Aggressive Afterload Lowering to Improve the Right Ventricle: A New Target for Medical Therapy in Pulmonary Arterial Hypertension?

Despite numerous therapeutic advances in pulmonary arterial hypertension, patients continue to suffer high morbidity and mortality, particularly considering a median age of 50 years. This article explores whether early, robust reduction of right ventricular afterload would facilitate substantial improvement in right ventricular function and thus whether afterload reduction should be a treatment goal for pulmonary arterial hypertension. The earliest clinical studies of prostanoid treatment in pulmonary arterial hypertension demonstrated an important link between lowering mean pulmonary arterial pressure (or pulmonary vascular resistance) and improved survival. Subsequent studies of oral monotherapy or sequential combination therapy demonstrated smaller reductions in mean pulmonary arterial pressure and pulmonary vascular resistance. More recently, retrospective reports of initial aggressive prostanoid treatment or initial combination oral and parenteral therapy have shown marked afterload reduction along with significant improvements in right ventricular function. Some data suggest that reaching threshold levels for pressure or resistance (components of right ventricular afterload) may be key to interrupting the self-perpetuating injury of pulmonary vascular disease in pulmonary arterial hypertension and could translate into improved long-term clinical outcomes. Based on these clues, the authors postulate that improved clinical outcomes might be achieved by targeting significant afterload reduction with initial oral combination therapy and early parenteral prostanoids.

Carbon Quantum Dots Based on Marine Polysaccharides: Types, Synthesis, and Applications.

The marine environment offers a vast array of resources, including plants, animals, and microorganisms, that can be utilized to extract polysaccharides such as alginate, carrageenan, chitin, chitosan, agarose, ulvan, porphyra, and many more. These polysaccharides found in marine environments can serve as carbon-rich precursors for synthesizing carbon quantum dots (CQDs). Marine polysaccharides have a distinct advantage over other CQD precursors because they contain multiple heteroatoms, including nitrogen (N), sulfur (S), and oxygen (O). The surface of CQDs can be naturally doped, reducing the need for excessive use of chemical reagents and promoting green methods. The present review highlights the processing methods used to synthesize CQDs from marine polysaccharide precursors. These can be classified according to their biological origin as being derived from algae, crustaceans, or fish. CQDs can be synthesized to exhibit exceptional optical properties, including high fluorescence emission, absorbance, quenching, and quantum yield. CQDs' structural, morphological, and optical properties can be adjusted by utilizing multi-heteroatom precursors. Moreover, owing to their biocompatibility and low toxicity, CQDs obtained from marine polysaccharides have potential applications in various fields, including biomedicine (e.g., drug delivery, bioimaging, and biosensing), photocatalysis, water quality monitoring, and the food industry. Using marine polysaccharides to produce carbon quantum dots (CQDs) enables the transformation of renewable sources into a cutting-edge technological product. This review can provide fundamental insights for the development of novel nanomaterials derived from natural marine sources.

Assistance Robotics and Sensors.

In recent years, the exploitation of assistive robotics has experienced significant growth, mostly based on the development of sensor and processing technologies with the increasing interest in improving the interactions between robots and humans and making them more natural [...].

An Unmanned Surface Vehicle (USV): Development of an Autonomous Boat with a Sensor Integration System for Bathymetric Surveys.

A reliable yet economical unmanned surface vehicle (USV) has been developed for the bathymetric surveying of lakes. The system combines an autonomous navigation framework, environmental sensors, and a multibeam echosounder to collect submerged topography, temperature, and wind speed and monitor the vehicle's status during prescribed path-planning missions. The main objective of this research is to provide a methodological framework to build an autonomous boat with independent decision-making, efficient control, and long-range navigation capabilities. Integration of sensors with navigation control enabled the automatization of position, orientation, and velocity. A solar power integration was also tested to control the duration of the autonomous missions. The results of the solar power compared favorably with those of the standard LiPO battery system. Extended and autonomous missions were achieved with the developed platform, which can also evaluate the danger level, weather circumstances, and energy consumption through real-time data analysis. With all the incorporated sensors and controls, this USV can make self-governing decisions and improve its safety. A technical evaluation of the proposed vehicle was conducted as a measurable metric of the reliability and robustness of the prototype. Overall, a reliable, economic, and self-powered autonomous system has been designed and built to retrieve bathymetric surveys as a first step to developing intelligent reconnaissance systems that combine field robotics with machine learning to make decisions and adapt to unknown environments.

