Search

INTRODUCTION: The Abdominal Compartment Society (WSACS) developed a medical management algorithm with a stepwise approach to keep intra-abdominal pressure (IAP) ≤ 15 mm Hg. The role of point-of-care ultrasound (POCUS) as a bedside modality in the critical care patients is not well studied in relation to the intra-abdominal hypertension (IAH) management algorithm. AIM: To test the role of point-of-care ultrasound (POCUS) in the medical management of patients with intra-abdominal hypertension (IAH). METHOD: We conducted a prospective observational study. Those who met the inclusion criteria were assigned to undergo POCUS and small bowel ultrasound as adjuvant tools in their IAH management. RESULTS: A total of 22 patients met the inclusion criteria and were included in the study. The mean age of the study participants was 65 ± 22.6 years, 61% were men, and the most frequent admission diagnoses were hepatic encephalopathy and massive ascites (five cases). Ultrasound and abdominal X-rays were comparable in confirming correct NGT position, but the ultrasound was superior in determining the gastric content (fluid vs. solid) and diagnoses of gastric paresis in two cases. Small bowel obstruction was present in four patients and confirmed with abdominal CT; two of the patients underwent surgical intervention for mesenteric vessel occlusion and transmesenteric internal hernia. Enema treatment was found to empty the bowel incompletely 72%, 56%, and 42% of the time on days 1, 2, and 3, respectively. Four patients with cirrhosis admitted with upper gastrointestinal bleeding and hepatic encephalopathy (out of a total of 8) were found to have large amounts of ascites, and US-guided paracentesis was performed. CONCLUSION: POCUS can be used in the nonoperative management of IAH. It is an important tool in the diagnosis and treatment of patients with IAH. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s40477-020-00546-8) contains supplementary material, which is available to authorized users.

Introduction: Patients with ADTKD-MUC1 have one allele producing normal mucin-1 (MUC1) and one allele producing mutant MUC1, which remains intracellular. We hypothesized that ADTKD-MUC1 patients, who have only 1 secretory-competent wild-type MUC1 allele, should exhibit decreased plasma mucin-1 (MUC1) levels. To test this hypothesis, we repurposed the serum CA15-3 assay used to measure MUC1 in breast cancer to measure plasma MUC1 levels in ADTKD-MUC1. Methods: This cross-sectional study analyzed CA15-3 levels in a reference population of 6,850 individuals, in 85 individuals with ADTKD-MUC1, and in a control population including 135 individuals with ADTKD-UMOD and 114 healthy individuals. Results: Plasma CA15-3 levels (mean ± standard deviation) were 8.6 ± 4.3 U/mL in individuals with ADTKD-MUC1 and 14.6 ± 5.6 U/mL in controls (p < 0.001). While there was a significant difference in mean CA15-3 levels, there was substantial overlap between the 2 groups. Plasma CA15-3 levels were MUC1 patients, in 0/249 controls, and in 1% of the reference population. Plasma CA15-3 levels were >20 U/mL in 1/85 ADTKD-MUC1 patients, in 18% of control individuals, and in 25% of the reference population. Segregation of plasma CA15-3 levels by the rs4072037 genotype did not significantly improve differentiation between affected and unaffected individuals. CA15-3 levels were minimally affected by gender and estimated glomerular filtration rate. Discussion/Conclusions: Plasma CA15-3 levels in ADTKD-MUC1 patients are approximately 40% lower than levels in healthy individuals, though there is significant overlap between groups. Further investigations need to be performed to see if plasma CA15-3 levels would be useful in diagnosis, prognosis, or assessing response to new therapies in this disorder.

Objective: To measure the acceptance of a coronavirus disease 2019 (COVID-19) vaccine among the sector of the oil company adult population in Kuwait and assess its determinants. Subjects and Methods: A cross-sectional email study enrolled adults working for Kuwait oil companies (n = 1689; aged ≥21 years). Acceptance of a COVID-19 vaccine was considered if participants selected the options and received the vaccine, definitely or probably will accept vaccination against COVID-19 once a vaccine is available.” A modified Poisson regression was used to investigate the associations and calculate the adjusted prevalence ratios (aPRs) and their 95% confidence intervals (CIs). Results: In total, 92.5% (1563/1689) of the participants were willing to accept COVID-19 vaccines once available. No difference in sex was observed in the willingness to accept a COVID-19 vaccine (92.5 vs. 92%, p 0.5). Responders who believed vaccines in general to have health-related risks were less likely to get vaccinated (aPR = 0.39, 95% CI: 0.35 - 0.44). In addition, participants who received the influenza vaccine were more willing to have a COVID-19 vaccine (aPR = 1.44, 95% CI: 1.31 - 1.58). Acceptance of the vaccine against COVID-19 increased as the self-perceived chances of contracting the infection increased (p < 0.001). Conclusion: Overall, 92.5% of the study participants demonstrated a willingness to be vaccinated against COVID-19. However, we found that public health authorities should address several factors influencing the level of acceptance.

Stevens‐Johnson syndrome (SJS) is serious conditions that happen as a result of infection, side effects to medications, or unknown etiology. Carbamazepine is one of the common medications that can cause SJS. Good history taking is crucial if treatment with carbamazepine is clinically indicated. We would like to alert all physicians that carbamazepine should be avoided in any patient with a previous history of drug reaction such as mast cell activation syndrome.

