Chest wall loading during supine and prone position in patients with COVID-19 ARDS: effects on respiratory mechanics and gas exchange.

BACKGROUND: Recent reports of patients with severe, late-stage COVID-19 ARDS with reduced respiratory system compliance described paradoxical decreases in plateau pressure and increases in respiratory system compliance in response to anterior chest wall loading. We aimed to assess the effect of chest wall loading during supine and prone position in ill patients with COVID-19-related ARDS and to investigate the effect of a low or normal baseline respiratory system compliance on the findings. METHODS: This is a single-center, prospective, cohort study in the intensive care unit of a COVID-19 referral center. Consecutive mechanically ventilated, critically ill patients with COVID-19-related ARDS were enrolled and classified as higher (≥ 40 ml/cmH2O) or lower respiratory system compliance (< 40 ml/cmH2O). The study included four steps, each lasting 6 h: Step 1, supine position, Step 2, 10-kg continuous chest wall compression (supine + weight), Step 3, prone position, Step 4, 10-kg continuous chest wall compression (prone + weight). The mechanical properties of the respiratory system, gas exchange and alveolar dead space were measured at the end of each step. RESULTS: Totally, 40 patients were enrolled. In the whole cohort, neither oxygenation nor respiratory system compliance changed between supine and supine + weight; both increased during prone positioning and were unaffected by chest wall loading in the prone position. Alveolar dead space was unchanged during all the steps. In 16 patients with reduced compliance, PaO2/FiO2 significantly increased from supine to supine + weight and further with prone and prone + weight (107 ± 15.4 vs. 120 ± 18.5 vs. 146 ± 27.0 vs. 159 ± 30.4, respectively; p < 0.001); alveolar dead space decreased from both supine and prone position after chest wall loading, and respiratory system compliance significantly increased from supine to supine + weight and from prone to prone + weight (23.9 ± 3.5 vs. 30.9 ± 5.7 and 31.1 ± 5.7 vs. 37.8 ± 8.7 ml/cmH2O, p < 0.001). The improvement was higher the lower the baseline compliance. CONCLUSIONS: Unlike prone positioning, chest wall loading had no effects on respiratory system compliance, gas exchange or alveolar dead space in an unselected cohort of critically ill patients with C-ARDS. Only patients with a low respiratory system compliance experienced an improvement, with a higher response the lower the baseline compliance.

Central venous pressure swing outperforms diaphragm ultrasound as a measure of inspiratory effort during pressure support ventilation in COVID-19 patients.

PURPOSE: The COVID-19-related shortage of ICU beds magnified the need of tools to properly titrate the ventilator assistance. We investigated whether bedside-available indices such as the ultrasonographic changes in diaphragm thickening ratio (TR) and the tidal swing in central venous pressure (ΔCVP) are reliable estimates of inspiratory effort, assessed as the tidal swing in esophageal pressure (ΔPes). METHODS: Prospective, observational clinical investigation in the intensive care unit of a tertiary care Hospital. Fourteen critically-ill patients were enrolled (age 64 ± 7 years, BMI 29 ± 4 kg/m2), after 6 [3; 9] days from onset of assisted ventilation. A three-level pressure support trial was performed, at 10 (PS10), 5 (PS5) and 0 cmH2O (PS0). In each step, the esophageal and central venous pressure tidal swing were recorded, as well as diaphragm ultrasound. RESULTS: The reduction of pressure support was associated with an increased respiratory rate and a reduced tidal volume, while minute ventilation was unchanged. ΔPes significantly increased with reducing support (5 [3; 8] vs. 8 [14; 13] vs. 12 [6; 16] cmH2O, p < 0.0001), as did the diaphragm TR (9.2 ± 6.1 vs. 17.6 ± 7.2 vs. 28.0 ± 10.0%, p < 0.0001) and the ΔCVP (4 [3; 7] vs. 8 [5; 9] vs. 10 [7; 11] cmH2O, p < 0.0001). ΔCVP was significantly associated with ΔPes (R2 = 0.810, p < 0.001), as was diaphragm TR, albeit with a lower coefficient of determination (R2 = 0.399, p < 0.001). CONCLUSIONS: In patients with COVID-19-associated respiratory failure undergoing assisted mechanical ventilation, ΔCVP is a better estimate of inspiratory effort than diaphragm ultrasound.

