Clinical benefit of AI-assisted lung ultrasound in a resource-limited intensive care unit.

BACKGROUND: Interpreting point-of-care lung ultrasound (LUS) images from intensive care unit (ICU) patients can be challenging, especially in low- and middle- income countries (LMICs) where there is limited training available. Despite recent advances in the use of Artificial Intelligence (AI) to automate many ultrasound imaging analysis tasks, no AI-enabled LUS solutions have been proven to be clinically useful in ICUs, and specifically in LMICs. Therefore, we developed an AI solution that assists LUS practitioners and assessed its usefulness in  a low resource ICU. METHODS: This was a three-phase prospective study. In the first phase, the performance of four different clinical user groups in interpreting LUS clips was assessed. In the second phase, the performance of 57 non-expert clinicians with and without the aid of a bespoke AI tool for LUS interpretation was assessed in retrospective offline clips. In the third phase, we conducted a prospective study in the ICU where 14 clinicians were asked to carry out LUS examinations in 7 patients with and without our AI tool and we interviewed the clinicians regarding the usability of the AI tool. RESULTS: The average accuracy of beginners' LUS interpretation was 68.7% [95% CI 66.8-70.7%] compared to 72.2% [95% CI 70.0-75.6%] in intermediate, and 73.4% [95% CI 62.2-87.8%] in advanced users. Experts had an average accuracy of 95.0% [95% CI 88.2-100.0%], which was significantly better than beginners, intermediate and advanced users (p < 0.001). When supported by our AI tool for interpreting retrospectively acquired clips, the non-expert clinicians improved their performance from an average of 68.9% [95% CI 65.6-73.9%] to 82.9% [95% CI 79.1-86.7%], (p < 0.001). In prospective real-time testing, non-expert clinicians improved their baseline performance from 68.1% [95% CI 57.9-78.2%] to 93.4% [95% CI 89.0-97.8%], (p < 0.001) when using our AI tool. The time-to-interpret clips improved from a median of 12.1 s (IQR 8.5-20.6) to 5.0 s (IQR 3.5-8.8), (p < 0.001) and clinicians' median confidence level improved from 3 out of 4 to 4 out of 4 when using our AI tool. CONCLUSIONS: AI-assisted LUS can help non-expert clinicians in an LMIC ICU improve their performance in interpreting LUS features more accurately, more quickly and more confidently.

Effectiveness of Continuous Endotracheal Cuff Pressure Control for the Prevention of Ventilator-Associated Respiratory Infections: An Open-Label Randomized, Controlled Trial.

BACKGROUND: An endotracheal tube cuff pressure between 20 and 30 cmH2O is recommended to prevent ventilator-associated respiratory infection (VARI). We aimed to evaluate whether continuous cuff pressure control (CPC) was associated with reduced VARI incidence compared with intermittent CPC. METHODS: We conducted a multicenter open-label randomized controlled trial in intensive care unit (ICU) patients within 24 hours of intubation in Vietnam. Patients were randomly assigned 1:1 to receive either continuous CPC using an automated electronic device or intermittent CPC using a manually hand-held manometer. The primary endpoint was the occurrence of VARI, evaluated by an independent reviewer blinded to the CPC allocation. RESULTS: We randomized 600 patients; 597 received the intervention or control and were included in the intention to treat analysis. Compared with intermittent CPC, continuous CPC did not reduce the proportion of patients with at least one episode of VARI (74/296 [25%] vs 69/301 [23%]; odds ratio [OR] 1.13; 95% confidence interval [CI] .77-1.67]. There were no significant differences between continuous and intermittent CPC concerning the proportion of microbiologically confirmed VARI (OR 1.40; 95% CI .94-2.10), the proportion of intubated days without antimicrobials (relative proportion [RP] 0.99; 95% CI .87-1.12), rate of ICU discharge (cause-specific hazard ratio [HR] 0.95; 95% CI .78-1.16), cost of ICU stay (difference in transformed mean [DTM] 0.02; 95% CI -.05 to .08], cost of ICU antimicrobials (DTM 0.02; 95% CI -.25 to .28), cost of hospital stay (DTM 0.02; 95% CI -.04 to .08), and ICU mortality risk (OR 0.96; 95% CI .67-1.38). CONCLUSIONS: Maintaining CPC through an automated electronic device did not reduce VARI incidence. CLINICAL TRIAL REGISTRATION: NCT02966392.

A modified Sequential Organ Failure Assessment score for dengue: development, evaluation and proposal for use in clinical trials.