Background Significant coagulopathy and hyperinflammation are found in patients with coronavirus disease 2019 (COVID-19). Expert consensus has recommended prophylactic anticoagulation in COVID-19 patients due to the risk of thrombo-embolism. However, the use of therapeutic anticoagulation in these patients is still a matter of debate. Case summary We describe a patient with COVID-19 pneumonia and a clinical hyperinflammatory state. He developed early respiratory depression and required ventilation, and he subsequently developed haemodynamic instability. Point-of-care echocardiography demonstrated a right atrial thrombus and right ventricular dysfunction suggestive of acute massive pulmonary embolism. He was managed with veno-arterial extracorporeal membrane oxygenation and local thrombolysis. Discussion Critical cases of COVID-19 pneumonia are associated with hypercoagulation, and these patients should be monitored closely for complications. Therapeutic anticoagulation may play a role in the management and prevention of thrombo-embolism.

Neuronal intranuclear inclusion disease (NIID) is a progressive neurodegenerative disorder categorized into 3 phenotypic variants: infantile, juvenile, and adult. Four recent reports have linked NIID to CGG expansions in the NOTCH2NLC gene in adult NIID (aNIID) and several juvenile patients. Infantile NIID (iNIID) is an extremely rare neuropediatric condition. We present a 7-year-old male patient with severe progressive neurodegenerative disease that included cerebellar symptoms with cerebellar atrophy on brain MRI, psychomotor developmental regression, pseudobulbar syndrome, and polyneuropathy. The diagnosis of iNIID was established through a postmortem neuropathology work-up. We performed long-read sequencing of the critical NOTCH2NLC repeat motif and found no expansion in the patient. We also re-evaluated an antemortem skin biopsy that was collected when the patient was 2 years and 8 months old and did not identify the intranuclear inclusions. In our report, we highlight that the 2 methods (skin biopsy and CGG expansion testing in NOTCH2NLC) used to identify aNIID patients may provide negative results in iNIID patients.

Thoracic duct injury is a rare complication of dorsal spine operations. Ultrasound chest plays an important tool for rapid diagnosis of acute dyspnea, drainage of massive effusion, and daily follow‐up. Conservative treatment of postoperative chylous with measures to decrease chylous formation can lead to a resolution of chylothorax.

Drugs that inhibit voltage-dependent sodium channels are commonly used to treat epilepsy. Old and novel antiepileptic drugs are used either as monotherapy or in combination to control epilepsy. For a long time, carbamazepine has been used as the first choice for the treatment of simple and complex partial seizures. In the USA, lacosamide was approved in October 2008 as an adjunctive treatment for partial-onset seizures. We describe the effect of two sodium channel blockers on the heart of a patient with epilepsy. LEARNING POINTS: Approximately 30% of patients with epilepsy require combination therapy with antiepileptic drugs for seizure reduction. Lacosamide and carbamazepine are both sodium channel blockers but exert their effects through different mechanisms. Electrocardiogram monitoring is necessary when lacosamide and carbamazepine are used together as this combination may predispose to seizures, conduction abnormalities and dysrhythmia.

A 56-year-old male was admitted to the emergency department for acute pulmonary edema and septic shock, yet no clear source of infection was noted upon physical examination. Due to his unstable condition, bedside ultrasound was performed. A heterogeneous mass in the liver was noted; hence, a tentative diagnosis of liver abscess was made. The abscess was confirmed by abdominal magnetic resonance imaging. Drainage of the abscess was attempted and guided by early ultrasound. This case highlights that point-of-care ultrasound, when performed by an ultrasound-capable critical care physician, can significantly decrease the time to diagnosis for septic patients.

Background Chest radiography (CXR) and computerized tomography (CT) are the standard methods for lung imaging in diagnosing COVID‐19 pneumonia in the intensive care unit (ICU), despite their limitations. This study aimed to assess the performance of bedside lung ultrasound examination by a critical care physician for the diagnosis of COVID‐19 pneumonia during acute admission to the ICU. Method This was an observational, prospective, single‐center study conducted in the intensive care unit of Adan General Hospital from April 10, 2020, to May 26, 2020. The study included adults with suspicion of COVID‐19 Infection who were transferred to the ICU. Patients were admitted to the ICU directly from the ED after reverse transcriptase‐polymerase chain reaction (RT‐PCR) swabs were sent to the central virology laboratory in Kuwait, and the results were released 16 to 24 hours after the time of admission. A certified intensivist in critical care ultrasound performed the lung ultrasound within 12 hours of the patient's admission to the ICU. The treating physician confirmed the diagnosis of COVID‐19 pneumonia based on a set of clinical features, inflammatory markers, biochemical profile studies, RT‐PCR test results, and CXR. Results Of 77 patients with suspected COVID‐19 pneumonia, 65 (84.4%) were confirmed. The median age of the patients was 48 (31‐68) years, and 51 (71%) were men. In the group of patients with confirmed COVID‐19 pneumonia, LUS revealed four signs suggestive of COVID‐19 pneumonia in 63 patients (96.9%) (sensitivity 96.9%, CI 85%‐99.5%). Two patients presented with unilateral lobar pneumonia without other ultrasonic signs of COVID‐19 pneumonia but with positive RT‐PCR results. Among patients in the group without COVID‐19 pneumonia who had negative RT‐PCR results, 11 (91.7%) were LUS negative for COVID‐19 pneumonia (specificity 91.7%, 95% CI 58.72%‐99.77%). Conclusions During the COVID‐19 outbreak, LUS allows the identification of early signs of interstitial pneumonia. LUS patterns that show a combination of the four major signs offer high sensitivity and specificity compared to nasopharyngeal RT‐PCR., During the COVID‐19 outbreak, LUS allows the identification of early signs of interstitial pneumonia. LUS patterns that show a combination of the four major signs offer high sensitivity and specificity compared to nasopharyngeal RT‐PCR.

