Critically ill patients who required mechanical ventilation and received the probiotic Lactobacillus rhamnosus GG were as likely to develop ventilator-associated pneumonia as those who received placebo, a randomized clinical trial showed.
“Among critically ill patients, randomized trials suggest that probiotics reduce infection rates by 20% and may decrease the risk of ventilator-associated pneumonia by 25% to 30%,” Jennie Johnstone, MD, PhD, an associate professor of medical microbiology in the department of laboratory medicine and pathobiology at the University of Toronto, and colleagues wrote in JAMA. “Current guidelines suggest probiotic use for selected medical and surgical ICU patients for whom trials have documented safety and benefit.”
According to a previous review, ventilator-associated pneumonia may account for as many as 47% of ICU-acquired infections, making it the second-most common nosocomial infection in the United States.
In the new trial, Johnstone and colleagues analyzed data from 2,650 patients (mean age, 59.8 years; 40.1% women) who were hospitalized in either an American, Canadian or Saudi Arabian ICU. The mean Acute Physiology and Chronic Health Evaluation II score of all patients was 22 (out of a maximum of 71) at baseline and all were predicted to require mechanical ventilation for at least 72 hours. The patients were randomly assigned in an approximate 1:1 ratio to receive either enteral L. rhamnosus GG (1 × 1010 colony-forming units) or placebo twice daily for a median of 9 days.
Johnstone and colleagues reported that ventilator-associated pneumonia developed in 21.9% of patients who received probiotics and 21.3% of those who received placebo (HR = 1.03; 95% CI, 0.87-1.22; absolute difference = 0.6%; 95% CI, –2.5% to 3.7%). There were no significant differences between the two groups regarding other ICU-acquired infections, diarrhea, antimicrobial use, mortality or length of stay and more than a dozen other clinical outcomes.
Fifteen patients who were administered L. rhamnosus GG experienced an adverse event compared with 1 patient who received placebo (OR = 14.02; 95% CI, 1.79-109.58). Two patients in the probiotic group experienced a serious adverse event, and both died, the researchers reported.
Johnstone and colleagues noted several limitations to their study.
“Results may have differed using an alternate dose, genus, species or strain or if studied in specialized populations such as patients who experienced trauma or were of low surgical risk with lower antimicrobial exposure or lower infectious risk,” they wrote. “Second, it was not possible to examine pulmonary microbiota over time or between groups, or probiotic gastrointestinal colonization in this international trial. Third, there are inherent limitations of each [ventilator-associated pneumonia] definition and no universal reference standard; however, our analyses were strengthened by protocolized data collection and use of several definitions.”
Regardless, they concluded that their findings “do not support the use of [L. rhamnosus GG] for prevention of ventilator-associated pneumonia in critically ill patients requiring mechanical ventilation.”
Grap MJ, et al. J Emerg Med. 2012;doi:10.1016/j.jemermed.2010.05.042.
Johnstone J, et al. JAMA. 2021;doi:10.1001/jama.2021.13355.
Morrow LE, et al. Am J Respir Crit Care Med. 2010;doi:10.1164/rccm.200912-1853OC.
Todd W. Rice, MD, MSc
In general, critical care nutrition guidelines are ambivalent regarding probiotic use in critically ill patients. This ambivalence derives from the lack of high quality, randomized trials evaluating probiotic use in this population.
This study by Johnstone and colleagues from the Canadian Critical Care Trials group provides some of that much needed rigorous evaluation and high-quality evidence. Administration of the commonly prescribed probiotic Lactobacillus rhamnosus GG did not reduce the risk of ventilator-associated pneumonia or improve other clinical outcomes in their multicenter, international, blinded, placebo-controlled randomized trial.
While results are overall disappointing, it is exciting to see such meticulous research in critical care nutrition, and specifically probiotics, from a premiere critical care clinical trials group. This is the exact high-quality science that will better advance the field and help us better understand the role for nutritional supplements, probiotics and other critical care nutritional interventions moving forward.
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UF celebrates the construction of a new Student Health Care Center – WCJB
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GAINESVILLE, Fla. (WCJB) – UF Health officials held a beam-signing event today to celebrate the construction of the new Student Health Care Center.
With the current facility being about 100 years old, officials with UF Health, said they’re thrilled to get a new building.
“Our current building was designed for in-patient infirmary, people stayed overnight there, and that’s not the way a modern medical office building for outpatient care is done,” said Dr. Ronald Berry, the Director of the Student Health Care Center.
