Antifungal screening of selenium nanoparticles biosynthesized by microcystin-producing Desmonostoc alborizicum.

Metal nanoparticles exhibit excellent antifungal abilities and are seen as a good substitute for controlling different kinds of fungi. Of all known taxa, cyanobacteria have received significant consideration as nanobiofactories, as a result of the cellular assimilation of heavy metals from the environment. The cellular bioactive enzymes, polysaccharides and pigments can be used as reducers and coatings during biosynthesis. The probability of the antifungal activity of selenium nanoparticles (SeNPs) to prevent plant fungi that can affect humans was evaluated and a toxic Iranian cyanobacterial strain of Desmonostoc alborizicum was used to study the biotechnology of SeNP synthesis for the first time. Characterization of nanoparticles with a UV-Vis spectrophotometer showed the formation of SeNPs in the range of 271-275 nm with the appearance of an orange color. Morphological examination of nanoparticles with Transmission Electron Microscopy (TEM), revealed the spherical shape of nanoparticles. The results of X-Ray Diffraction (XRD) showed 7 peaks and a hexagonal structure of average crystal size equal to 58.8 nm. The dispersion index of SeNPs was reported as 0.635, which indicated the homogeneity of the nanoparticle droplet size. The zeta potential of the nanoparticles was + 22.7. Fourier-transform infrared spectroscopy (FTIR) analysis exhibited a sharp and intense peak located at the wave number of 404 cm- 1, related to the SeNPs synthesized in this research. The results of the antifungal activity of SeNPs showed among the investigated fungi, Pythium ultimum had the highest resistance to SeNPs (14.66 ± 0.52 µg/ml), while Alternaria alternata showed the highest sensitivity (9.66 ± 0.51 µg/ml) (p < 0.05). To the best of our knowledge this is the first report concerning the characterization and antifungal screening of SeNPs biosynthesized by Iranian cyanobacteria, which could be used as effective candidates in medical applications.

Predictors and Outcomes of Extracorporeal Membrane Oxygenation in COVID-19 Patients With ARDS: A Propensity-Matched Analysis of National Inpatient Sample.

Extracorporeal membrane oxygenation (ECMO) is a significant treatment modality for COVID-19 patients on ventilators. The current data is limited for understanding the indicators and outcomes of ECMO in COVID-19 patients with acute respiratory distress syndrome (ARDS). The National Inpatient Sample (NIS) database from 2020 was queried in this study. Among 1,666,960 patients admitted with COVID-19, 99,785 (5.98%) patients developed ARDS, and 60,114 (60.2%) were placed on mechanical ventilation. Of these mechanically ventilated COVID-ARDS patients, 2580 (4.3%) were placed on ECMO. Patients with ECMO intervention had higher adjusted odds (aOR) of blood loss anemia (aOR 9.1, 95% CI: 6.16-13.5, propensity score-matched (PSM) 42% vs 5.4%, P < 0.001), major bleeding (aOR 3.79, 95% CI: 2.5-5.6, PSM 19.9% vs 5.9%, P < 0.001) and acute liver injury (aOR 1.7, 95% CI: 1.14-2.6 PSM 14% vs 6%, P = 0.009) compared to patients without ECMO intervention. However, in-hospital mortality, acute kidney injury, transfusions, acute MI, and cardiac arrest were insignificant. On subgroup analysis, patients placed on veno-arterial ECMO had higher odds of cardiogenic shock (aOR 13.4, CI 3.95-46, P < 0.0001), cardiac arrest (aOR 3.5, CI 1.45-8.47, P = 0.0057), acute congestive heart failure (aOR 4.18, CI 1.05-16.5, P = 0.042) and lower odds of major bleeding (aOR 0.26, CI 0.07-0.92). However, there was no significant difference in mortality, intracranial hemorrhage, and acute MI. Further studies are needed before considering COVID-19 ARDS patients for placement on ECMO.

Pulmonary hypertension inhaled therapies: An updated review.