Introduction. One of the ultrasonic features of COVID-19 pneumonia is the presence of subpleural consolidation (SPC), and the number of SPCs varies among patients with COVID-19 pneumonia. Aim. To examine the relationship between disease severity and the number of SPCs on admission. Methodology. This observational, prospective, single‐center study included patients with suspected COVID-19 infection who had been transferred to the ICU. A specialized intensivist in critical care ultrasound performed lung ultrasound (LUS) and echocardiography within 12 hours of a patient’s admission to the ICU. The aeration score was calculated, and the total number of SPCs was quantified in 12 zones of the LUS. Results. Of 109 patients with suspected COVID-19 pneumonia, 77 (71%) were confirmed. The median patient age was 53 (82–36) years, and 81 of the patients (73.7%) were men. The aeration score and the counts of subpleural consolidation in each zone were significantly higher in patients with COVID-19 pneumonia ( P = 0.018 and P < 0.0001 , respectively). There was an inverse relationship between PO2/FiO2, the aeration score, and the number of subpleural consolidations. The higher the number of SPCs, the worse the PO2/FiO2 will be. Conclusions. Sonographic SPC counts correlate well with the severity of COVID-19 pneumonia and PO2/FiO2. The number of SPCs should be considered when using LUS to assess disease severity.

International audience; Damaging, cracking, and strain localization mechanisms often lead to unstable structural responses characterized by snap-backs(i.e., the force and the displacement decrease simultaneously). The usual nonlinear Newton-based solution algorithms with displacement/force control cannot capture the complete equilibrium curve in a numerical context. This shortcoming can be circumventedusing path-following formulations. They rely on two hypotheses: (i) the decomposition of loading into two parts, one knownand the other unknown (only its direction is imposed); (ii) the use of path-following equations so that the unknown load (forceor displacement) contribution can be determined indirectly. Collecting the essential concepts and the formalism of path-followingarc-length methods, we design a unique framework into the Cast3M toolbox, capable of receiving existing and new path-followingequations without significant modifications. Three path-following constraints were chosen to demonstrate its applicability: a constrainton the combination of the displacement increment at a given set of nodes, a constraint on the maximum strain incrementover the computational domain, and a constraint on the maximum elastic predictor of the damage/plastic criterion function over thecomputational domain. Two- and three- dimensional strain localization simulations show that the proposed framework behaves ina stable and convergent manner, even in the presence of multiple severe snap-back instabilities. The proposed study proves helpfulbecause the user can focus on developing new path-following equations into the Cast3M toolbox. The developments discussed inthis manuscript will be made available to the users/developers community with Cast3M 2021 (release date: April 2021).

Cholesterol embolization syndrome (CES) is an atherosclerotic complication affecting different systems with various clinical manifestations, usually triggered iatrogenically by interventional and surgical procedures or thrombolytic therapy, although spontaneous cases have been reported. The hepatobiliary system can also be affected when the showered cholesterol crystals obliterate small vessels within this system causing both ischaemic and inflammatory responses. We describe a case of a male patient who initially developed multiple lacunar cerebral infarcts 10 days post-thrombolytic therapy and percutaneous coronary intervention (PCI) due to acute myocardial infarction. Several weeks later he developed acalculous cholecystitis complicated by liver abscess and kidney injury. The consequences and latency of manifestations within different organs and the temporal relationship with well-known trigger factors raised the suspicion of CES. LEARNING POINTS Cholesterol embolization syndrome (CES) is an atherosclerotic complication that usually develops after a vascular procedure/surgery or thrombolytic therapy or, rarely, spontaneously, and results in nonspecific cutaneous, renal, central nervous system and, less often, gastrointestinal manifestations that may mimic other systemic diseases. The delayed appearance of multi-organ manifestations from the precipitating factors may lead to difficulties in diagnosing CES. Complicated acalculous cholecystitis can be one of the infrequent hepatobiliary manifestations of CES.

COVID-19 infection can present with thrombotic manifestations like PE with no ultrasonographic evidence of lung parenchymal affection. BLUE protocol provides excellent step by step approach for diagnosis of acute dyspnoea. Adding FECHO to BLUE protocol complete the picture and help making solid diagnosis especially in sub-massive and massive PE

A 39-year-old woman who was taking the contraceptive pill was admitted with right leg deep venous thrombosis (DVT). She was started on apixaban tablets, but after 8 days developed proximal progression of the DVT and pulmonary embolism. Her medical history later showed a history of sleeve gastrectomy. The patient responded to a vitamin K antagonist after heparin. The failure of the antithrombotic drug shed light on the efficacy and changed pharmacodynamics of direct oral anticoagulants (DOACs) after bariatric surgery in the absence of commercially available blood monitoring tests. LEARNING POINTS Bariatric surgery causes complicated changes in the pharmacodynamics of direct oral anticoagulants (DOACs). The absence of clinical data on the efficacy of DOACs after various bariatric procedures makes it difficult to justify their use after bariatric surgery.

