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Background First-line antifungal treatment for invasive mucormycosis (IM) consists of liposomal amphotericin B. Salvage treatment options are limited and often based on posaconazole oral suspension. With the approval of posaconazole new formulations, patients could benefit from improved pharmacokinetics, safety and tolerability. Objectives Our aim was to assess the effectiveness of posaconazole new formulations for IM treatment. Methods We performed a case-matched analysis with proven or probable IM patients from the FungiScope® Registry. First-line posaconazole new formulations (1st-POSnew) and first-line amphotericin B plus posaconazole new formulations (1st-AMB+POSnew) cases were matched with first-line amphotericin B-based (1st-AMB) treatment controls. Salvage posaconazole new formulations (SAL-POSnew) cases were matched with salvage posaconazole oral suspension (SAL-POSsusp) controls. Each case was matched with up to three controls (based on severity, haematological/oncological malignancy, surgery and/or renal dysfunction). Results Five patients receiving 1st-POSnew, 18 receiving 1st-AMB+POSnew and 22 receiving SAL-POSnew were identified. By day 42, a favourable response was reported for 80.0% (n = 4/5) of patients receiving 1st-POSnew, for 27.8% (n = 5/18) receiving 1st-AMB+POSnew and for 50.0% (n = 11/22) receiving SAL-POSnew. Day 42 all-cause mortality of patients receiving posaconazole new formulations was lower compared with controls [20.0% (n = 1/5) in 1st-POSnew versus 53.3% (n = 8/15) in 1st-AMB; 33.3% (n = 6/18) in 1st-AMB+POSnew versus 52.0% (n = 26/50) in 1st-AMB; and 0.0% (n = 0/22) in SAL-POSnew versus 4.4% (n = 2/45) in SAL-POSsusp]. Conclusions Posaconazole new formulations were effective in terms of treatment response and associated mortality of IM. While posaconazole new formulations may be an alternative for treatment of IM, the limited sample size of our study calls for a cautious interpretation of these observations.

Aim: This study aims to test the tensile strength and growth of Candida albicans on Viscogel tissue conditioner when incorporated with coconut oil (CCO) and to compare its efficacy with other antifungal agents. Settings and Design: Evaluative - In-vitro study design. Materials and Methods: Fifty dumbbell-shaped samples (n = 10) of Viscogel tissue conditioner were fabricated according to ASTM standard and were classified into 5 groups (10% CCO, 30% w/w tea tree oil, 5% w/w fluconazole, 0.03% w/w silver nanoparticles, and plain tissue conditioner). These samples were compared and evaluated for their tensile strength. Further to test the antifungal activity, a total of 60 samples (n = 15) were fabricated, each group (n = 15) was further divided into three subgroups (n = 5), namely 24-h, 3-day, and 5-day period, which were inoculated in sabouraud dextrose agar plate to test for the growth of C. albicans. Statistical Analysis Used: Oneway ANOVA and post hoc Tukey honestly significant difference test. Results: 10% w/w CCO yielded a mean tensile strength of 20.06 as compared to the plain tissue conditioner which showed a mean tensile strength of 17.81. Similarly, 10% w/w CCO incorporated into Viscogel tissue conditioner showed a significant reduction in the colonization of C. albicans on the 5th day. Conclusions: 10% w/w of CCO when mixed with Viscogel tissue conditioner showed a significant reduction in the growth of C. albicans, and addition of the same increased the tensile strength of the tissue conditioner.

