Fatal hemorrhagic bronchopneumonia caused by Bordetella bronchiseptica in an immunocompetent patient.

Introduction: Bordetella bronchiseptica is a rare cause of hemorrhagic bronchopneumonia. Important to the clinician is a clear understanding that the treatment of this rare organism differs greatly from the successful antibiotic treatment of the more common Bordetella species, pertussis and parapertussis. Case report: A 64-year-old female presented to the emergency department after experiencing one week of worsening hemoptysis. Upon admission, she was afebrile and all initial laboratory test results were normal. Bronchoalveolar hemorrhage suggested by radiographic imaging was confirmed by bronchoscopy. Bronchoalveolar lavage (BAL) cultures contained unspeciated Bordetella. Rapid worsening of the hemoptysis led to intubation and the decision to perform bronchial artery embolization. However, the intensity of the hemoptysis persisted. Septic shock ensued despite treatment with broad spectrum antibiotics including azithromycin, vancomycin, and cefepime. The microbiological speciation results finalized shortly after the patient's death. The identified organism was B. bronchiseptica. Conclusions: Although macrolide antibiotics are first line treatment for B. pertussis and parapertussis, macrolide antibiotics are generally not effective against B. bronchiseptica. Clinical suspicion of B. bronchiseptica infection should prompt consideration of alternative antibiotics known to be effective against this rare species, including carbapenems and fluoroquinolones. The use of these latter antibiotics may advisably be considered as an empirical treatment during the delay of microbiological speciation.

Impact of transcatheter aortic valve implantation on circulating von Willebrand factor in patients with severe aortic stenosis.

INTRODUCTION: Severe aortic stenosis (AS) can lead to degradation of high molecular weight (HMW) von Willebrand factor (VWF) which can result in haemostatic abnormalities. While studies have explored changes in VWF profiles before and after surgical aortic valve replacement (SAVR), the longer-term changes in VWF profiles pre- and post-transcatheter aortic valve implantation (TAVI) are less understood. AIM: Our primary objective was to identify differences in VWF multimer profiles and VWF function pre-TAVI and 1-month post-TAVI. Our secondary objective was to correlate VWF markers with measures of AS severity. METHODS: Adult patients with severe AS referred for TAVI at our institution were prospectively enrolled in this cohort study. Blood samples were collected for plasma analysis at three time points for all patients: 1 day pre-TAVI, 3 days post-TAVI, and 1-month post-TAVI. VWF antigen, activity, propeptide, collagen binding, multimers, and factor VIII coagulant activity were determined at each time point. Correlations between VWF parameters and severity of AS were assessed. RESULTS: Twenty participants (15 males, five females) with severe AS were recruited for the study. There was a significant increase in HMW VWF between pre-procedure and 1-month post-TAVI (p < .05). There was a transient increase in VWF antigen levels and activity at 3-days post TAVI that decreased to pre-TAVI levels at 1-month. There were no statistically significant correlations between VWF markers and AS severity. CONCLUSIONS: This is the first study to elucidate longer-term (>1 week) improvements in HMW VWF after a TAVI procedure in severe AS patients.

An efficient design for real-time obstructive sleep apnea OSA detection through esophageal pressure Pes signal.

Obstructive Sleep Apnea (OSA) is a potentially common sleep disorder in which the upper airways are collapsed either partially or completely. The golden standard method for treating OSA, is the full night Continuous Positive Airway Pressure (CPAP). Yet, due to the ensuing discomfort, it incurs on patients, researchers have been motivated to investigate other alternatives, whereby, OSA can be effectively treated. Recently, an increasingly popular OSA treatment has been developed that consists in activating the protrusion muscles of the tongue by stimulating the Hypoglossal Nerve (HGN). In this context, the present work is conducted to propose the design of apnea detector module as part of an implantable HGN stimulator based on the esophageal Pressure Pes signal as a new approach for controlling OSA occurrence. Specifically, an effective real-time apnea event detecting algorithm is put forward. Following the achievement of satisfactory simulation results, attained through the Modelsim simulation tool, we proceeded with assessing the possibility of its hardware implementation on a Field-Programmable Gate Array (FPGA) device. To this end, the apnea detector module was synthesized and designed. The low power consumption and the small size, characterizing this module, which have made it possible to integrate it as part of a wirelessly-powered implantable HGN stimulator.

Physico-Chemical Characterization of Tunisian Canary Palm (Phoenix canariensis Hort. Ex Chabaud) Dates and Evaluation of Their Addition in Biscuits.

