Absorbable antibiotic beads for treatment of LVAD driveline infections.

BACKGOUND: Infections of the left ventricular assist device (LVAD) driveline are a dreaded complication that results in high mortality and morbidity. METHOD: We retrospectively reviewed five consecutive patients with severe continuous-flow LVAD (HVAD, Heartmate 2, and Heartmate 3) driveline infection. These infections, which developed on an average of 960.4 ± 843.9 days after LVAD placement, were refractory to systemic antibiotics and local wound care. All were treated with extensive surgical debridement, local installation of absorbable antibiotic-loaded calcium sulfate beads (vancomycin and tobramycin), primary wound closure, and 6 weeks of systemic antibiotics after surgery. RESULTS: Four patients had resolution of DLI, and one had a recurrent infection at another part of the driveline 7 months after the complete resolution of the previous site. This patient was successfully treated with debridement and bead placements. Three patients still have their LVADs, while two received orthotopic heart transplants. At the time of the transplant, there was no evidence of gross infection of the LVAD drivelines or pumps. At the average follow-up time of 425.8 ± 151 days, no patients have an active infection. CONCLUSION: Treatment of LVAD driveline infection with absorbable antibiotic beads with primary wound closure is a viable option and merits further investigation.

An Eclectic Review on Dicarboxylic Acid Production Through Yeast Cell Factories and Its Industrial Prominence.

Dicarboxylic acid (DCA) is a multifaceted chemical intermediate, recoursed to produce many industrially important products such as adhesives, plasticizers, lubricants, polymers, etc. To bypass the shortcomings of the chemical methods of synthesis of DCA and to reduce fossil fuel footprints, bio-based synthesis is gaining attention. In pursuit of an eco-friendly sustainable alternative method of DCA production, microbial cell factories, and renewable organic resources are gaining popularity. Among the plethora of microbial communities, yeast is being favored industrially compared to bacterial fermentation due to its hyperosmotic and low pH tolerance and flexibility for gene manipulations. By application of rapidly evolving genetic manipulation techniques, the bio-based DCA production could be made more precise and economical. To bridge the gap between supply and demand of DCA, many strategies are employed to improve the fermentation. This review briefly outlines the advancements in DCA production using yeast cell factories with the exemplification of strain improvement strategies.

Arabinose as an overlooked sugar for microbial bioproduction of chemical building blocks.

The circular economy is anticipated to bring a disruptive transformation in manufacturing technologies. Robust and industrial scalable microbial strains that can simultaneously assimilate and valorize multiple carbon substrates are highly desirable, as waste bioresources contain substantial amounts of renewable and fermentable carbon, which is diverse. Lignocellulosic biomass (LCB) is identified as an inexhaustible and alternative resource to reduce global dependence on oil. Glucose, xylose, and arabinose are the major monomeric sugars in LCB. However, primary research has focused on the use of glucose. On the other hand, the valorization of pentose sugars, xylose, and arabinose, has been mainly overlooked, despite possible assimilation by vast microbial communities. The present review highlights the research efforts that have explicitly proven the suitability of arabinose as the starting feedstock for producing various chemical building blocks via biological routes. It begins by analyzing the availability of various arabinose-rich biorenewable sources that can serve as potential feedstocks for biorefineries. The subsequent section outlines the current understanding of arabinose metabolism, biochemical routes prevalent in prokaryotic and eukaryotic systems, and possible products that can be derived from this sugar. Further, currently, exemplar products from arabinose, including arabitol, 2,3-butanediol, 1,2,3-butanetriol, ethanol, lactic acid, and xylitol are discussed, which have been produced by native and non-native microbial strains using metabolic engineering and genome editing tools. The final section deals with the challenges and obstacles associated with arabinose-based production, followed by concluding remarks and prospects.

Effective Prevention of Arterial Thrombosis with Albumin-Thrombin Inhibitor Conjugates.

