Trauma in Pregnancy.

Trauma in pregnancy can range from a mild injury, such as a fall from standing height, to a major injury, involving a penetrating injury or a high force motor vehicle collision. Providing care to a pregnant patient with trauma presents a unique challenge as 2 patients are at risk for complications, that is, the mother and the fetus, both of whom require evaluation and management. Health care professionals should be aware of and be prepared to manage complications of trauma in pregnancy, given its significant associated morbidity and mortality. This article details the epidemiology, etiology, assessment, diagnosis, and management of trauma in pregnancy.

Toxicological Emergencies.

Poisoning, drug overdose, and adverse drug effects continue to be a common encounter, especially in the intensive care unit (ICU). Patients are often critically ill or have a potential to rapidly deteriorate and warrant ICU admission. Adults suffering from overdoses rarely give a complete and accurate description of the quantity or type of medications ingested. In most adult cases, multiple substances are involved. A tentative diagnosis in most overdose and poisoning cases can be made by physical examination and simple laboratory tests (electrolyte panel, creatinine, serum osmolarity, urinalysis, etc). Supportive care, with particular attention to airway management, oxygenation, and circulation, is the mainstay of treatment. Basic treatment principles include limiting the amount of toxin absorbed, enhancing the elimination of ingested toxin, and preventing the conversion of non-toxic compounds to toxic metabolites. Drugs or poisons, where specific antidotes or effective therapies exist (especially acetaminophen, salicylates, methanol, ethylene glycol, and digitalis), should be aggressively sought and treated after initial stabilization has been accomplished. For those drugs or poisons where specific quantitative tests are available, levels should be obtained before treatment and may be repeated as clinically indicated.

De-novo fabrication of sunlight irradiated silver nanoparticles and their efficacy against E. coli and S. epidermidis.

Silver nanoparticles (AgNPs) gained significant attention due to their activity against microbial pathogens, cancer cells, and viral particles etc. Traditional fabrication methods require hazardous chemicals as reducing agents and their usage and disposal pose a significant hazard to environmental ecosystem. Here, a de novo, robust, cost effective and an eco-friendly method is reported to fabricate AgNPs irradiated with sunlight (SL) while using Salvadora persica root extract (SPE) as reducing agent. Sunlight (SL) irradiated S. persica silver nanoparticles (SpNPs) i.e., SL-SpNPs were characterized using multiple techniques and their antibacterial efficacy was evaluated. The SL-SpNPs were synthesized in 10 min. Field emission scanning electron microscopy (FE-SEM) and transmission electron microscopy (TEM) analysis revealed their spherical morphology with a size range of 4.5-39.7 nm, while surface plasmon resonance (SPR) peaked at 425 nm. Fourier transform infrared spectroscopy (FTIR) analysis suggested that the reduction of SL-SpNPs was due to the presence of phytochemicals in the SPE. Furthermore, X-ray powder diffraction (P-XRD) pattern depicted the crystal structure of SL-SpNPs, hence proving the presence of AgNPs. Further the antibacterial studies were carried out against Escherichia coli (ATCC 11229) and Staphylococcus epidermidis (ATCC 12228) using Kirby Bauer method. The minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) for E. coli were determined to be 1.5 µg/mL and 3.0 µg/mL respectively while MIC and MBC values for S. epidermidis were found to be 12.5 µg/mL and 25 µg/mL respectively. The solar irradiation-based fabrication method and resulting SL-SpNPs can find their utility in many biomedical and environmental applications.

A case of acquired immunodeficiency syndrome-related Kaposi sarcoma in a patient with COVID-19 - A brief review of HIV-COVID Co-infection and its Therapeutic challenges!

