Critical care outcomes in decompensated cirrhosis: a United States national inpatient sample cross-sectional study.

BACKGROUND: Prior assessments of critical care outcomes in patients with cirrhosis have shown conflicting results. We aimed to provide nationwide generalizable results of critical care outcomes in patients with decompensated cirrhosis. METHODS: This is a retrospective study using the National Inpatient Sample from 2016 to 2019. Adults with cirrhosis who required respiratory intubation, central venous catheter placement or both (n = 12,945) with principal diagnoses including: esophageal variceal hemorrhage (EVH, 24%), hepatic encephalopathy (58%), hepatorenal syndrome (HRS, 14%) or spontaneous bacterial peritonitis (4%) were included. A comparison cohort of patients without cirrhosis requiring intubation or central line placement for any principal diagnosis was included. RESULTS: Those with cirrhosis were younger (mean 58 vs. 63 years, p < 0.001) and more likely to be male (62% vs. 54%, p < 0.001). In-hospital mortality was higher in the cirrhosis cohort (33.1% vs. 26.6%, p < 0.001) and ranged from 26.7% in EVH to 50.6% HRS. Mortality when renal replacement therapy was utilized (n = 1580, 12.2%) was 46.5% in the cirrhosis cohort, compared to 32.3% in other hospitalizations (p < 0.001), and was lowest in EVH (25.7%) and highest in HRS (51.5%). Mortality when cardiopulmonary resuscitation was used was increased in the cirrhosis cohort (88.0% vs. 72.1%, p < 0.001) and highest in HRS (95.7%). CONCLUSIONS: One-third of patients with cirrhosis requiring critical care did not survive to discharge in this U.S. nationwide assessment. While outcomes were worse than in patients without cirrhosis, the results do suggest better outcomes compared to previous studies.

COVID-19 circuit management: la Rabta experience.

Covid-19 pandemic was associated to fear among patients, doctors and nurses, it was responsible of a work impairment in health structures organisation. All patients were at home, only Covid patients were at hospital. Our country has a quick reaction, we declared the pandemic as a social disease with free management. All hospital had the order to create their own Covid-19 circuit. We report the experience of our hospital in the crisis management with the creation of the circuit, its organisation, the management of the different financial, technical, human, sanitary, psychological and logistical aspects. The great point of this crisis was the fear, stress of caregivers for themselves and their families. The other point for members of Covid Cell was the race against time, the learning of a new job: a manager or a polyvalent chief. The presence of a Covid-19 circuit is necessary for each hospital at the epidemic time but it must be managed by infectious diseases doctors, lung specialists, intensive care givers and emergency room caregivers in collaboration. An enhancement of the structures is necessary at the level of medical wards and beds of intensive care.

Ultrasound stroke volume variation induced by passive leg raising and fluid responsiveness: An observational cohort study / Variación ultrasónica del volumen sistólico inducida por la elevación pasiva de la pierna y la respuesta de fluidos: estudio de cohortes observacional

Objective: To assess the performance of the ultrasound measurement of stroke volume (SV) coupled to passive leg raising (PLR) in predicting fluid responsiveness (FR). Design: A prospective cohort study was carried out in patients requiring volume expansion (VE). A transthoracic Doppler echocardiography (TTE) device was used for the measurement of SV. Four measurements were obtained: before and 90s after PLR, and before and after VE. The patients were subsequently classified according to their hemodynamic response to VE. Responders were defined by an increase in SV of at least 15% in response to VE. Results: Thirty maneuvers were studied. An increase in SV>15% in response to PLR was recorded in 21 cases. Hemodynamic indices taken in the first stage showed significant differences in the distensibility index of the inferior vena cava (dIVC), in the velocity-time integral of aortic blood flow (VTIAo) and in SV, with respective p-values of 0.009, 0.012 and 0.025. The SV changes induced by VE were significantly correlated to the SV changes induced by PLR, with a Spearman coefficient of 0.77 and a linear equation y=0.82 x+1.68. Fluid responsiveness can be efficiently predicted by assessing the effects of PLR on SV monitored by Doppler TTE, with a sensitivity of 94.7% and a negative predictive value of 88%. Conclusion: Our data support the interest of Doppler TTE as an effective tool in predicting FR through the assessment of SV in response to PLR, in hemodynamically unstable patients

