Epidemiology of Renal Replacement Therapy for Critically Ill Patients across Seven Health Jurisdictions.

INTRODUCTION: Acute kidney injury (AKI) requiring treatment with renal replacement therapy (RRT) is a common complication after admission to an intensive care unit (ICU) and is associated with significant morbidity and mortality. However, the prevalence of RRT use and the associated outcomes in critically patients across the globe are not well described. Therefore, we describe the epidemiology and outcomes of patients receiving RRT for AKI in ICUs across several large health system jurisdictions. METHODS: Retrospective cohort analysis using nationally representative and comparable databases from seven health jurisdictions in Australia, Brazil, Canada, Denmark, New Zealand, Scotland, and the USA between 2006 and 2023, depending on data availability of each dataset. Patients with a history of end-stage kidney disease receiving chronic RRT and patients with a history of renal transplant were excluded. RESULTS: A total of 4,104,480 patients in the ICU cohort and 3,520,516 patients in the mechanical ventilation cohort were included. Overall, 156,403 (3.8%) patients in the ICU cohort and 240,824 (6.8%) patients in the mechanical ventilation cohort were treated with RRT for AKI. In the ICU cohort, the proportion of patients treated with RRT was lowest in Australia and Brazil (3.3%) and highest in Scotland (9.2%). The in-hospital mortality for critically ill patients treated with RRT was almost fourfold higher (57.1%) than those not receiving RRT (16.8%). The mortality of patients treated with RRT varied across the health jurisdictions from 37 to 65%. CONCLUSION: The outcomes of patients who receive RRT in ICUs throughout the world vary widely. Our research suggests that differences in access to and provision of this therapy are contributing factors.

Physician engagement strategies in health information system implementations.

Health information system implementations are expensive and risky. They have the potential to transform healthcare when implemented successfully. Health leaders need to effectively engage physicians as an important constituent in the project. This can be accomplished by applying user-centred design principles, facilitating physician leadership, and planning for training. When done effectively, a sense of shared ownership and allegiance between management and the physician group is created that will lead to a successful project.

Self-similar propagation of optical pulses in fibers with positive quartic dispersion.

We study the propagation of ultrashort pulses in optical fiber with gain and positive (or normal) quartic dispersion by self-similarity analysis of the modified nonlinear Schrödinger equation. We find an exact asymptotic solution, corresponding to a triangle-like T4/3 intensity profile, with a T1/3 chirp, which is confirmed by numerical simulations. This solution follows different amplitude and width scaling compared to the conventional case with quadratic dispersion. We also suggest, and numerically investigate, a fiber laser consisting of components with positive quartic dispersion that emits quartic self-similar pulses.

Towards subdiffraction imaging with wire array metamaterial hyperlenses at MIR frequencies.

We describe the fabrication of metamaterial magnifying hyperlenses with subwavelength wire array structures for operation in the mid-infrared (around 3 µm). The metadevices are composed of approximately 500 tin wires embedded in soda-lime glass, where the metallic wires vary in diameter from 500 nm to 1.2 µm along the tapered structure. The modeling of the hyperlenses indicates that the expected overall losses for the high spatial frequency modes in such metadevices are between 20 dB to 45 dB, depending on the structural parameters selected, being promising candidates for far-field subdiffraction imaging in the mid-infrared. Initial far-field subdiffraction imaging attempts are described, and the problems encountered discussed.

Optimized laser-written ZBLAN fiber Bragg gratings with high reflectivity and low loss.

We report the direct femtosecond laser inscription of type-I fiber Bragg gratings (FBGs) into the core of soft-glass ZBLAN fibers. We investigate and compare various fabrication methods such as single pass (line by line), double pass, and stacking (plane by plane) to create the highest reflectivity FBGs (99.98%) for mid-infrared (mid-IR) applications. In addition, we experimentally demonstrate how the parameters that influence the coupling coefficient, i.e., refractive index modulation and overlap factor, can be controlled in these gratings to specifically tailor the FBG properties. The performance of the direct-written type-I gratings after 6 h of annealing is further analyzed, and the reflectivity increases by approximately 10 dB. To the best of our knowledge, this is the first demonstration of temperature-stable mid-IR FBGs with highest coupling coefficient (464 m-1) and lowest loss (<0.5 dB/cm) without the use of an expensive phase mask.