Building a Multidisciplinary Care Pathway Supported by a Surgical Approach to Local Bone Formation.

Osteoporosis is the most common disease of bone mineral metabolism. In Spain, it affects approximately 3 million people, of whom 80% are females and 20% are males. Despite the advances that have been made in this field, we continue to witness alarming levels of fragility hip fractures. In 2010, the cost of osteoporosis in the European Union was estimated to be 37,000 million euros, which included the costs for the treatment of incident fractures (66%), pharmacological prevention (5%), and long-term fracture care (29%). A multidisciplinary care pathway supported by a surgical approach to local bone formation is needed. Recently, the International Osteoporosis Foundation (IOF) and the European Society for Clinical and Economic Aspects of Osteoporosis (ESCEO) included in their treatment guidelines a local osteo-enhancement procedure (LOEP) as a treatment option. In the Ossure™ LOEP technique (AgNovos Healthcare USA, LLC, Rockville, MD), a calcium-based triphasic osteoconductive implant material (AGN1), which has been shown to increase bone mineral density (BMD) and proximal femoral strength, is introduced percutaneously in the femoral neck and intertrochanteric region. Basically, the procedure consists of three percutaneous steps: prepare, clean, and fill the cavity with AGN1. It can be carried out with sedation and local anaesthesia or spinal anaesthesia. This report presents a clinical case and discusses how to select patients who could potentially benefit from this technique.

Lignocellulosic Biomass for the Fabrication of Triboelectric Nano-Generators (TENGs)-A Review.

Growth in population and increased environmental awareness demand the emergence of new energy sources with low environmental impact. Lignocellulosic biomass is mainly composed of cellulose, lignin, and hemicellulose. These materials have been used in the energy industry for the production of biofuels as an eco-friendly alternative to fossil fuels. However, their use in the fabrication of small electronic devices is still under development. Lignocellulose-based triboelectric nanogenerators (LC-TENGs) have emerged as an eco-friendly alternative to conventional batteries, which are mainly composed of harmful and non-degradable materials. These LC-TENGs use lignocellulose-based components, which serve as electrodes or triboelectric active materials. These materials can be derived from bulk materials such as wood, seeds, or leaves, or they can be derived from waste materials from the timber industry, agriculture, or recycled urban materials. LC-TENG devices represent an eco-friendly, low-cost, and effective mechanism for harvesting environmental mechanical energy to generate electricity, enabling the development of self-powered devices and sensors. In this study, a comprehensive review of lignocellulosic-based materials was conducted to highlight their use as both electrodes and triboelectric active surfaces in the development of novel eco-friendly triboelectric nano-generators (LC-TENGs). The composition of lignocellulose and the classification and applications of LC-TENGs are discussed.

Exploring the Non-Covalent Bonding in Water Clusters.

QTAIM and source function analysis were used to explore the non-covalent bonding in twelve different water clusters (H2O)n obtained by considering n = 2-7 and various geometrical arrangements. A total of seventy-seven O-H⋯O hydrogen bonds (HBs) were identified in the systems under consideration, and the examination of the electron density at the bond critical point (BCP) of these HBs revealed the existence of a great diversity of O-H⋯O interactions. Furthermore, the analysis of quantities, such as |V(r)|/G(r) and H(r), allowed a further description of the nature of analogous O-H⋯O interactions within each cluster. In the case of 2-D cyclic clusters, the HBs are nearly equivalent between them. However, significant differences among the O-H⋯O interactions were observed in 3-D clusters. The assessment of the source function (SF) confirmed these findings. Finally, the ability of SF to decompose the electron density (ρ) into atomic contributions allowed the evaluation of the localized or delocalized character of these contributions to ρ at the BCP associated to the different HBs, revealing that weak O-H⋯O interactions have a significant spread of the atomic contributions, whereas strong interactions have more localized atomic contributions. These observations suggest that the nature of the O-H⋯O hydrogen bond in water clusters is determined by the inductive effects originated by the different spatial arrangements of the water molecules in the studied clusters.