Objetivo: Evaluar el rendimiento de la medida del volumen sistólico (VS) por ultrasonido junto con la elevación pasiva de piernas (EPP) para predecir la respuesta de fluidos (RF). Diseño: Estudio prospectivo de cohorte realizado en pacientes que requieren expansión de volumen (EV). Se utilizó un dispositivo doppler ecocardiográfico transtorácico (ETT) para la medición del VS. Se obtuvieron 4 mediciones: antes y 90s después de la EPP, y antes y después de la EV. Posteriormente, los pacientes se clasificaron según su respuesta hemodinámica a VE. Los respondedores se definieron por un aumento del VS de al menos 15% en respuesta a EV. Resultados: Se estudiaron 30 maniobras. Un aumento del VS>15% en respuesta a la EPP se informó en 21 casos. Los índices hemodinámicos tomados en la primera etapa mostraron diferencias significativas en el índice de distensibilidad de la vena cava inferior (dVCI), en la integral velocidad-tiempo del flujo sanguíneo aórtico (IVTAo) y en el VS con valores p respectivos en 0,009, 0,012 y 0,025. Los cambios del VS inducidos por EV se correlacionaron significativamente con los cambios del VS inducidos por EPP con un coeficiente de Spearman en 0,77 y una ecuación lineal en y=0,82× +1,68. La respuesta de fluidos se puede predecir eficazmente mediante la evaluación de los efectos de EPP en el VS vigilado por ETT-doppler con sensibilidad en el 94,7% y VPN en el 88%. Conclusión: Nuestros datos respaldan el interés del ETT-doppler como una herramienta eficaz en la predicción de la RF por la evaluación del VS en respuesta a la EPP en pacientes hemodinámicamente inestables

Ultrasound stroke volume variation induced by passive leg raising and fluid responsiveness: An observational cohort study.

OBJECTIVE: To assess the performance of the ultrasound measurement of stroke volume (SV) coupled to passive leg raising (PLR) in predicting fluid responsiveness (FR). DESIGN: A prospective cohort study was carried out in patients requiring volume expansion (VE). A transthoracic Doppler echocardiography (TTE) device was used for the measurement of SV. Four measurements were obtained: before and 90s after PLR, and before and after VE. The patients were subsequently classified according to their hemodynamic response to VE. Responders were defined by an increase in SV of at least 15% in response to VE. RESULTS: Thirty maneuvers were studied. An increase in SV>15% in response to PLR was recorded in 21 cases. Hemodynamic indices taken in the first stage showed significant differences in the distensibility index of the inferior vena cava (dIVC), in the velocity-time integral of aortic blood flow (VTIAo) and in SV, with respective p-values of 0.009, 0.012 and 0.025. The SV changes induced by VE were significantly correlated to the SV changes induced by PLR, with a Spearman coefficient of 0.77 and a linear equation y=0.82 x+1.68. Fluid responsiveness can be efficiently predicted by assessing the effects of PLR on SV monitored by Doppler TTE, with a sensitivity of 94.7% and a negative predictive value of 88%. CONCLUSION: Our data support the interest of Doppler TTE as an effective tool in predicting FR through the assessment of SV in response to PLR, in hemodynamically unstable patients.

Enhancing the absorption capabilities of thin-film solar cells using sandwiched light trapping structures.