Implementation of population-level screening for frailty among patients admitted to adult intensive care in Alberta, Canada.

PURPOSE: A substantial proportion of patients admitted to intensive care units (ICUs) are frail; however, the epidemiology of frailty has not been explored at a population-level. Following implementation of a validated frailty measure into a provincial ICU clinical information system, we describe the population-based prevalence and outcomes of frailty in patients admitted to ICUs. METHODS: Retrospective cohort study of adult admissions to 17 ICUs. Data were captured using eCritical Alberta. A Clinical Frailty Scale (CFS) score assigned at ICU admission was used to define the exposure (CFS score ≥ 5). Primary outcome was hospital mortality. Secondary outcomes were ICU and hospital stay, and receipt of organ support. RESULTS: Fifteen thousand two hundred and thirty-eight patients (81%) were assigned a CFS score at ICU admission. Of these, 28% (95% confidence interval [CI], 27 to 28) were frail. Prevalence of frailty was 9-43% across ICUs. Frail patients were older [mean (standard deviation) 63 (15) vs 56 (17) yr; P < 0.001], more likely to be male (54% vs 46% female; P < 0.001), and had higher APACHE II scores [22 (8) vs 17 (8); P < 0.001] compared with non-frail patients. Frail patients received less mechanical ventilation (62% vs 68%; P < 0.001) and vasoactive therapy (24% vs 57%; P < 0.001), but more non-invasive ventilation (22% vs 9%; P < 0.001). Frail patients had higher hospital mortality (23% vs 9%; adjusted odds ratio, 1.80; 95% CI, 1.64 to 2.05, along with longer ICU stay (median [interquartile range] 4 [2-8] vs 3 [2-6] days; P < 0.001), and longer hospital stay (16 [8-36] vs 10 [5-20] days; P < 0.001) compared with non-frail patients. CONCLUSION: A validated measure of frailty can be implemented at the population level in ICU. Frailty is common in ICU patients and has implications for health service use and clinical outcomes.

Direct inscription of Bragg gratings into coated fluoride fibers for widely tunable and robust mid-infrared lasers.

We report the development of a widely tunable all-fiber mid-infrared laser system based on a mechanically robust fiber Bragg grating (FBG) which was inscribed through the polymer coating of a Ho3+-Pr3+ co-doped double clad ZBLAN fluoride fiber by focusing femtosecond laser pulses into the core of the fiber without the use of a phase mask. By applying mechanical tension and compression to the FBG while pumping the fiber with an 1150 nm laser diode, a continuous wave (CW) all-fiber laser with a tuning range of 37 nm, centered at 2870 nm, was demonstrated with up to 0.29 W output power. These results pave the way for the realization of compact and robust mid-infrared fiber laser systems for real-world applications in spectroscopy and medicine.

Mid-IR absorption sensing of heavy water using a silicon-on-sapphire waveguide.

We demonstrate a compact silicon-on-sapphire (SOS) strip waveguide sensor for mid-IR absorption spectroscopy. This device can be used for gas and liquid sensing, especially to detect chemically similar molecules and precisely characterize extremely absorptive liquids that are difficult to detect by conventional infrared transmission techniques. We reliably measure concentrations up to 0.25% of heavy water (D2O) in a D2O-H2O mixture at its maximum absorption band at around 4 µm. This complementary metal-oxide-semiconductor (CMOS) compatible SOS D2O sensor is promising for applications such as measuring body fat content or detection of coolant leakage in nuclear reactors.

Silicon-on-sapphire pillar waveguides for Mid-IR supercontinuum generation.

We propose pillar integrated silicon waveguides to exploit the entire transparent window of silicon. These geometries posses a broad and flat dispersion (from 2 to 6 µm) with four zero dispersion wavelengths. We calculate supercontinuum generation spanning over two octaves (2 to >8 µm) with long wavelengths interacting weakly with the lossy substrate. These structures have higher mode confinement in the silicon - away from the substrate, which makes them substrate independent and are promising for exploring new nonlinear phenomena and highly sensitive molecular sensing over the entire silicon's transparency range.