Introduction Pneumothorax is a rare complication among mechanically ventilated patients and is even higher in patients with high positive end-expiratory pressure (PEEP). Herein we describe a case series of nine patients who were intubated due to acute respiratory disease syndrome (ARDS) secondary to coronavirus disease 2019 (COVID-19) and developed pneumothorax in due course. Case Description Nine patients with COVID-19 pneumonia who were on ventilators and eventually developed pneumothorax were analyzed retrospectively and outcomes were studied. The characteristics of patients like age, gender, and body mass index (BMI) were compared. Past medical history including smoking history was taking into consideration as well. We compared the total number of days on the ventilator, the highest PEEP they received, and the ventilator day when pneumothorax developed. Treatment: Cases 1,2,3,5,8 and 9 were treated with high dose steroids, hydroxychloroquine, tocilizumab, and convalescent plasma. Case 9 was treated with remdesivir. Case 7 received a high dose of steroids and hydroxychloroquine. Cases 4 and 6 were treated only with hydroxychloroquine. All patients died at the end of their hospital stay. Discussion Patients with COVID19 are at a higher risk of pneumothorax due to severe inflammation. It can be seen in any stage of the disease and might not be associated with the severity of the illness. Bullae formation and pneumothorax can be seen in previously healthy lungs. In our case-series of patients with COVID-19 who developed a pneumothorax, the mortality was noted to be 100%. The majority of patients were non-smokers and had no history of lung disease. Only one patient was a former smoker and had chronic obstructive pulmonary disease. High PEEP & low Fraction of inspired oxygen (FiO2) strategy is commonly used in patients with ARDS who are on a ventilator. As per NIH NHLBI ARDS Clinical Network Mechanical Ventilation Protocol, patients with ARDS and mechanical ventilation can be managed with 2 strategies: high PEEP, low FiO2, or low PEEP, high FiO2. Literature suggests that there is no significant difference between the outcomes in the two strategies. COVID-19 is a new illness with no specific guidelines on the management of ventilators. Intensivists should be cautious while maintaining PEEP in such patients and all efforts should be made to prevent pneumothorax. High FiO2 and low PEEP strategy should be considered while managing patients with COVID19 who are on a ventilator. There is a need for large-scale studies to co-relate with these outcomes.

Activated protein C (APC) is a plasma serine protease with antithrombotic and cytoprotective functions. Based on the hypothesis that specific inhibition of APC’s anticoagulant but not its cytoprotective activity can be beneficial for hemophilia therapy, 2 types of inhibitory monoclonal antibodies (mAbs) are tested: A type I active-site binding mAb and a type II mAb binding to an exosite on APC (required for anticoagulant activity) as shown by X-ray crystallography. Both mAbs increase thrombin generation and promote plasma clotting. Type I blocks all APC activities, whereas type II preserves APC’s cytoprotective function. In normal monkeys, type I causes many adverse effects including animal death. In contrast, type II is well-tolerated in normal monkeys and shows both acute and prophylactic dose-dependent efficacy in hemophilic monkeys. Our data show that the type II mAb can specifically inhibit APC’s anticoagulant function without compromising its cytoprotective function and offers superior therapeutic opportunities for hemophilia., Activated protein C (APC) is a plasma serine protease with antithrombotic and cytoprotective functions. Here, the authors develop a monoclonal antibody that specifically inhibits APC’s anticoagulant function without compromising its cytoprotective function, and shows efficacy in animal models.

The objectives of this study were to study the effect of COPD medication of 6 months or more duration on oral health parameters of adult patients. A cross-sectional study was conducted to assess and compare the decayed, missing, and filled teeth (DMFT), oral hygiene index-simplified (OHI-S), periodontal disease index (PDI) scores, and presence of candida (colony-forming units [CFU]) among adult patients aged 20-45 years who had a history of 6 months or longer duration usage of chronic respiratory disease medications, with controls. A total of 170 participants each were taken in both the groups. Oral health parameters like DMFT scores (p ≤ 0.002), OHI-S (p ≤ 0.001), calculus scores (p ≤ 0.001), plaque scores (p ≤ 0.001), and CFU/ml of candida species (p ≤ 0.001) were higher among cases than controls. DMFT scores and candida presence were significantly higher among those whose treatment duration was greater than 5 years as compared to those with lesser duration. Gingival-periodontal component scores of PDI were lower among cases than controls (p ≤ 0.001). Our findings suggest the need for regular oral health maintenance for those under COPD treatment and for greater research into the possible protective role of inhaled corticosteroids in limiting periodontal disease among patients.