A novel structure for thin-film solar cells is simulated with the purpose of maximizing the absorption of light in the active layer and of reducing the parasitic absorption in other layers. In the proposed structure, the active layer is formed from an amorphous silicon thin film sandwiched between silicon nanowires from above and photonic crystal structures from below. The upper electrical contact consists of an indium tin oxide layer, which serves also as an antireflection coating. A metal backreflector works additionally as the other contact. The simulation was done using a new reliable, efficient and generic optoelectronic approach. The suggested multiscale simulation model integrates the finite-difference time-domain algorithm used in solving Maxwell's equation in three dimensions with a commercial simulation platform based on the finite element method for carrier transport modeling. The absorption profile, the external quantum efficient, and the power conversion efficiency of the suggested solar cell are calculated. A noticeable enhancement is found in all the characteristics of the novel structure with an estimated 32% increase in the total conversion efficiency over a cell without any light trapping mechanisms.

Simulating the dispersive behavior of semiconductors using the Lorentzian-Drude model for photovoltaic devices.

Unique light-trapping structures that improve the efficiency of thin-film solar cells require advanced computational methods that can simulate the propagation of light through the thickness of each material in the solar cell. The simulations community that uses the Lorentz-Drude (LD) model cannot precisely simulate the propagation of light through the entire spectrum of the Sun, due to the difficulty in extrapolating the coefficients of each solar cell material. In this paper, a new technique for modeling dispersive and absorptive material over the Sun's entire wavelength range (200-1700 nm) using the LD model is suggested. The new numerical models are used for simulating light propagation through various one-dimensional light-trapping structures, including metal backreflectors and distributed Bragg reflectors. All the numerical simulation results show agreement with previously published theoretical and experimental results. The proposed simulation technique will help the simulations community in using the LD model to simulate the propagation of light in solar cells more accurately.

Nanowire photovoltaic efficiency enhancement using plasmonic coupled nano-fractal antennas.

We suggest the use of nano-fractal antennas for plasmonic coupling to enhance nanowire (NW) photovoltaic power conversion efficiency. Silicon radial pn junction NWs positioned inside Apollonian and Sierpinski nano-fractal antennas are simulated with different topologies and NW lengths. An enhancement in power conversion efficiency ranging from 12% to up to 24% over the same NW without antenna case is achieved.

Multiresistance and endemic status of acinetobacter baumannii associated with nosocomial infections in a tunisian hospital: a critical situation in the intensive care units

Acinetobacter baumannii is often implicated in hospital outbreaks in Tunisia. It's a significant opportunistic pathogen associated with serious underlying diseases such as pneumoniae, meningitis and urinary tract infections. The aim of our study was to evaluate its degree of endemicity and its antibiotic resistance evolution essentially in the unit care where its isolation was predominant (57 percent). This study used 3 methods: antibiotyping, RAPD using 2 primers VIL 1, VIL5 and PFGE with ApaI restriction enzyme. The presence of integron1 and 2 was also studied. Antibiotyping showed that 92 percent of patients were resistant of all ß- lactams (except Imipenem) and that the resistance to Imipenem occurred in 47 percent of cases. RAPD profiles obtained with the 2 arbitrarily primers VIL1 and VIL5 gave respectively 5 and 4groups and PFGE fingerprinting patterns revealed 22 different pulsotypes. Integron 1 was present in 25 percent of unrelated strains and type 2 integron was not detected in any of the studied strains. Among 204 strains, multiple and heterogeneous groups were detected with the genomic studies. In addition, any correlation was obtained with the antibiotyping results. These findings demonstrate the endemic status of A. baumannii in our hospital and the persistence of a large number of multiresistant strains in the unit's care. When outbreaks of A. baumannii occur, it's essential to develop restricted hygiene procedures and a serious surveillance of critical units such as ICU for very ill patients.

Multiresistance and endemic status of acinetobacter baumannii associated with nosocomial infections in a tunisian hospital: a critical situation in the intensive care units.