Treatments of pulmonary hypertension (PH) continue to evolve with approval of new therapies. The currently FDA approved inhaled PH therapies include inhaled iloprost for group 1 pulmonary arterial hypertension (PAH), inhaled treprostinil solution and treprostinil dry powder inhaler for both group 1 PAH and group 3 PH associated with interstitial lung disease (PH-ILD). Inhaled treprostinil was recently approved for group 3 PH-ILD based on the results of INCREASE trial and the newer formulation of treprostinil dry powder that comes with a new inhaler was recently approved for both group 1 PAH and group 3 PH-ILD based on BREEZE study. The pipeline for inhaled PH therapies includes several promising molecules that can enrich the current PH therapeutic era and mitigate several systemic side effects by directly delivering the drug to the target organ. In this review article we summarize the evidence for the currently approved inhaled PAH/PH therapies, discuss the available inhalation devices, present a roadmap for successful treatment strategy, and present several inhaled PAH/PH therapies in the pipeline.

A young man presenting with encephalopathy and seizures secondary to SARS-CoV-2.

COVID-19 has now emerged from a respiratory illness to a systemic viral illness with multisystem involvement. There is still a lot to learn about this illness as new disease associations with COVID-19 emerge consistently. We present a unique case of a neurological manifestation of a patient with structural brain disease who was COVID-19 positive and developed mental status changes, new-onset seizures and findings suggestive of viral meningitis on lumbar puncture. We also review the literature and discuss our case in the context of the other cases reported. We highlight the value of considering seizures and encephalopathy as one of the presenting features of COVID-19 disease.

Pulmonary Aspergillosis: Spectrum of Disease.

Aspergillus species are ubiquitous in the environment. Aspergillosis is acquired by inhalation of Aspergillus spores. In normal hosts, spore inhalation rarely causes lung disease. Pulmonary Aspergillosis covers a wide spectrum of clinical syndromes depending on the interaction between Aspergillus and the host (immune-status, prior bronchopulmonary disease). It runs the gamut from invasive Aspergillosis to Aspergillus bronchitis. Invasive Aspergillosis usually occurs in severely immunocompromised patients, typically in neutropenic but also in non-neutropenic patients. Chronic pulmonary Aspergillosis affects patients with chronic structural lung disease such as COPD or previous mycobacterial lung disease, but without other significant immunocompromise. Aspergillus bronchitis affects patients with bronchial disease such as bronchiectasis. Allergic bronchopulmonary Aspergillosis affects patients with bronchial asthma or cystic fibrosis, and is due to an allergic response to Aspergillus.

Lung ultrasound in early SARS-CoV-2 pneumonia and the LUS-CoV criteria.

There is a scarcity of data on lung ultrasound (LUS) in SARS-CoV-2 pneumonia. As with many other pulmonary conditions, ultrasound may be a better diagnostic tool than routine chest radiography. In an era where computed tomography scanning is deferred because of the potential for cross-contamination, we evaluated the ability of LUS to detect a pattern of lung injury in SARS-CoV-2 pneumonia. A limited anterolateral LUS was performed to limit time spent in isolation rooms by ultrasound operators. We chose to use a hand-held ultrasound device due to portability and superior confidence in infection control. Both linear and phased array probes were used to obtain images of the pleura and lung. Of 69 patients who had lung ultrasound images saved and were included in the analysis, 36 were positive for SARS-CoV-2. Multifocal confluent B-lines, pleural irregularities, and the absence of moderate or large pleural effusions were the predominant pattern observed in most (86%) of SARS-CoV-2-positive patients. We evaluated the accuracy of the above criteria (LUS-CoV) and report a high sensitivity (91%) and specificity (86%) for SARS-CoV-2 pneumonia. In conclusion, a characteristic sonographic pattern of multifocal confluent B-lines with irregular pleural markings was seen on LUS in patients with SARS-CoV-2 pneumonia.

A 34-Year-Old Woman With Hoarseness of Voice and an Abnormal Echocardiogram.

CASE PRESENTATION: A 34-year-old woman presented for evaluation of several months of a hoarse voice and dyspnea on exertion that progressed over the last 3 years. She had a clinical diagnosis of asthma that had been treated with bronchodilators and inhaled corticosteroids for a few years. She continued to use her inhalers but with minimal symptomatic improvement. The patient was a lifelong nonsmoker with no history of drug abuse. She worked as a college professor and denied any significant environmental exposures or recent travel.