Aims The current study aimed at determining the differences between the cutaneous microbial flora of patients with Type 2 diabetes mellitus (T2DM) and those without, and thus evaluate for cutaneous microbiome dysbiosis in diabetes. Methods We employed a case-control study design with 41 participants in each group. The skin over the toe-web space was swabbed and cultured aerobically. Data was analyzed for differences in microbial prevalences and growths between the two groups. Predictors for heavy colonization by microbes were analysed using logistic regression. Results We found significantly higher prevalences of Staphylococcus epidermidis among patients with T2DM (77.5% vs. 53.7%, p = 0.02). Further, when prevalent, these bacteria showed a significantly greater degree of skin colonization i.e. CFUs/cm 2 among these patients, p = 0.03. Highly pathogenic bacteria such as S. aureus were more prevalent among patients with T2DM. The regression model determined a significant association between T2DM status and heavy colonization by S. epidermidis (OR – 5.40, p = 0.02). Also, agricultural workers were significantly more likely to have heavy colonization by S. epidermidis (OR – 3.75, p = 0.02). Other predictor variables did not show significant association with heavy colonization by any of the isolated microbes. Conclusions Our findings support the existence of cutaneous microbiome dysbiosis among patients with T2DM. Literature suggests that microbiome dybiosis in T2DM could stem from the same activated innate immune response that is thought to be central to the development of T2DM. This dysbiosis could increase the risk of developing skin infections.

The genus Tritirachium is a mitosporic fungus which inhabits in soil and decaying plant material and also a notable insect pathogen. Human infections with Tritirachium species though rare were previously reported to cause corneal ulcers, otomycosis, onychomycosis, and dermatomycosis of the scalp and hence may be considered as a potential pathogen. Here we report a case of distal lateral subungual onychomycosis involving right great toenail in a 22-year-old female, wherein direct potassium hydroxide preparations, fungal cultures, and molecular sequencing of the isolate established Tritirachium oryzae as the etiological agent. Antifungal susceptibility performed by the microbroth technique of CLSI revealed increased MICs to amphotericin B and low MICs to azoles and echinocandins. The case was managed with surgical nail avulsion followed by topical application of 2% ketoconazole cream resulting regrowth of normal nail. To the best of our knowledge, this is the first report of non-dermatophytic mold T. oryzae causing onychomycosis in India.

Probiotics play a vital role in clinical applications for the treatment of diarrhea, obesity and urinary tract infections. Phytate, an anti-nutrient, chelates essential minerals that are vital for human health. In the past few decades, research reports emphasize extensively on phytate degradation in animals. There is a growing need for finding alternate strategies of phytate utilization in human, as they are unable to produce phytase. At this juncture, probiotics can be utilized for phytase production to combat mineral deficiency in humans. The main focus of this review is on improving phosphate bioavailability by employing two approaches: supplementation of (1) fermented food products that contain probiotics and (2) recombinant phytase producing bacteria. In addition, several factors influencing phytase activity such as bacterial viability, optimal pH, substrate concentration and specificity were also discussed.

Purpose. To report a case series of three patients who developed significant bradycardia while receiving the combination of dexmedetomidine and fentanyl for sedation and analgesia. Materials and Methods. This is a case series of patients obtained from a mixed medical, surgical, and cardiac ICU in a community teaching hospital. Three intubated patients receiving fentanyl and dexmedetomidine infusion developed sudden bradycardia requiring intervention. In all three cases, adjustments to therapy were required. Results. All three patients experienced significant bradycardia, with a heart rate less than 50 bpm, and one patient briefly developed asystole. In Case 1, the fentanyl infusion rate was reduced by 67% and the dexmedetomidine infusion rate was reduced by 25%. In Case 2, the sedation was changed to midazolam, and in Case 3, both fentanyl and dexmedetomidine were discontinued. In all three cases, there were no further incidences of significant bradycardia following intervention. Conclusions. Fentanyl used in combination with dexmedetomidine can result in clinically significant bradycardia. Further study is warranted to identify risk factors and elucidate the mechanisms that result in life-threatening bradycardia.

This article is a Letter to the Editor and does not include an Abstract.

Schizophyllum commune is an emerging basidiomycetous fungus increasingly reported attributing pulmonary infections. However, the involvement of S. commune in primary cutaneous ulcerative lesions in humans has not yet been reported. The aetiology of S. commune in wound infection may be overlooked or misdiagnosed. This may be due to the atypical colony morphology, lack of sporulation, and familiarity with this fungus as well as the difficulty in accurate identification. We report here the first case of an ulcerative cutaneous infection caused by S. commune in the plantar aspect of foot in a healthy individual. Skin grafting was performed and the wound healed completely.