Per- and polyfluoroalkyl substances (PFASs) in consumable species and food products.

Per- and polyfluoroalkyl substances (PFASs) are a group of thousands of manmade chemicals widely used in consumer products and industrial processes. Toxicological studies have suggested that exposure to PFASs may lead to several adverse effects, including infertility and cancer development. In light of their widespread use, the contamination of food products has created health concerns in sites directly influenced by industrial and anthropogenic activity. In the present contribution, the current knowledge of PFAS contamination was systematically reviewed in order to provide with the knowledge gaps and main sources of contamination, as well as critically evaluate estimated dietary intake and relative risk values of the consulted studies. Legacy PFASs remain the most abundant despite their production restrictions. Edible species from freshwater bodies exhibit higher PFAS concentrations than marine species, probably due to low hydrodynamics and dilution in lentic ecosystems. Studies in food products from multiple sources, including aquatic, livestock, and agricultural, agree that the proximity to factories and fluorochemical industries rendered significantly higher and potentially hazardous PFAS contamination. Short-chain PFAS are suggested as chemicals of emerging concern to food security. However, the environmental and toxicological implications of short-chain congeners are not fully understood and, thus, much research is needed in this sense.

Diaphragmatic plication among lung transplant patients: A single-center experience.

BACKGROUND: There is lack of data reporting outcomes among patients needing diaphragmatic plication (DP) during or after lung transplantation (LT). We sought to assess the association of DP with post-transplant spirometry among other outcomes. METHODS: We included all patients who underwent LT between 2012 and 2016 (n = 324, mean age 56.3±13.4 years; M:F 198:126). We compared early and late outcomes based on the need for DP. RESULTS: The frequency of diaphragmatic dysfunction (DD) on pre-transplant fluoroscopy was 52.2%. A total of 38 DP procedures were performed among 37 patients (11.4% of LT patients). DP was done for anatomic (sizing or spacing issues) or functional indications (symptomatic DD). While patients with DP had significantly lower spirometry throughout the 3-year follow-up period, their slope of decline, functional assessments at the first annual visit, the risk of CLAD, and mortality were similar to patients without DP. A sub-group analysis limited to patients with restrictive lung diseases as the transplant indication had similar findings. CONCLUSIONS: Pre-transplant DD is common among LT candidates although it did not predict the need for DP. DP may be performed for functional or anatomic indications especially for addressing the donor-recipient size mismatch. Despite the lack of favorable effect on post-transplant spirometry, patients undergoing DP have acceptable and comparable early and late outcomes.

Predictors and outcomes of respiratory failure among lung transplant patients with COVID-19.

BACKGROUND: There is limited data on the predictors and outcomes of new or worsening respiratory failure among lung transplant (LT) patients with Coronavirus disease 2019 (COVID-19). METHODS: We included all the LT patients diagnosed with COVID-19 during a 1-year period (March 2020 to February 2021; n = 54; median age: 60, 20-73 years; M:F 37:17). Development of new or worsening respiratory failure (ARF) was the primary outcome variable. RESULTS: The overall incidence of ARF was 48.1% (n = 26). More than 20% of patients (n = 11) needed intubation and mechanical ventilation. Body mass index > 25 Kg/m2 (adjusted OR: 5.7, .99-32.93; P = .05) and peak D-dimer levels > .95 mcg/ml (adjusted OR: 24.99, 1.77-353.8; P = .017) were independently associated with ARF while anticoagulation use prior to COVID-19 was protective (adjusted OR: .024, .001-.55; P = .02). Majority patients survived the acute illness (85.2%). Pre-infection chronic lung allograft dysfunction (CLAD) was an independent predictor of mortality (adjusted HR: 5.03, 1.14-22.25; P = .033). CONCLUSIONS: COVID-19 is associated with significant morbidity and mortality among LT patients. Patients on chronic anticoagulation seem to enjoy favorable outcomes, while higher BMI and peak D-dimer levels are associated with development of ARF. Pre-infection CLAD is associated with an increased risk of death from COVID-19.