Phoenix canariensis Hort. Ex Chabaud, also known as the Canary Island palm or ornamental palm, is an endemic species of the Canary Islands and has been widely propagated globally. It has become one of the most important and appreciated ornamental plants, especially in the Mediterranean climate. The fruits are edible but used only for feed as they are bitter. Despite its diffusion, not much data on the composition of these fruits and their application as food are available. The aim of this study was to define the chemical characteristics, especially those of the polyphenolic constituents, of red and yellow varieties of Canary palm dates, and to evaluate their use alone or in different mixes in biscuit production. The yellow variety had higher quantities of fiber (36.88% DW (Dry Weight)) and polyphenolic compounds, while the red variety had a high content of sugars, mainly glucose (22.8% DW). Epicatechin is the most important polyphenol of dates (562 mg/g DW). The use of date palm powder on biscuit production resulted in an increase in hardness, polyphenol and fiber content, and antioxidant activity. Sensory analysis showed that the biscuits obtained with a 25/75 mix of red/yellow date powder had the most overall liking.

Transvenous Renal Biopsy of Critically Ill Patients: Safety and Diagnostic Yield.

OBJECTIVES: Transvenous renal biopsy is an alternative way to obtain kidney samples from patients with bleeding risk factors (e.g., antiplatelet therapy and anticoagulation or coagulation disorders). This study was undertaken to determine the safety and diagnostic yield of transvenous renal biopsy of critically ill patients. DESIGN: Monocenter, retrospective, observational cohort study. SETTING: A 26-bed French tertiary ICU. PATIENTS: All patients undergoing in-ICU transvenous renal biopsy between January 2002 and February 2018. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Eighty patients (male/female sex ratio, 0.95; mean ± SD age, 47.3 ± 18.3 yr) were included. A histologic diagnosis was obtained for 77 patients (96.3%), with acute tubular necrosis being the most frequent: 23 (29.9%). A potentially treatable cause was found for 47 patients (58.7%). The numbers of patients with 0, 1, 2, or 3 factors (i.e., antiplatelet therapy, thrombopenia [< 150 G/L], and preventive or curative anticoagulation) at the time of the biopsy were, respectively: seven (8.8%), 37 (46.2%), 31 (38.7%), and five (6.3%). Four (5%) and two (2.5%) patients, respectively, had renal hematoma and macroscopic hematuria; none required any specific treatment. Six patients (7.5%) died in-ICU, and 90-day mortality was 8 of 80 (10%). No death was related to transvenous renal biopsy, and median biopsy-to-death interval was 38 days (interquartile range, 19.7-86 d). CONCLUSIONS: Based on this cohort of ICU patients with acute kidney injury, transvenous renal biopsy was safe and obtained a high diagnostic yield for these selected critically ill patients, even in the presence of multiple bleeding risk factors.

CT pulmonary angiography: an over-utilized imaging modality in hospitalized patients with suspected pulmonary embolism.

AIMS: To determine if computed tomographic pulmonary angiography (CTPA) was overemployed in the evaluation of hospitalized patients with suspected acute pulmonary embolism (PE). METHODS: Data were gathered retrospectively on hospitalized patients (n=185) who had CTPA for suspected PE between June and August 2009 at our institution. RESULTS: CTPA was done in 185 hospitalized patients to diagnose acute PE based on clinical suspicion. Of these, 30 (16.2%) patients were tested positive for acute PE on CTPA. The Well's pretest probability for PE was low, moderate, and high in 77 (41.6%), 83 (44.9%), and 25 (13.5%) patients, respectively. Out of the 30 PE-positive patients, pretest probability was low in 2 (6.6%), moderate in 20 (66.7%), and high in 8 (26.6%) (p=0.003). Modified Well's criteria applied to all patients in our study revealed 113 (61%) with low and 72 (39%) with high clinical pretest probability. When modified Well's criteria was applied to 30 PE-positive patients, 10 (33.3%) and 20 (66.6%) were found to have low and high pretest probability, respectively (p=0.006). D-dimer assay was done in 30 (16.2%) of the inpatients with suspected PE and all of them were found to have elevated levels. A lower extremity duplex ultrasound confirmed deep venous thrombosis in 17 (9.1%) of the patients with suspected PE, at least 1 week prior to having CTPA. CONCLUSION: Understanding the recommended guidelines, evidence-based literature, and current concepts in evaluation of patients with suspected acute PE will reduce unnecessary CTPA examinations.

[Glaucoma--threatening in darkness]. / Glaucomul--amenintarea din umbra; efect final = cecitate.

Glaucoma is not just an unique affliction but a group of afflictions that have in common optic nerve damage and loss of visual field. The 2 main types of glaucoma are POAG and PACG. AS early stages of glaucoma are largely asymptomatic, patients tend to seek help rather late, especially in low-income countries. Once vision is lost, no matter what type of glaucoma is involved, it cannot be done anything to restore it!!!

[The risk of blindness in diabetic retinopathy]. / Riscul cecitatii în retinopatia diabetica.

A good control of blood sugar <110 mg/dl, HbA1c <7%, diastolic BP <80 mmHg and systolic BP <140 mmHg, cholesterol <200 mg/dl, triglycerides <150 mg/dl are the best way to set a limit to the progression of diabetic retinopathy. Progression of DR leads finally to blindness! Blindness is visual acuity less than 3/60 with the best possible correction. Low-vision is a visual acuity less than 6/18, but equal to or better than 3/60, best possible correction in the better eye.