Now, the new facility is being built with all the same services as the current one, and more.
“The infectious unit here is probably the first of its kind in a student health,” said Berry.
He said they started the design stage of the infectious care unit during the pandemic, giving the work even more meaning.
“You’ll be able to enter into the waiting area to infectious care, from a door at the front of the building that’s not going to the rest of the building,” said Berry.
The air in this unit does not get recirculated, making it one of the safest areas in the building.
UF Health is also implementing programs that promote a healthy lifestyle.
“There’s going to be the inclusion of the demo kitchen where our dietitian can host interactive cooking lessons for students, for faculty, and staff throughout campus,” said Adeel Markatia, an Assistant Director within the cabinet of health affairs in Student Government.
Markatia said the building will also have a sun terrace where students can study, hangout, or just relax.
“Things like that, like these new features, definitely make this building a great enhancement for our campus,” he said.
Berry said with a new facility, he hopes to provide more learning opportunities for medical students.
The construction is expected to be done around this time next year, and open for students in Spring 2023.
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What Causes Narcolepsy? These Factors May Play a Role | Health.com – Health.com
In many cases, chronic sleepiness is tied to low levels of certain brain chemicals.
When diagnosed with a new condition, the first question is almost always "How?" We naturally want to know exactly what brought us to that moment. This curiosity may be even stronger with something like narcolepsy, a chronic sleep disorder that is both under-recognized and misunderstood, according to the nonprofit Project Sleep.
While scientists have yet to pinpoint the exact cause of narcolepsy, a majority of cases are tied to low levels of a brain chemical involved in regulating our sleep-wake cycle, according to the Cleveland Clinic. And other factors are thought to play a role in triggering the disease process.
Here's how sleep experts explain the causes of narcolepsy.
Before delving into the causes, let's consider what narcolepsy looks like.
Narcolepsy is characterized by excessive daytime sleepiness, hallucinations, sleep paralysis, vivid dreams, and more, says Steven Thau, MD, division chief of the Pulmonary and Sleep Medicine Department and medical director of the Sleep Center at Phelps Hospital/Northwell Health.
It can present at any point in a person's life, but most commonly it initially occurs in a person's teens or 20s, Dr. Thau tells Health.
While each case is different, excessive daytime sleepiness is generally the first symptom to surface. Symptoms such as hallucinations, sleep paralysis, and cataplexy may follow, says Manjamalai Sivaraman, MD, FAASM, a sleep medicine specialist and neurologist at the University of Missouri. The latter may not happen for a few years, if at all.
RELATED: What Are the Types of Narcolepsy? Sleep Experts Explain the Differing Presentations of This Sleep Disorder
There are two main types of narcolepsy: types 1 and 2. There's also a third known as secondary narcolepsy. (More on that one below.)
Narcolepsy type 1 covers anyone who has low levels of hypocretin (a brain chemical that controls wakefulness) and experiences cataplexy (sudden muscle loss), according to the Mayo Clinic. Type 1 makes up about 70% of narcolepsy cases, says Richard Bogan, MD, a medical officer at SleepMed, Inc. and associate clinical professor at the University of South Carolina School of Medicine and the Medical University of South Carolina in Charleston.
People with narcolepsy type 2 may experience all the symptoms of narcolepsy except cataplexy—and their symptoms are often less severe, says the National Institute of Neurological Disorders and Stroke (NINDS). And their hypocretin levels are usually normal.
While there are no known ways to prevent or cure type 1 or type 2 narcolepsy, NINDS notes that lifestyle changes and medications may be helpful for maintaining alertness and managing other symptoms.
RELATED: Is Narcolepsy Genetic? What Sleep Experts Say About Inheriting This Chronic Disorder
While the science is still evolving, here's what's known so far.
People with type 1 narcolepsy have very low levels of brain chemicals called hypocretins. These chemicals, first discovered in 1998, are important for a couple of reasons, per the Division of Sleep Medicine at Harvard Medical School. For one thing, they keep people awake and alert. They also prevent people from drifting off into REM (rapid-eye movement) sleep while they're awake.
In people type 1 narcolepsy, however, the nerve cells that produce hypocretins die off, and the resulting dearth of these chemicals leads to sleepiness and poorly regulated REM sleep, per Harvard's Sleep Medicine Division.
Research by two separate investigative teams suggests that type 1 narcolepsy is caused by a severe loss of neurons that produce these chemicals, per a 2015 review in the New England Journal of Medicine.