Characteristics and outcomes among vaccinated lung transplant patients with breakthrough COVID-19.

BACKGROUND: Despite multiple studies evaluating the immunological responsiveness to vaccines, the clinical effectiveness of the two-dose mRNA vaccine schedule among lung transplant (LT) patients has not been evaluated. METHODS: We included LT patients who tested positive for SARS-CoV-2 on a nasopharyngeal swab between March 1, 2020, and August 25, 2021 (n = 70). The study group was divided based on their vaccination status. RESULTS: During the study period, 14 fully vaccinated LT patients with one of the mRNA vaccines tested positive for COVID-19 (median age 54, range 30-62 years, M:F 9:5). The vaccinated cohort was younger with bilateral LT, have suppurative conditions as the transplant indication, and present with milder symptoms. However, pulmonary parenchymal involvement was seen among all 12 patients where computed tomography (CT) of chest was available. The laboratory profile indicated a more subdued inflammatory response among the vaccinated group. A lower proportion of vaccinated patients developed respiratory failure, needed ICU admission or ventilator support, although none of the differences achieved statistical significance. None of the vaccinated patients succumbed to COVID-19 during the study period, while the 4-week mortality among unvaccinated patients was nearly 15% (8/56). CONCLUSIONS: In this cohort of vaccinated LT patients who developed breakthrough COVID-19, the clinical course, risk of complications, and outcomes trended better than unvaccinated patients. However, universal involvement of the allograft demonstrates the continued vulnerability of these patients to significant sequelae from COVID-19. Future studies may evaluate the incremental protection of vaccination after the completion of the third dose of mRNA vaccines among LT patients.

Safety and Efficacy of B-Cell Depletion with Rituximab for the Treatment of Systemic Sclerosis-associated Pulmonary Arterial Hypertension: A Multicenter, Double-Blind, Randomized, Placebo-controlled Trial.

Rationale: Systemic sclerosis (SSc)-pulmonary arterial hypertension (PAH) is one of the most prevalent and deadly forms of PAH. B cells may contribute to SSc pathogenesis. Objectives: We investigated the safety and efficacy of B-cell depletion for SSc-PAH. Methods: In an NIH-sponsored, multicenter, double-blinded, randomized, placebo-controlled, proof-of-concept trial, 57 patients with SSc-PAH on stable-dose standard medical therapy received two infusions of 1,000 mg rituximab or placebo administered 2 weeks apart. The primary outcome measure was the change in 6-minute-walk distance (6MWD) at 24 weeks. Secondary endpoints included safety and invasive hemodynamics. We applied a machine learning approach to predict drug responsiveness. Measurements and Main Results: We randomized 57 subjects from 2010 to 2018. In the primary analysis, using data through Week 24, the adjusted mean change in 6MWD at 24 weeks favored the treatment arm but did not reach statistical significance (23.6 ± 11.1 m vs. 0.5 ± 9.7 m; P = 0.12). Although a negative study, when data through Week 48 were also considered, the estimated change in 6MWD at Week 24 was 25.5 ± 8.8 m for rituximab and 0.4 ± 7.4 m for placebo (P = 0.03). Rituximab treatment appeared to be safe and well tolerated. Low levels of RF (rheumatoid factor), IL-12, and IL-17 were sensitive and specific as favorable predictors of a rituximab response as measured by an improved 6MWD (receiver operating characteristic area under the curve, 0.88-0.95). Conclusions: B-cell depletion therapy is a potentially effective and safe adjuvant treatment for SSc-PAH. Future studies in these patients can confirm whether the identified biomarkers predict rituximab responsiveness. Clinical trial registered with www.clinicaltrails.gov (NCT01086540).

