MACHINE LEARNING FOR PREDICTING HEMODYNAMIC DETERIORATION OF PATIENTS WITH INTERMEDIATE-RISK PULMONARY EMBOLISM IN INTENSIVE CARE UNIT.

ABSTRACT: Background: Intermediate-risk pulmonary embolism (PE) patients in the intensive care unit (ICU) are at a higher risk of hemodynamic deterioration than those in the general ward. This study aimed to construct a machine learning (ML) model to accurately identify the tendency for hemodynamic deterioration in the ICU patients with intermediate-risk PE. Method: A total of 704 intermediate-risk PE patients from the MIMIC-IV database were retrospectively collected. The primary outcome was defined as hemodynamic deterioration occurring within 30 days after admission to ICU. Four ML algorithms were used to construct models on the basis of all variables from MIMIC IV database with missing values less than 20%. The extreme gradient boosting (XGBoost) model was further simplified for clinical application. The performance of the ML models was evaluated by using the receiver operating characteristic curve, calibration plots, and decision curve analysis. Predictive performance of simplified XGBoost was compared with the simplified Pulmonary Embolism Severity Index score. SHapley Additive explanation (SHAP) was performed on a simplified XGBoost model to calculate the contribution and impact of each feature on the predicted outcome and presents it visually. Results: Among the 704 intermediate-risk PE patients included in this study, 120 patients experienced hemodynamic deterioration within 30 days after admission to the ICU. Simplified XGBoost model demonstrated the best predictive performance with an area under the curve of 0.866 (95% confidence interval, 0.800-0.925), and after recalibrated by isotonic regression, the area under the curve improved to 0.885 (95% confidence interval, 0.822-0.935). Based on the simplified XGBoost model, a web app was developed to identify the tendency for hemodynamic deterioration in ICU patients with intermediate-risk PE. Conclusion: A simplified XGBoost model can accurately predict the occurrence of hemodynamic deterioration for intermediate-risk PE patients in the ICU, assisting clinical workers in providing more personalized management for PE patients in the ICU.

BFGF attenuates aortic valvular interstitial cell calcification by inhibiting endoplasmic reticulum stress-mediated apoptosis.

The potential protective effect of basic fibroblast growth factor (BFGF) on the cardiovascular system has been proposed previously, however, its effect on calcific aortic valve disease (CAVD) and underlying mechanisms have not been elucidated. The valvular interstitial cell (VIC) were isolated from porcine aortic valve leaflets. To investigate the effect of BFGF on osteogenic differentiation of VIC, the osteogenic induced medium (OIM) and BFGF were added. The protein expression level was detected by Western blot, and apoptosis was determined by flow cytometry. The effect of BFGF on CAVD process in vivo was assessed by a rat CAVD model, which was identified by echocardiography and Alizarin red staining. The expression level of BFGF in the aortic valve and serum were significantly upregulated in CAVD patients compared to control group. In addition, exogenous BFGF injection attenuates CAVD process in vivo. The protein markers of osteogenic differentiation, endoplasmic reticulum stress (ERS), and apoptosis were significantly upregulated by culture with OIM. On the contrary, the aforementioned proteins were suppressed after adding 100 ng/mL of BFGF. Inhibition of PI3K/Akt and ERK1/2 pathways by specific inhibitors abolished the protective effect of BFGF. In conclusion, BFGF could alleviate the VIC calcification by inhibiting ERS-mediated apoptosis, which is partly regulated by activation of the PI3K/Akt and ERK1/2 signaling pathways. BFGF may provide a potential avenue for CAVD therapy.

Influences of Cu Doping on the Microstructure, Optical and Resistance Switching Properties of Zinc OxideThin Films.

Copper-doped zinc oxide films (Zn1-xCuxO) (x = 0, 2%, 4%, 6%) were fabricated on conductive substrates using the sol-gel process. The crystal structure, optical and resistive switching properties of Zn1-xCuxO films are studied and discussed. RRAM is made using Zn1-xCuxO as the resistive layer. The results show that the (002) peak intensity and grain size of Zn1-xCuxOfilms increase from 0 to 6%. In addition, PL spectroscopy shows that the oxygen vacancy defect density of Zn1-xCuxO films also increases with the increase in Cu. The improved resistive switching performance of the RRAM device can be attributed to the formation of conductive filaments and the destruction of more oxygen vacancies in the Zn1-xCuxO film. Consequently, the RRAM device exhibits a higher low resistance state to high resistance state ratio and an HRS state of higher resistance value.