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the World Health Organization (WHO) declared it a pandemic on 11 March 2020. Point-of-care ultrasound (POCUS) is a real-time bedside tool used by physicians to guide rapid, focused and accurate evaluation in order to identify or rule out various pathologies. We describe the case of an elderly man who had fallen at home 3 days previously and was hypoxic at presentation to the emergency department (ED). POCUS in the ED helped to identify a combination of lung and vascular involvement that indicated COVID-19 infection, which was confirmed by a laboratory test. LEARNING POINTS: COVID-19 is a contagious disease caused by SARS-CoV-2 that attacks endothelial cells and most organs, resulting in different manifestations and clinical scenarios. Point-of-care ultrasound in the emergency room including lung ultrasound (LUS) and focused echocardiography (FECHO) can be useful in identifying pulmonary and vascular manifestations of COVID-19 disease during the current pandemic. Characteristic LUS signs suggesting bilateral interstitial pneumonia in addition to signs of acute right ventricular strain suggesting pulmonary embolism on FECHO raised the suspicion of COVID-19 infection in our patient.

Patient in sinus rhythm with dilated cardiomyopathy and low ejection fraction < 35% have a 4% risk of embolic event (1). This is a soft indication for therapeutic anti-coagulation(controversial) (2). Presence of excess Intra-cardiac Smoke-like Echoes increase risk of embolic event and switch the soft indication to strong one

In specific situations such as patient with severely dilated left ventricle (LV) and spontaneous echo contrast (SEC) who suffered an ischemic stroke previously may be an acceptable indication for oral anticoagulation to prevent further TE events.

Stevens-Johnson Syndrome (SJS) happen as a result of infection, side effects to medications or of unknown etiology. Carbamazepine is a common cause (SJS). Good history taking is crucial if clinically indicated treatment with carbamazepine. carbamazepine should be avoided with previous history of severe drug reaction like mast cell activation syndrome.

BackgroundPoint-of-care ultrasound (POCUS) has a major role in the management of patients with acute hypoxic respiratory and circulatory failure and guides hemodynamic management. There is scarce literature on POCUS assessment characteristics in COVID-19 pneumonia with hypoxic respiratory failure.MethodsThe study is an observational, prospective, single‐center study conducted in the intensive care unit of Adan General Hospital from May 1st, 2020, to June 25, 2020. The study included adults suspected to have COVID-19 transferred to the intensive care unit (ICU) with fever or suspected respiratory infection. Patients were transferred to the ICU directly from the ED or general medical wards after reverse transcriptase-polymerase chain reaction (RT-PCR) testing. A certified intensivist in critical care ultrasound who was blinded to the RT-PCR results, if available at the time of examination, performed the lung ultrasound and echocardiology within 12 hours of the patient’s admission to the ICU. We calculated the E/e’, E/A ratio, left ventricular ejection fraction EF, IVC diameter, RV size and systolic function. We performed ultrasound in 12 chest areas.ResultsOf 92 patients with suspected COVID-19 pneumonia, 77 (84%) cases were confirmed. The median age of the patients was 53 (82-36) years, and 71 (77%) were men.In the group of patients with confirmed COVID-19 pneumonia, echocardiographic findings showed normal E/e’, deceleration time (DT), and transmittal E/A ratio in comparison to the non-COVID19 patients (P .001 for both). The IVC diameter was 50% collapsibility in 62 (81%) patients with COVID-19 pneumonia; a diameter of > 2 cm and < 50% collapsibility in all patients, with a P value of 0.001, was detected among those with non-COVID-19 pneumonia. There were 3 cases of myocarditis with poor EF (5.5%), severe RV dysfunction was seen in 9 cases (11.6%), and 3 cases showed RV thrombus.Chest US revealed four signs suggestive of COVID-19 pneumonia in 77 patients (98.6%) (sensitivity 96.9%, CI 85%‐99.5%) when compared with RT-PCR results.ConclusionPOCUS plays an important role in bedside diagnosis, hemodynamic assessment and management of patients with acute hypoxic respiratory and circulatory failure in patients with COVID-19 pneumonia.

A 39-year-old woman was admitted with right leg deep venous thrombosis (DVT). She was started on apixaban tablets but developed pulmonary embolism. The medical history showed sleeve gastrectomy. The failure of the antithrombotic drug shed light on the efficacy and pharmacodynamic changes of DOACs after bariatric surgery

Colistin is considered as a last resort treatment for infections caused by multidrug-resistant Enterobacteriaceae. Plasmid-mediated mobile colistin resistance (mcr) genes contributed to the global spread of colistin resistance. This is the first report of plasmid-mediated colistin resistance mcr-8 gene from a clinical Klebsiella pneumoniae K9 isolate recovered from Lebanon. The isolate was characterized phenotypically and genotypically through both short and long read whole-genome sequencing, plasmid typing and conjugation assays. k9 belonged to sequence type 15 and harbored 31 antimicrobial resistance genes. The mcr-8.1 variant was carried on a novel ~ 300 kb multireplicon plasmid having IncFIA, IncR and IncHI1B. The plasmid was conjugative and carried a plethora of antimicrobial resistance determinants. The introduction of novel mcr variants in Lebanon poses an alarming health concern. Surveillance and screening for colistin resistant Enterobacteriaceae and mcr in livestock, animal farms, imported meat and poultry is highly recommended along with monitoring antibiotic use.

Wellens syndrome (WS) is identified by ECG changes in the precordial leads after resolution of angina chest pain. WS indicates critical stenosis of the proximal left anterior descending (LAD) artery. On the other hand, Kounis syndrome (KS) is an allergic reaction to various substances resulting in acute coronary syndrome. Contrast media can trigger the allergic reaction associated with KS. We describe a patient with WS who developed an allergic reaction to contrast media after percutaneous coronary intervention and experienced recurrent myocardial infarction on re-exposure. LEARNING POINTS: Despite its rarity, physicians and radiologists should be aware of Kounis syndrome triggered by contrast media so it can be rapidly diagnosed and treated. The initial target of the prevention and treatment of KS is avoidance of the precipitating stimulus or allergen. There are three KS variants: angina due to allergic coronary spasm, allergic myocardial infarction and allergy-induced stent thrombosis.