Thromboprophylaxis is indicated in patients at an elevated risk of developing thrombotic disorders, typically using direct oral anticoagulants or low-molecular-weight heparins. We postulated that transient thromboprophylaxis (days-weeks) could be provided by a single dose of an anticoagulant engineered for prolonged pharmacokinetics. In the present work, d-phenylalanyl-l-prolyl-l-arginine chloromethyl ketone (PPACK) was used as a model anticoagulant to test the hypothesis that conjugation of thrombin inhibitors to the surface of albumin would provide durable protection against thrombotic insults. Covalent conjugates were formed between albumin and PPACK using click chemistry, and they were tested in vitro using a thrombin activity assay and a clot formation assay. Thromboprophylactic efficacy was tested in mouse models of arterial thrombosis, both chemically induced (FeCl3) and following ischemia-reperfusion (transient middle cerebral artery occlusion; tMCAO). Albumin-PPACK conjugates were shown to have nanomolar potency in both in vitro assays, and following intravenous injection had prolonged circulation. Conjugates did not impact hemostasis (tail clipping) or systemic coagulation parameters in normal mice. Intravenous injection of conjugates prior to FeCl3-induced thrombosis provided significant protection against occlusion of the middle cerebral and common carotid arteries, and injection immediately following ischemia-reperfusion reduced stroke volume measured 3 days after injury by ∼40% in the tMCAO model. The data presented here provide support for the use of albumin-linked anticoagulants as an injectable, long-circulating, safe thromboprophylactic agent. In particular, albumin-PPACK provides significant protection against thrombosis induced by multiple mechanisms, without adversely affecting hemostasis.

Readmission with acute kidney injury following ileostomy: patterns and predictors of a common phenomenon.

PURPOSE: Ileostomy is associated with various complications, often necessitating rehospitalization. High-output ileostomy is common and may lead to acute kidney injury (AKI). Here we describe the temporal pattern of readmission with AKI following ileostomy formation and identify risk factors. METHODS: Patients that underwent formation of ileostomy between 2008 and 2021 were included in this study. Readmission with AKI with high output ileostomy was defined as readmission with serum creatinine > 1.5-fold compared to the level at discharge or latest baseline (at least stage-1 AKI according to Kidney Disease: Improving Global Outcome (KDIGO) criteria), accompanied by ileostomy output > 1000 ml in 24 h. Patient characteristics and perioperative course were assessed to identify predictors for readmission with AKI. RESULTS: Of 1191 patients who underwent ileostomy, 198 (16.6%) were readmitted with a high output stoma and AKI. The mean time to readmission with AKI was 98.97 ± 156.36 days. Eighty-six patients (43.4%) had early readmission (within 30 days), and 66 (33%) were readmitted after more than 90 days. Over 90% of patients had more than one readmission, and 110 patients (55%) had 5 or more. Patient-related predictors for readmission with AKI were age > 65, body mass index > 30 kg/m2, and hypertension. Factors related to the postoperative course were AKI with creatinine > 2 mg/dl, postoperative hemoglobin < 8 g/dl or blood transfusion, albumin < 20 g/dl, high output stoma and need for loperamide, and length of hospital stay > 20 days. Factors related to early versus late readmissions and multiple readmissions were also analyzed. CONCLUSIONS: Readmission with AKI following ileostomy formation is a consequential event with distinct risk factors. Acknowledging these risk factors is the foundation for designing interventions aiming to reduce frequency of AKI readmissions in predisposed patient populations.

Packing the donor heart: Is SherpaPak cold preservation technique safer compared to ice cold storage.

INTRODUCTION: The present study aimed to compare the clinical outcomes of heart transplant patients whose donor hearts were preserved with the SherpaPak controlled cold organ system versus the conventional ice storage technique. METHODS: All patients undergoing heart transplantation at our center between January 2019 and April 2021 were divided into two groups according to the technique used during donor heart preservation and transport. The first group consisted of 34 SherpaPak controlled temperature preservation patients, and the second group consisted of 47 patients where the conventional three bags and ice technique was utilized during organ transportation. The two groups were compared based on demographics, operative details, and postoperative outcomes. RESULTS: There were no significant differences between the groups regarding Vasoactive Inotropic Score (VIS), Primary Graft Dysfunction (PGD), and the need for a transient pacer. However, the VIS, PGD, and pacing trends were lower in the SherpaPak patients even though the total ischemic and cardiopulmonary bypass times were significantly longer. Furthermore, SherpaPak patients exhibited a shorter stay in the ICU with no severe PGD and mortality. CONCLUSION: The SherpaPak donor heart preservation provides safe outcomes in heart transplant patients. Further research is needed to utilize this method for longer durations of ischemic time and expand travel distances for organ transportation.

Safe heart flush technique during recovery from donors after circulatory death.