Activation Energy and Bipolar Switching Properties for the Co-Sputtering of ITOX:SiO2 Thin Films on Resistive Random Access Memory Devices.

Activation energy, bipolar resistance switching behavior, and the electrical conduction transport properties of ITOX:SiO2 thin film resistive random access memory (RRAM) devices were observed and discussed. The ITOX:SiO2 thin films were prepared using a co-sputtering deposition method on the TiN/Si substrate. For the RRAM device structure fabrication, an Al/ITOX:SiO2/TiN/Si structure was prepared by using aluminum for the top electrode and a TiN material for the bottom electrode. In addition, grain growth, defect reduction, and RRAM device performance of the ITOX:SiO2 thin film for the various oxygen gas flow conditions were observed and described. Based on the I-V curve measurements of the RRAM devices, the turn on-off ratio and the bipolar resistance switching properties of the Al/ITOX:SiO2/TiN/Si RRAM devices in the set and reset states were also obtained. At low operating voltages and high resistance values, the conductance mechanism exhibits hopping conduction mechanisms for set states. Moreover, at high operating voltages, the conductance mechanism behaves as an ohmic conduction current mechanism. Finally, the Al/ITOX:SiO2/TiN/Si RRAM devices demonstrated memory window properties, bipolar resistance switching behavior, and nonvolatile characteristics for next-generation nonvolatile memory applications.

Bipolar Switching Properties of the Transparent Indium Tin Oxide Thin Film Resistance Random Access Memories.

In this study, the bipolar switching properties and electrical conduction behaviors of the ITO thin films RRAM devices were investigated. For the transparent RRAM devices structure, indium tin oxide thin films were deposited by using the RF magnetron sputtering method on the ITO/glass substrate. For the ITO/ITOX/ITO/glass (MIM) structure, an indium tin oxide thin film top electrode was prepared to form the transparent RRAM devices. From the experimental results, the 102 On/Off memory ratio and bipolar switching cycling properties for set/reset stable states were found and discussed. All transparent RRAM devices exhibited the obvious memory window and low set voltage for the switching times of 120 cycles. The electrical transport mechanisms were dominated by the ohmic contact and space charge limit conduction (SCLC) models for set and reset states. Finally, the transmittances properties of the transparent ITO/ITOX/ITO RRAM devices for the different oxygen growth procedures were about 90% according to the UV-Vis spectrophotometer for the visible wavelength range.

First Order Rate Law Analysis for Reset State in Vanadium Oxide Thin Film Resistive Random Access Memory Devices.

In the reset state, the decay reaction mechanism and bipolar switching properties of vanadium oxide thin film RRAM devices for LRS/HRS are investigated and discussed here. To discover the properties of I-V switching curves, the first order rate law behaviors of the reset state between the resistant variety properties and the reaction time were observed. To verify the decay reaction mechanism in the reset state, vanadium oxide thin films from RRAM devices were measured by different constant voltage sampling and exhibited the same decay reaction rate constant. Finally, the electrical conduction transfer mechanism and metallic filament forming model described by I-V switching properties of the RRAM devices were proven and investigated.

Accuracy of calculating mechanical power of ventilation by one commonly used equation.