Barriers posed by the COVID-19 pandemic have led to reduced access to Human Immunodeficiency virus (HIV) care, leaving untreated patients at risk for various superimposed infections and malignancies such as Kaposi sarcoma (KS). We recently encountered a 37-year-old African-American male with a past medical history of HIV who tested positive for SARS-CoV-2 and was diagnosed with AIDS-related disseminated KS, representing the first reported case of COVID-19 infection with a newly diagnosed concomitant KS. The patient experienced multi-organ failure requiring tracheostomy, renal replacement therapy, and a prolonged intensive care unit (ICU) stay. Goals of care were changed to comfort measures and the patient passed away shortly afterwards. He was made comfort measures and passed away shortly afterwards. AIDS-related KS is a vascular tumor seen in association with Human Herpes Virus-8 (HHV-8). Management of limited AIDS-related KS typically includes combined antiretroviral therapy (ART) while multi-organ KS disease demands systemic chemotherapy. Immunosuppression should be avoided in patients with AIDS-related KS as it can lead to progression of KS. This recommendation is in conflict with the usual standard of care for patients with COVID-19 pneumonia, requiring clinical judgment and a customized approach based on the stage and severity of both the KS and the COVID-related disease. We briefly review HIV-COVID-19 coinfection, AIDS related KS and challenges associated with their management.

Amidst COVID-19 pandemic: the catastrophic sequelae of an inadvertent carotid artery insertion during central venous catheter placement - a case report.

Introduction: Central venous catheter (CVC) placement is one of the most commonly performed procedures in the intensive care unit for the institution of high-risk medications and nutrients. Despite the frequent use of ultrasound, inadvertent placement of CVC into the carotid artery is still possible. It carries significant morbidity due to the incidence of bleeding, arteriovenous fistula, and stroke. Methods: We present a case of accidental placement of CVC into the right carotid artery, which led to the right-sided temporoparietal stroke. Case Summary: A 71-year-old male was admitted to hospital with symptoms of cough, fatigue, and shortness of breath. He was diagnosed with coronavirus disease-19 and did require mechanical ventilation due to progressive hypoxic respiratory failure. The patient developed distributive shock and underwent CVC placement at the day of admission. On the 24th day of intubation, the patient was unable to move his left upper and lower extremities. Computed tomography (CT) head revealed showed a large temporoparietal stroke. CT Angiogram of head and neck revealed a misplaced CVC within the right common carotid artery . He was transferred to the Neuro ICU at our hospital where the patient underwent catheter removal and carotid artery sheath placement followed by dual antiplatelet therapy. Although the patient survived, he still required long-term facility placement due to the stroke. Conclusion: We reiterate that an experienced clinician must perform the CVC placement with ultrasound guidance and verify its placement with multiple confirmation techniques afterwards. Providers must manage unintentional carotid artery placement promptly to prevent long-term sequelae associated with it.

Pancreatic cancer Masquerading as lung nodules: A Diagnostic Dilemma.

To our knowledge, this is the first report of isolated pulmonary nodules as an initial presentation of underlying pancreatic cancer. We present a case of metastatic pancreatic cancer which manifested as worsening bilateral pulmonary nodules and normal abdominal imaging in a 72-year-old female patient. A navigational bronchoscopy with biopsy of lung nodules was performed which showed poorly differentiated adenocarcinoma. Carcinoembryonic antigen and CA 19-9 levels were elevated so endoscopic ultrasound with fine needle aspiration was done which revealed an underlying occult pancreatic adenocarcinoma. The patient was treated with chemotherapy. Patients with pulmonary metastasis have been shown to confer longer survival as compared to metastatic disease involving other organs. We have briefly reviewed the epidemiology, clinical characteristics and management of such cases in our report.

Primary Esophageal Small Cell Carcinoma Masquerading as Non-Hodgkin Lymphoma in a Young Patient.

BACKGROUND/AIM: Small cell cancer of the esophagus (SCCE) is an extremely rare entity with an aggressive clinical course, thus early diagnosis and treatment are important for improved survival. CASE REPORT: A 35-year-old male presented with dysphagia, loss of appetite and weight loss. Diagnostic workup revealed an esophageal mass, which was diagnosed as primary non-Hodgkin lymphoma (NHL) on initial biopsy. Despite receiving rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) chemotherapy for 3 months, there was an interval increase in the size of the esophagus mass, which unveiled underlying SCCE. A re-review of the previous biopsy specimen with immunohistochemical staining confirmed the initial diagnosis as SCCE as well. Despite 4 cycles of platinum-based chemotherapy and radiotherapy, the malignancy progressed and proved fatal. CONCLUSION: SCCE and non-Hodgkin lymphomas are rare entities, whose morphologies can be diagnostically challenging, hence they require special immunostaining for accurate diagnosis. Prompt diagnosis and initiation of treatment can confer better quality of life and survival.

