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BackgroundMost patients undergoing anti-reflux surgery (ARS) have a history of preoperative proton pump inhibitor (PPI) use. It is well-established that ARS is effective in restoring the anti-reflux barrier, eliminating the ongoing need for costly PPIs. Current literature lacks objective evidence supporting an optimal postoperative PPI cessation or weaning strategy, leading to wide practice variations. We sought to objectively gauge current practice and opinion surrounding the postoperative management of PPIs among expert foregut surgeons and gastroenterologists in the United States.MethodsWe created a survey of postoperative PPI management protocols, with an emphasis on discontinuation and timing of PPI cessation, and aimed to determine what factors played a role in the decision-making. An electronic survey tool (Qualtrics XM, Qualtrics, Provo, UT) was used to distribute the survey and to record the responses anonymously for a period of three months.ResultsThe survey was viewed 2658 times by 373 institutions and shared with 644 members. In total, 121 respondents participated in the survey and 111 were surgeons (92%). Fifty respondents (42%) always discontinue PPIs immediately after ARS. Of the remaining 70 respondents (58%), 46% always wean or taper PPIs postoperatively and 47% wean or taper them selectively. The majority (92%) of practitioners taper within a 3-month period postoperatively. Five respondents never discontinue PPIs after ARS. Overall, only 23 respondents (19%) stated their protocol is based on medical literature or evidence-based medicine. Instead, decision-making is primarily based on anecdotal evidence/personal preference (42%, n = 50) or prior training/mentors (39%, n = 47).ConclusionsThere are two major protocols used for PPI discontinuation after ARS: Nearly half of providers abruptly stop PPIs, while just over half gradually tapers them, most often in the early postoperative period. These decisions are primarily driven by institutional practices and personal preferences, underscoring the need for evidence-based recommendations.

Purpose of ReviewThe optimal management of external ventricular drains (EVD) in the setting of acute brain injury remains controversial. Therefore, we sought to determine whether there are optimal management approaches based on the current evidence.Recent FindingsWe identified 2 recent retrospective studies on the management of EVDs after subarachnoid hemorrhage (SAH) which showed conflicting results. A multicenter survey revealed discordance between existing evidence from randomized trials and actual practice. A prospective study in a post-traumatic brain injury (TBI) population demonstrated the benefit of EVDs but did not determine the optimal management of the EVD itself. The recent CLEAR trials have suggested that specific positioning of the EVD in the setting of intracerebral hemorrhage with intraventricular hemorrhage may be a promising approach to improve blood clearance.SummaryEvidence on the optimal management of EVDs remains limited. Additional multicenter prospective studies are critically needed to guide approaches to the management of the EVD.

Background Difficult-to-wean patients, typically identified as those failing the initial spontaneous breathing trial (SBT), face elevated mortality rates. Pendelluft, frequently observed in patients experiencing SBT failure, can be conveniently detected through bedside monitoring with electrical impedance tomography (EIT). This study aimed to explore the impact of pendelluft during SBT on difficult-to-wean patients. Methods This retrospective observational study included difficult-to-wean patients undergoing spontaneous T piece breathing, during which EIT data were collected. Pendelluft occurrence was defined when its amplitude exceeded 2.5% of global tidal impedance variation. Physiological parameters during SBT were retrospectively retrieved from the EIT Examination Report Form. Other clinical data including mechanical ventilation duration, length of ICU stay, length of hospital stay, and 28-day mortality were retrieved from patient records in the hospital information system for each subject. Results Pendelluft was observed in 72 (70.4%) of the 108 included patients, with 16 (14.8%) experiencing mortality by day 28. The pendelluft group exhibited significantly higher mortality (19.7% vs. 3.1%, p  = 0.035), longer median mechanical ventilation duration [9 (5–15) vs. 7 (5–11) days, p  = 0.041] and shorter ventilator-free days at day 28 [18 (4–22) vs. 20 (16–23) days, p  = 0.043]. The presence of pendellfut was independently associated with increased mortality at day 28 (OR = 10.50, 95% confidence interval   1.21–90.99, p  = 0.033). Conclusions Pendelluft occurred in 70.4% of difficult-to-wean patients undergoing T piece spontaneous breathing. Pendelluft was associated with worse clinical outcomes, including prolonged mechanical ventilation and increased mortality in this population. Our findings underscore the significance of monitoring pendelluft using EIT during SBT for difficult-to-wean patients.

