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Despite the legislation targets set by several governments of a full electrification of new light-duty vehicle fleets by 2035, the development of innovative, environmental-friendly Internal Combustion Engines (ICEs) is still crucial to be on track toward the complete decarbonization of on road-mobility of the future. In such a framework, the PHOENICE (PHev towards zerO EmissioNs & ultimate ICE efficiency) project aims at developing a C SUV-class plug-in hybrid (P0/P4) vehicle demonstrator capable to achieve a -10% fuel consumption reduction with respect to current EU6 vehicle while complying with upcoming EU7 pollutant emissions limits.Such ambitious targets will require the optimization of the whole engine system, exploiting the possible synergies among the combustion, the aftertreatment and the exhaust waste heat recovery systems. Focusing on the first aspect, the combined use of innovative in-cylinder charge motion, Miller cycle with high compression ratio, lean mixture with cooled EGR and electrified turbocharger will enable a highly diluted combustion process capable to achieve a peak indicated efficiency of 47% and, at the same time, to minimize the engine out emissions. Numerical simulations were intensively exploited to reduce the engine calibration time and to preliminary assess the benefits of the abovementioned technologies. In particular, 3D-CFD simulations highlighted the capabilities of the SwumbleTM intake ports to produce an increase of about 50% of the Turbulent Kinetic Energy (TKE), while 1D-CFD models showed possible further enhancements of the brake thermal efficiency through the use of the new turbocharger (+2%) and of an aggressive Millerization of the cycle (+1.1%).Finally, a preliminary experimental campaign, performed on the first engine prototype, confirmed the encouraging results of the simulation activity. With an AFR = 1.43 and an EGR ratio close to 5%, the PHOENICE engine showed a further improvement in the BTE up to 4% and a simultaneous reduction of the NOx emissions of more than 70% in comparison with conventional stoichiometric, undiluted operation.

The paper deals with the reduction of pollutant emissions in urban areas by considering a Zero-Emission Zone (ZEZ) in which hybrid electric vehicles (HEVs) are allowed to be driven without using the internal combustion engine, as several cities have planned to realize in the next decades. Moreover, since vehicle connectivity has spread more and more in the last years, a vehicle-to-network (V2N) communication system has been taken into account to retrieve real-time navigation data from a map service provider and thus reconstructing the so-called electronic horizon, which is a reconstruction of the future conditions of the vehicle on the road ahead. The speed profile and the road slope are used as input for an on-board predictive control strategy of a plug-in HEV (PHEV). In particular, a dedicated algorithm predicts the amount of necessary energy to complete the city event in full-electric mode, giving a state of charge (SoC) target value. With this aim, an adaptive equivalent consumption minimization strategy (A-ECMS) has been modified to use navigation data for approaching the ZEZ with the target SoC. The paper finally quantifies the benefits of such an approach in terms of CO2 emissions by comparing it with a heuristic, rule-based one, which represents the standard OEM solution.

COVID-19 has high mortality rate mainly stemming from acute respiratory distress leading to respiratory failure (ARF). Aim of the study was to evaluate the management of severe ARF due to COVID-19 pneumonia using noninvasive ventilatory support (NIVS), studying safety and effectiveness of NIVS.This is a retrospective, multicenter study. Primary outcomes were NIVS failure with intubation rate and hospital mortality. Secondary outcomes were hospital stay and factors related to NIVS failure and mortality. These outcomes were compared with patients intubated and admitted to ICU.One hundred sixty-two patients were hospitalized because of severe respiratory failure (PaOinf2/inf/FiOinf2/infratio250). One hundred thirty-eight patients were admitted to Respiratory Intermediate Care Unit (RICU) for a NIVS trial. One hundred patients were treated successfully with NIVS (74.5%); 38 failed NIVS trial (27.5%). In-hospital mortality was 23.18% in RICU group and 30.55% in ICU group. Patients with NIVS failure were older, had a lower number of lymphocytes, a higher IL-6, lower PaOinf2/inf, PaC Oinf2/inf, PaOinf2/inf/FiOinf2/infratio, higher respiratory rate (RR) and heart rate at admission and lower PaO2, and PaOinf2/inf/FiOinf2/infratio and higher RR after 1-6 hours. Multivariate analysis identified higher age, C-reactive protein as well as RR after 1-6 hours and PaOinf2/inf/FiOinf2/infratio after 1-6 hours as an independent predictor mortality.NIVS is a safe and effective strategy in the treatment of severe ARF due to COVID-19 related pneumonia, that reduces mortality and length of hospital stay in the carefully selected patients.