Background Onychomycosis is extremely rare in neonates, infrequently reported in children and is considered to be exclusively a disease of adults. Case presentation We, herein report a case of fingernail onychomycosis in a 28-day-old, healthy, male neonate. The child presented with a history of yellowish discoloration of the fingernail of the left hand for one week. The etiological agent was demonstrated both by microscopic examination and culture of nail clippings. The isolate grown on culture was identified as Candida albicans by phenotypic characteristics and by matrix-assisted laser desorption ionization-time of flight mass spectrometry. Antifungal sensitivity testing was performed by broth dilution method as per the Clinical & Laboratory Standards Institute guidelines. An oral swab culture of the child also yielded C. albicans with the same antibiogram as the nail isolate. The case was diagnosed as distal and lateral subungual candida onychomycosis of severity index score 22 (severe) and was treated with syrup fluconazole 6 mg/kg body weight/week and 5% amorolfine nail lacquer once/week for three months. After three months of therapy, the patient completely recovered with the development of a healthy nail plate. Conclusions The case is presented due to its rarity in neonates which, we suppose is the first case report of onychomycosis from Nepal in a 28-day-old neonate. Oral colonization with pathogenic yeasts and finger suckling could be risk factors for neonatal onychomycosis.

UNLABELLED ESSENTIALS: Antithrombin III (AT)β binds heparin with higher affinity than ATα. A conformation-specific antibody against ATβ, TPP2009, was made to investigate ATβ in hemostasis. TPP2009 bound specifically to heparin-ATβ and greatly reduced the anticoagulant effect of AT. This antibody was effective in elucidating the importance of ATβ in hemostasis. BACKGROUND Antithrombin III (AT)β is an isoform of AT that lacks the post-translational carbohydrate modification at Asn135. This isoform binds heparin with greater affinity than ATα, and has been shown to target antithrombotic function to the extracellular vascular endothelial injury site. OBJECTIVES To characterize a conformation-specific antibody against ATβ and begin to investigate the role of ATβ in maintaining hemostasis. METHODS Surface plasmon resonance (SPR), antigen binding and functional assays were conducted to characterize the mode of action of antibodies generated against heparin-bound ATβ (ATβ*H) by the use of phage display. RESULTS SPR and binding studies showed that one of the antibodies, TPP2009, bound specifically to ATβ*H and glycosaminoglycan-associated ATβ on endothelial cells. In diluted prothrombin and activated factor X (FXa)-induced clotting assays, TPP2009 dose-dependently reduced the anticoagulant effect of heparin in non-hemophilic and FVIII-deficient human plasma, with half-maximal effective concentrations (EC50 ) of 10.5 nm and 4.7 nm, respectively. In AT-deficient human plasma, TPP2009 dose-dependently inhibited the effects of exogenously added ATβ and heparin. In purified systems with ATβ and pentasaccharide, TPP2009 restored > 91% of FXa activity. TPP2009 dose-dependently reversed the effects of heparin in rabbit (EC50 , 25.7 nm) and cynomolgus monkey (EC50 , 21.5 nm) plasma, but not in mouse plasma. TPP2009 was also effective in partially restoring FXa activity in rabbit and cynomolgus monkey plasma treated with FVIII function-neutralizing antibodies. CONCLUSIONS TPP2009 specifically targets a unique conformational epitope on ATβ*H and blocks ATβ-mediated anticoagulation. It effectively promotes coagulation in plasma, indicating the importance of ATβ in hemostasis.

Aspergillus and Fusarium are the most common fungi causing mycotic keratitis. Injury to the eye with vegetable matter, cow tail injury, long-term use of topical steroids are some of the risk factors for mycotic keratitis. There are few case reports of keratitis caused by Bipolaris. The human pathogenic species in the genus are Bipolaris spicifera, Bipolaris hawaiiensis, Bipolaris papendorfii, and Bipolaris australiensis. Most commonly reported keratitis is caused by B. hawaiiensis, followed by B. spicifera. Literature review showed only one case report of keratitis due to B. australiensis reported from Australia. We present a first case report of keratitis due to B. australiensis (currently Curvularia australienis) from India.