Analytical Approaches in Official Food Safety Control: An LC-Orbitrap-HRMS Screening Method for the Multiresidue Determination of Antibiotics in Cow, Sheep, and Goat Milk.

The presence of unauthorized substances, such as residues of veterinary medicines or chemical contaminants, in food can represent a possible health concern. For this reason, a complete legislative framework has been established in the European Union (EU), which defines the maximum limits allowed in food and carries out surveillance programs to control the presence of these substances. Official food control laboratories, in order to ensure a high level of consumer protection, must respond to the challenge of improving and harmonizing the performance of the analytical methods used for the analysis of residues of authorized, unauthorized, or prohibited pharmacologically active substances. Laboratories must also consider the state of the art of the analytical methodologies and the performance requirements of current legislation. The aim of this work was to develop a multiresidue method for the determination of antibiotics in milk, compliant with the criteria and procedures established by Commission Implementing Regulation (EU) 2021/808. The method uses an LC-Orbitrap-HRMS for the determination of 57 molecules of antibiotic and active antibacterial substances belonging to different chemical classes (beta-lactams, tetracyclines, sulfonamides, quinolones, pleuromutilins, macrolides, and lincosamides) in bovine, ovine, and goat milk samples. It provides a simple and quick sample pretreatment and a subsequent identification phase of analytes, at concentrations equal to or lower than the maximum residual limit (MRL), in compliance with Commission Regulation (EU) 2010/37. The validation parameters: selectivity, stability, applicability, and detection capability (ccß), are in agreement with the requirements of Commission Implementing Regulation (EU) 2021/808 and demonstrated the effectiveness of the method in detecting veterinary drug residues at the target screening concentration (at the MRL level or below), with a false positive rate of less than 5%. This method represents an effective solution for detecting antibiotics in milk, which can be successfully applied in routine analyses for official food control plans.

Unitarity and Page Curve for Evaporation of 2D AdS Black Holes.

We explore the Hawking evaporation of two-dimensional anti-de Sitter (AdS2), dilatonic black hole coupled with conformal matter, and derive the Page curve for the entanglement entropy of radiation. We first work in a semiclassical approximation with backreaction. We show that the end-point of the evaporation process is AdS2 with a vanishing dilaton, i.e., a regular, singularity-free, zero-entropy state. We explicitly compute the entanglement entropies of the black hole and the radiation as functions of the horizon radius, using the conformal field theory (CFT) dual to AdS2 gravity. We use a simplified toy model, in which evaporation is described by the forming and growing of a negative mass configuration in the positive-mass black hole interior. This is similar to the "islands" proposal, recently put forward to explain the Page curve for evaporating black holes. The resulting Page curve for AdS2 black holes is in agreement with unitary evolution. The entanglement entropy of the radiation initially grows, closely following a thermal behavior, reaches a maximum at half-way of the evaporation process, and then goes down to zero, following the Bekenstein-Hawking entropy of the black hole. Consistency of our simplified model requires a non-trivial identification of the central charge of the CFT describing AdS2 gravity with the number of species of fields describing Hawking radiation.

Harmonize: a shared environment for extended immersive entertainment.

Virtual reality (VR) and augmented reality (AR) applications are very diffuse nowadays. Moreover, recent technology innovations led to the diffusion of commercial head-mounted displays for immersive VR: users can enjoy entertainment activities that fill their visual fields, experiencing the sensation of physical presence in these virtual immersive environments. Even if AR and VR are mostly used separately, they can be effectively combined to provide a multi-user shared environment (SE), where two or more users perform some specific tasks in a cooperative or competitive way, providing a wider set of interactions and use cases compared to immersive VR alone. However, due to the differences between the two technologies, it is difficult to develop SEs offering a similar experience for both AR and VR users. This paper presents Harmonize, a novel framework to deploy applications based on SEs with a comparable experience for both AR and VR users. Moreover, the framework is hardware-independent, and it has been designed to be as much extendable to novel hardware as possible. An immersive game has been designed to test and to evaluate the validity of the proposed framework. The assessment of the system through the System Usability Scale questionnaire and the Game Experience Questionnaire shows a positive evaluation.