As for what causes type 2 narcolepsy? It's possible that people who have this form of the disorder may sustain less injury to their neurons than those with type 1, according to that same review, which references a 2009 Sleep study. But data on the disease process involved in type 2 narcolepsy "are quite limited," notes the New England Journal.
Bottom line: Scientists don't fully understand what triggers the loss of hypocretin-producing cells, although it appears that one or more of the following factors may be involved:
Most people with narcolepsy, especially type 1, have a gene variation known as HLA-DQB1*06:02. It is a variation of the HLA-DQB1 gene, which "provides instructions for making part of a protein that plays an important role in the immune system," according the US National Library of Medicine. The risk of narcolepsy associated with this variation and related genes is unclear to researchers at this time.
That same gene variation is found in 50% of people with narcolepsy type 2, but only 12-30% of the general population, according to the New England Journal.
Speaking of risk factors, narcolepsy isn't a disorder that tends to run in the family. According to NINDS, just up to 10% of people with type 1 narcolepsy have a close family member who presents with similar symptoms. If a parent has narcolepsy, the odds of passing it down to a child is only about 1%, says Mayo Clinic.
People with the HLA-DQB1*06:02 gene variation may be at increased risk of developing narcolepsy after being exposed to a trigger, such as an infection, says NINDS. That's based on studies of people after they developed narcolepsy.
Upper airway infections such as streptococcus pyogenes and influenza A (including H1N1) are strongly associated with narcolepsy, per a 2011 study in the Annals of Neurology, especially in cases where it begins in childhood, notes Dr. Sivaraman.
We know that people with narcolepsy type 1 have low hypocretin levels—but why? A leading theory considers narcolepsy to be an autoimmune disorder.
"There are supporting evidences for autoimmune destruction—the immune system in one's body attacking its own healthy cells—of hypocretin neurons in the hypothalamus of the brain," says Dr. Sivaraman. To break it down, if this theory is true, then a person's own immune system is responsible for the brain lacking in hypocretin.
As Dr. Thau puts it, in this case, "the cells that control wakefulness are damaged."
Currently, researchers are working on using immunotherapy to reverse this loss, Dr. Bogan tells Health. According to a 2020 review published in Current Treatment Options in Neurology, small studies have shown an improvement in symptoms for narcolepsy patients after using immunotherapy treatment, especially those who recently presented with the disease. However, the experiments were uncontrolled and did not have clear endpoints, requiring more research to achieve any definitive answer on the treatment's benefits.
RELATED: 7 Narcolepsy Symptoms to Know, According to Sleep Specialists
Unlike narcolepsy types 1 and 2, doctors do know the "why" behind secondary narcolepsy. This form of narcolepsy occurs when the brain's hypothalamus region gets damaged, according to Harvard's Division of Sleep Medicine.
These people can experience all of the same symptoms as those with types 1 and 2. However, they might also have severe neurological problems and require a large amount of sleep—typically 10 hours or more.
"In rare cases, brain lesions or diseases such as tumors, vascular malformations, strokes or inflammatory diseases of the brain can result in the destruction of the signaling pathways that increase brain activity and promote wakefulness," says Dr. Thau.
According to the National Health Service, secondary narcolepsy causes include:
As Dr. Thau notes, "a healthy lifestyle and avoiding smoking or the use of illicit drugs decrease the risk of some of the disorders that cause secondary narcolepsy."
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Mount Laurel police asks public's help in finding child – Courier Post
MOUNT LAUREL – Police are asking the public’s help in finding a 6-year-old girl who was allegedly abducted by her non-custodial mother.
The girl, Grace Craytor of Pennsauken, was last seen around 7:10 p.m. Monday with her mother, Kristina Maletteri, at Lifetime Fitness in Mount Laurel, according to township police.
The girl’s father, who has a full custody order for Grace, had invited Maletteri to swim with the child during a supervised visit at the facility at Church and Fellowship roads, said a police account.
“At some point, Ms. Maletteri is said to have taken her daughter and left the area without consent,” the account said.
Maletteri is known to drive a 2017 silver Audi Q3 with New Jersey license plates “S64MPY.”
The missing child is 46 inches tall, 70 pounds, with blonde hair and hazel eyes, police said.
Anyone with information is asked to call Mount Laurel police at 856-234-8300 or the confidential tip line 856-234-1414, extension 1599.
Tips can also be emailed to Lamaro@mountlaurelpd.org.
Jim Walsh covers public safety, economic development and other beats for the Courier-Post, Burlington County Times and The Daily Journal.
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