Enteral nutrition better than proton pump inhibitors?

PURPOSE OF REVIEW: Stress ulcer prophylaxis in critically-ill patients has been a subject of extensive research, with multiple clinical trials attempting to study the best method of stress ulcer prophylaxis with the least adverse effects. Until recently, pharmacologic prophylaxis has prevailed as the primary choice for the prevention of stress ulcers but recent clinical studies have attempted to evaluate the role of enteral nutrition in stress ulcer prophylaxis. RECENT FINDINGS: The incidence of stress ulcers that result in clinically important gastrointestinal bleeding (CIGIB) has drastically decreased over the last two decades. Furthermore, in the current era CIGB in the ICU does not seem to be associated with an increased mortality. Multiple recent clinical studies aimed to evaluate the role of proton pump inhibitors (PPIs) in patients who tolerate enteral nutrition in the ICU. SUMMARY: The results of multiple recent clinical studies call for re-evaluation of the routine use of PPIs in critically ill patients who tolerates enteral nutrition in the ICU. Despite the promising preliminary results, definitive recommendations need larger clinical trials that are powered to evaluate any added benefits of using PPI in critically ill patients who tolerate enteral nutrition given the low incidence of CIGB in the current era.

Ehrlichiosis masquerading as thrombotic thrombocytopenic purpura.

Ehrlichiosis is a rare tickborne illness that can manifest from an asymptomatic, self-limiting disease to a severe presentation with encephalopathy and renal failure. Ehrlichiosis is diagnosed largely based on patient history with confirmatory tests including peripheral blood smear, serology and PCR. Empiric treatment is warranted in patients with suspected tick bites as a delay in treatment can result in multiorgan failure. We discuss a case of ehrlichiosis that presented with the classic pentad of thrombotic thrombocytopenic purpura (TTP). A history of a tick bite was elicited and intravenous doxycycline 100 mg two times a day was initiated. Tick panel results revealed a positive Ehrlichia chaffeensis IgG and IgM titres, consistent with human monocytic ehrlichiosis. Autoimmune workup and antibodies to Borreliaburgdorferi were negative, and ADAMTS13 activity assay results were inconsistent with TTP. The patient completed 14 days of intravenous doxycycline and had an uneventful recovery.

Predicting fluid responsiveness: A review of literature and a guide for the clinician.

Volume resuscitation is of utmost importance in the treatment of shock. It is imperative that this resuscitation be guided using a reliable method of ascertaining volume status to avoid the ill-effects of hypovolemia while also avoiding those of over-resuscitation. There are numerous tools and methods available in this era to aid the bedside physician in guiding volume resuscitation, many of which will be described in this review of literature. The methods to assess preload responsiveness are broadly divided into static and dynamic measurements. Static measurements involve 'snapshot' estimations of preload. Dynamic measurements rely on fluctuations in heart-lung interactions or a simulated volume challenge to predict whether increasing preload by volume loading will be beneficial. Dynamic measurements are favored over static measurements, however the conditions to be met for most dynamic measurements to be valid leave these methods to be used reliably in a very discrete critically-ill population. This issue is overcome by utilizing maneuvers that have been developed to assess fluid responsiveness that liberalize the conditions required for most dynamic measurements, such as passive leg raising, end expiratory occlusion, and mini-fluid boluses. This review of literature highlights the differences between static and dynamic measurements of fluid responsiveness, and proposes a guide to choosing the most reliable methods of ascertaining volume responsiveness individualized to each patient.

Comparing Changes in Carotid Flow Time and Stroke Volume Induced by Passive Leg Raising.