Tolerant and intolerant macaques show different levels of structural complexity in their vocal communication.

We tested the social complexity hypothesis which posits that animals living in complex social environments should use complex communication systems. We focused on two components of vocal complexity: diversity (number of categories of calls) and flexibility (degree of gradation between categories of calls). We compared the acoustic structure of vocal signals in groups of macaques belonging to four species with varying levels of uncertainty (i.e. complexity) in social tolerance (the higher the degree of tolerance, the higher the degree of uncertainty): two intolerant species, Japanese and rhesus macaques, and two tolerant species, Tonkean and crested macaques. We recorded the vocalizations emitted by adult females in affiliative, agonistic and neutral contexts. We analysed several acoustic variables: call duration, entropy, time and frequency energy quantiles. The results showed that tolerant macaques displayed higher levels of vocal diversity and flexibility than intolerant macaques in situations with a greater number of options and consequences, i.e. in agonistic and affiliative contexts. We found no significant differences between tolerant and intolerant macaques in the neutral context where individuals are not directly involved in social interaction. This shows that species experiencing more uncertain social interactions displayed greater vocal diversity and flexibility, which supports the social complexity hypothesis.

Assisted mechanical ventilation promotes recovery of diaphragmatic thickness in critically ill patients: a prospective observational study.

BACKGROUND: Diaphragm atrophy and dysfunction are consequences of mechanical ventilation and are determinants of clinical outcomes. We hypothesize that partial preservation of diaphragm function, such as during assisted modes of ventilation, will restore diaphragm thickness. We also aim to correlate the changes in diaphragm thickness and function to outcomes and clinical factors. METHODS: This is a prospective, multicentre, observational study. Patients mechanically ventilated for more than 48 h in controlled mode and eventually switched to assisted ventilation were enrolled. Diaphragm ultrasound and clinical data collection were performed every 48 h until discharge or death. A threshold of 10% was used to define thinning during controlled and recovery of thickness during assisted ventilation. Patients were also classified based on the level of diaphragm activity during assisted ventilation. We evaluated the association between changes in diaphragm thickness and activity and clinical outcomes and data, such as ventilation parameters. RESULTS: Sixty-two patients ventilated in controlled mode and then switched to the assisted mode of ventilation were enrolled. Diaphragm thickness significantly decreased during controlled ventilation (1.84 ± 0.44 to 1.49 ± 0.37 mm, p < 0.001) and was partially restored during assisted ventilation (1.49 ± 0.37 to 1.75 ± 0.43 mm, p < 0.001). A diaphragm thinning of more than 10% was associated with longer duration of controlled ventilation (10 [5, 15] versus 5 [4, 8.5] days, p = 0.004) and higher PEEP levels (12.6 ± 4 versus 10.4 ± 4 cmH2O, p = 0.034). An increase in diaphragm thickness of more than 10% during assisted ventilation was not associated with any clinical outcome but with lower respiratory rate (16.7 ± 3.2 versus 19.2 ± 4 bpm, p = 0.019) and Rapid Shallow Breathing Index (37 ± 11 versus 44 ± 13, p = 0.029) and with higher Pressure Muscle Index (2 [0.5, 3] versus 0.4 [0, 1.9], p = 0.024). Change in diaphragm thickness was not related to diaphragm function expressed as diaphragm thickening fraction. CONCLUSION: Mode of ventilation affects diaphragm thickness, and preservation of diaphragmatic contraction, as during assisted modes, can partially reverse the muscle atrophy process. Avoiding a strenuous inspiratory work, as measured by Rapid Shallow Breathing Index and Pressure Muscle Index, may help diaphragm thickness restoration.

Sensors for Entertainment.

Sensors are becoming ubiquitous in all areas of science, technology, and society. In this Special Issue on "Sensors for Entertainment", developments in progress and the current state of application scenarios for sensors in the field of entertainment is explored.

Adding pluggable and personalized natural control capabilities to existing applications.