BACKGROUND: Donation after circulatory death is the donation after cardiac arrest. This technique has been employed and adopted by clinicians to overcome the shortage of available hearts for transplant. Warm ischemia time plays a pivotal role in the survival outcome of the heart recipients. AIM OF THE STUDY: To assess the efficacy of using the Foley catheter to flush the heart during procurement from donation after circulatory death donors. METHODS: We utilized a 2-WAY Foley catheter to flush the heart during procurement. The catheter was prepared and modified on the back table. RESULTS: We were successfully able to flush the heart within 3 minutes from skin incision with a good recipient outcome. CONCLUSIONS: Using the Foley catheter to flush the heart during recovery from donation after circulatory death donors was both efficient and fast.

Accelerated LVAD pump thrombosis in COVID-19 patient: Case report and mini review.

BACKGROUND: Coronavirus (COVID-19) infection exposes patients with heart failure specially who are on mechanical support to a higher risk of morbidity and mortality. AIMS: To investigate the impact of COVID-19 infection on left ventricular assist device (LVAD) thrombosis in heart failure patients. MATERIALS & METHODS: We searched the medical electronic records, Medline, PubMed and Cochrane databases for; (LVAD) AND (thrombosis)) AND (covid-19)) AND (heart failure). We divided cases reported into, LVAD thrombosis with COVID-19 infection and compare them with LVAD thrombosis without COVID-19 infection. Demographic data, LVAD device, presentation, treatment and outcomes were reviewed in all the LVAD thrombosis patients. RESULTS: In addition to our case, 8 other cases of LVAD thrombosis associated with COVID and 9 cases of LVAD thrombosis without covid infection were found. Patients with Covid infection had worse presentation and outcomes (3 deaths VS. 1 death in non-covid group). DISCUSSION: In LVAD patients, pump malfunction due to thrombus development in the inflow cannula, device body, or outflow graft can result in hemodynamic instability, hemolysis and other life-threatening complications. COVID infection significantly increases the risk of mortality in LVAD patient by accelerating the pump thrombosis due to elevated levels of endothelial protein C receptor and thrombomodulin along with procoagulants such as factor VIII, P-selectin, and von Willebrand factor. CONCLUSION: Significant morbidity and mortality are attributed to LVAD thrombosis, which are exasperated by prothrombotic conditions created in COVID-19 infections.

Controlled temperatures in cold preservation provides safe heart transplantation results.

BACKGROUND: We aimed to investigate the short-term outcomes of heart transplant patients who underwent SherpaPak™ donor organ preservation. METHOD: We prospectively collected the data of patients who underwent heart transplantation using SherpaPak™ system for donor organ transportation from February 2020 to March 2021. Donor and recipient demographic data, preoperative and postoperative echocardiographic and hemodynamic parameters, total ischemic time and SherpaPak temperatures, vasoactive inotropic scores (VIS), primary graft dysfunction (PGD) status, intensive care unit stay, complications, and mortality during follow-up were assessed. RESULTS: A total of 39 consecutive heart transplant patients with SherpaPak system were included in the study. The mean donor age was 32.2 ± 6.7 (range: 16-46). The mean recipient age was 57.5 ± 12 (range: 19-73). The mean preoperative ejection fraction (EF) was 23.7 ± 15.4 (range: 5-75). All recipients underwent a standard bicaval technique for orthotopic heart implantation. The mean total ischemic time was 230.1 ± 41 (range: 149-342) min. The mean Sherpa temperature was 5.6 ± 0.8°C (range: 3.7-7.5). The mean VIS was 10.2 ± 6.5 (range: 2-32). The number of mild PGD was 5 (14.7%), and moderate PGD was 4 (11.8%). There was no severe PGD. The postoperative EF was 64.3 ± 5.5 (range: 50-78). Mean intubation time was 47.4 ± 64 (range: 8-312, median: 22) h. The mean time of intensive care unit stay was 6.3 ± 5 (range: 2-31, median: 5) days. Two patients required chest revision (5.8%), two patients had lung infection (5.8%). Two patients had a stroke (5.8%). There was no mortality. CONCLUSION: Using the SherpaPak system during heart transplantation is safe and not associated with significant recipient morbidity. None of the recipients experienced significant PGD and mortality.

Unlocking the potential of insect and ruminant host symbionts for recycling of lignocellulosic carbon with a biorefinery approach: a review.