Salvadora persica mediated synthesis of silver nanoparticles and their antimicrobial efficacy.

Silver nanoparticles (AgNPs) exhibit strong antimicrobial properties against many pathogens. Traditionally employed chemical methods for AgNPs synthesis are toxic for the environment. Here, we report a quicker, simpler, and environmentally benign process to synthesize AgNPs by using an aqueous 'root extract' of Salvadora persica (Sp) plant as a reducing agent. The synthesized Salvadora persica nano particles (SpNPs) showed significantly higher antimicrobial efficacy compared to earlier reported studies. We characterized SpNPs using UV-Vis spectroscopy, Fourier Transform Infrared Spectroscopy (FTIR), Transmission Electron Microscopy (TEM), Field Emission Scanning Electron Microscopy (FE-SEM), Dynamic Light Scattering (DLS) and X-ray powder diffraction (P-XRD). UV-Vis spectrum showed the highest absorbance at 420 nm. FTIR analysis depicts presence of bond stretching including OH- (3300 cm-1), C=N- (2100 cm-1) and NH- (1630 cm-1) which are attributed in the involvement of phenolics, proteins or nitrogenous compounds in reduction and stabilization of AgNPs. TEM, FE-SEM and DLS analysis revealed the spherical and rod nature of SpNPs and an average size of particles as 37.5 nm. XRD analysis showed the presence of the cubic structure of Ag which confirmed the synthesis of silver nanoparticles. To demonstrate antimicrobial efficacy, we evaluated SpNPs antimicrobial activity against two bacterial pathogens (Escherichia coli (ATCC 11229) and Staphylococcus epidermidis (ATCC 12228)). SpNPs showed a significantly high inhibition for both pathogens and minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) were found to be 0.39 µg/mL and 0.78 µg/mL for E. coli while 0.19 µg/mL and 0.39 µg/mL for S. epidermidis respectively. Further, Syto 16 staining of bacterial cells provided a supplemental confirmation of the antimicrobial efficacy as the bacterial cells treated with SpNPs stop to fluoresce compared to the untreated bacterial cells. Our highly potent SpNPs will likely have a great potential for many antimicrobial applications including wound healing, water purification, air filtering and other biomedical applications.

Nonpharmacological Therapies in COPD.

Chronic obstructive pulmonary disease has recently been gaining more attention, as beyond impacting roughly 10% of the world's population, it also carries high morbidity and mortality. The mainstay of management is optimizing pharmacological therapy, but various nonpharmacological therapies have shown benefits in providing symptom improvement and relief, prevention and mitigation of exacerbations, quality of life, and even mortality rate. Such modalities include supplemental oxygen therapy, pulmonary rehabilitation, viral and bacterial vaccinations, and noninvasive positive pressure ventilation therapy.

Evaluation and management of lower gastrointestinal bleeding.

Lower gastrointestinal bleeding (LGIB) is a common cause of presentation to the emergency department and hospital admissions. The incidence of LGIB increases with age and the most common etiologies are diverticulosis, angiodysplasia, malignancy and anorectal diseases. Foremost modality for evaluation and treatment of LGIB is colonosopy. Other diagnostic tools such as nuclear scintigraphy, computed tomography, angiography and capsule endoscopy are also frequently used in the workup of LGIB. Choice of treatment modality depends on the hemodynamic status of the patient, rate of bleeding, expertise and available resources. We present a comprehensive review of the evaluation and management of LGIB.

The mimic of tracheal carcinoid in elderly female.

We present a case of a glomus tumor of trachea in an elderly female who presented with a mass originating from the posterior trachea. She underwent rigid bronchoscopy with tumor debulking combined with laser therapy. Frozen section initially suggested carcinoid tumor but later turned out to be a glomus tumor. She improved with additional laser therapy. We present her clinical course and a literature review on glomus tumor.