Background. Central venous-arterial carbon dioxide difference (PCO2 gap) can be a marker of cardiac output adequacy in global metabolic conditions that are less affected by the impairment of oxygen extraction capacity. We investigated the relation between the PCO2 gap, serum lactate, and cardiac index (CI) and prognostic value on admission in relation to fluid administration in the early phases of resuscitation in sepsis. We also investigated the chest ultrasound pattern A or B. Method. We performed a prospective observational study and recruited 28 patients with severe sepsis and septic shock in a mixed ICU. We determined central venous PO2, PCO2, PCO2 gap, lactate, and CI at 0 and 6 hours after critical care unit (CCU) admission. The population was divided into two groups based on the PCO2 gap (cutoff value 0.8 kPa). Results. The CI was significantly lower in the high PCO2 gap group (P=0.001). The high PCO2 gap group, on admission, required more administered fluid and vasopressors (P=0.01 and P=0.009, respectively). There was also a significant difference between the two groups for low mean pressure (P=0.01), central venous O2 (P=0.01), and lactate level (P=0.003). The mean arterial pressure was lower in the high PCO2 gap group, and the lactate level was higher, indicating global hypoperfusion. The hospital mortality rate for all patients was 24.5% (7/28). The in-hospital mortality rate was 20% (2/12) for the low gap group and 30% (5/16) for the high gap group; the odds ratio was 1.6 (95% CI 0.5–5.5; P=0.53). Patients with a persistent or rising PCO2 gap larger than 0.8 kPa at T = 6 and 12 hours had a higher mortality change (n = 6; in-hospital mortality was 21.4%) than patients with a PCO2 gap of less than 0.8 kPa at T = 6 (n = 1; in-hospital mortality was 3%); this odds ratio was 5.3 (95% CI 0.9–30.7; P=0.08). The PCO2 gap had no relation with the chest ultrasound pattern. Conclusion. The PCO2 gap is an important hemodynamic variable in the management of sepsis-induced circulatory failure. The PCO2 gap can be a marker of the adequacy of the cardiac output status in severe sepsis. A high PCO2 gap value (>0.8 kPa) can identify situations in which increasing CO can be attempted with fluid resuscitation in severe sepsis. The PCO2 gap carries an important prognostic value in severe sepsis.

Gliosis with hemorrhagic transformation is a late reported complication of stroke. Sometimes there is a big discrepancy between clinical and radiological diagnosis, and clinical decisions must be multi‐aspect decisions and not dependent on a single discrepant investigation result.

A case of ST elevation myocardial infarction reported post Coronavirus disease 2019 (COVID-19) vaccine. Probably premature to draw a link between COVID-19 vaccine and myocardial infarction.

Myocardial infarction is considered the most common cause of left ventricular pseudoaneurysm. Large missed pseudoaneurysm of the left ventricle incidentally diagnosed and treated conservatively.

Introduction Portal venous gas is a rare finding in adults and is typically associated with underlying intestinal ischemia. Portal venous gas can be detected by a bedside point of care ultrasound (POCUS) examination in adult patients in critical care units (CCU). Findings include echogenic bubbles flowing centrifugally throughout the portal venous system. Case presentation We present the case of a 73-year-old female with advanced ischemic cardiomyopathy and cardiorenal syndrome who was managed in the CCU. She developed vague abdominal pain and respiratory depression requiring intubation and dialysis during her course of treatment in the CCU. Her findings were consistent with portal venous gas upon POCUS, prompting computed tomography of her abdomen and surgical consultation. She was ultimately found to have nonobstructive mesenteric ischemia. Clinical discussion PVG is an ominous radiological sign and reflects intestinal ischemia in up to 72% of cases. Acute mesenteric ischemia of the small bowel could be due to occlusive or nonocclusive obstruction of the arterial blood supply or obstruction of venous outflow. Nonocclusive obstruction accounts for 5% to 15% of patients with acute mesenteric ischemia. Conclusion With the increasing use of POCUS, critical care physicians should be aware of findings consistent with portal venous gas as a bedside tool for directing the treating physician toward an ominous diagnosis in patients with shock., Highlights • Portal vein gas detected by point-of-care ultrasound in situations of unidentified shock indicates a high likelihood of underlying intestinal ischemia. • Point-of-care ultrasound plays an important role in detecting the sources of surgical emergencies. • Nonobstructive mesenteric ischemia can present with nonspecific symptoms in critically ill patients, leading to a delay in diagnosis.

In the last two decades, microbiology laboratories have radically changed by the introduction of novel technologies, like Next-Generation Sequencing (NGS) and Matrix-Assisted Laser Desorption/Ionization Time-of-Flight Mass Spectrometry (MALDI-TOF MS). Nevertheless, emergence of antibiotic-resistant microorganisms represents a global threat of current medicine, being responsible for increasing mortality and health-care direct and indirect costs. In addition, the identification of antibiotic-resistant microorganisms, like OXA-48 carbapenemase-producing Enterobacteriaceae, has been changeling for clinical microbiology laboratories. Even the cost of NGS technology and MALDI-TOF MS equipment is relatively high, both technologies are increasingly used in diagnostic and research protocols. Therefore, the aim of this review is to present applications of these technologies used in clinical microbiology, especially in detection of antibiotic resistance and its surveillance, and to propose a combinatory approach of MALDI-TOF MS and NGS for the investigation of microbial associated infections.