Advancements in input device and sensor technologies led to the evolution of the traditional human-machine interaction paradigm based on the mouse and keyboard. Touch-, gesture- and voice-based interfaces are integrated today in a variety of applications running on consumer devices (e.g., gaming consoles and smartphones). However, to allow existing applications running on desktop computers to utilize natural interaction, significant re-design and re-coding efforts may be required. In this paper, a framework designed to transparently add multi-modal interaction capabilities to applications to which users are accustomed is presented. Experimental observations confirmed the effectiveness of the proposed framework and led to a classification of those applications that could benefit more from the availability of natural interaction modalities.

The function of greetings in male Tonkean macaques.

Males living in multi-male groups are both strong rivals and potential allies. In several primate species they regularly interact through ritualized exchanges known as greetings. We studied five captive groups of Tonkean macaques (Macaca tonkeana) to test five hypotheses regarding the social function of greetings. We found that greetings were mostly reciprocal interactions, and that they often involved physical contact and facial displays. Although they were mostly initiated by the higher-ranking individual in each dyad, subordinates could initiate approximately one-third of greetings, which indicates that greetings do not serve as a formal acknowledgement of dominance relationships. Although greeting frequencies were negatively correlated to the frequency of supplantations and conflicts, they were not significantly influenced by age and dominance status, showing that greetings are not used to appease partners or decrease tension between males. Males most frequently greeted partners with whom they spent more time in proximity and body contact, and this is consistent with the hypothesis that greetings play a role in reinforcing social relationships. Lastly, greetings increased in frequency between individuals involved in challenges for rank, lending support to the hypothesis that males assess the state of their social relationships through greetings.

Advances in target detection and tracking in Forward-Looking InfraRed (FLIR) imagery.

Here we give context to the Special Issue on "Detection and Tracking of Targets in Forward-Looking InfraRed (FLIR) Imagery" in Sensors. We start with an introduction to the role of infrared images in today's vision-based applications, by outlining the specific challenges that characterize detection and tracking in FLIR images. We then illustrate why selected papers have been chosen to represent the domain of interest, by summarizing their main contributions to the state-of-the-art. Lastly, we sum up the main evidence found, and we underline some of the aspects that are worthy of further investigation in future research activities.

The use of extracorporeal blood purification therapies and sequential extracorporeal support in patients with septic shock (EROICASS): a study protocol for a national, non-interventional, observational multicenter, prospective study.

BACKGROUND: Septic shock, a critical condition characterized by organ failure, presents a substantial mortality risk in intensive care units (ICUs), with the 28-day mortality rate possibly reaching 40%. Conventional management of septic shock typically involves the administration of antibiotics, supportive care for organ dysfunction, and, if necessary, surgical intervention to address the source of infection. In recent decades, extracorporeal blood purification therapies (EBPT) have emerged as potential interventions aimed at modulating the inflammatory response and restoring homeostasis in patients with sepsis. Likewise, sequential extracorporeal therapy in sepsis (SETS) interventions offer comprehensive organ support in the setting of multiple organ dysfunction syndrome (MODS). The EROICASS study will assess and describe the utilization of EBPT in patients with septic shock. Additionally, we will evaluate the potential association between EBPT treatment utilization and 90-day mortality in septic shock cases in Italy. METHODS: The EROICASS study is a national, non-interventional, multicenter observational prospective cohort study. All consecutive patients with septic shock at participating centers will be prospectively enrolled, with data collection extending from intensive care unit (ICU) admission to hospital discharge. Variables including patient demographics, clinical parameters, EBPT/SETS utilization, and outcomes will be recorded using a web-based data capture system. Statistical analyses will encompass descriptive statistics, hypothesis testing, multivariable regression models, and survival analysis to elucidate the associations between EBPT/SETS utilization and patient outcomes. CONCLUSIONS: The EROICASS study provides valuable insights into the utilization and outcomes of EBPT and SETS in septic shock management. Through analysis of usage patterns and clinical data, this study aims to guide treatment decisions and enhance patient care. The implications of these findings may impact clinical guidelines, potentially improving survival rates and patient outcomes in septic shock cases.

Effects of Age, Fulton's Condition Index (K) and Muscle Fat on Total Mercury Content in Raw, Pre-Canning and Canned Samples of Atlantic Bluefin Tuna (Thunnus thynnus).

