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Background Acute kidney injury (AKI) is an important complication encountered during the course of diabetic ketoacidosis (DKA). Plasma-Lyte with lower chloride concentration than saline has been shown to be associated with reduced incidence of AKI in adults with septic shock. No study has compared this in DKA. Methods This double-blind, parallel-arm, investigator-initiated, randomized controlled trial compared 0.9% saline with Plasma-Lyte-A as initial fluid in pediatric DKA. The study was done in a tertiary care, teaching, and referral hospital in India in children (> 1 month–12 years) with DKA as defined by ISPAD. Children with cerebral edema or known chronic kidney/liver disease or who had received pre-referral fluids and/or insulin were excluded. Sixty-six children were randomized to receive either Plasma-Lyte ( n  = 34) or 0.9% saline ( n  = 32). Main outcomes Primary outcome was incidence of new or progressive AKI, defined as a composite outcome of change in creatinine (defined by KDIGO), estimated creatinine clearance (defined by p-RIFLE), and NGAL levels. The secondary outcomes were resolution of AKI, time to resolution of DKA (pH > 7.3, bicarbonate> 15 mEq/L & normal sensorium), change in chloride, pH and bicarbonate levels, proportion of in-hospital all-cause mortality, need for renal replacement therapy (RRT), and length of ICU and hospital stay. Results Baseline characteristics were similar in both groups. The incidence of new or progressive AKI was similar in both [Plasma-Lyte 13 (38.2%) versus 0.9% saline 15 (46.9%); adjusted OR 1.22; 95% CI 0.43–3.43, p  = 0.70]. The median (IQR) time to resolution of DKA in Plasma-Lyte-A and 0.9% saline were 14.5 (12 to 20) and 16 (8 to 20) h respectively. Time to resolution of AKI was similar in both [Plasma-Lyte 22.1 versus 0.9% saline 18.8 h (adjusted HR 1.72; 95% CI 0.83–3.57; p  = 0.14)]. Length of hospital stay was also similar in both [Plasma-Lyte 9 (8 to 12) versus 0.9% saline 10 (8.25 to 11) days; p  = 0.39]. Conclusions The incidence of new or progressive AKI and resolution of AKI were similar in both groups. Plasma-Lyte-A was similar to 0.9% Saline in time to resolution of DKA, need for RRT, mortality, and lengths of PICU and hospital stay. Trial registration Clinical trial registry of India, CTRI/2018/05/014042 ( ctri.nic.in ) (Retrospectively registered).

There is limited evidence regarding early treatment of novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection to mitigate symptom progression. To examine whether high-dose zinc and/or high-dose ascorbic acid reduce the severity or duration of symptoms compared with usual care among ambulatory patients with SARS-CoV-2 infection. This multicenter, single health system randomized clinical factorial open-label trial enrolled 214 adult patients with a diagnosis of SARS-CoV-2 infection confirmed with a polymerase chain reaction assay who received outpatient care in sites in Ohio and Florida. The trial was conducted from April 27, 2020, to October 14, 2020. Patients were randomized in a 1:1:1:1 allocation ratio to receive either 10 days of zinc gluconate (50 mg), ascorbic acid (8000 mg), both agents, or standard of care. The primary end point was the number of days required to reach a 50% reduction in symptoms, including severity of fever, cough, shortness of breath, and fatigue (rated on a 4-point scale for each symptom). Secondary end points included days required to reach a total symptom severity score of 0, cumulative severity score at day 5, hospitalizations, deaths, adjunctive prescribed medications, and adverse effects of the study supplements. A total of 214 patients were randomized, with a mean (SD) age of 45.2 (14.6) years and 132 (61.7%) women. The study was stopped for a low conditional power for benefit with no significant difference among the 4 groups for the primary end point. Patients who received usual care without supplementation achieved a 50% reduction in symptoms at a mean (SD) of 6.7 (4.4) days compared with 5.5 (3.7) days for the ascorbic acid group, 5.9 (4.9) days for the zinc gluconate group, and 5.5 (3.4) days for the group receiving both (overall P = .45). There was no significant difference in secondary outcomes among the treatment groups. In this randomized clinical trial of ambulatory patients diagnosed with SARS-CoV-2 infection, treatment with high-dose zinc gluconate, ascorbic acid, or a combination of the 2 supplements did not significantly decrease the duration of symptoms compared with standard of care. ClinicalTrials.gov Identifier: NCT04342728.