INTRODUCTION: Lung ultrasound (LUS) was used in COVID-19 pneumonia in case of identification, disease severity classification, and treatment allocation (1) For the severity of the disease, they mainly used the B lines as percentages in each field of the examined chest area (aeration score) (2) The correlation between the number of subpleural consolidation (SPC)and the severity of COVID-19 pneumonia was not studied METHODS: The study is an observational, prospective, single-center study conducted in the intensive care unit of Adan General Hospital, Kuwait, from May 1, 2020, to June 30, 2020 Patients were included if they were age >18 with suspicion of COVID-19 infection and had been transferred to the ICU with a suspected respiratory infection (3) Polymerase chain reaction (RT-PCR) had been performed;every patient admitted to ICU We performed lung ultrasonography for every patient admitted to the ICU using a 12-zone method (2) The signs of the high probability of COVID-19 pneumonia on lung ultrasound were documented (1) We calculated the aeration score and total number of SPCs in each area of the chest in 12 zones protocol and correlate it with PaO2/ FiO2 RESULTS: Of 109 patients with suspected COVID-19 pneumonia, 77 (71%) were confirmed The patients' median age was 53 (82-36) years, and 81 (73 7%) were men The clinical characteristics of the patients with confirmed COVID-19 pneumonia are shown in Table 1 The aeration score was significantly higher COVID-19 pneumonia (P0 018) and counting SPCs in each zone was significantly higher in COVID19 pneumonia (P>0 0001) There is an inverse relation between PO2/fiO2 and aeration score and SPC number The higher number of SPC, the lower the ratio (figure 1,2) The mean aeration score in COVID-19 pneumonia was 27 compared to the non-COVID group was 21 (P=0 018) The mean SPC score is 13 in COVID-19 pneumonia compared to non-COVID 1 (P

INTRODUCTION: Chest radiography (CXR) and computerized tomography (CT) are the standard methods for lung imaging in diagnosing COVID-19 pneumonia in the intensive care unit, despite their limitations This study aimed to assess the performance of bedside lung ultrasound examination by a critical care physician in the diagnosis of COVID-19 pneumonia in acute admission to the ICU METHODS: The study is an observational, prospective, single-center study conducted in the intensive care unit of Adan General Hospital from April 10, 2020,to May 26, 2020 The study included adults with suspicion of COVID-19 infection Patients were admitted to the ICU directly from the ED after performance of the reverse transcriptase-polymerase chain reaction (RT-PCR) at the central virology laboratory in Kuwait A certified intensivist in critical care ultrasound who was blinded to the result of the RT-PCR The four signs of COVID-19 pneumonia at lung ultrasound evaluation are (2): 1 Bilateral B-lines in both separate and coalescent forms, sometimes patchy, frequently giving the appearance of a shining white lung 2 Bilateral diffuse irregularities of the pleural line 3 Absence of significant pleural effusion 4 Presence of multiple subpleural consolidations of various sizes RESULTS: Of 77 patients with suspected COVID-19 pneumonia, 65 (84 4%) were confirmed The median age of the patients was 48 (68-31) years, and 51 (71%) were men The clinical characteristics of the patients in relation to confirmed COVID-19 pneumonia are shown in Table 1 In the group of patients with confirmed COVID-19 pneumonia (Table 2), LUS revealed the four signs suggestive of COVID-19 pneumonia in 63 (98 6%) (sensitivity 96 9%, CI 85%-99 5%) Two patients presented with unilateral lobar pneumonia without other ultrasonic signs of COVID-19 pneumonia but positive RT-PCR Of the patients in the group without COVID-19 pneumonia and negative RT-PCR, 10 (90%) were LUS negative for COVID-19 pneumonia (specificity 91 7%, 95% CI 58 72%-99 77%) CONCLUSIONS: LUS is sensitive and specific for diagnosing COVID-19 pneumonia in patients acutely admitted to ICU with respiratory involvement and is comparable to RT-PCR

This paper presents a kinematic enhanced plate model formulated within the Mindlin-Reissner theory. The main purpose of the model is to simulate the behavior of a structure up to membrane or bending failure. The shear strain is taken into account and the numerical shear locking problem is regularized by the Assumed Transverse Shear strain Field method. Two kinematic enhancements are applied at the level of the displacement fields by introducing two strong discontinuity fields. The first one is associated with the membrane displacement field and allows to describe the membrane failure and the second one is introduced in the rotation field to describe the bending failure. The Embedded Finite Element Method is used to incorporate the two kinematic discontinuities within a plate finite element, which allows to determine these new variables at the local level by the static condensation technique and to keep the architecture of the computational software unchanged. The kinematic and equilibrium operators associated with the enhancement variables are determined by fulfilling specific conditions. Case-studies are considered to asses the relevancy of the behavior of the enhanced membrane component as well as the behavior of the enhanced bending component. A mesh sensitivity analysis is also carried out. Finally, the Willam’s test is performed for both components to verify the numerical robustness of the model and to analyze the apparent anisotropy associated with the development of discontinuities within the element. The present results allow to demonstrate the robustness of the numerical framework reported in this paper.