A total of 30 samples of Atlantic bluefin tuna were analysed for total mercury concentration. Relationships between total mercury content and age, Fulton's condition index (K) and fat content were statistically evaluated. The effect of muscle status (raw, pre-canning, canned) on mercury content was also investigated. The average total mercury content was: 1.185 ± 0.662 mg/kg in raw, 1.481 ± 0.893 mg/kg in pre-canning and 1.393 ± 0.882 mg/kg in canned samples, respectively. Canning promotes a statistically significant increase in the concentration of mercury. The weight of fish, K and fat content are useful tools to estimate the mercury accumulation in Atlantic bluefin tuna. The results of the present study represent a contribution to the assessment of the EU mercury levels in Atlantic bluefin tuna.

Assessment of Inspiratory Effort in Spontaneously Breathing COVID-19 ARDS Patients Undergoing Helmet CPAP: A Comparison between Esophageal, Transdiaphragmatic and Central Venous Pressure Swing.

INTRODUCTION: The clinical features of COVID-19 are highly variable. It has been speculated that the progression across COVID-19 may be triggered by excessive inspiratory drive activation. The aim of the present study was to assess whether the tidal swing in central venous pressure (ΔCVP) is a reliable estimate of inspiratory effort. METHODS: Thirty critically ill patients with COVID-19 ARDS underwent a PEEP trial (0-5-10 cmH2O) during helmet CPAP. Esophageal (ΔPes) and transdiaphragmatic (ΔPdi) pressure swings were measured as indices of inspiratory effort. ΔCVP was assessed via a standard venous catheter. A low and a high inspiratory effort were defined as ΔPes ≤ 10 and >15 cmH2O, respectively. RESULTS: During the PEEP trial, no significant changes in ΔPes (11 [6-16] vs. 11 [7-15] vs. 12 [8-16] cmH2O, p = 0.652) and in ΔCVP (12 [7-17] vs. 11.5 [7-16] vs. 11.5 [8-15] cmH2O, p = 0.918) were detected. ΔCVP was significantly associated with ΔPes (marginal R2 0.87, p < 0.001). ΔCVP recognized both low (AUC-ROC curve 0.89 [0.84-0.96]) and high inspiratory efforts (AUC-ROC curve 0.98 [0.96-1]). CONCLUSIONS: ΔCVP is an easily available a reliable surrogate of ΔPes and can detect a low or a high inspiratory effort. This study provides a useful bedside tool to monitor the inspiratory effort of spontaneously breathing COVID-19 patients.

High-stress surgery in severely frail patients: a case report of personalized and multidisciplinary shared decision-making.

We report the case of a 65-year-old severely disabled man diagnosed with advanced renal neoplasm who was scheduled for major urologic surgery. Through a multidisciplinary approach, a shared decision-making process and mutual listening of all the health professionals involved, it was decided not to have major surgery due to the high risk of worsening the patient's health and quality of life.

Incidence, Risk Factors, and Consequences of Post-Traumatic Stress Disorder Symptoms in Survivors of COVID-19-Related ARDS.

Purpose: To assess the prevalence of symptoms of Post-Traumatic Stress Disorder (PTSD) in survivors of COVID-19 Acute Respiratory Distress Syndrome that needed ICU care; to investigate risk factors and their impact on the Health-Related Quality of life (HR-QoL). Materials and Methods: This multicenter, prospective, observational study included all patients who were discharged from the ICU. Patients were administered the European Quality of Life 5 Dimensions 5 Level Version (EQ-5D-5L) questionnaire, the Short-Form Health Survey 36Version 2 (SF-36v2), a socioeconomic question set and the Impact of Event Scale-Revised (IES-R) to assess PTSD. Results: The multivariate logistic regression model found that an International Standard Classification of Education Score (ISCED) higher than 2 (OR 3.42 (95% CI 1.28-9.85)), monthly income less than EUR 1500 (OR 0.36 (95% CI 0.13-0.97)), and more than two comorbidities (OR 4.62 (95% CI 1.33-16.88)) are risk factors for developing PTSD symptoms. Patients with PTSD symptoms are more likely to present a worsening in their quality of life as assessed by EQ-5D-5L and SF-36 scales. Conclusion: The main factors associated with the development of PTSD-related symptoms were a higher education level, a lower monthly income, and more than two comorbidities. Patients who developed symptoms of PTSD reported a significantly lower Health-Related Quality of life as compared to patients without PTSD. Future research areas should be oriented toward recognizing potential psychosocial and psychopathological variables capable of influencing the quality of life of patients discharged from the intensive care unit to better recognize the prognosis and longtime effects of diseases.