Gattinoni's equation, [Formula: see text], now commonly used to calculate the mechanical power (MP) of ventilation. However, it calculates only inspiratory MP. In addition, the inclusion of PEEP in Gattinoni's equation raises debate because PEEP does not produce net displacement or contribute to MP. Measuring the area within the pressure-volume loop accurately reflects the MP received in a whole ventilation cycle and the MP thus obtained is not influenced by PEEP. The MP of 25 invasively ventilated patients were calculated by Gattinoni's equation and measured by integration of the areas within the pressure-volume loops of the ventilation cycles. The MP obtained from both methods were compared. The effects of PEEPs on MP were also evaluated. We found that the MP obtained from both methods were correlated by R2 = 0.75 and 0.66 at PEEP 5 and 10 cmH2O, respectively. The biases of the two methods were 3.13 (2.03 to 4.23) J/min (P < 0.0001) and - 1.23 (- 2.22 to - 0.24) J/min (P = 0.02) at PEEP 5 and 10 cmH2O, respectively. These P values suggested that both methods were significantly incongruent. When the tidal volume used was 6 ml/Kg, the MP by Gattinoni's equation at PEEP 5 and 10 cmH2O were significantly different (4.51 vs 7.21 J/min, P < 0.001), but the MP by PV loop area was not influenced by PEEPs (6.46 vs 6.47 J/min, P = 0.331). Similar results were observed across all tidal volumes. We conclude that the Gattinoni's equation is not accurate in calculating the MP of a whole ventilatory cycle and is significantly influenced by PEEP, which theoretically does not contribute to MP.

Ventilator Parameters in the Diagnosis and Prognosis of Acute Respiratory Distress Syndrome in Postoperative Patients: A Preliminary Study.

This study investigated the usefulness of ventilator parameters in the prediction of development and outcome of acute respiratory distress syndrome (ARDS) in postoperative patients with esophageal or lung cancer on admission to the surgical intensive care unit (SICU). A total of 32 post-operative patients with lung or esophageal cancer from SICU in a tertiary medical center were retrospectively analyzed. The study patients were divided into an ARDS group (n = 21) and a non-ARDS group (n = 11). The ARDS group contained the postoperative patients who developed ARDS after lung or esophageal cancer surgery. The ventilator variables were analyzed in this study. Principal component analysis (PCA) was performed to reduce the correlated ventilator variables to a small set of variables. The top three ventilator variables with large coefficients, as determined by PCA, were considered as sensitive variables and included in the analysis model based on the rule of 10 events per variable. Firth logistic regression with selective stepwise elimination procedure was performed to identify the most important predictors of morbidity and mortality in patients with ARDS. Ventilator parameters, including rapid shallow breath index during mechanical ventilation (RSBIv), rate pressure product of ventilation (RPPv), rate pressure volume index (RPVI), mechanical work (MW), and inspiration to expiration time ratio (IER), were analyzed in this study. It was found that the ARDS patients had significantly greater respiratory rate (RR), airway resistance (Raw), RSBIv, RPPv, RPVI, positive end-expiratory pressure (PEEP), and IER and significantly lower respiratory interval (RI), expiration time (Te), flow rate (V˙), tidal volume (VT), dynamic compliance (Cdyn), mechanical work of ventilation (MW), and MW/IER ratio than the non-ARDS patients. The non-survivors of ARDS had significantly greater peak inspiratory pressure above PEEP (PIP), RSBIv, RPPv, and RPVI than the survivors of ARDS. By using PCA, the MW/IER was found to be the most important predictor of the development of ARDS, and both RPPv and RPVI were significant predictors of mortality in patients with ARDS. In conclusion, some ventilator parameters, such as RPPv, RPVI, and MW/IER defined in this study, can be derived from ventilator readings and used to predict the development and outcome of ARDS in mechanically ventilated patients on admission to the SICU.

Efficacy of induction regimens for cryptococcal meningitis in HIV-infected adults: a systematic review and network meta-analysis.

Cryptococcal meningitis (CM) is the most fatal adult meningitis in patients with human immunodeficiency virus (HIV). There is no conclusive evidence for the superiority of 1-week amphotericin B deoxycholate (AmphB) + flucytosine (5-FC) regimen over other antifungals in the management of HIV patients with CM (HIV-CM patients). We aimed to evaluate the differences in efficacy and tolerability of different antifungal agents in HIV-CM patients by conducting a current network meta-analysis NMA. Overall, 19 randomized controlled trials were included with 2642 participants. A regimen indicated a possibly lower early mortality rate, namely, AmphB + 5-FC + Azole (OR = 1.1E-12, 95% CIs = 1.3E-41 to 0.06) comparing to AmphB + 5-FC. The current NMA provides evidence that AmphB + 5-FC + Azole are superior to all the investigated treatments for induction regimen in HIV-CM patients.