Background and aims Chest radiography (CXR) and computerized tomography (CT) scan are the preferred methods for lung imaging in diagnosing pneumonia in the intensive care unit, in spite of their limitations. The aim of this study was to assess the performance of bedside lung ultrasound examination by a critical care physician, compared with CXR and chest CT, in the diagnosis of acute pneumonia in the ICU. Materials and Methods This was an observational, prospective, single‐center study conducted in the intensive care unit of Ahmadi General Hospital. Lung ultrasound examinations (LUSs) were performed by trained critical care physicians, and a chest radiograph was interpreted by another critical care physician blinded to the LUS results. CT scans were obtained when clinically indicated by the senior physician. Results Out of 92 patients with suspected pneumonia, 73 (79.3%) were confirmed to have a diagnosis of pneumonia based on radiological reports, clinical progress, inflammatory markers, and microbiology studies. Of the 73 patients, 31 (42.5%) were male, with a mean age of 68.3 years, and a range of 27 to 94 years. Eleven (15%) patients had community‐acquired pneumonia, and 62 (85%) had hospital‐acquired pneumonia. In the group of patients with confirmed pneumonia, 72 (98.6%) had LUSs positive for consolidation (sensitivity 98.6%, 95% CI 92.60%‐99.97%), and in the group without pneumonia, 16 (85%) had LUS negative for consolidation (specificity 84.2%, 95% CI 60.42%‐96.62%), compared with 40 (55%) with CXRs positive for consolidation (sensitivity 54.8%, 95% CI 42.70%‐66.48%) and 33 (45%) with CXRs negative for consolidation (specificity 63.16%, 95% CI 38.36%‐83.71%). A chest CT was performed in 38 of the 92 enrolled patients and was diagnostic for pneumonia in 32 cases. LUSs were positive in 31 of 32 patients with CT‐confirmed pneumonia (sensitivity 96%), and CXR was positive in 5 of 32 patients with CT‐confirmed pneumonia (sensitivity 15.6%). Conclusion Bedside lung ultrasound is a reliable and accurate tool that appears to be superior to CXR for diagnosing pneumonia in the ICU setting. LUS allows for a faster, non‐invasive, and radiation‐free method to diagnose pneumonia in the ICU.

Here we report an outbreak of extended spectrum β-lactamase-producing Klebsiella pneumoniae that occurred in a neonatal intensive care unit in Northern Italy and involved 97 patients. Progressively tightened sets of containment measures were implemented but the epidemic event was stopped only 9 months later. The final, effective, containment strategy consisted of the application of strict geographic cohorting of colonized infants and their nursing staff, the suspension of any new admission and a rigorous daily sterilization protocol for all surfaces and fomites in the ward. A posteriori characterization of the outbreak strain was performed using both traditional microbiology and molecular biology techniques, and whole genome sequencing, allowing to compare outbreak isolates with other strains collected in the previous two years. The results allowed to determine that the outbreak strain had been circulating inside the ward since the year before. Genomic characterization revealed that the strain carried a wide array of virulence and antibiotic resistance determinants, including gene bla(TEM-206), which had never been reported in a clinical isolate of K. pneumoniae before. The presence of such a high number of determinants for antibiotic resistance imposes significant therapeutic limitations on the treatment of infections, thus, further epidemiological investigations are needed to evaluate the prevalence of the newly described variant.

International audience; Various formulations of displacement-based Timoshenko multi-fiber beams are compared in this article. After a short literature review, the presentation of the shape functions leading to the stiffness matrices and the consistent nodal forces relative to each formulation are presented and their performances are studied using elastic or elastic perfectly plastic constitutive laws and simple to complex static loadings. The advantages and disadvantages of each formulation are highlighted and general conclusions are drawn on the use of displacement-based Timoshenko multi-fiber beams in engineering. An innovative solution is finally proposed to improve the performance for the case of axial-bending interactions.

Chronic hepatitis C virus infection is attributed as a cause of circulating mixed cryoglobulinemia and immune mediated extrahepatic complications. Massive pulmonary haemorrhages with chronic hepatitis C has been scarcely reported; and has been associated with renal failure and cryoglobulinemia. The most commonly used treatment modalities include the use of cyclophosphamide, prednisolone, and plasmapheresis, with conflicting views regarding alternative treatments in resistant cases. Rituximab is an option in resistant cases due to its potent immunosuppressive effects on B cells. We describe a case of hepatitis C– associated mixed cryoglobulinemia and pulmonary hemorrhage resistant to standard treatment. Rituximab led to hepatitis C virus reactivation and fulminant hepatitis.

International audience; A novel multi-fiber beam finite element formulation based on the Timoshenko model is proposed in this paper to simulate failure of reinforced concrete structural elements subjected to static monotonic loadings. The beam section can have an arbitrary shape and each fiber has a local constitutive law representing a specific material. The embedded discontinuity concept is adopted to enrich the displacement field of the fibers in order to describe the opening of cracks and the development of plastic hinges. The material behavior at the discontinuity is characterized by a cohesive law linking the axial stress and the displacement jump by a linear relation, which allows capturing the released fracture energy. The variational formulation is presented in the context of the incompatible modes method. Moreover, the additional modes are statically condensed at the element level. The corresponding computational procedure is detailed in the paper. Several numerical applications and general remarks are finally provided to illustrate the performance of the proposed element.