Positive and negative phototunability of chalcogenide (AMTIR-1) microdisk resonator.

We demonstrate externally photo-induced partially-reversible tuning of the resonance of a microdisk made of AMTIR-1 (Ge(33)As(12)Se(55)). We have achieved for the first time, to the best of our knowledge, both positive and negative shift in a microresonator with external tuning. A positive resonance shift of 1 nm and a negative resonance shift of 0.5 nm on a single microdisk has been measured. We have found that this phenomenon is due to initial photo-expansion of the microdisk followed by the photo-bleaching of the AMTIR-1. The observed shifts and the underlying phenomenon is controllable by varying the illumination power (i.e. the low power illumination suppresses the photobleaching process). We measure a loaded quality factor of 1.2x10(5) at 1550nm (limited by the measuring instrument). This holds promise for non-contact low power reversible-tunning of photonic circuit elements.

Ultrafast pulses from a mid-infrared fiber laser.

Ultrafast laser pulses at mid-infrared wavelengths (2-20 µm) interact strongly with molecules due to the resonance with their vibration modes. This enables their application in frequency comb-based sensing and laser tissue surgery. Fiber lasers are ideal to achieve these pulses, as they are compact, stable, and efficient. We extend the performance of these lasers with the production of 6.4 kW at a wavelength of 2.8 µm with complete electric field retrieval using frequency-resolved optical gating techniques. Contrary to the problems associated with achieving a high average power, fluoride fibers have now shown the capability of operating in the ultrafast, high-peak-power regime.

Factors Associated with Failure of Non-invasive Positive Pressure Ventilation in a Critical Care Helicopter Emergency Medical Service.

INTRODUCTION: Non-invasive positive pressure ventilation (NIPPV) is used to treat severe acute respiratory distress. Prehospital NIPPV has been associated with a reduction in both in-hospital mortality and the need for invasive ventilation. HYPOTHESIS/PROBLEM: The authors of this study examined factors associated with NIPPV failure and evaluated the impact of NIPPV on scene times in a critical care helicopter Emergency Medical Service (HEMS). Non-invasive positive pressure ventilation failure was defined as the need for airway intervention or alternative means of ventilatory support. METHODS: A retrospective chart review of consecutive patients where NIPPV was completed in a critical care HEMS was conducted. Factors associated with NIPPV failure in univariate analyses and from published literature were included in a multivariable, logistic regression model. RESULTS: From a total of 44 patients, NIPPV failed in 14 (32%); a Glasgow Coma Scale (GCS)<15 at HEMS arrival was associated independently with NIPPV failure (adjusted odds ratio 13.9; 95% CI, 2.4-80.3; P=.003). Mean scene times were significantly longer in patients who failed NIPPV when compared with patients in whom NIPPV was successful (95 minutes vs 51 minutes; 39.4 minutes longer; 95% CI, 16.2-62.5; P=.001). CONCLUSION: Patients with a decreased level of consciousness were more likely to fail NIPPV. Furthermore, patients who failed NIPPV had significantly longer scene times. The benefits of NIPPV should be balanced against risks of long scene times by HEMS providers. Knowing risk factors of NIPPV failure could assist HEMS providers to make the safest decision for patients on whether to initiate NIPPV or proceed directly to endotracheal intubation prior to transport.

Resident Work Hour Restrictions and Change Management: A Cautionary Tale.

Residents are a significant part of coverage in many hospitals. Resident associations are negotiating work hour limits to prevent fatigue-induced medical errors. Our intensive care unit experienced an unexpected resident shortage and used the opportunity to trial a shift schedule for one month. Post-surveys were sent to nurses, attending physicians and residents to evaluate the effects on staff interactions, patient safety and education quality. The trial was clearly a failure on all fronts. Work hour restrictions are a reality in medical education, and administrators need to start considering alternative staffing models and discussing alternative schedules with their medicine faculty.

Hybrid Brillouin/thulium multiwavelength fiber laser with switchable single- and double-Brillouin-frequency spacing.