Background Chlorhexidine-gluconate (CHG) impregnated dressings may prevent catheter-related bloodstream infections (CRBSI). Chlorhexidine-impregnated sponge dressings (sponge-dress) and gel dressings (gel-dress) have never been directly compared. We used the data collected for two randomized-controlled trials to perform a comparison between sponge-dress and gel-dress. Methods Adult critically ill patients who required short-term central venous or arterial catheter insertion were recruited. Our main analysis included only patients with CHG-impregnated dressings. The effect of gel-dress (versus sponge-dress) on major catheter-related infections (MCRI) and CRBSI was estimated using multivariate marginal Cox models. The comparative risks of dressing disruption and contact dermatitis were evaluated using logistic mix models for clustered data. An explanatory analysis compared gel-dress with standard dressings using either CHG skin disinfection or povidone iodine skin disinfection. Results A total of 3483 patients and 7941 catheters were observed in 16 intensive care units. Sponge-dress and gel-dress were utilized for 1953 and 2108 catheters, respectively. After adjustment for confounders, gel-dress showed similar risk for MCRI compared to sponge-dress (HR 0.80, 95% CI 0.28–2.31, p  = 0.68) and CRBSI (HR 1.13, 95% CI 0.34–3.70, p  = 0.85), less dressing disruptions (OR 0.72, 95% CI 0.60–0.86, p  < 0.001), and more contact dermatitis (OR 3.60, 95% CI 2.51–5.15, p  < 0.01). However, gel-dress increased the risk of contact dermatitis only if CHG was used for skin antisepsis (OR 1.94, 95% CI 1.38–2.71, p  < 0.01). Conclusions We described a similar infection risk for gel-dress and sponge-dress. Gel-dress showed fewer dressing disruptions. Concomitant use of CHG for skin disinfection and CHG-impregnated dressing may significantly increase contact dermatitis. Trials registration These studies were registered within ClinicalTrials.gov (numbers NCT01189682 and NCT00417235 ).

Background. Eradication of methicillin-resistant Staphylococcus aureus (MRSA) carriage may reduce the risk of MRSA infection and prevent transmission of the organism to other patients. Methods. To determine the efficacy of decolonization therapy, patients colonized with MRSA were randomized (3 : 1 allocation) to receive treatment (2% chlorhexidine gluconate washes and 2% mupirocin ointment intranasally, with oral rifampin and doxycycline for 7 days), or no treatment. Follow-up samples for MRSA culture were obtained from the nares, perineum, skin lesions, and catheter exit sites monthly for up to 8 months. The primary outcome measure was detection of MRSA at 3 months of follow-up. Univariate and multivariable analyses were performed to identify variables associated with treatment failure. Results. Of 146 patients enrolled in the study, 112 patients (87 treated; 25 not treated) were followed up for at least 3 months. At 3 months of follow-up, 64 (74%) of those treated had culture results negative for MRSA, compared with 8 (32%) of those not treated (P = .0001). This difference remained significant at 8 months of follow-up, at which time, 54% of those treated had culture results negative for MRSA (χ2 = 64.4; P < .0001, by log-rank test). The results of the multivariable analysis indicated that having a mupirocin-resistant isolate at baseline was associated with treatment failure (relative risk, 9.4; 95% confidence interval, 2.8–31.9; P = .0003), whereas decolonization therapy was protective (relative risk, 0.1; 95% confidence interval, 0.04–0.4; P = .0002). Mupirocin resistance emerged in only 5% of follow-up isolates. Conclusions. Treatment with topical mupirocin, chlorhexidine gluconate washes, oral rifampin, and doxycycline for 7 days was safe and effective in eradicating MRSA colonization in hospitalized patients for at least 3 months.