Infants and children with congenital heart disease (CHD) often require supplemental nutrition via tube feeding before and after surgery. Tube feeding may be required due to poor weight gain, inadequate oral-motor skills, and/or reduced endurance for oral feeding. Our team has described a successful approach to weaning this population (Horsley et al. (2022) Pediatr Cardiol 43:1429–1437). A subgroup of tube-fed patients with CHD who demonstrate oral feeding aversion (OA) presents unique challenges to the tube weaning process. We discuss our team’s experience with tube weaning orally averse children with CHD. Of 36 patients enrolled in the Cincinnati Children’s Heart Institute Cardiology Feeding Tube Wean Clinic, 11 (31%) were determined to have oral feeding aversion (OA) by a speech-language pathologist (SLP). Descriptive data comparing the OA group to the non-averse group was gathered prior to and during the wean. Both groups had the ability to tube wean successfully, although the OA group had lower median oral intake (9 vs 24%) and higher age at start of the wean (9 vs 4 months). Those with OA also had a longer median duration of wean in days (17 vs 12 days) and higher likelihood of return to tube feeds within six-month post-wean (22 vs 0%). Additionally, the OA group had a higher percentage of genetic syndromes (36 vs 16%), although this was not found to be statistically significant in this study. Children with OA present with unique challenges for tube weaning. The results of this study show that weaning children with CHD and OA is possible with a multidisciplinary team who is knowledgeable about this population.

We commend the authors for their insightful study on inspiratory muscle training (IMT) in mechanically ventilated patients with difficult weaning, highlighting the robust use of maximum inspiratory pressure (MIP) as a key outcome. We suggest that a lower baseline maximum inspiratory pressure cutoff could better target patients with significant inspiratory dysfunction, improving the study's precision. Additionally, alternative imputation techniques, such as multiple imputation, could strengthen the handling of missing data. While the sample size calculation was appropriate, the unbalanced group sizes raise concerns about generalisability. Future research could benefit from subgroup analyses, individual response curves, and further investigation into the unexpected adverse effects observed in the low-intensity group to refine the inspiratory muscle training protocols.

We report a retrospective case series of COVID-19 pneumonitis (C19P) patients in hypoxic respiratory failure who experienced a symptom rebound upon cessation or weaning of steroids following an initial positive response. The post-steroid rebound phenomenon in C19P is not well described in the literature and we aim to add to the body of evidence exploring this pathology. Methods : Post-steroid rebound COVID-19 pneumonitis (PSRCP) cases at our institution were identified for notes review from respiratory department follow-up records. The inclusion criteria were as follows: Hospital admissions with radiologically and PCR-confirmed C19P. Administration of a corticosteroid course for the indication of hypoxia due to C19P. An objective relapse of the index presentation with differential diagnoses other than post-steroid rebound excluded by appropriate clinicians. A literature search was performed using Medline, Ovid and Google Scholar and the search terms “rebound and COVID-19”, “rebound and COVID-19 and pneumonitis” “post-COVID and pneumonitis” “relapse and COVID-19”, “relapse and coronavirus and pneumonitis”. Results : Eighteen patients were identified between 2021 and 2024 with ages ranging from 48 to 80 years. The most common comorbidities were hypertension (50%) and obesity (39%) while 89% had a history of regular smoking. Seventeen of the 18 had evidence of hyperinflammation at first C19P presentation with a C-reactive protein (CRP) ≥ 75 mg/dl. Notably, 15 patients had a CRP blood test at least 48 h prior to discharge, steroid cessation or weaning and of these, 11 (73%) showed persisting CRP elevation. Seventeen of the 18 responded upon diagnosis of PSRCP to steroid rechallenge with survival to discharge. Conclusions : As COVID-19 becomes endemic, clinicians should remain wary of the risk of PSRCP. Greater recognition of the importance of steroid weans and rechallenges in C19P narratives will help avoid poor outcomes, readmissions and the risk of post-C19P sequelae. Awareness of the PSRCP phenomenon should lower the threshold for slow steroid weans upon an initial C19P diagnosis over the standard UK regimen of a 10-day duration or less dexamethasone course. A definition for PSRCP is proposed as well as a decision aid around steroid strategies in patients both with and at risk of PSRCP.