BACKGROUND: Dengue is a neglected tropical disease, for which no therapeutic agents have shown clinical efficacy to date. Clinical trials have used strikingly variable clinical endpoints, which hampers reproducibility and comparability of findings. We investigated a delta modified Sequential Organ Failure Assessment (delta mSOFA) score as a uniform composite clinical endpoint for use in clinical trials investigating therapeutics for moderate and severe dengue. METHODS: We developed a modified SOFA score for dengue, measured and evaluated its performance at baseline and 48 h after enrolment in a prospective observational cohort of 124 adults admitted to a tertiary referral hospital in Vietnam with dengue shock. The modified SOFA score included pulse pressure in the cardiovascular component. Binary logistic regression, cox proportional hazard and linear regression models were used to estimate association between mSOFA, delta mSOFA and clinical outcomes. RESULTS: The analysis included 124 adults with dengue shock. 29 (23.4%) patients required ICU admission for organ support or due to persistent haemodynamic instability: 9/124 (7.3%) required mechanical ventilation, 8/124 (6.5%) required vasopressors, 6/124 (4.8%) required haemofiltration and 5/124 (4.0%) patients died. In univariate analyses, higher baseline and delta (48 h) mSOFA score for dengue were associated with admission to ICU, requirement for organ support and mortality, duration of ICU and hospital admission and IV fluid use. CONCLUSIONS: The baseline and delta mSOFA scores for dengue performed well to discriminate patients with dengue shock by clinical outcomes, including duration of ICU and hospital admission, requirement for organ support and death. We plan to use delta mSOFA as the primary endpoint in an upcoming host-directed therapeutic trial and investigate the performance of this score in other phenotypes of severe dengue in adults and children.

Association of the Quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) Score With Excess Hospital Mortality in Adults With Suspected Infection in Low- and Middle-Income Countries.

Importance: The quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) score has not been well-evaluated in low- and middle-income countries (LMICs). Objective: To assess the association of qSOFA with excess hospital death among patients with suspected infection in LMICs and to compare qSOFA with the systemic inflammatory response syndrome (SIRS) criteria. Design, Settings, and Participants: Retrospective secondary analysis of 8 cohort studies and 1 randomized clinical trial from 2003 to 2017. This study included 6569 hospitalized adults with suspected infection in emergency departments, inpatient wards, and intensive care units of 17 hospitals in 10 LMICs across sub-Saharan Africa, Asia, and the Americas. Exposures: Low (0), moderate (1), or high (≥2) qSOFA score (range, 0 [best] to 3 [worst]) or SIRS criteria (range, 0 [best] to 4 [worst]) within 24 hours of presentation to study hospital. Main Outcomes and Measures: Predictive validity (measured as incremental hospital mortality beyond that predicted by baseline risk factors, as a marker of sepsis or analogous severe infectious course) of the qSOFA score (primary) and SIRS criteria (secondary). Results: The cohorts were diverse in enrollment criteria, demographics (median ages, 29-54 years; males range, 36%-76%), HIV prevalence (range, 2%-43%), cause of infection, and hospital mortality (range, 1%-39%). Among 6218 patients with nonmissing outcome status in the combined cohort, 643 (10%) died. Compared with a low or moderate score, a high qSOFA score was associated with increased risk of death overall (19% vs 6%; difference, 13% [95% CI, 11%-14%]; odds ratio, 3.6 [95% CI, 3.0-4.2]) and across cohorts (P < .05 for 8 of 9 cohorts). Compared with a low qSOFA score, a moderate qSOFA score was also associated with increased risk of death overall (8% vs 3%; difference, 5% [95% CI, 4%-6%]; odds ratio, 2.8 [95% CI, 2.0-3.9]), but not in every cohort (P < .05 in 2 of 7 cohorts). High, vs low or moderate, SIRS criteria were associated with a smaller increase in risk of death overall (13% vs 8%; difference, 5% [95% CI, 3%-6%]; odds ratio, 1.7 [95% CI, 1.4-2.0]) and across cohorts (P < .05 for 4 of 9 cohorts). qSOFA discrimination (area under the receiver operating characteristic curve [AUROC], 0.70 [95% CI, 0.68-0.72]) was superior to that of both the baseline model (AUROC, 0.56 [95% CI, 0.53-0.58; P < .001) and SIRS (AUROC, 0.59 [95% CI, 0.57-0.62]; P < .001). Conclusions and Relevance: When assessed among hospitalized adults with suspected infection in 9 LMIC cohorts, the qSOFA score identified infected patients at risk of death beyond that explained by baseline factors. However, the predictive validity varied among cohorts and settings, and further research is needed to better understand potential generalizability.