The effects of Ca concentration and pH on the composition, microstructural, and functional properties of Mozzarella cheese were studied. Cheeses were made using a starter culture (control) or by direct acidification of the milk with lactic acid or lactic acid and glucono-δ-lactone. In each of three trials, four cheeses were produced: a control, CL, and three directly-acidified cheeses, DA1, DA2, and DA3. The cheeses were stored at 4°C for 70 d. The Ca content and pH were varied by altering the pH at setting, pitching, and plasticization. The mean pH at 1 d and the Ca content (mg/g of protein) of the various cheeses were: CL, 5.42 and 27.7; DA1, 5.96 and 21.8; DA2, 5.93 and 29.6; DA3, 5.58 and 28.7. For cheeses with a high pH (i.e., ∼5.9), reducing the Ca content from 29.6 to 21.8mg/g of protein resulted in a significant decrease in the protein level and increases in the moisture content and mean level of nonexpressible serum (g/g of protein). Reducing the Ca concentration also resulted in a more swollen, hydrated para-casein matrix at 1 d. The decrease in Ca content in the high-pH cheeses coincided with increases in the mean stretchability and flowability of the melted cheese over the 70-d storage period. The fluidity of the melted cheese also increased when the Ca content was reduced, as reflected by a lower elastic shear modulus and a higher value for the phase angle, δ, of the melted cheese, especially after storage for <12 d. The melt time, flowability, and stretchability of the low-Ca, high-pH DA1 cheese at 1 d were similar to those for the CL cheese after storage for ≥12 d. In contrast, the mean values for flowability and stretchability of the high-pH, high-Ca DA2 cheese over the 70-d period were significantly lower than those of the CL cheese. Reducing the pH of high-Ca cheese (27.7 to 29.6mg/g of protein) from ∼5.95 to 5.58 resulted in higher flowability, stretchability, and fluidity of the melted cheese. For cheeses with similar pH and Ca concentration, the method of acidification had little effect on composition, microstructure, flowability, stretchability, and fluidity of the melted cheese.

There are no compatibility studies for neonatal parenteral nutrition solutions without cysteine containing calcium chloride or calcium gluconate using light obscuration as recommended by the United States Pharmacopeia (USP). The purpose of this study was to do compatibility testing for solutions containing calcium chloride and calcium gluconate without cysteine. Solutions of TrophAmine and Premasol (2.5% amino acids), containing calcium chloride or calcium gluconate were compounded without cysteine. Solutions were analyzed for particle counts using light obscuration. Maximum concentrations tested were 15 mmol/L of calcium and 12.5 mmol/L of phosphate. If the average particle count of three replicates exceeded USP guidelines, the solution was determined to be incompatible. This study found that 12.5 and 10 mmol/L of calcium and phosphate, respectively, are compatible in neonatal parenteral nutrition solutions compounded with 2.5% amino acids of either TrophAmine or Premasol. There did not appear to be significant differences in compatibility for solutions containing TrophAmine or Premasol when solutions were compounded with either CaCl2 or CaGlu-Pl. This study presents data in order to evaluate options for adding calcium and phosphate to neonatal parenteral nutrition solutions during shortages of calcium and cysteine.

Background Central line-associated bloodstream infections (CLABSIs) result in approximately 28,000 deaths and approximately $2.3 billion in added costs to the U.S. healthcare system each year, and yet, many of these infections are preventable. At two large health systems in the southeast United States, CLABSIs continue to be an area of opportunity. Despite strong evidence for interventions to prevent CLABSI and reduce associated patient harm, such as use of chlorhexidine gluconate (CHG) bathing, the adoption of these interventions in practice is poor. The primary objective of this study was to assess the effect of a tailored, multifaceted implementation program on nursing staff’s compliance with the CHG bathing process and electronic health record (EHR) documentation in critically ill patients. The secondary objectives were to examine the (1) moderating effect of unit characteristics and cultural context, (2) intervention effect on nursing staff’s knowledge and perceptions of CHG bathing, and (3) intervention effect on CLABSI rates. Methods A stepped wedged cluster-randomized design was used with units clustered into 4 sequences; each sequence consecutively began the intervention over the course of 4 months. The Grol and Wensing Model of Implementation helped guide selection of the implementation strategies, which included educational outreach visits and audit and feedback. Compliance with the appropriate CHG bathing process and daily CHG bathing documentation were assessed. Outcomes were assessed 12 months after the intervention to assess for sustainability. Results Among the 14 clinical units participating, 8 were in a university hospital setting and 6 were in community hospital settings. CHG bathing process compliance and nursing staff’s knowledge and perceptions of CHG bathing significantly improved after the intervention ( p = .009, p = .002, and p = .01, respectively). CHG bathing documentation compliance and CLABSI rates did not significantly improve; however, there was a clinically significant 27.4% decrease in CLABSI rates. Conclusions Using educational outreach visits and audit and feedback implementation strategies can improve adoption of evidence-based CHG bathing practices. Trial registration ClinicalTrials.gov, NCT03898115 , Registered 28 March 2019.