Background Porcine reproductive and respiratory syndrome virus (PRRSV) and influenza A virus (IAV) are swine pathogens that can significantly impact the performance of post-weaning pigs. While oral fluid (OF) samples are widely used for monitoring these viruses, postmortem tongue fluid (TF) samples present a cost-effective alternative with potential advantages in viral detection. This study aimed to compare the performance of TF and OF samples collected from nursery and finishing pig herds in detecting PRRSV and IAV using reverse transcription-quantitative polymerase chain reaction (RT-qPCR). A Bayesian latent class model was used to estimate diagnostic sensitivity and specificity for TF and OF under the assumption of conditional independence. The study also examined the relationship between mortality rates and RT-qPCR outcomes, the success rate of Sanger sequencing for the PRRSV ORF-5 region, and the effect of pooling daily aggregated TF samples on the probability of PRRSV detection. Results IAV was detected in 34.9% of OF samples and 30.2% of TF samples, while PRRSV was identified in 67.4% of OF and 53.5% of TF samples. TF samples had a significantly lower mean Ct for PRRSV (29.1) compared to OF samples (32.8) but had a similar Ct (30.9) to OF (29.7) for IAV. The hierarchical latent class Bayesian model estimated the sensitivity and specificity values for OF as 37.3% and 61.7% for IAV, and 64.3% and 35.1% for PRRSV. The estimated sensitivity and specificity values for TF were 33.5% and 66.0% for IAV, and 53.0% and 47.0% for PRRSV. Among 22 matched TF and OF pairs submitted for PRRSV sequencing, 45.5% of OF samples and 63.6% of TF samples were successfully sequenced, with the higher success rate for TF attributed to having lower Ct values. Additionally, mortality rates were notably higher when PRRSV was detected, especially in cases with concurrent IAV detection. Regarding sample pooling, our results indicated that pooling TF samples significantly increased detection probabilities, with a 1/7 dilution achieving a 79% RT-qPCR detection rate, compared to a detection rate of 14.3% when testing a single day's TF sample from a week with only one positive day. Conclusion The findings support the use of TF samples as a viable complement or alternative to OF samples for PRRSV and IAV surveillance in post-weaning pigs when mortalities are available. The cost-efficiency of TF sampling can enhance monitoring compliance, improve early pathogen detection, and facilitate timely responses to emerging threats in swine production. This study advocates for the adoption of TF as a risk-based sampling strategy in nursery and grow-finish settings, complementing live animal samples such as OF, ultimately contributing to better herd health management.

Maternal separation with early weaning (MSEW) is a popular early life stress (ELS) model in rodents, which emulates childhood neglect through scheduled mother-offspring separation. Although variations of ELS models, including maternal separation and MSEW, have been published for the mouse species, the reported results are inconsistent. Corticosterone is considered the main stress hormone involved in regulating stress responses in rodents—yet generating a robust and reproducible corticosterone response in mouse models of ELS has been elusive. Considering the current lack of standardization for MSEW protocols, these inconsistent results may be attributed to variations in model methodologies. Here, we compared the effects of select early wean diet sources—which are the non-milk diets used to complete early weaning in MSEW pups—on the immediate stress phenotype of C57BL/6J mice at postnatal day 21. Non-aversive handling was an integral component of our modified MSEW model. The evaluation of body weight and serum corticosterone revealed the early wean diet to be a key variable in the resulting stress phenotype. Interestingly, select non-milk diets facilitated a stress phenotype in which low body weight was accompanied by significant corticosterone elevation. Our data indicate that dietary considerations are critical in MSEW-based studies and provide insight into improving the reproducibility of key stress-associated outcomes as a function of this widely used ELS paradigm.