This is a case of an elderly woman who presented to our emergency room with an episode of a witnessed fall. The past medical history of the patient was significant for post-stroke epilepsy for which she was on oxcarbazepine. Initial blood work showed a white cell count of 4.5, haemoglobin of 12.4, and platelet count of 15,000. Peripheral blood smear showed normal platelet and red cell morphology without clumping. The patient's history suggested that she was recently started on oxcarbazepine prompting discontinuing of the drug. The platelet count improved from 15,000 cells/mL to 80,000 cells/mL on discharge.Antiepileptic medications have been reported to cause various blood dyscrasias in the literature. There are few studies that report the association of carbamazepine and thrombocytopenia and much fewer written about oxcarbazepine. Thrombocytopenia appears to be an uncommon reported side effect of oxcarbazepine; more commonly reported side effects include dizziness, tiredness, memory problems and headache. The treatment of antiepileptic drug-associated thrombocytopenia is discontinuing the medication and monitoring the platelet counts. In few cases, immunoglobulin infusion is required. Antiepileptic drug-associated thrombocytopenia is difficult to predict and so it is imperative to monitor the platelet level when antiepileptic drugs are started and even after the medication is switched to a different one.

The potential role of actinobacteria at the frontiers of mammalian infectious diseases is often misapprehended. Most often they are overlooked, and their involvement conceivably cascades into the gray zones of routine diagnostic bacteriology and medical mycology. This chapter provides an impression of the unique structure, evolution, distribution, and taxonomy of pathogenic actinobacteria, with emphasis on the genus Nocardia. It explores the relatively undermined pathogenic prospect of members of this group. It begins with various phenotypic attributes such as morphology, physiology, growth requirements, and virulence profiles. It encompasses various diagnostic modalities, susceptibility profiles, protocols, and algorithms for phenotypic and genotypic identification. Towards the end, it comprehends the clinical significance, and management of actinobacteria associated infections will be discussed.

Introduction: The auxanographic carbohydrate assimilation had been an important method for differentiation of yeasts. Prevailing methods described in the literature for carbohydrate assimilation has limited scope for use in large scale yeast identification. Aim: To optimize the large scale auxanographic carbohydrate assimilation method for yeast identification. Materials and Methods: A modified auxanographic carbohydrate assimilation method was developed and a total of 35 isolates of Candida species comprising of four ATCC (American Type Culture Collection) Candida strains (Candida albicans ATCC 90028, Candida tropicalis ATCC 90018, Candida parapsilosis ATCC 750, Candida krusei ATCC 6258) and 31 clinical isolates of Candida tropicalis (n=13), Candida krusei (n=7), Candida glabrata (n=3), Candida kefyr (n=3), Candida albicans (n=5) were validated. The carbohydrates tested were Glucose, Sucrose, Maltose, Lactose, Cellubiose, Raffinose, Trehalose, Xylose, Galactose and Dulcitol. Results: A total of 35 Candida species were tested for their carbohydrate assimilative property and the results were consistent with the existing standard protocols. A well circumscribed opaque yeast growth indicated assimilation of the test carbohydrate and translucent to opalescent growth with the outline of initial inoculum alone indicated lack of assimilation. The control plate indicated no growth of the Candida species. Conclusion: The carbohydrate assimilation tests finds utility for yeast diversity studies exploring novel ecological niches. The technique described here facilitates testing of an extended range of carbohydrates and yeasts in a cost effective manner.