Background The addition of calcium to resuscitation fluids is a common practice in horses, but studies evaluating the effects of calcium supplementation are limited. In healthy horses, decreases in heart rate and changes in serum electrolyte concentrations have been reported. Hypothesis Calcium gluconate administration at a rate of 0.4 mg/kg/min to eliminated endurance horses with metabolic problems will affect heart rate, gastrointestinal sounds, and serum electrolyte concentrations. Animals Endurance horses eliminated from the Tevis Cup 100‐mile (160 km) endurance ride for metabolic problems and requiring IV fluid therapy were eligible. Methods Sixteen horses were randomly assigned to receive 0.4 mg/kg/min of calcium (23% calcium gluconate solution) over 1 hour diluted in 10 L of a non‐calcium containing isotonic crystalloid (CAL group) or 10 L of a non‐calcium containing isotonic crystalloid (CON group). Staff members administering the fluids were blinded to treatment group. Blood samples were collected and physical examinations performed before and after treatment. Heart rates were recorded every 15 min during fluid administration. Data were compared using 2‐way analysis of variance (ANOVA) with repeated measures for continuous variables and Fisher's exact test for categorical variables. Results Calcium was associated with lower heart rates 45 min after starting the infusion (P = .002). Gastrointestinal sounds were less likely to improve in the calcium group compared with the control group (P = .005). An increase in plasma phosphorus concentration (P = .03) was associated with calcium administration. Conclusions Intravenous calcium supplementation to endurance horses eliminated from competition after development of metabolic problems may decrease heart rate but impairs improvement in gastrointestinal sounds.

•Oil pulling perform plaque regrowth inhibition similar with chlorhexidine gluconate.•Plaque inhibition with CHX is greater in the buccal surfaces of anterior sites.•Oil pulling results in less tooth staining. The aim of this study was to evaluate the plaque-inhibiting effects of oil pulling using 4- day plaque regrowth study model compared to 0.2% chlorhexidine gluconate (CHX) containing mouthrinse. The study was an observer-masked, randomized, cross-over design clinical trial, involving 29 volunteers to compare 0.2% CHX and oil pulling therapy in a 4- day plaque regrowth model. After the preparatory period, in which the subjects received professional prophylaxis, the subjects commenced rinsing with their allocated rinsed. On day 5 plaque index (PI), gingival index (GI), stain index (SI), bleeding on probing (BOP) were recorded from the subjects. Each participant underwent a 14- day wash out period and then used the other mouthrinse for four days. Oil pulling therapy presented similar inhibitory activity on plaque regrowth compared with CHX (PI = 1.67 ± 0.24, 1.61 ± 0.20, respectively) with less staining (SI = 0.21 ± 0.13, 0.47 ± 0.27, respectively). In addition, GI and BOP was similar in both groups (p > 0.05). Oil pulling with coconut oil seems to have similar plaque inhibition activity as CHX. In addition it caused less tooth staining than CHX. These findings suggest that oil pulling therapy may be an alternative to CHX rinse.

Aims: The aim of this in vitro study was to evaluate the effects of newly proposed irrigants; the pomegranate, apple cider, and grape vinegars in comparison with contemporary irrigants; sodium hypochlorite (NaOCl), chlorhexidine gluconate (CHX), and octenidine-hydrochloride (OCT) on microhardness and surface roughness of human root canal dentin. Subjects and Methods: The crowns of the 105 mandibular incisor teeth were removed, and roots were separated longitudinally. Root halves were embedded in acrylic-resin and were ground flat. The specimens were randomly divided into following six test groups (n = 30); pomegranate vinegar, apple cider vinegar, grape vinegar, 2.5% NaOCl, 2% CHX, OCT and a control group based on the treatment time, samples were then divided into two subgroups (15 min or 30 min). Each specimen was first subjected to surface roughness and then Vickers microhardness testing. The data were statistically analyzed. Results: Pomegranate, apple cider, and grape vinegars exhibited similar roughness values (P > 0.05) and presented higher results than other groups (P < 0.05). There was no statistically significant difference between the microhardness values of the irrigant groups (P > 0.05). The microhardness decreased when the exposure time increased from 15 min to 30 min (P < 0.05). Conclusions: The use of vinegar for endodontic irrigation may have a softening effect on root canal dentin with time and may increase dentin roughness.