High photocatalytic efficiency of a ZnO nanoplate/Fe2O3 nanospindle hybrid using visible light for methylene blue degradation.

In this work, ZnO nanoplates and Fe2O3 nanospindles were successfully fabricated via a simple hydrothermal method using inorganic salts as precursors. The ZnO/Fe2O3 hybrid was fabricated using a mechanical mixture of two different ZnO : Fe2O3 weight ratios to investigate the effect of weight ratio on catalytic properties. Scanning electron microscopy (SEM) and transmission electron microscopy (TEM) images showed that ZnO nanoplates (NPls) are about 20 nm thick with lateral dimensions of 100 × 200 nm, and Fe2O3 nanospindles (NSs) are about 500 nm long and 50 nm wide. X-ray diffraction (XRD) patterns revealed the successful formation of the ZnO, Fe2O3, and ZnO/Fe2O3 samples and indicated that their crystallite sizes varied from 20 to 29 nm depending on the ZnO : Fe2O3 weight ratio. Ultraviolet-visible (UV-vis) spectra showed that the bandgap energies of ZnO and Fe2O3 were 3.15 eV and 2.1 eV, respectively. Energy dispersive X-ray spectroscopy (EDS) results revealed the successful combination of ZnO and Fe2O3. Photocatalytic activity of the materials was evaluated through the degradation of methylene blue (MB) in aqueous solution under green light-emitting diode (GLED) irradiation. The results indicated that the ZnO/Fe2O3 composite showed a remarkable enhanced degradation capacity compared to bare ZnO NPls and Fe2O3 NSs. The ZnO : Fe2O3 = 3 : 2 sample demonstrated the best performance among all samples under identical conditions with a degradation efficiency of 99.3% for MB after 85 min. The optimum photocatalytic activity of the sample with ZnO : Fe2O3 = 3 : 2 was nearly 3.6% higher than that of the pure ZnO sample and 1.12 times more than that of the pristine Fe2O3 sample. Moreover, the highest photo-degradation was obtained at a photocatalyst dosage of 0.25 g l-1 in dye solution.

Clinical evaluation of AI-assisted muscle ultrasound for monitoring muscle wasting in ICU patients.

Muscle ultrasound has been shown to be a valid and safe imaging modality to assess muscle wasting in critically ill patients in the intensive care unit (ICU). This typically involves manual delineation to measure the rectus femoris cross-sectional area (RFCSA), which is a subjective, time-consuming, and laborious task that requires significant expertise. We aimed to develop and evaluate an AI tool that performs automated recognition and measurement of RFCSA to support non-expert operators in measurement of the RFCSA using muscle ultrasound. Twenty patients were recruited between Feb 2023 and July 2023 and were randomized sequentially to operators using AI (n = 10) or non-AI (n = 10). Muscle loss during ICU stay was similar for both methods: 26 ± 15% for AI and 23 ± 11% for the non-AI, respectively (p = 0.13). In total 59 ultrasound examinations were carried out (30 without AI and 29 with AI). When assisted by our AI tool, the operators showed less variability between measurements with higher intraclass correlation coefficients (ICCs 0.999 95% CI 0.998-0.999 vs. 0.982 95% CI 0.962-0.993) and lower Bland Altman limits of agreement (± 1.9% vs. ± 6.6%) compared to not using the AI tool. The time spent on scans reduced significantly from a median of 19.6 min (IQR 16.9-21.7) to 9.4 min (IQR 7.2-11.7) compared to when using the AI tool (p < 0.001). AI-assisted muscle ultrasound removes the need for manual tracing, increases reproducibility and saves time. This system may aid monitoring muscle size in ICU patients assisting rehabilitation programmes.

Green, facile and fast synthesis of silver nanoparticles by using solution plasma techniques and their antibacterial and anticancer activities.

We herein present a simple, fast, efficient and environmentally friendly method for preparing silver nanoparticles (AgNPs) using the solution plasma method in the presence of extracts from Paramignya trimera (P. trimera). The effects of P. trimera extract concentrations and the applied voltage on the formation of AgNPs were investigated. Surface plasmon resonance spectra show a strong peak at 413 nm for the prepared samples. The Fourier-transform infrared spectroscopy measurement results indicated the presence of possible functional groups in the prepared AgNPs. Morphological analysis revealed that the AgNPs were spherical with an average size of 8 nm. The prepared AgNPs exhibited good stability in solution compared to that of AgNPs prepared by the solution plasma technique without P. trimera extract. The formation mechanism of AgNPs is also proposed. The prepared AgNPs exhibited high antibacterial ability against Gram (+) Staphylococcus aureus, Gram (-) Pseudomonas aeruginosa bacteria and strong anticancer activity for the AGS gastric cancer cell line. The obtained results demonstrated that this is a simple, rapid, environmentally friendly method for preparing AgNPs instead of conventional methods using chemical reducing agents for potential applications.