Polymicrobial pneumonia may be caused by the combination of respiratory viruses, bacteria and fungi in a host. Colonization by Streptococcus pneumoniae was associated with increased risk of Intensive Care Unit admission or death in the setting of influenza infection, whereas the colonization by methicillin sensible Staphylococcus aureus co-infection was associated with severe disease and death in adults and children. The principal association of pathogens in community-acquired pneumonia (CAP) is bacteria and viral co-infection, and accounts approximately for 39% of microbiological diagnosed cases of CAP. The differential clinical diagnosis between a viral and a bacterial CAP is not easy: no clinical signs or radiological findings help the clinician to suspect to the diagnosis. Patients with polymicrobial infections are more likely to have underlying medical conditions and have more severe outcome. Severe respiratory failure and need of mechanical ventilation occur in several cases. Non invasive ventilation (NIV) use aims to avoid invasive mechanical ventilation. NIV treatment is controversial owing to high reported treatment failure. In this case series we report three cases of severe polymicrobial CAP: all of them required NIV with a good outcome.

In the past, anaerobes were the most common cause of community-acquired lung abscess; Streptococcus species were the second most common cause. In recent years, this has changed. Klebsiella pneumoniae is now most common cause of community- acquired lung abscess, although Streptococcus species remain pathogen of major importance. We present two cases of pulmonary cavitation due to Streptococcus pneumoniae which resembled pulmonary tuberculosis with regards to their history and radiological findings. These are examples of a common diagnosis presenting in an uncommon way. Our cases had some peculiarities: they had a clinical picture strongly suggestive of pulmonary tuberculosis or lung cancer rather than necrotizing infectious pneumonia in patients with no comorbidities or underlying diseases (including oral or dental pathologies). Radiological findings did not help the clinicians: pulmonary tuberculosis was the first diagnostic hypothesis in both cases. An underlying lung cancer was excluded in the first case only after invasive pulmonary procedures.

OBJECTIVE: Thoracentesis is one of the bedside procedures most commonly associated with iatrogenic complications, particularly pneumothorax. Various risk factors for complications associated with thoracentesis have recently been identified, including an inexperienced operator; an inadequate or inexperienced support team; the lack of a standardized protocol; and the lack of ultrasound guidance. We sought to determine whether ultrasound-guided thoracentesis can reduce the risk of pneumothorax and improve outcomes (fewer procedures without fluid removal and greater volumes of fluid removed during the procedures). In our comparison of thoracentesis with and without ultrasound guidance, all procedures were performed by a team of expert pulmonologists, using the same standardized protocol in both conditions. METHODS: A total of 160 participants were randomly allocated to undergo thoracentesis with or without ultrasound guidance (n = 80 per group). The primary outcome was pneumothorax following thoracentesis. Secondary outcomes included the number of procedures without fluid removal and the volume of fluid drained during the procedure. RESULTS: Pneumothorax occurred in 1 of the 80 patients who underwent ultrasound-guided thoracentesis and in 10 of the 80 patients who underwent thoracentesis without ultrasound guidance, the difference being statistically significant (p = 0.009). Fluid was removed in 79 of the 80 procedures performed with ultrasound guidance and in 72 of the 80 procedures performed without it. The mean volume of fluid drained was larger during the former than during the latter (960 ± 500 mL vs. 770 ± 480 mL), the difference being statistically significant (p = 0.03). CONCLUSIONS: Ultrasound guidance increases the yield of thoracentesis and reduces the risk of post-procedure pneumothorax. (Chinese Clinical Trial Registry identifier: ChiCTR-TRC-12002174 [http://www.chictr.org/en/])

Ovarian hyperstimulation syndrome is a serious and potentially life-threatening physiological complication that may be encountered in patients who undergo controlled ovarian hyperstimulation cycles. The syndrome is typically associated with regimes of exogenous gonadotropins, but it can be seen, albeit rarely, when clomiphene is administered during the induction phase. Although this syndrome is widely described in scientific literature and is well known by obstetricians, the knowledge of this pathological and potentially life-threatening condition is generally less than satisfactory among physicians. The dramatic increase in therapeutic strategies to treat infertility has pushed this condition into the realm of acute care therapy. The potential complications of this syndrome, including pulmonary involvement, should be considered and identified so as to allow a more appropriate diagnosis and management. We describe a case of a woman with an extremely severe (Stage 6) ovarian hyperstimulation syndrome who presented ascites, bilateral pleural effusion and severe respiratory failure treated with non-invasive ventilation. The patient was admitted to the intensive care unit because of severe respiratory failure, ascites, and bilateral pleural effusion due to ovarian hyperstimulation syndrome. Treatment included non-invasive ventilation and three thoracentesis procedures, plus the administration of albumin, colloid solutions and high-dose furosemid. Severe form of ovarian hyperstimulation syndrome is observed in 0.5-5% of the women treated, and intensive care may be required for management of thromboembolic complications, renal failure and severe respiratory failure. Pulmonary intensive care may involve thoracentesis, oxygen supplementation and, in more severe cases, assisted ventilation. To our knowledge, there have been only two studies in English language medical literature that describe severe respiratory failure treated with non-invasive ventilation.