Uprising fossil fuel depletion and deterioration of ecological reserves supply have led to the search for alternative renewable and sustainable energy sources and chemicals. Although first generation biorefinery is quite successful commercially in generating bulk of biofuels globally, the food versus fuel debate has necessitated the use of non-edible feedstocks, majorly waste biomass, for second generation production of biofuels and chemicals. A diverse class of microbes and enzymes are being exploited for biofuels production for a series of treatment process, however, the conversion efficiency of wide range of lignocellulosic biomass (LCB) and consolidated way of processing remains challenging. There were lot of research efforts in the past decade to scour for potential microbial candidate. In this context, evolution has developed the gut microbiota of several insects and ruminants that are potential LCB degraders host eco-system to overcome its host nutritional constraints, where LCB processed by microbiomes pretends to be a promising candidate. Synergistic microbial symbionts could make a significant contribution towards recycling the renewable carbon from distinctly abundant recalcitrant LCB. Several studies have assessed the bioprospection of innumerable gut symbionts and their lignocellulolytic enzymes for LCB degradation. Though, some reviews exist on molecular characterization of gut microbes, but none of them has enlightened the microbial community design coupled with various LCB valorization which intensifies the microbial diversity in biofuels application. This review provides a deep insight into the significant breakthroughs attained in enrichment strategy of gut microbial community and its molecular characterization techniques which aids in understanding the holistic microbial community dynamics. Special emphasis is placed on gut microbial role in LCB depolymerization strategies to lignocellulolytic enzymes production and its functional metagenomic data mining eventually generating the sugar platform for biofuels and renewable chemicals production.

Bilateral lung transplantation for pulmonary artery aneurysm with severe pulmonary hypertension: An evolution or a revolution?

The surgical treatment of pulmonary hypertension (PH), with or without pulmonary artery aneurysm, has evolved during the last 40 years from heart-lung transplants to bilateral lung transplants as the treatment of choice for PH patients with preserved right and left ventricular function and without complex cardiac abnomalies.

Agitation Techniques to Enhance Drainage of Retained Hemothorax.

Background. Retained hemothorax (RH) is a common problem in cardiothoracic and trauma surgery. We aimed to determine the optimum agitation technique to enhance thrombus dissolution and drainage and to apply the technique to a porcine-retained hemothorax. Methods. Three agitation techniques were tested: flush irrigation, ultrasound, and vibration. We used the techniques in a benchtop model with tissue plasminogen activator (tPA) and pig hemothorax with tPA. We used the most promising technique vibration in a pig hemothorax without tPA. Statistics. We used 2-sample t tests for each comparison and Cohen d tests to calculate effect size (ES). Results. In the benchtop model, mean drainages in the agitation group and control group and the ES were flush irrigation, 42%, 28%, and 2.91 (P = .10); ultrasound, 35%, 27%, and .76 (P = .30); and vibration, 28%, 19%, and 1.14 (P = .04). In the pig hemothorax with tPA, mean drainages and the ES of each agitation technique compared with control (58%) were flush irrigation, 80% and 1.14 (P = .37); ultrasound, 80% and 2.11 (P = .17); and vibration, 95% and 3.98 (P = .06). In the pig hemothorax model without tPA, mean drainages of the vibration technique and control group were 50% and 43% (ES = .29; P = .65). Discussion. In vitro studies suggested flush irrigation had the greatest effect, whereas only vibration was significantly different vs the respective controls. In vivo with tPA, vibration showed promising but not statistically significant results. Results of in vivo experiments without tPA were negative. Conclusion. Agitation techniques, in combination with tPA, may enhance drainage of hemothorax.

Recent nanobiotechnological advancements in lignocellulosic biomass valorization: A review.

Increase in human population, rapid industrialization, excessive utilization of fossil fuel utilization and anthropogenic activities have caused serious threats to the environment in terms of greenhouse gas emissions (GHGs), global warming, air pollution, acid rain, etc. This destruction in sustainability can be averted by a paradigm shift in the fuel production from fossil resources to bioenergy. Amongst different forms of bioenergy, lignocellulosic biomass can be utilized as an attractive substrate for the production of several high-value products owing to its renewability, easy availability, and abundance. Additionally, utilization of these waste biomasses reduces the environmental hazards associated with its disposal. Impedance of lignin and crystalline nature of cellulose pose major bottlenecks in biomass based energy. Though, several physio-chemicals processes are recommended as mitigation route but none of them seems to be promising for large scale application. In recent years, a right fusion of biological treatment combined with nanotechnology for efficient pretreatment and subsequent hydrolysis of biomass by ubiquitous enzymes seems to be promising alternative. In addition, to overcome these difficulties, nanotechnology-based methods have been recently adopted in catalytic valorization of lignocellulosic biomass. The present review has critically discussed the application of nano-biotechnology in lignocellulosic biomass valorization in terms of pretreatment and hydrolysis. A detailed discussion on the application of various nanoparticles in these processes, enzyme immobilization and end-production utilization is presented in this review. Finally, the review emphasizes the major challenges of this process along with different routes and recommendations to address the issues.