BACKGROUND: Determining volume responsiveness in critically ill patients is challenging. We sought to determine if passive leg raise (PLR) induced changes in pulsed wave Doppler of the carotid artery flow time could predict fluid responsiveness in critically ill patients. MATERIALS AND METHODS: Medical intensive care unit patients ≥18 years old with a radial arterial line and FloTrac/Vigileo monitor in place were enrolled. Pulsed wave Doppler of the carotid artery was performed to measure the change in carotid flow time (CFTC) in response to a PLR. Patients were categorized as fluid responders if stroke volume increased by ≥15% on a Vigileo monitor. The main outcome measure was the accuracy of CFTC to detect a change in response to a PLR. We also calculated the percentage increase in CFTC that could predict fluid responsiveness. RESULTS: We enrolled 22 patients. Using an increase of ≥24.6% in the CFTC in response to PLR to predict fluid responsiveness there was a sensitivity of 60%, specificity of 92%, positive likelihood ratio of 7.2, negative likelihood ratio of 0.4, positive predictive value of 86%, negative predictive value of 73% and receiver operating characteristic of 0.75 (95% CI: 0.54-0.96). CONCLUSIONS: CFTC performs well compared to stroke volume measurements on a Vigileo monitor. The use of CFTC is highlighted in resource-limited environments and when time limits the use of other methods. CFTc should be validated in a larger study with more operators against a variety of hemodynamic monitors.

Enteral nutrition as stress ulcer prophylaxis in critically ill patients: A randomized controlled exploratory study.

PURPOSE: We investigated whether early enteral nutrition alone may be sufficient prophylaxis against stress-related gastrointestinal (GI) bleeding in mechanically ventilated patients. MATERIALS AND METHODS: Prospective, double blind, randomized, placebo-controlled, exploratory study that included mechanically ventilated patients in medical ICUs of two academic hospitals. Intravenous pantoprazole and early enteral nutrition were compared to placebo and early enteral nutrition as stress-ulcer prophylaxis. The incidences of clinically significant and overt GI bleeding were compared in the two groups. RESULTS: 124 patients were enrolled in the study. After exclusion of 22 patients, 102 patients were included in analysis: 55 patients in the treatment group and 47 patients in the placebo group. Two patients (one from each group) showed signs of overt GI bleeding (overall incidence 1.96%), and both patients experienced a drop of >3 points in hematocrit in a 24-hour period indicating a clinically significant GI bleed. There was no statistical significant difference in the incidence of overt or significant GI bleeding between groups (p=0.99). CONCLUSION: We found no benefit when pantoprazole is added to early enteral nutrition in mechanically ventilated critically ill patients. The routine prescription of acid-suppressive therapy in critically ill patients who tolerate early enteral nutrition warrants further evaluation.

Impella percutaneous left ventricular assist device for severe acute ischaemic mitral regurgitation as a bridge to surgery.

Ischaemic papillary muscle rupture causing acute severe mitral regurgitation (MR) has a dramatic presentation and a very high mortality. Emergent surgical repair improves outcomes, which necessitates robust preoperative stabilisation. Here we discuss a patient with cardiogenic shock with an acute severe MR that was deemed very high risk for emergent valve replacement due to haemodynamic instability and respiratory failure. A percutaneous left ventricular assist device Impella 2.5 (Abiomed, Danvers, MA) drastically improved clinical status, and the patient underwent a successful surgical mitral valve replacement soon after placement of the temporary assist device. Our case highlights that percutaneous ventricular assist devices may help to stabilise patients with severe acute ischaemic MR, and it can serve as a bridge to surgery in high risk patients.

Mucous Membrane Pemphigoid Causing Central Airway Obstruction.

Mucous membrane pemphigoid (MMP) is a rare variant of the skin disease pemphigoid, which predominantly involves the mucous membranes. This rare autoimmune disease that infrequently affects the respiratory tract is characterized by subepithelial blister formation that may result in scarring. Immunopathologic examination of mucous membranes reveals the deposition of immunoglobulins and complement within the subepithelial basement membrane. We describe a patient with undiagnosed MMP, with a near-fatal presentation of central airway obstruction causing acute respiratory distress. The patient was successfully treated with emergent rigid bronchoscopic resection of a ball valve-like endotracheal mass, and diagnosed with a rare variant of pemphigoid disease, MMP. The patient was treated with mycophenolate and was clinically in remission, with bronchoscopically stable lesions at 1 year of follow-up.