We demonstrate a multiwavelength laser at 2 µm based on a hybrid gain scheme consisting of a Brillouin gain medium and a thulium-doped fiber. The laser has switchable frequency spacing, corresponding to the single and double Brillouin frequency shifts. In the 20 dB bandwidth, seven lasing channels with a frequency spacing of 0.1 nm (7.62 GHz) and eleven channels with a double-spacing of 0.2 nm (15.24 GHz) are obtained. A wavelength tunability of 1.3 nm is realized for both laser configurations by shifting the pump wavelength. Strong four wave mixing is observed in the double-spacing laser resulting in an improved performance: larger number of channels and better temporal stability.

Stable, self-starting, passively mode-locked fiber ring laser of the 3 µm class.

We report a passively mode-locked Ho(3+)Pr(3+)-doped fluoride fiber laser, producing 6 ps pulses at a repetition rate of 24.8 MHz, with a peak power of 465 W. For the first time, a ring cavity was demonstrated in a fluoride fiber laser arrangement which was essential to the generation of stable and self-starting mode-locked pulses.

1.9 octave supercontinuum generation in a As2S3 step-index fiber driven by mid-IR OPCPA.

Using a 3.1-µm optical parametric chirped-pulse amplifier (OPCPA), we generate a supercontinuum in a step-index chalcogenide fiber that spans from 1.6 to 5.9 µm at the -20 dB points. The rugged step-index geometry allows for long-term operation, while the spectral bandwidth is limited by the transmission of the As2S3 fiber.

Aim at the bottom: directly exciting the lower level of a laser transition for additional functionality.

We introduce the concept of directly exciting the lower level of a laser transition in addition to the upper laser level for the provision of new possibilities for light emission from a fiber. In a first demonstration, using diode laser light at 1150 and 1950 nm, we respectively excite the upper and lower laser level of the 5I(6)→5I(7) transition (2.9 µm) of Ho3+-doped ZBLAN, demonstrating a power-scalable arrangement that can switch between free-running and superluminescent spectral output. The spectral composition of the gain-switched pulse derived from modulating the upper laser level pump light depends entirely on the degree of lower laser level excitation at 1950 nm.

Low-threshold Brillouin laser at 2 µm based on suspended-core chalcogenide fiber.

We present, to the best of our knowledge, the first demonstration of a 2 µm Brillouin laser based on a thulium-doped fiber pump and a chalcogenide fiber. A short 1.5 m piece of suspended-core chalcogenide As38Se62 fiber is employed as a gain medium, taking advantage of its small effective mode area and high Brillouin gain coefficient. A record-low lasing threshold of 52 mW is achieved, which is about 10 times lower than previously demonstrated in silica fiber cavities.

An analysis of the feasibility of carbon management policies as a mechanism to influence water conservation using optimization methods.

Studies of how carbon reduction policies would affect agricultural production have found that there is a connection between carbon emissions and irrigation. Using county level data we develop an optimization model that accounts for the gross carbon emitted during the production process to evaluate how carbon reducing policies applied to agriculture would affect the choices of what to plant and how much to irrigate by producers on the Texas High Plains. Carbon emissions were calculated using carbon equivalent (CE) calculations developed by researchers at the University of Arkansas. Carbon reduction was achieved in the model through a constraint, a tax, or a subsidy. Reducing carbon emissions by 15% resulted in a significant reduction in the amount of water applied to a crop; however, planted acreage changed very little due to a lack of feasible alternative crops. The results show that applying carbon restrictions to agriculture may have important implications for production choices in areas that depend on groundwater resources for agricultural production.

Single-frequency fiber laser operating at 2.9 µm.

We report the demonstration of a single-longitudinal-mode fiber laser operating at 2914 nm, which exhibits a spectrometer-limited linewidth of <0.4 nm, in a 49 mm long holmium/praseodymium co-doped ZBLAN fiber. Narrow-linewidth feedback is provided by a fiber Bragg grating inscribed directly in the ZBLAN fiber using the femtosecond laser point-by-point technique. Measurements of the temporal stability and coherence confirm that the laser is operating on a single longitudinal mode.