Epigastric pain is a manifestation of several medical and surgical conditions. However, when persistent epigastric pain is associated with microscopic or frank haematuria and elevated lactate dehydrogenase (LDH), especially in patients with increased risk of thromboembolic events, acute renal infarction (ARI) should be considered. We report the case of a 77-year-old male patient who presented with sudden persistent epigastric pain and elevated LDH who was found to have atrial fibrillation. The patient was diagnosed with ARI. ARI is not usually a typical differential diagnosis in patients with persistent epigastric pain and elevated LDH in whom the risk of thromboembolic events is high. Thus, physicians should perform a contrast-enhanced CT scan as early as possible to rule out or confirm renal infarction.

Aims The polymicrobial nature of diabetic foot infection has been well documented in the literature. Patients with diabetic foot infection not exposed to antibiotics are not well studied before. The relative frequency of bacterial isolates cultured from community-acquired foot infections that are not exposed to antimicrobial agents for 30 days is studied. In addition, the bacterial comparative in vitro susceptibility to the commonly used antibacterial agents is assessed. Methods This is a prospective study in which the infected wounds of 86 consecutive diabetic patients seen in the diabetic foot clinic in Adan Teaching Hospital were cultured when visiting the clinic. The patients did not receive antimicrobial therapy 30 days prior to taking the cultures. The specimen was cultured using aerobic and anaerobic microbiological techniques. Isolates were tested for susceptibility to commonly used antimicrobial therapy. Result Staphylococcus aureus was the most common isolate, being recovered from 38.4% of cases. Other organisms were Pseudomonas aeruginosa (17.5%) and Proteus mirabilis (18%), anaerobic gram-negative organisms (10.5%), mainly Bacteroides fragilis . Imipenem, meropenem, and cefepime were the most effective agents against gram-negative organisms. Vancomycin was the most effective against gram-positive organisms. Conclusion S. aureus and P. aeruginosa were the most common causes of diabetic foot infections. Anaerobic organisms are still a common cause for infection, although the prevalence is less. These wounds may require use of combined antimicrobial therapy for initial management.

Both non-Hodgkin’s lymphoma (NHL) in pregnancy and acute spontaneous tumor-lysis (ASTL) syndrome are rare. Here we present a 32-year-old Egyptian woman in the 27th week of pregnancy, who was admitted with epistaxis, lethargy, vomiting and dehydration. This patient developed ASTL syndrome secondary to undiagnosed NHL, but was not on any medication associated with the syndrome.At 28 weeks, she gave birth to a healthy baby who, unfortunately, died within a few days. To our knowledge, this is the first case of ASTL syndrome in a pregnant woman. nt|mis]This case was studied and reviewed at the Medical Department of Adan Hospital, Fahahil, Kuwait.

A hypocalcaemia case is presented with convulsions, electrocardiogram (ECG) changes and laboratory findings suggestive of osteomalacia. This case constitutes a rare presentation of osteomalacia-induced hypocalcaemia.

Acute myocarditis may mimic myocardial infarction because the affected patients report ‘classical’ chest pain; the ECG changes and echocardiography are identical to those observed in acute coronary syndromes, and serum markers are increased. We describe a case with ST segment elevation on admission ECG, and coronary angiography was normal. Cardiac magnetic resonance with myocardial delayed enhancement sequences is a non-invasive alternative for diagnosing myocarditis.

A lung ultrasound (US) can be routinely performed at the bedside by a trained intensive care unit physician and may provide accurate information about a lung's status that has diagnostic and therapeutic relevance. Oesophageal perforations are rare, and due to the rarity of this type of perforation and its non-specific presentation, the diagnosis and treatment are delayed, leading to a high mortality rate. We present a 70-year-old woman with a postoesophagoscopy perforated oesophagus. Lung US detected pneumothorax and mild pleural effusion that were not present on the postoperative chest X-ray. The early detection of the perforation led to a good outcome.

Background Echocardiography and the N-terminal pro-brain-type natriuretic peptide (NT-proBNP) level are important tests for assessing left ventricular function in patients presenting to the emergency department with acute dyspnea. Chest ultrasound is becoming an important tool in diagnosing acute pulmonary edema. Aim To assess the diagnostic accuracy of chest ultrasound examination using echocardiography and a curvilinear probe for detecting B-lines in patients presenting with acute pulmonary edema compared with assessment using NT-proBNP. Methods This paper reports a prospective observational study of 61 consecutive patients presenting with symptoms and signs of pulmonary edema and B-profile detected by echocardiography with a 5 MHz curvilinear probe. The emergency department physicians ordered NT-proBNP levels, and critical care physicians trained in ultrasound examination performed echocardiography and chest ultrasounds. The findings of the chest ultrasound were reviewed by another senior physician. Results Sixty-one participants were enrolled over a period of 6 months (49.2 % male, with a mean age 66.8). Forty-seven of the 61 patients had a B-profile. The median NT-proBNP level in the patients with B-profile was 6200, compared with the mean level in the patients with an A-profile of 180 (CI 0.33–0.82). The distributions in the two groups differed significantly (p = 0.034). Based on a threshold level of NT-proBNP in relation to age, the sensitivity and specificity (including the 95 % confidence interval) were determined; the sensitivity of finding B-profile on ultrasound was 92.0 %, and the specificity was 91.0 %. The positive predictive value of the B-profile was 97.0 %, and the negative predictive value was 71.0 %. The systolic function in the subjects with a B-profile was below 50 in 84.3 % of the subjects and normal in 15.7 % of the subjects. An A-profile was present in all of the subjects with systolic function >55 %. In the subjects with a B-profile, 94 % had a Framingham score of CHF >4; the subjects with all A-profile had scores 3 in 96 % of the subjects with a B-profile, and all of the subjects with an A-profile had scores