Abstract In U.S. breeding herds, data collection is widespread but often fragmented across systems. While producers rely on performance summaries, integration of these data to improve productivity remains underutilized. This study evaluated sow-level factors associated with sow efficiency, defined as weaning-to-estrus interval (WEI), percentage of sows bred within 7 days post-weaning, subsequent farrowing success, and total piglets born. Data were sourced from six lactation trials on a commercial sow farm, with sows of the same genetics (PIC line 1050), housing, and free of Porcine Reproductive and Respiratory Syndrome Virus (PRRSV) and Porcine Epidemic Diarrhea Virus (PEDV). The dataset contained 4,300 observations, including reproductive performance, daily feed intake, sow and litter weights. Generalized linear regression models were constructed with 23 variables; trial was included as a random effect, and model selection performed through manual stepwise forward selection based on biological plausibility. Pairwise comparisons were made using t-tests with the Tukey-Kramer adjustment at P <0.05 significance. Parity (P < 0.001), nursed piglets (P = 0.01), and average daily feed intake (ADFI0 in the first three days (P = 0.01) were associated with WEI. Sows nursing ≥15 piglets had a 1.3-day increase in WEI (P = 0.01), while ADFI <4.5kgs (10lbs) for the first three days was associated with 1-day increase in WEI (P <0.001). Factors associated with breeding within 7 days included parity (P = 0.05), first-week ADFI (P = 0.01), and nursed piglets (P = 0.009). Subsequent farrowing success was associated with prior litter size (P = 0.02), stillbirth rate (P = 0.01), first-week ADFI (P = 0.01), nursed piglets (P = 0.02), and body weight change (P = 0.01). Sows with ≥1 stillborn piglet had a 7% lower farrowing probability (P = 0.01), and those nursing >15 piglets had a 12% reduction (P = 0.02) in farrowing success. Factors associated with subsequent total born included parity (P < 0.001), previous litter size (P = 0.01), piglet birth weight (P = 0.01), caliper change (P = 0.04), stillbirth rate (P 0.01), and the interaction between body weight change and litter wean weight (P = 0.002). Sows with average litter birth weights <1 kg (2.4lbs) produced two more piglets than those >1.5kgs (3.5lbs). Stillbirth rates >5% reduced subsequent litter size by 2 piglets (P <0.05), and caliper gains >1 unit added 2 piglets compared to sows losing a unit of caliper (P  0.05). Overall, early lactation feed intake, litter size, and body condition were associated with reproductive outcomes. Low early lactation—first week- feed intake and high nursing burden extended WEI, delayed rebreeding, and reduced farrowing success, providing evidence-based targets to improve sow productivity. Lay Summary Swine farms collect diverse information on sow performance, siloed in different software, yet much of it remains underutilized to guide daily decisions. This study examined individual sow characteristics that influence reproductive performance, aiming to identify practical management targets to enhance sow productivity. Data was collected from over 4,000 observations on a commercial sow farm. Variables included lactation feed intake, sow reproductive performance, and piglet weights at birth and weaning. The study focused on key indicators of sow efficiency, including the time it took for sows to return to estrus, whether they were bred within 7 days post-weaning, their likelihood of farrowing again, and the number of piglets born in the next litter. The results showed that high feed intake in the first 3 and 7 days and the number of piglets suckling were associated with increased wean-to-estrus days and lower chances of farrowing again. Sows with any stillborn piglet al.o showed reduced reproductive success in the following cycle and subsequent litter size. These findings highlight the importance of early lactation feeding strategies and monitoring of cross-fostering. Identifying these key factors allows producers to target at-risk sows with timely interventions, improving breeding outcomes and sustaining herd productivity. Early lactation feed intake, stillbirth rate, and number of piglets suckling are associated with key reproductive outcomes in sows. These factors are linked to longer wean-to-estrus intervals, reduced farrowing success, and smaller subsequent litter, providing evidence-based targets to improve sow management and herd productivity.

Background High-frequency ventilation (HFV) is commonly used in neonatal intensive care units to provide respiratory support for critically ill neonates. Currently, there is no standardized procedure for weaning from HFV. Two commonly used strategies are transitioning from HFV to conventional mechanical ventilation (CMV) before extubation (HFV-CMV) and extubation after decreasing mean airway pressure during HFV (HFV-HFV). The impact of these strategies on neonatal cerebral oxygenation and hemodynamics remains incompletely understood. Methods We will conduct a prospective, single-center, randomized controlled trial to investigate the effects of two different HFV weaning strategies (HFV-CMV, HFV-HFV) on neonatal cerebral oxygenation and hemodynamics. The patients enrolled in the trial will be randomly allocated to either the HFV-CMV group or the HFV-HFV group in a 1:1 ratio. The primary outcome will be cerebral oxygen saturation (S c O 2 ) before and after the intervention. Second outcomes are cerebral fractional tissue oxygen extraction, heart rate, blood pressure, and the incidence and severity of intraventricular hemorrhage and periventricular leukomalacia. We hypothesize that HFV-CMV results in positive impact on neonatal cerebral oxygenation compared to HFV-HFV. This study aims to identify a better weaning strategy for HFV and contribute evidence-based data to enhance its clinical application in newborns, potentially improving the care and outcomes for neonates receiving HFV. Discussion This study aims to assessing the impact of different HFV weaning strategies on neonatal cerebral oxygenation and hemodynamics, as well as the relationship between the duration of HFV under different strategies and neurological complications, to identify better weaning methods for HFV. We hope to contribute evidence-based data to enhance clinical application of HFV in newborns, potentially improving the care and outcomes for neonates receiving HFV. Trial registration Chinese Clinical Trial Registry: ChiCTR2400088628. Registered on August 22, 2024, https://www.chictr.org.cn/bin/project/edit?pid=235926 .