Effect of Peptide Dose on Radiation Dosimetry for Peptide Receptor Radionuclide Therapy with 177Lu-DOTATOC: A Pilot Study.

BACKGROUND: Optimal peptide concentration in treatment with 177Lu-DOTATOC/DOTATATE is a matter of debate. Most of the studies with peptide receptor radionuclide therapy mention peptide dose ranging between 100 and 250 µg. The aim of this is to identify possible differences in radiation-absorbed doses (D/Gy) to tumor and kidney as a function of the peptide mass dose in order to identify the most suitable peptide dose for treatment. The therapeutic index (Dtumor/Dkidneys) was assessed as a key parameter for the treatment response. MATERIALS AND METHODS: Five patients with metastasized Grade 1 to Grade 2 neuroendocrine tumor were analyzed in this study. Patients (n = 4) received two cycles of treatment with intravenously injected 177Lu-DOTATOC containing peptide mass doses of 200 µg and 90 µg, alternatively; one patient was treated with 90 µg peptide mass in both the therapy cycles. Whole-body (head to mid-thigh) three-dimensional single-photon emission computerized tomography (3D SPECT)/CT images were acquired at 1, 4, 24, 48, and 72 h following the injection of 177Lu-DOTATOC. Attenuation correction for 3D SPECT images was performed using CT data acquired and fused with the SPECT data (SPECT/CT). RESULTS: Overall, 28 target lesions (liver n = 17, lung n = 4, lymph nodes n = 1, and bone n = 2) were analyzed after 1st and 2nd therapy cycles. Tumor normalized absorbed doses varied by a factor of 74 between 0.35 and 26 mGy/MBq. Averaged over all patients, a higher normalized mean tumor dose (10.51 mGy/MBq) was achieved for a peptide dose of 200 µg compared to 90 µg (4.58 mGy/MBq). Kidneys doses varied by a factor of up to 4 between patients (0.25-1.0 mGy/MBq) (independent of dose cycle and peptide dose) and by a factor of up to 2 between dose cycles. The mean kidney dose was 13.7% higher for the 90 µg peptide dose compared to 200 µg. Given the higher tumor dose, the mean therapeutic index of a 200 µg mass dose was considerably higher (16.95), compared to a 90 µg mass dose (9.63). This coincided with the observation, that lesion volume reduction was more pronounced after an initial treatment with a 200 µg mass dose. Biologically effective dose was only 5. 1%-19.3% higher than the absorbed dose for individual dose cycles. CONCLUSIONS: Higher peptide dose of 200 µg appears to be more suitable than 90 µg in terms of tumor dose, kidney dose, and therapeutic index for treatment with 177Lu-DOTATOC.

α-Glucosidase Inhibitor Can Effectively Inhibit the Risk of Tuberculosis in Patients with Diabetes: A Nested Case-Control Study.

Diabetes mellitus (DM) and tuberculosis (TB) are major public health and economic burdens. DM increases Mycobacterium tuberculosis (M.tb) infection rates and treatment durations. This study evaluated the relationship between five classes of oral DM medications and TB infection risk in DM patients. We used longitudinal records from the Taiwan Longitudinal Health Insurance Research Database. DM patients were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code 250 and A code A181. TB patients were identified using ICD-9-CM code 010.x-017.x. Oral DM medications were divided into five classes: sulfonylureas, biguanides, meglitinides, α-glucosidase inhibitors (AGIs), and thiazolidinediones. Users were classified as nonusers, low-concentration users, and high-concentration users. The incidence rate ratio (IRR) was derived using multivariate Poisson regression to calculate the relative risk of TB infection. DM patients using low- and high-concentration AGIs had significantly lower TB infection risks compared with nonusers. The IRRs of the sulfonylureas and AGI users were [CI] 0.693-0.948) and (95% CI 0.651-0.995), respectively. The other four classes of medications exhibited no significant effect on TB infection risk in DM patients. Furthermore, DM patients using high-concentration AGIs had a significantly lower TB infection risk compared with those using low-concentration AGIs (IRR 0.918, 95% CI: 0.854-0.987). We noted a dose-response relationship in the effects of DM medications on TB risk. Accordingly, we suggest that DM patients use AGIs to benefit from their protective effect on TB infection risk.