Inferior vena cava anomalies-a common cause of DVT and PE commonly not diagnosed.

A 62-year-old white male presented with recurrent pulmonary embolism (PE) despite having an inferior vena cava (IVC) filter. Investigations ruled out upper limb deep vein thrombosis (DVT) and IVC thrombus, the common causes for a PE in the presence of IVC filter. The culprit was double IVC with a persisting left supracardinal vein that allowed an alternate route for the leg DVT to cause PE. IVC anomalies have a propensity to cause lower limb DVT. Although rarely suspected recent studies have revealed that IVC anomalies are not rare if anticipated and evaluated. Chest CT scans in cases of suspected idiopathic PE should extend up to the renal veins as this will identify common IVC anomalies. Therapy to prevent recurrent DVT can be instituted. A good quality venacavagram should always precede any IVC filter placement as this will identify almost all IVC anomalies and appropriate steps can prevent a recurrent PE.

Cardiac herniation and volvulus with acquired dextrocardia: echocardiographic diagnosis.

We report an extremely rare cause of elevated jugular venous pulse where two esoteric causes for the same-cardiac volvulus and cardiac herniation have occurred together. Echocardiographic evidence for making the diagnosis of cardiac volvulus--subcostal long axis, subcostal short axis, and suprasternal views--have been presented. Awareness of this complication is necessary as immediate intervention is mandatory for a positive outcome.

Takotsubo cardiomyopathy--a new variant and widening disease spectrum.

Classic takotsubo cardiomyopathy had left ventricular apical ballooning. Variants with mid-ventricular ballooning without involvement of the apex have been described. We describe a new variant of takotsubo cardiomyopathy where apical contraction was preserved while the rest of the ventricle was dyskinetic.

Peak pressures during manual ventilation.

INTRODUCTION: Manual (bag) ventilation sometimes achieves better oxygenation than does a mechanical ventilator. We speculated that clinicians might generate very high airway pressure during manual ventilation (much higher than the pressure delivered by a mechanical ventilator), and that the high airway pressure causes alveolar recruitment and thus improves oxygenation. Such high pressure might injure alveoli in some patients. METHODS: We tested the hypothesis that manual ventilation may involve substantially higher pressure than is delivered by a mechanical ventilator. We asked experienced respiratory therapists to manually ventilate a lung model that was set to represent several typical clinical scenarios. RESULTS: We found that the peak airway pressure generated by the therapists was sometimes in excess of 100 cm H(2)O. CONCLUSIONS: The high airway pressure during manual ventilation would be considered extreme in the context of conventional mechanical ventilation, which raises questions about whether manual ventilation causes barotrauma.

Theoretical investigation of the absorption and ionization spectrum of the super greenhouse gas SF5CF3.

SF5CF3, recently found in the Earth's atmosphere, is an extremely potent greenhouse gas. Its behaviour under irradiation, as in the upper atmosphere, is of great importance for the possible impact on the global climate. The vertical absorption spectrum of the title compound is studied by various single- and multi-reference ab initio methods and the results are compared to experiments. The best results for valence states are obtained by the multi-state complete active space second order perturbation theory (MS-CASPT2) approach. In contrast, the popular time-dependent density functional theory (TDDFT) gives very poor results. Multi-reference configuration interaction (MRCI) does not yield very accurate energies because only a limited number of valence electrons can be included in the correlation treatment. The Rydberg states are calculated very accurately and efficiently by a frozen-core multi-configuration self-consistent field (FC-MCSCF) method. The accuracy is assessed by quantum defect theory and the experimental and ab initio calculated first ionization potential. The photoelectron spectrum is investigated by the outer-valence Green's functions (OVGF) method. The simulated spectrum is in excellent agreement with a recent experiment.

Theoretical study of the second-order nonlinear optical properties of [N]helicenes and [N]phenylenes.

The second-order nonlinear optical properties of helicenes and phenylenes have been theoretically investigated at the time-dependent Hartree-Fock level using the Austin model 1 semiempirical Hamiltonian. Both the antisymmetric isotropic component of the first hyperpolarizability (beta) and its projection on the dipole moment (beta(parallel)) have been determined for increasingly large helical systems as well as for their analogs substituted by donor/acceptor pairs. It is found that (i) in nonsubstituted helicenes and phenylenes, beta increases monotonically with the size of the system and slightly depends on the nature of the helix; (ii) the corresponding beta(parallel) is mostly determined by the radial component of the first hyperpolarizability vector; (iii) in helicenes, beta(parallel) is positive and presents quasiperiodic oscillations with the helix; (iv) in phenylenes, beta(parallel) depends upon the size of the helix and it can be either positive or negative as a result of the differences in evolution with N of the radial components of the dipole moment and first hyperpolarizability. Substituting the helicenes and phenylenes by the prototypical NH2/NO2 donor/acceptor pair provides a diversity of effects on beta and beta(parallel) that encompasses decrease, increase, and change in sign.