Regional and sex inequalities of avoidable mortality in Italy: A time trend analysis.

Objectives: This study provides a comprehensive analysis of avoidable mortality (AM), treatable mortality (TM), and preventable mortality (PM) across Italy, focusing on region- and gender-specific inequalities over a 14-year period. Study design: Time-trend analysis (2006-2019). Methods: The study was conducted using mortality data from the Italian Institute of Statistics to evaluate the extent and patterns of AM, TM, and PM in Italy. Biennial age-standardized mortality rates were calculated by gender and region using the joint OECD/Eurostat list. Results: The overall AM rates showed a large reduction from 2006/7 (221.0 per 100,000) to 2018/9 (166.4 per 100,000). Notably, females consistently displayed lower AM rates than males. Furthermore, both gender differences and the North-South gap of AM decreased during the period studied. The regions with the highest AM rates fluctuated throughout the study period. The highest percentage decrease in AM from 2006/7 to 2018/9, for both males (-41.3 %) and females (-34.2 %), was registered in the autonomous province of Trento, while the lowest reduction was observed in Molise for males (-17.4 %) and in Marche for females (-10.0 %). Conclusions: Remarkable gender and regional differences in AM between 2006 and 2019 have been recorded in Italy, although they have decreased over years. Continuous monitoring of AM and the implementation of region- and gender-specific interventions is essential to provide valuable insights for both policy and public health practice. This study contributes to the efforts to improve health equity between Italian regions.

Quality of Life in COVID-Related ARDS Patients One Year after Intensive Care Discharge (Odissea Study): A Multicenter Observational Study.

BACKGROUND: Investigating the health-related quality of life (HRQoL) after intensive care unit (ICU) discharge is necessary to identify possible modifiable risk factors. The primary aim of this study was to investigate the HRQoL in COVID-19 critically ill patients one year after ICU discharge. METHODS: In this multicenter prospective observational study, COVID-19 patients admitted to nine ICUs from 1 March 2020 to 28 February 2021 in Italy were enrolled. One year after ICU discharge, patients were required to fill in short-form health survey 36 (SF-36) and impact of event-revised (IES-R) questionnaire. A multivariate linear or logistic regression analysis to search for factors associated with a lower HRQoL and post-traumatic stress disorded (PTSD) were carried out, respectively. RESULTS: Among 1003 patients screened, 343 (median age 63 years [57-70]) were enrolled. Mechanical ventilation lasted for a median of 10 days [2-20]. Physical functioning (PF 85 [60-95]), physical role (PR 75 [0-100]), emotional role (RE 100 [33-100]), bodily pain (BP 77.5 [45-100]), social functioning (SF 75 [50-100]), general health (GH 55 [35-72]), vitality (VT 55 [40-70]), mental health (MH 68 [52-84]) and health change (HC 50 [25-75]) describe the SF-36 items. A median physical component summary (PCS) and mental component summary (MCS) scores were 45.9 (36.5-53.5) and 51.7 (48.8-54.3), respectively, considering 50 as the normal value of the healthy general population. In all, 109 patients (31.8%) tested positive for post-traumatic stress disorder, also reporting a significantly worse HRQoL in all SF-36 domains. The female gender, history of cardiovascular disease, liver disease and length of hospital stay negatively affected the HRQoL. Weight at follow-up was a risk factor for PTSD (OR 1.02, p = 0.03). CONCLUSIONS: The HRQoL in COVID-19 ARDS (C-ARDS) patients was reduced regarding the PCS, while the median MCS value was slightly above normal. Some risk factors for a lower HRQoL have been identified, the presence of PTSD is one of them. Further research is warranted to better identify the possible factors affecting the HRQoL in C-ARDS.