Synthesis of cuprous oxide/silver (Cu2O/Ag) hybrid as surface-enhanced Raman scattering probe for trace determination of methyl orange.

Recently, there have been publications on preparing hybrid materials between noble metal and semiconductor for applications in surface-enhanced Raman scattering (SERS) substrates to detect some toxic organic dyes. However, the use of cuprous oxide/silver (Cu2O/Ag) to measure the trace amounts of methyl orange (MO) has not been reported. Therefore, in this study, the trace level of MO in water solvent was determined using a SERS substrate based on Cu2O microcubes combined with silver nanoparticles (Ag NPs). Herein, a series of Cu2O/Agx (x= 1-5) hybrids with various Ag amounts was synthesized via a solvothermal method followed by a reduction process, and their SERS performance was studied in detail. X-ray diffraction (XRD) and scanning electron microscopy results confirmed that 10 nm Ag NPs were well dispersed on 200-500 nm Cu2O microcubes to form Cu2O/Ag heterojunctions. Using the as-prepared Cu2O and Cu2O/Agx as MO probe, the Cu2O/Ag5 nanocomposite showed the highest SERS activity of all samples with the limit of detection as low to 1 nM and the enhancement factor as high as 4 × 108. The logarithm of the SERS peak intensity at 1389 cm-1 increased linearly with the logarithm of the concentration of MO in the range from 1 nM to 0.1 mM.

Urinary catecholamine excretion, cardiovascular variability, and outcomes in tetanus.

Severe tetanus is characterized by muscle spasm and cardiovascular system disturbance. The pathophysiology of muscle spasm is relatively well understood and involves inhibition of central inhibitory synapses by tetanus toxin. That of cardiovascular disturbance is less clear, but is believed to relate to disinhibition of the autonomic nervous system. The clinical syndrome of autonomic nervous system dysfunction (ANSD) seen in severe tetanus is characterized principally by changes in heart rate and blood pressure which have been linked to increased circulating catecholamines. Previous studies have described varying relationships between catecholamines and signs of ANSD in tetanus, but are limited by confounders and assays used. In this study, we aimed to perform detailed characterization of the relationship between catecholamines (adrenaline and noradrenaline), cardiovascular parameters (heart rate and blood pressure) and clinical outcomes (ANSD, mechanical ventilation required, and length of intensive care unit stay) in adults with tetanus, as well as examine whether intrathecal antitoxin administration affected subsequent catecholamine excretion. Noradrenaline and adrenaline were measured by ELISA from 24-h urine collections taken on day 5 of hospitalization in 272 patients enrolled in a 2 × 2 factorial-blinded randomized controlled trial in a Vietnamese hospital. Catecholamine results measured from 263 patients were available for analysis. After adjustment for potential confounders (i.e., age, sex, intervention treatment, and medications), there were indications of non-linear relationships between urinary catecholamines and heart rate. Adrenaline and noradrenaline were associated with subsequent development of ANSD, and length of ICU stay.

Enhanced power conversion efficiency of an n-Si/PEDOT:PSS hybrid solar cell using nanostructured silicon and gold nanoparticles.

Herein, the effect of nanostructured silicon and gold nanoparticles (AuNPs) on the power conversion efficiency (PCE) of an n-type silicon/poly(3,4-ethylene dioxythiophene):poly(styrene sulfonate) (n-Si/PEDOT:PSS) hybrid solar cell was investigated. The Si surface modified with different nanostructures including Si nanopyramids (SiNPs), Si nanoholes (SiNHs) and Si nanowires (SiNWs) was utilized to improve light trapping and photo-carrier collection. The highest power conversion efficiency (PCE) of 8.15% was obtained with the hybrid solar cell employing SiNWs, which is about 8%, 20% and 40% higher compared to the devices using SiNHs, SiNPs and planar Si, respectively. The enhancement is attributed to the low reflectance of the SiNW structures and large PEDOT:PSS/Si interfacial area. In addition, the influence of AuNPs on the hybrid solar cell's performance was examined. The PCE of the SiNW/PEDOT:PSS hybrid solar cell with 0.5 wt% AuNP is 8.89%, which is ca. 9% higher than that of the device without AuNPs (8.15%). This is attributed to the increase in the electrical conductivity and localized surface plasmon resonance of the AuNP-incorporated PEDOT:PSS coating layer.