Anti-tuberculosis drugs seldom cause serious haematological side effects. However, among these drugs, isoniazid and rifampicin, especially when administered intermittently, may very rarely be linked to acute autoimmune haemolytic anaemia. Ethambutol (EMB) can cause dose-related retrobulbar neuritis. In this paper, we present the first reported case of acute fatal autoimmune haemolytic anaemia due to EMB.

Different optimization strategies for the optimization of the calibration of a turbocharged GDI engine through numerical simulation were analyzed, aiming to evaluate the opportunities offered by direct optimization techniques. A one-dimensional fluid dynamic engine model was used to predict engine performance, taking into account knock and exhaust temperature constraints. Air fuel ratio, spark advance, boost pressure and cam phasing were optimized by means of different optimization strategies, including direct search as well as numerical methods. Both full load (with maximum bmep targets) and part load (with minimum bsfc targets) were considered. The potential for remarkable improvements (up to 10% bmep increase at full load and 8 g/kWh bsfc decrease at part load) in comparison with the baseline engine calibration was highlighted, and a ranking between different optimization methods was obtained, based on the requested computational efforts and on their capabilities to handle constrained optimization problems

The ovarian hyperstimulation syndrome (OHSS) is a serious but rarely fatal complication of medical interventions that seek to induce fertility; it is typically encountered in women who undergo controlled ovarian hyperstimulation, but there are very rare patients who have genetic defects who present with OHSS. In recent years, its pathogenesis has been elucidated; this knowledge will decrease the frequency of this syndrome. Clinical signs may include any or all of the following: rapid weight gain, ascites, oliguria, hemoconcentration, leukocytosis, along with intravascular hypovolemia, hyponatremia, and hyperkalemia. If the patient is not diagnosed early, ascites, pleural and more rarely pericardial effusions, severe respiratory failure and ARDS, hypercoagulability with tromboembolism and multiple organ system failure can occur. Due to the increased use of therapeutic strategies for infertility (particularly those using human chorionic gonadotropin), the systemic, particularly the pulmonary, complications of this syndrome must be identified early to allow appropriate diagnosis and management. We describe two cases of women with extremely severe OHSS presenting bilateral pleural effusions, and severe respiratory failure (paO2/FiO2200) treated with non-invasive ventilation (NIV). The severe form of OHSS varies between 0.5% and 5%, depending on the population studied: intensive care may be required for management of tromboembolic complications, renal failure and severe respiratory failure. The diagnosis of severe OHSS was made, largely based on bedside ultrasonography showing increased ovarian size, mild ascites and bilateral pleural effusions. Owing to severe respiratory failure the patients were admitted to Respiratory Intermediate Care. Pulmonary intensive care may involve thoracentesis, oxygen supplementation and in more severe cases assisted ventilation. There are only a few studies in English that describe severe respiratory failure treated with non-invasive ventilation, but all of them have had good outcomes.

Summary Aims We prospectively enrolled 207 patients (121 were 75 or older and 86 younger than 75) who were admitted to three Respiratory Monitoring Units. The primary outcomes were intubation and mortality rates; the secondary outcomes were changes in arterial blood gases analysis, non-invasive ventilation (NIV) duration and length of hospital stay. Results Hospital mortality was similar in the two groups, as were intubation rates. The proportion who died in the very old patient group was 19.8% (24/121) vs. 10.4% (9/86) in the younger group. Intubation rate was 10.7% (13/121) in the very old patient group and 11.6% (10/86) in the younger group. The presence of comorbidities, the severity of illness (SAPS II), the level of consciousness, NIV failure (intubation), absolute value of pH prior to NIV, as well as the changes in pH and paCO2 and PaO2/FiO2 after 2 h of NIV, were the variables associated with higher mortality. Very old patients had significantly higher NIV duration than younger patients (69.0 ± 47.0 vs. 57.0 ± 27.0 h) (p ≤ 0.03) and hospital stays (11.6 ± 3.8 vs. 8.4 ± 1.4) (p ≤ 0.02). Conclusions The use of NIV in very old patients was effective in many cases. Endotracheal intubation after NIV failure was not efficacious in either group.