Better airway resistance reduction profile in intubated COPD patients by personalized bronchodilator dosing: A pilot randomized control trial.

INTRODUCTION: The optimal dose of inhaled metered-dose bronchodilators for intubated patients with chronic obstructive pulmonary disease (COPD) is unknown. In this study, we proposed a bronchodilator dosing schedule based on an individual's airway resistance (Raw) and tested its efficacy in reducing Raw. METHODS: A total of 51 newly admitted patients with invasively ventilated COPD were randomly assigned to receive personalized or fixed bronchodilator dosing. Personal target Raw was defined by measuring each individual's Raw after maximal pharmacologic bronchodilatation. Thereafter, Raw was measured every 8 h until the 28th day. Patients in the fixed-dosing group received only predetermined doses. Additional doses of bronchodilators were given to patients in the personalized-dosing group when the measured Raw exceeded their target Raw. RESULTS: The median daily doses of salmeterol/fluticasone were 9.2 (personalized-dosing) vs 7.6 (fixed-dosing) puffs (P < 0.001). The relative deviation of Raw from the personal target was expressed as (measured Raw - target Raw)/target Raw. The experimental group showed a smaller relative Raw deviation than the control group (0.09 ±â€¯0.10 vs 0.44 ±â€¯0.11, P = 0.02). There were no differences between the two groups in terms of ventilator-free days from day 1 to day 28, number of episodes of nosocomial pneumonia, total number of puffs of rescue bronchodilator, number of drug-related adverse effects or mortality rate at day 180. CONCLUSION: Personalized dosing of inhaled bronchodilator administered to invasively ventilated COPD patients can produce a better reduction in Raw. Further studies with larger sample size are required to verify the conclusion of this pilot study.

Dielectric, Piezoelectric, and Vibration Properties of the LiF-Doped (Ba0.95Ca0.05)(Ti0.93Sn0.07)O3 Lead-Free Piezoceramic Sheets.

By the conventional solid state reaction method, a small amount of lithium fluoride (LiF) was used as the sintering promoter to improve the sintering and piezoelectric characteristics of (Ba0.95Ca0.05)(Ti0.93Sn0.07)O3 (BCTS) lead-free piezoceramic sheets. Using X-ray diffraction (XRD) and a scanning electron microscope (SEM), the inferences of the crystalline and surface microstructures were obtained and analyzed. Then, the impedance analyzer and d33-meter were used to measure the dielectric and piezoelectric characteristics. In this study, the optimum sintering temperature of the BCTS sheets decreased from 1450 °C to 1390 °C due to LiF doping. For the 0.07 wt % LiF-doped BCTS sheets sintered at 1390 °C, the piezoelectric constant (d33) is 413 pC/N, the electric-mechanical coupling coefficient (kp) is 47.5%, the dielectric loss (tan δ) is 3.9%, and the dielectric constant (εr) is 8100, which are all close to or even better than that of the pure undoped BCTS ceramics. The Curie temperature also improved, from 85 °C for pure BCTS to 140 °C for BCTS-0.07 LiF sheets. Furthermore, by using the vibration system and fixing 1.5 g tip mass at the end of the sheets, as the vibration frequency is 20 Hz, the proposed piezoelectric ceramic sheets also reveal a good energy harvesting performance at the maximum output peak voltage of 4.6 V, which is large enough and can be applied in modern low-power electronic products.

Bipolar Switching Properties of Neodymium Oxide RRAM Devices Using by a Low Temperature Improvement Method.

Bipolar resistive switching properties and endurance switching behavior of the neodymium oxide (Nd2O3) thin films resistive random access memory (RRAM) devices for a high resistive status/low resistive status (HRS/LRS) using a low temperature supercritical carbon dioxide fluid (SCF) improvement post-treatment process were investigated. Electrical and physical properties improvement of Nd2O3 thin films were measured by X-ray diffraction (XRD), scanning electron microscopy (SEM), X-ray photoelectron spectroscopy (XPS), and current versus voltage (I-V) measurement. The metal-like behavior of ohmic conduction mechanism and metallic cluster reaction of hopping conduction mechanism in initial metallic filament path forming process of the SCF-treated thin films RRAM devices was assumed and discussed. Finally, the electrical conduction mechanism of the thin films RRAM derives for set/reset was also discussed and verified in filament path physical model.