Assessment of a Passive Lumbar Exoskeleton in Material Manual Handling Tasks under Laboratory Conditions.

Manual material handling tasks in industry cause work-related musculoskeletal disorders. Exoskeletons are being introduced to reduce the risk of musculoskeletal injuries. This study investigated the effect of using a passive lumbar exoskeleton in terms of moderate ergonomic risk. Eight participants were monitored by electromyogram (EMG) and motion capture (MoCap) while performing tasks with and without the lumbar exoskeleton. The results showed a significant reduction in the root mean square (VRMS) for all muscles tracked: erector spinae (8%), semitendinosus (14%), gluteus (5%), and quadriceps (10.2%). The classic fatigue parameters showed a significant reduction in the case of the semitendinosus: 1.7% zero-crossing rate, 0.9% mean frequency, and 1.12% median frequency. In addition, the logarithm of the normalized Dimitrov's index showed reductions of 11.5, 8, and 14% in erector spinae, semitendinosus, and gluteus, respectively. The calculation of range of motion in the relevant joints demonstrated significant differences, but in almost all cases, the differences were smaller than 10%. The findings of the study indicate that the passive exoskeleton reduces muscle activity and introduces some changes of strategies for motion. Thus, EMG and MoCap appear to be appropriate measurements for designing an exoskeleton assessment procedure.

Characteristics and outcomes among patients with community-acquired respiratory virus infections during the first year after lung transplantation.

BACKGROUND: The current study describes the spectrum of community-acquired respiratory infections (CARV) during the first year after lung transplantation (LT). Additionally, we elucidate variables associated with CARV, management strategies utilized, and impact on early and late outcomes. METHODS: This was a retrospective study among patients transplanted between 2012 and 2015 (n = 255, mean age 55.6 ± 13.5 years, M: F 152:103). The diagnosis of CARV was based on the multiplex PCR on nasopharyngeal swab samples. Baseline characteristics, post-transplant variables, and outcomes were compared among patients with and without CARV. RESULTS: Eighty CARV infections developed among a quarter of the study group (n = 62, 24.3%). Rhinovirus/enterovirus was the most commonly isolated CARV (n = 24) followed by coronavirus (n = 17) and RSV (n = 9). A significant proportion of episodes (43.8%) required hospitalization. The use of nasal corticosteroids and left single LT was independently associated with an increased risk of CARV. CARV infections did not impact the lung functions during the first year or the CLAD-free survival at 3 years. CONCLUSIONS: There is a significant burden of CARV infections during the first year after LT. The use of nasal corticosteroids may increase the risk of CARV infection. CARV infections did not impact outcomes.

Characteristics and outcomes among lung transplant patients with respiratory syncytial virus infection.

BACKGROUND: To describe characteristics and outcomes among lung transplantation (LT) patients with respiratory syncytial virus (RSV) infection and elucidate the predictors of 1-year survival after RSV infection. METHODS: This was a retrospective chart review study among LT patients with RSV infection between 2013 and 2018 (90 episodes among 87 patients; mean age 56.3 ± 13.1 years, M:F 52:35). A contemporaneous control group consisting of LT patients without RSV infection (n = 183) was included. One-year survival after the RSV infection was the primary endpoint. RESULTS: Median time from LT to RSV infection was 30 (1-155) months. Before RSV infection, the median decline in forced vital capacity (FVC) was 9.7 cc (-17.8 to 83 cc) or 0.29% (-1.4% to 4.6%) per month, while the forced expiratory volume (FEV1 ) decline was 7.5 cc (-8.8 to 58 cc) or 0.3% (-0.57% to 4.3%) per month with no statistically significant change after RSV infection. One-year survival among patients with RSV infection was 86.2% (75/87). Pre-infection diagnosis of chronic lung allograft dysfunction (CLAD; adjusted HR: 4.29, 1.08-17.0; P = .038) and FVC or FEV1 decline >10% during 6 months post infection (adjusted HR: 35.1, 3.26-377.1; P = .003) were independently associated with worse survival. On propensity score matched analysis, RSV infection was not associated with worse post-transplant survival (HR with 95% CI: 0.79, 0.47-1.34; P = .38). CONCLUSIONS: A majority of LT patients in the current cohort did not experience an alteration in the trajectory of FVC or FEV1 decline after developing RSV infection, and their post-transplant survival was not adversely impacted. Established CLAD at the time of RSV infection and post infection >10% decline in FVC or FEV1 are independently associated with worse survival after RSV infection.

