disinfectant containing 1,000 parts per million of chlorine – the amount and time recommended by the Department of Health and Social Care– the team found that all strains of C. difficile spores still survived on the gowns and did not reduce, allowing them to potentially transfer to other items. The research took place because the gowns were suspected to be contributing to C. difficile transmission in a USA hospital. Contaminated gowns from the USA hospital were tested for presence of C. difficile and a deadly 027 type strain was isolated, showing that the gowns can pick up and retain the spores. In this study, new gowns had the bacteria ‘spiked’ onto them for testing purposes. Three strains of C. difficile were tested including R20291, which caused severe outbreaks in UK hospitals between 2003 and 2006. This strain is known to cause mortality in patients as it is becoming resistant to the main antibiotic treatments, vancomycin and metronidazole. To examine the ability of C. difficile to adhere to, and subsequently transfer from, hospital surgical gowns, spores were applied directly to the surgical gowns in water for 10 seconds, 30 seconds, 1 minute, 5 minutes and 10 minutes before being removed and discarded. This was designed to mimic transfer of infectious bodily fluids in the clinical setting and assess the potential for onward transmission to patients. There was no significant difference between the amount of spores recovered from the gowns and the contact time of the spores to the gowns; suggesting that the spore transfer between surfaces occurred within the first 10 seconds of contact. The items were then treated with 1,000 ppm chlorine-releasing disinfectant, sodium dichloroisocyanurate (NaDCC) to try and tackle the bug. Principal investigator and study lead Dr Tina Joshi, part of the Institute of Translational and Stratified Medicine (ITSMed) at the University of Plymouth, explains that this work can be applied to hospitals anywhere in the world, and should help inform future guidelines on infection control and biocides (bacteria killers). She said: “C. difficile is a really nasty superbug and it’s so important that hospitals stop it from spreading. This study shows that even when we think an item has been suitably cleaned, it hasn’t been necessarily – 1,000 parts per million of chlorine just isn’t enough as the bacteria survived and grew after disinfection. “As well as possibly upping the concentration of the biocide, the research highlights the need for appropriate hygiene practices. Gowns should not be worn outside of isolated areas as our work has shown that C. difficile spores are good at sticking to clinical surfaces, and can so easily be transferred, causing infections in patients. In an age where infections are becoming resistant to antibiotics, it’s worrying to think that other bacteria are becoming resistant to biocides. So the best thing we can do is ensure that infection control procedures are robust and standardized.”
University of Plymouthhttps://tinyurl.com/yxpr4dhf
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ForaCare Suisse AG has launched its FORA Autonomous Temperature Measuring Station. The station allows for accurate and precise temperature readings without the need for human operation of the thermometer.
“ForaCare understands the challenges of making temperature measurements in the Covid-19 environment. We observed workers in public health, government, education, and corporations manually taking temperature measurements, and saw the need to develop a system that would provide safe distance in performing and monitoring temperature checks. We also realized the need for an almost instant reading that is accurate, and connected to a device that could capture the data,” said Ty-Minh Tan, CEO of ForaCare Suisse AG. “Our goal was to put all of those needs together in a system that could allow for monitoring from a mobile measurement station. A single person can simultaneously monitor multiple temperature station results from a remote location, thereby providing increased efficiency and reduced possibilities of cross-infection.”
The FORA Autonomous Temperature Measuring Station includes three components: a FORA IR41 non-contact forehead thermometer that uses infrared sensors to take measurements, an iPad with a customized software displaying the measured temperature, and a medical-grade wheeled station to provide easy mobility of the system.
The Temperature Station’s thermometer, FORA IR41, provides quick measurement with results in just two seconds and records data using Bluetooth connectivity. The thermometer is clinically validated with ± 0.2 ̊C accuracy, and complies with ASTM E1965-98 and EN ISO 80601-2-56 standard requirements for clinical thermometer and body temperature measurement.
For more information visit: www.foracare.ch/news-fcs-fight-covid-19
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Jackson ImmunoResearch manufactures secondary antibodies and conjugates, with an outstanding reputation for quality, earned over 30 years. Our products are used in Western Blotting, IHC/ICC/IF, Flow Cytometry, ELISA, Electron Microscopy and many other immunological techniques. From our UK office we serve Europe with euro pricing, technical service and fast delivery.www.jacksonimmuno.com Booth # 1F03-9
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Artificial intelligence (AI) has shown promise to select heart failure patients for expensive treatments to prevent lethal arrhythmias, reports a study presented today at ICNC 2019. The study is the first to use a machine-learning algorithm to predict sudden death in heart failure patients.
Around 1-2% of adults in developed countries have heart failure, a clinical syndrome characterised by breathlessness, ankle swelling, and fatigue. A high proportion of deaths in these patients, especially those with milder symptoms, occur suddenly due to ventricular arrhythmias. Implantable cardioverter defibrillators (ICDs) or cardiac resynchronisation therapy with a pacemaker and defibrillator (CRT-D) are recommended for some patients to correct potentially lethal arrhythmias and reduce the risk of sudden death. However, these treatments are expensive and do not work in all patients.