Schottky Emission Distance and Barrier Height Properties of Bipolar Switching Gd:SiOx RRAM Devices under Different Oxygen Concentration Environments.

In this study, the hopping conduction distance and bipolar switching properties of the Gd:SiOx thin film by (radio frequency, rf) rf sputtering technology for applications in RRAM devices were calculated and investigated. To discuss and verify the electrical switching mechanism in various different constant compliance currents, the typical current versus applied voltage (I-V) characteristics of gadolinium oxide RRAM devices was transferred and fitted. Finally, the transmission electrons' switching behavior between the TiN bottom electrode and Pt top electrode in the initial metallic filament forming process of the gadolinium oxide thin film RRAM devices for low resistance state (LRS)/high resistance state (HRS) was described and explained in a simulated physical diagram model.

Structural, Electrical, Magnetic and Resistive Switching Properties of the Multiferroic/Ferroelectric Bilayer Thin Films.

Bi0.8Pr0.2Fe0.95Mn0.05O3/Bi3.96Gd0.04Ti2.95W0.05O12 (BPFMO/BGTWO) bilayer thin films with Multiferroic/Ferroelectric (MF/FE) structures were deposited onto Pt(111)/Ti/SiO2/Si(100) substrates by using the sol-gel method with rapid thermal annealing. The BPFMO/BGTWO thin films exhibited well-saturated ferromagnetic and ferroelectric hysteresis loops because of the electro-magnetic coupling induced by the MF/FE structure. The remnant magnetization (2Mr) and remnant polarization (2Pr) were 4.6 emu/cm³ and 62 µC/cm², respectively. Moreover, the bipolar I-V switching curves of BPFMO/BGTWO bilayer thin films resistive random access memory (RRAM) devices were discussed, and investigated for LRS/HRS.

Intraoperative nerve monitoring reduces recurrent laryngeal nerve injury in geriatric patients undergoing thyroid surgery.

OBJECTIVE: This research was aimed to investigate whether the intraoperative nerve monitoring (IONM) can reduce the incidence of recurrent laryngeal nerve (RLN) injury in geriatric patients undergoing thyroid surgery. METHODS: This retrospective cohort study included 522 geriatric patients undergoing thyroid surgery between January 2013 and June 2016 in the Sun Yat-sen Memorial Hospital. Patients with IONM during the surgery (n = 340) were compared with patients without IONM (n = 212). RLN injury was verified by direct or indirect laryngoscope and relative factors for injury would be retrospectively analyzed. RESULTS: The use of IONM group showed significant reduction in both total and transient RLN injury incidence, when compared with that in control group (1.76 versus 4.72%, p = .01 and 1.32 versus 3.67%, p = .03, respectively). However, the permanent RLN injury incidence did not show difference between the two groups (p = .3). CONCLUSIONS: Our finding showed the use of IONM resulted in significantly reduction in RLN injury incidence. The technology of IONM is safe and convenient to detect, track and monitor the complete function of RLN and to provide the guidance for the surgeons during the thyroid surgery in geriatric patients, who are at high risk of RLN injury.

Bridging the gap between observation and brace treatment for adolescent idiopathic scoliosis.

Adolescent idiopathic scoliosis (AIS) remains the most common and potentially severe form of scoliosis during the rapid growth period. It is generally accepted that AIS is a multifactorial disease controlled by genetic, hormonal, neuromuscular, and environmental factors. Herein, we describe a case of 12-year-old scoliotic girl with a double curve of initially 26° thoracic and 23° lumbar, seeking chiropractic care. The therapy was provided three times/twice a week for 6 months. Adjustments of the spine through chiropractic, both soreness and mobility, were shown to improve. A total correction in Cobb angle of 6° (23%) in the thoracic curve and 7° (30%) in the lumbar curve was illustrated on consequent radiographs. This case highlights the advantage of chiropractic adjustment of early scoliosis primarily because the medical community does not offer any treatment for such a mild scoliosis. Further, randomized trial is warranted to support this viability for AIS.