Post-infection pulmonary sequelae after COVID-19 among patients with lung transplantation.

BACKGROUND: There is limited data on outcomes among lung transplant (LT) patients who survive Coronavirus disease 2019 (COVID-19). METHODS: Any single or bilateral LT patients who tested positive for SARS-CoV-2 between March 1, 2020, to February 15, 2021 (n = 54) and survived the acute illness were included (final n = 44). Each patient completed at least 3 months of follow-up (median: 4.5; range 3-12 months) after their index hospitalization for COVID-19. The primary endpoint was a significant loss of lung functions (defined as > 10% decline in forced vital capacity (FVC) or forced expiratory volume in 1 s (FEV1 ) on two spirometries, at least 3 weeks apart compared to the pre-infection baseline). RESULTS: A majority of the COVID-19 survivors had persistent parenchymal opacities (n = 29, 65.9%) on post-infection CT chest. Patients had significantly impaired functional status, with the majority reporting residual disabilities (Karnofsky performance scale score of 70% or worse; n = 32, 72.7%). A significant loss of lung function was observed among 18 patients (40.9%). Three patients met the criteria for new chronic lung allograft dysfunction (CLAD) following COVID-19 (5.6%), with all three demonstrating restrictive allograft syndrome phenotype. An absolute lymphocyte count < 0.6 × 103 /dl and ferritin > 150 ng/ml at the time of hospital discharge was independently associated with significant lung function loss. CONCLUSIONS: A significant proportion of COVID-19 survivors suffer persistent allograft injury. Low absolute lymphocyte counts (ALC) and elevated ferritin levels at the conclusion of the hospital course may provide useful prognostic information and form the basis of a customized strategy for ongoing monitoring and management of allograft dysfunction. TWEET: Twitter handle: @AmitBangaMD Lung transplant patients who survive COVID-19 suffer significant morbidity with persistent pulmonary opacities, loss of lung functions, and functional deficits. Residual elevation of the inflammatory markers is predictive.

Prevention of Perioperative Hypothermia: A Prospective, Randomized, Controlled Trial of Bair Hugger Versus Inditherm in Patients Undergoing Elective Arthroscopic Shoulder Surgery.