Acinetobacter baumannii is often implicated in hospital outbreaks in Tunisia. It's a significant opportunistic pathogen associated with serious underlying diseases such as pneumoniae, meningitis and urinary tract infections. The aim of our study was to evaluate its degree of endemicity and its antibiotic resistance evolution essentially in the unit care where its isolation was predominant (57%). This study used 3 methods: antibiotyping, RAPD using 2 primers VIL 1, VIL5 and PFGE with ApaI restriction enzyme. The presence of integron1 and 2 was also studied. Antibiotyping showed that 92% of patients were resistant of all ß- lactams (except Imipenem) and that the resistance to Imipenem occurred in 47% of cases. RAPD profiles obtained with the 2 arbitrarily primers VIL1 and VIL5 gave respectively 5 and 4groups and PFGE fingerprinting patterns revealed 22 different pulsotypes. Integron 1 was present in 25% of unrelated strains and type 2 integron was not detected in any of the studied strains. Among 204 strains, multiple and heterogeneous groups were detected with the genomic studies. In addition, any correlation was obtained with the antibiotyping results. These findings demonstrate the endemic status of A. baumannii in our hospital and the persistence of a large number of multiresistant strains in the unit's care. When outbreaks of A. baumannii occur, it's essential to develop restricted hygiene procedures and a serious surveillance of critical units such as ICU for very ill patients.

[Pnemocystis jiroveci pneumonia: Comparison between conventional PCR and staining techniques]. / Pneumocystose à Pneumocystis jiroveci : étude comparée de la PCR et des techniques de coloration.

Diagnosis of pneumocystis pneumonia is usually based on clinical features and X-rays photography and confirmed in the laboratory by visualisation of Pneumocystis organisms in stained preparations of respiratory specimens using several techniques (Gomori-Grocott, May-Grünwald Giemsa, bleu de toluidine O). Actually, PCR has considerably increased sensitivity of detection of Pneumocystis. The aim of this study is to compare conventional PCR results to those of staining techniques (Gomori-Grocott, May-Grünwald Giemsa) in addition to the X-ray and clinical findings in order to evaluate the contribution of each method. Sixty-four respiratory specimens were collected from 54 immuno-compromised patients with clinical symptoms of pulmonary infection. We diagnosed pneumocystis pneumonia in 16 patients according to staining techniques and/or typical clinical and radiological findings and/or response to treatment. Of the 15 patients, 14 were positive by PCR and only five were positive by direct examination, yielding a sensitivity and specificity of 93.3 and 87.1% for PCR and 33.3 and 100% for staining techniques. Conventional PCR provides a sensitive and objective method for the detection Pneumocystis jiroveci from less invasive sample.

Phenotypic and molecular epidemiology of Acinetobacter baumannii strains isolated in Rabta Hospital, Tunisia.

Acinetobacter baumannii (A. baumannii) is often implicated in hospital outbreaks in Tunisia. It's a significant opportunistic pathogen that is usually associated with serious underlying diseases such as pneumoniae, meningitis and urinary tract infections. The aim of this prospective study was to evaluate the global state of its endemicity and the antibiotic resistance evolution. The possibility of nosocomial transmission of one or more epidemic strain(s) was investigated by means of 3 methods: biotyping, antibiotyping and Random Amplified Polymorphic DNA analysis (RAPD). MIC for imipenem by Ellipsometer-test strip (E-TEST). The presence of metallo-beta-lactamases (MBL) was detected according to the double synergy test of EDTA and imipenem disks. A. baumannii strains were mainly localized in intensive care (52.2%) and surgery units (23.6%). Among 224 strains that were studied, 4 biotypes were delineated with a predominance of biotype1. Resistance to beta-lactams was mostly associated with the production of cephalosporinases and penicilinases (84.3%). 45% of strains were resistant to imipenem which were associated with MBL production. RAPD gave 5 genomic groups. This study demonstrates the epidemic behaviour airborne spread of A. baumannii in hospital wards. The multiresistance was often responsible for failure of antibiotics therapy. The prevention of nosocomial infection and severe hygiene controls must be performed.