A Rare Case of Aortoatrial Fistula from Streptococcal Endocarditis.

We represent an unfortunate case of postinfluenza streptococcal endocarditis in a 34-year-old healthy male. He presented with hypoxic respiratory failure and was found to have mitral and aortic valve vegetation. Hospital course was complicated by the presence of an aortoatrial fistula from an aortic root abscess, persistent septic shock, and multiorgan failure.

Metastatic renal carcinoid: To skin, lungs, and pancreas.

Carcinoid tumors rarely originate in the urogenital system. We represent a unique case of primary renal carcinoid tumor which was initially diagnosed as renal cell cancer and 10 years later correctly diagnosed as metastatic renal carcinoid.

Leiomyosarcoma of the Innominate Vein: A Smooth Muscle Criminal.

Leiomyosarcomas of vascular origin are extremely rare malignant tumors that can present a diagnostic challenge when they present as a mediastinal mass. Although they portend a poor prognosis with both aggressive local symptoms and metastatic disease, we present a rare case in which surgical en bloc resection of the tumor was curative.

A Case of Tuberculous Meningitis with Tuberculoma in Nonimmunocompromised Immigrant.

We present a case of tuberculous (TB) meningitis in nonimmunocompromised immigrant worker who initially presented with headache and later with generalized tonic clonic seizures and disseminated tuberculosis.

Acute Pneumonia.

Acute pneumonia is an active infection of the lungs that results when an individual at risk gets exposed to a particular microbiological pathogen. Acute pneumonia is the leading cause of death in the United States that is attributable to an infection. The risk factors, pathogenesis, and microbiological organisms involved differ if the pneumonia develops in the community versus health care-associated environment. The development of concise and comprehensive guidelines has led to an improvement in the management of the problem. However, the emergence of multidrug-resistant organisms and the increase in the percentage of elderly population keep mortality risk very substantial.

Acute Pneumothorax.

Pneumothorax is defined as the abnormal presence of air within the pleural space (cavity) that results in the partial or complete collapse of a lung. It can occur spontaneously or due to a traumatic event. Symptoms can vary from a nondescriptive complaint of shortness of breath or chest pain to complete cardiopulmonary collapse. Diagnosis is based on a combination of clinical suspicion along with supporting imaging studies. Treatment often involves surgical or nonsurgical approaches with goal to alleviate symptoms and prevent recurrence.

A Case of Spontaneous Rupture of the Diaphragm in a Young Pregnant Female Presenting with Hydropneumothorax.

We present a case of spontaneous rupture of the diaphragm in a young pregnant female mimicking hydropneumothorax. She had a chest tube placed on admission without any improvement in her symptoms, which led to further imaging. Chest and abdomen CT after a barium swallow confirmed the clinical diagnosis. She had definitive surgical repair followed by an uneventful clinical recovery.

A non-ionic surfactant reduces the induction time and enhances expression levels of bubaline somatotropin in Pichia pastoris.

This study describes a simple approach for enhanced secretory expression of bubaline somatotropin (BbST) in the methylotropic yeast Pichia pastoris. A Mut(s) Pichia transformant carrying multi-copy, non-codon optimized BbST cDNA sequence, expressed and secreted the recombinant protein into the culture medium to a level of 25 % of the total proteins in the culture supernatant, after 120 h of induction. Inclusion of polysorbate-80 in the inducing medium resulted in a significant improvement in the BbST expression (up to 45 % of the total culture supernatant proteins) with concomitant reduction in the induction time to 48 h. The amount of BbST obtained was 148 mg/L, which was around fivefold higher than that obtained without the surfactant. BbST was purified to near homogeneity by FPLC on Q-sepharose FF anion-exchange column. Protein authenticity was judged by SDS-PAGE and western blot analyses. A bioassay based on proliferation of Nb2 rat lymphoma cell lines confirmed that the purified, recombinant BbST is biologically active. Use of polysorbate-80 in combination with methanol, during the induction phase, is likely to have general applicability in lowering the induction time and enhancing the secretory expression of other commercially important proteins in Mut(s) strains of P. pastoris.