Electric shock-induced cardiac injuries requiring surgical intervention: Case series and a brief review.

BACKGROUND: Electric shock-induced cardiac injuries, such as myocardial infarction, thrombosis, and dissection, are rare. Few cases have been previously reported. The right coronary artery is most often affected because of its proximity to the chest wall. AIMS: To study the extend of electrical injuries on cardiac tissues and its surgical management. MATERIALS AND METHODS: We conducted a retrospective study on our patients in the last five years, looking for cardiac electrical injuries treated surgically in our department, we identified three cases. RESULT: Our three-case series, reported herein, showed that multiple cardiac tissues are susceptible to electrical injuries, specifically the left coronary artery, inferior vena cava, and right ventricular free wall. In our series, the first patient was a 32-year-old man with triple vessel thrombosis and dissection who survived the electric shock. The second patient was a 23-year-old man who had an inferior vena cava burn and bruising; his heart was used for transplantation. After the transplant, the recipient had a left coronary artery dissection and underwent coronary artery bypass grafting. The third patient was a 30-year-old man (potential heart donor) who had a hematoma of the right ventricular free wall, possible coronary artery dissection, inferior vena cava bruising, and tissue damage. His heart was not used for transplant because of quality concerns. CONCLUSION: We recommend that any person who sustains high voltage (500 V or more) electric shock should be evaluated carefully in the emergency department, including with echocardiography and cardiac catheterization, if indicated, to determine the extent of the injury and the viability of the heart, for patients who do not survive as a donor organ.

Kidney transplantation on extracorporeal life support for primary cardiac allograft dysfunction.

Patients undergoing heart-kidney transplants who have primary graft dysfunction (PGD) of the heart are at risk of losing both organs, which may cause reluctance on the part of the transplant team to proceed with transplanting the kidney while the transplanted heart is being supported by mechanical device. We describe a case series in which 2 patients received kidney transplants while on veno-arterial ECMO support for PGD after heart transplant. Both patients are alive more than 1 year following transplant, with good cardiac and renal function and no signs of cardiac rejection. Kidney transplant surgery is safe for patients on veno-arterial ECMO support for cardiac PGD. It allows the heart recipient to receive a kidney from the same donor with both immunologic and survival advantages.

Three-Dimensional-Printed Model as a Template for Chest Wall Reconstruction.

BACKGROUND: To our knowledge, this is the first time that a three-dimensional (3D)-printed model was used as an intraoperative template to recreate the resected portion of the lateral chest wall after resection of a large chest-wall tumour. METHODS: Fabrication of 3D-printed models requires collaboration among a surgeon, radiologist, segmenter, and 3D printing centre. Three-dimensional models are created with computed tomographic and magnetic resonance data. These models can provide an accurate guide for surgical resection and can be used intraoperatively as a template to construct tailored prostheses. RESULTS: We achieved complete resection of the chest wall defect, restored skeletal function and physiologic chest excursion, and achieved the best cosmetic appearance in all cases. CONCLUSIONS: Small- to medium-sized chest wall defects can be repaired with musculocutaneous flaps with or without prosthetic materials, but more complicated defects require increasingly sophisticated reconstructive techniques and technologies. An advanced technique is the use of a 3D-printed model of the chest wall as an intraoperative template.

Extracorporeal membrane oxygenation as a salvage therapy for patients with severe primary graft dysfunction after heart transplant.

BACKGROUND: Severe primary graft dysfunction (PGD) is the leading cause of early death after heart transplant. AIM: To examine the outcomes of heart transplant recipients who received venoarterial extracorporeal membrane oxygenation (VA-ECMO) for severe PGD. METHODS: We reviewed electronic health records of adult patients who underwent heart transplant from November 2005 through June 2015. We defined severe PGD according to International Society for Heart and Lung Transplantation consensus statements. RESULTS: Of 1030 heart transplant patients, 31 (3%) had severe PGD and required VA-ECMO. The mean (range) age was 59 (43-69) years. Fifteen patients (48%) underwent prior sternotomy and 10 (32%) received a left ventricular assist device as a bridge to transplant. Severe PGD manifested as failure to wean from cardiopulmonary bypass in 20 patients (65%) and as severe hemodynamic instability in the immediate postoperative period in 10 (32%), including cardiac arrest in 3 (10%). Twenty-five patients (81%) were successfully weaned from VA-ECMO, and 19 (61%) were discharged; the other 12 (39%) died. CONCLUSIONS: Although VA-ECMO is a common method for providing mechanical circulatory support to patients with PGD, multicenter studies are needed to assess factors associated with successful outcomes and improved survival of these patients.