Study author Professor Kenichi Nakajima, of Kanazawa University Hospital, Japan, said: "Our model calculated the probability of a sudden arrhythmic event with an area under the curve (AUC) of 0.74, where 1.0 is perfect prediction and 0.5 is a random result. This could be used to identify very low risk patients for whom an ICD or CRT-D is not required, and very high risk patients who should receive a device. Optimising risk evaluation in this way will improve the cost effectiveness of treatment."
The study included 529 heart failure patients with known two-year outcomes for sudden arrhythmic events (including arrhythmic death, sudden cardiac death, and appropriate shock from an ICD) and death due to heart failure.
Machine learning — a type of AI used by the Google search engine and face recognition on smartphones — was used to discover how eight variables used to predict prognosis of heart failure patients were connected and create a formula correlating them to two-year outcomes.
The eight factors were age, sex, heart failure severity (New York Heart Association functional class), heart pumping function (left ventricular ejection fraction), whether heart failure was caused by restricted blood supply (ischaemia), B-type natriuretic peptide level in the blood, kidney function (estimated glomerular filtration rate), and a nuclear imaging parameter.
During the two-year follow-up there were 141 events (27%) consisting of 37 sudden arrhythmic events (7%) and 104 deaths due to heart failure (20%). The AUC for predicting all events was 0.87, while for arrhythmic events and heart failure death it was 0.74 and 0.91, respectively.
Professor Nakajima said: "This is a preliminary study and we can improve the prediction of arrhythmic events by adding variables and continuing to train the machine learning algorithm."
The imaging parameter was heart-to-mediastinum ratio (HMR) of 123Iodine-metaiodobenzylguanidine (MIBG) uptake. MIBG is a radioisotope analogue of norepinephrine and is used to assess the activity of cardiac sympathetic nerves. Previous studies have shown that HMR predicts cardiac death in patients with heart failure. The measure is obtained by injecting MIBG into a vein, then using imaging to assess uptake in the heart and upper mediastinum (centre of the thoracic cavity).
Professor Nakajima noted that while MIBG imaging is approved in the US and Japan for clinical practice, and in Europe for clinical research, it is less commonly used outside Japan due to its cost. A typical MIBG tracer costs €350 in Japan compared to €1,900-3,400 in the US.3 He said: "While the costs of the scan may be high, it would be value for money if unnecessary device implantations were avoided."
ScienceDaily
https://tinyurl.com/y3qx6zso
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HEALTH DATA Researchers from the University of Copenhagen and Rigshospitalet have used data on more than 230,000 intensive care patients to develop a new algorithm. Among other things, it uses disease history from the past 23 years to predict patients’ chances of survival in intensive care units.
Every year, tens of thousands of patients are admitted to intensive care units throughout Denmark. Determining which treatment is best for the individual patient is a great challenge. To make this decision, doctors and nurses use various methods to try to predict the patient’s chances of survival and mortality. However, the existing methods can be significantly improved.
Therefore, researchers from the Faculty of Health and Medical Sciences at the University of Copenhagen and Rigshospitalet have developed a new algorithm which much more accurately predicts an intensive care patient’s chances of surviving.
‘We have used Danish health data in a new way, using an algorithm to analyse file data from the individual patient’s disease history. The Danish National Patient Registry contains data on the disease history of millions of Danes, and in principle the algorithm is able to draw on the history of the individual citizen of benefit to the individual patient in connection with treatment,’ says Professor Søren Brunak from the Novo Nordisk Foundation Center for Protein Research.
Developing the algorithm, the researchers used data on more than 230,000 patients admitted to intensive care units in Denmark in the period 2004-2016. In the study the algorithm analysed the individual patient’s disease history, covering as much as 23 years. At the same time, they included in their calculations measurements and tests made during the first 24 hours of the admission in question. The result was a significantly more accurate prediction of the patient’s mortality risk than offered by existing methods.
‘Excessive treatment is a serious risk among terminally ill patients treated in Danish intensive care units. Doctors and nurses have lacked a support tool capable of instructing them on who will benefit from intensive care. With these results we have come a significant step closer to testing such tools and directly improving treatment of the sickest patients,’ says Professor Anders Perner from the Department of Clinical Medicine and the Department of Intensive Care, Rigshospitalet.
The algorithm made three predictions: the risk of the patient dying in hospital (which could be any number of days following admission), within 30 days of admission and within 90 days of admission. For example, the researchers could tell that up to 10-year-old diagnoses affected predictions, and that young age lowered the risk of dying, even when other values were critical, while old age increased mortality risk. The algorithm is not just a useful tool in everyday practice in intensive care units throughout the country. It can also tell us which factors are significant when it comes to a person’s death or survival.
’We “train” the algorithm to remember which previous diagnoses have had the greatest effect on the patient’s chances of survival. No matter whether they are one, five or 10 years old. This is possible when we also have data from the actual admission, such as heart rate or answers to blood tests. By analysing the method, we are able to understand the importance it attaches to the various parameters with regard to death and survival,’ says Søren Brunak.
University of Copenhagen The Faculty of Health and Medical Scienceshttps://tinyurl.com/y237ogab
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