PURPOSE: To determine if a clinically significant difference in the core body temperature (CBT) exists between the Bair Hugger (BH) and Inditherm (IT) warming devices in patients undergoing arthroscopic shoulder surgery. METHODS: This was a parallel, 2-treatment, prospective, randomized, controlled trial conducted in patients undergoing elective arthroscopic shoulder surgery in the beach-chair position using room-temperature irrigation fluid. The BH was used as the indicative forced-air warming device, whereas the IT served as the indicative resistive heating system. By use of a minimal clinically significant difference of 0.6°C and standard deviation of 0.6°C, a power analysis showed that a sample size of 90 patients (45 per group) would be required. Patients fulfilling the inclusion criteria were recruited from the clinics of the senior authors. Anesthetic and surgical protocols were standardized. The intraoperative CBT was recorded every 5 minutes using a nasopharyngeal thermistor probe. Demographic data as well as the volume of irrigation fluid used were also noted. RESULTS: A steady decline in the CBT was observed in both groups up to 30 minutes after induction of anesthesia. Beyond 30 minutes, the BH group showed a gradual increase in temperature whereas it continued to decline in the IT group. A statistically significant difference in the CBT was observed from 60 minutes onward (P = .025). This difference continued to increase up to 90 minutes (P < .001). At no time was a rise in the CBT observed in the IT group. At completion of the study and surgical procedure, 13 of 47 patients in the BH group and 32 of 44 patients in the IT group had hypothermia (P = .0002). CONCLUSIONS: The CBT was statistically significantly better with the use of the BH compared with the IT mattress. However, the differences in the CBT did not reach the level of clinical significance of 0.6°C. Far fewer patients in the BH group had hypothermia at the end of surgery. Therefore, this study supports the use of the BH in elective arthroscopic shoulder surgery for the prevention of hypothermia. LEVEL OF EVIDENCE: Level I.

Assistance Robotics and Biosensors 2019.

This Special Issue is focused on breakthrough developments in the field of assistive and rehabilitation robotics. The selected contributions include current scientific progress from biomedical signal processing and cover applications to myoelectric prostheses, lower-limb and upper-limb exoskeletons and assistive robotics.

Bacterial Cellulose-Graphene Based Nanocomposites.

Bacterial cellulose (BC) and graphene are materials that have attracted the attention of researchers due to their outstanding properties. BC is a nanostructured 3D network of pure and highly crystalline cellulose nanofibres that can act as a host matrix for the incorporation of other nano-sized materials. Graphene features high mechanical properties, thermal and electric conductivity and specific surface area. In this paper we review the most recent studies regarding the development of novel BC-graphene nanocomposites that take advantage of the exceptional properties of BC and graphene. The most important applications of these novel BC-graphene nanocomposites include the development of novel electric conductive materials and energy storage devices, the preparation of aerogels and membranes with very high specific area as sorbent materials for the removal of oil and metal ions from water and a variety of biomedical applications, such as tissue engineering and drug delivery. The main properties of these BC-graphene nanocomposites associated with these applications, such as electric conductivity, biocompatibility and specific surface area, are systematically presented together with the processing routes used to fabricate such nanocomposites.

Insult to Injury: Development of Alveolar Hemorrhage after Initiation of Extracorporeal Membrane Oxygenation.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is associated with complications that are separate from the underlying diagnoses that require its use. One of the foremost complications of ECMO is a high incidence of bleeding, including alveolar hemorrhage (AH), which is believed to be due to both prophylactic anticoagulation and critical illness-induced systemic coagulopathy. However, akin to systemic inflammatory response syndrome after cardiopulmonary bypass, ECMO causes widespread systemic inflammation and acute lung injury, which likely further predisposes patients to AH. The burden of clinically significant AH among patients on ECMO for advanced lung disease remains unknown. PATIENTS AND METHODS: Charts of patients with advanced lung disease who required ECMO at a single institution were reviewed. The clinical course and variables of patients who developed AH and those who did not were compared. RESULTS: This report describes five patients who developed AH after initiation of venovenous ECMO for refractory hypoxemia. Clinical and laboratory variables did not predict the development or the prognosis of AH. Two of these patients with refractory hypoxemia and AH were treated with pulse-dose corticosteroids, with a dramatic response in one case. CONCLUSION: The acute decompensation of the patients and response to corticosteroids suggest AH was mediated by a systemic inflammatory process, as opposed to coagulopathy alone. Judicious use of steroids may be considered among select patients who develop AH without symptoms of systemic coagulopathy after initiation of ECMO. HOW TO CITE THIS ARTICLE: Williams S, Batra K, Mohanka M, Bollineni S, Kaza V, Torres F, et al. Insult to Injury: Development of Alveolar Hemorrhage after Initiation of Extracorporeal Membrane Oxygenation. Indian J Crit Care Med 2020;24(12):1201-1205.