A concerted enzymatic de-structuring of lignocellulosic materials using a compost-derived microbial consortia favoring the consolidated pretreatment and bio-saccharification.

The robustness of microbial consortia isolated from compost habitat encompasses the complementary metabolism that aids in consolidated bioprocessing (CBP) of lignocellulosic biomass (LCB) by division of labor across the symbionts. Composting of organic waste is deemed to be an efficient way of carbon recycling, where the syntrophic microbial population exerts a concerted action of lignin and polysaccharide (hemicellulose and cellulose) component of plant biomass. The potential of this interrelated microorganism could be enhanced through adaptive laboratory evolution (ALE) with LCB for its desired functional capabilities. Therefore, in this study, microbial symbionts derived from organic compost was enriched on saw dust (SD) (woody biomass), aloe vera leaf rind (AVLR) (agro-industrial waste) and commercial filter paper (FP) (pure cellulose) through ALE under different conditions. Later, the efficacy of enriched consortium (EC) on consolidated pretreatment and bio-saccharification was determined based on substrate degradation, endo-enzymes profiling and fermentable sugar yield. Among the treatment sets, AVLR biomass treated with EC-5 has resulted in the higher degradation rate of lignin (47.01 ± 0.66%, w/w) and polysaccharides (45.87 ± 1.82%, w/w) with a total sugar yield of about 60.01 ± 4.24 mg/g. In addition, the extent of structural disintegration of substrate after EC-treatment was clearly deciphered by FTIR and XRD analysis. And the factors of Pearson correlation matrix reinforces the potency of EC-5 by exhibiting a strong positive correlation between AVLR degradation and the sugar release. Thus, a consortium based CBP could promote the feasibility of establishing a sustainable second generation biorefinery framework.

Recent advances in bio-based production of top platform chemical, succinic acid: an alternative to conventional chemistry.

Succinic acid (SA) is one of the top platform chemicals with huge applications in diverse sectors. The presence of two carboxylic acid groups on the terminal carbon atoms makes SA a highly functional molecule that can be derivatized into a wide range of products. The biological route for SA production is a cleaner, greener, and promising technological option with huge potential to sequester the potent greenhouse gas, carbon dioxide. The recycling of renewable carbon of biomass (an indirect form of CO2), along with fixing CO2 in the form of SA, offers a carbon-negative SA manufacturing route to reduce atmospheric CO2 load. These attractive attributes compel a paradigm shift from fossil-based to microbial SA manufacturing, as evidenced by several commercial-scale bio-SA production in the last decade. The current review article scrutinizes the existing knowledge and covers SA production by the most efficient SA producers, including several bacteria and yeast strains. The review starts with the biochemistry of the major pathways accumulating SA as an end product. It discusses the SA production from a variety of pure and crude renewable sources by native as well as engineered strains with details of pathway/metabolic, evolutionary, and process engineering approaches for enhancing TYP (titer, yield, and productivity) metrics. The review is then extended to recent progress on separation technologies to recover SA from fermentation broth. Thereafter, SA derivatization opportunities via chemo-catalysis are discussed for various high-value products, which are only a few steps away. The last two sections are devoted to the current scenario of industrial production of bio-SA and associated challenges, along with the author's perspective.

Outcome of lung transplantation in patients with pulmonary alveolar microlithiasis in the era of COVID-19 infection.

Lung transplant recipients are at higher risk of developing COVID-19 infection compared to other solid organ transplants. The risk further increases in the unvaccinated patients. We present a case of a 43-year-old male who underwent bilateral sequential lung transplantation for pulmonary alveolar microlithiasis (PAM) and had an uneventful recovery. However, two years post-transplantation, the patient developed chronic lung allograft dysfunction (CLAD) with bronchiolitis obliterans syndrome and two episodes of COVID-19 infection. During the second episode of COVID-19 infection, the patient developed sepsis and multi-organ dysfunction ultimately resulting in death. Our case report highlights the increased susceptibility of PAM patients' post-lung transplant to COVID-19 infection. Continuous follow-up of PAM patients' post-lung transplantation is necessary to prevent unfavorable outcomes.