Background Poultry farming and consumption of poultry ( Gallus gallus domesticus ) meat and eggs are common gastronomical practices worldwide. Till now, a detailed understanding about the gut colonisation of Gallus gallus domesticus by yeasts and their virulence properties and drug resistance patterns in available literature remain sparse. This study was undertaken to explore this prevalent issue. Results A total of 103 specimens of fresh droppings of broiler chickens (commercial G domesticus ) and domesticated chickens (domesticated G domesticus ) were collected from the breeding sites. The isolates comprised of 29 (33%) Debaryozyma hansenii ( Candida famata) , 12 (13.6%) Sporothrix catenata ( C. ciferrii ), 10 (11.4%) C. albicans , 8 (9.1%) Diutnia catenulata ( C. catenulate) , 6 (6.8%) C. tropicalis , 3 (3.4%) Candida acidothermophilum (C. krusei) , 2 (2.3%) C. pintolopesii , 1 (1.1%) C. parapsilosis , 9 (10.2%) Trichosporon spp. (T. moniliiforme, T. asahii) , 4 (4.5%) Geotrichum candidum , 3 (3.4%) Cryptococcus macerans and 1 (1%) Cystobasidium minuta (Rhodotorula minuta ). Virulence factors, measured among different yeast species, showed wide variability. Biofilm cells exhibited higher Minimum Inhibitory Concentration (MIC) values (μg/ml) than planktonic cells against all antifungal compounds tested: (fluconazole, 8–512 vs 0.031–16; amphotericin B, 0.5–64 vs 0.031–16; voriconazole 0.062–16 vs 0.062–8; caspofungin, 0.062–4 vs 0.031–1). Conclusions The present work extends the current understanding of in vitro virulence factors and antifungal susceptibility pattern of gastrointestinal yeast flora of G domesticus. More studies with advanced techniques are needed to quantify the risk of spread of these potential pathogens to environment and human.

The incidence of Invasive Aspergillosis (IA), an opportunistic infection is on the rise; mainly due to an increasing number of immunocompromised patients. Early diagnosis of IA remains challenging and treatment options are limited. Histopathologic or cytological evidence of fungus still remains main diagnostic criteria for proven invasive Aspergillosis cases. Detection of the fungus in the specimens of immunosuppressed patients is difficult. Detection methods based on cell-wall antigens of Aspergillus such as galactomannan and β-d-glucan has been reported and are in clinical use. However cross reactivity of these tests with other fungi limits their use. Recently an Aspergillus-specific monoclonal antibody, JF5, specifically bindinggalactomannan antigen, for point-of-care diagnosis of IPA using lateral-flow technology is being examined. Quantitative polymerase chain reaction assays for Aspergillus has theoretical advantages but is not validated for clinical use. This necessitates development of dependable, sensitive and specific methods for the detection of Aspergilli pathogens in clinical samples. Further extensive use of antifungal drugs in prophylactic and therapeutic practice has led to development of drug resistance. Development of novel strategies for finding new biomarkers to provide early and accurate diagnosis is thus vital. Proteomics approach can provide a means to screen for both host- and pathogen-derived biomarkers that could be suitable for the diagnosis, as well as to study the host-pathogen interaction in invasive pulmonary Aspergillosis. Identification of novel biomarkers from Aspergillus and its thoughtful use in molecular and serological diagnostic techniques into clinical practice will undoubtedly improve the scope of IA diagnosis.

Primary cutaneous nocardiosis can present as an abscess or cellulitis with sporotrichoid morphology. Deep inoculation in the subcutaneous tissue can present as a mycetoma. Mycetoma over the elbow region is rare. We herein describe a case of primary cutaneous nocardiosis presenting as a mycetoma, caused by Nocardia asteroides. The patient had extensive keloidal lesions with few sinuses extruding serous discharge over the right forearm around elbow joint. Initially pus and later, the deep tissue biopsy samples were sent for culture and sensitivity, without suspecting nocardial infection. Gram stain of the pus showed few WBCs and occasional Gram positive branching filaments. Modified Kinyoun stain of the same revealed acid-fast filamentous structures. Culture of the tissue specimen yielded Nocardia asteroides. The patient responded well to a modified Ramam's regime. On follow-up, the patient showed no recurrence at 1 year. Our case demonstrates the need for focused clinical search with a high degree of suspicion, and appropriate laboratory procedures in the diagnosis and management of cutaneous nocardiosis.

Background:Anesthetics, analgesics, and surgery may profoundly affect sleep architecture and aggravate sleep-related breathing disturbances. The authors hypothesized that patients with preoperative polysomnographic evidence of obstructive sleep apnea (OSA) would experience greater changes in these parameters than patients without OSA.Methods:After obtaining approvals from the Institutional Review Boards, consented patients underwent portable polysomnography preoperatively and on postoperative nights (N) 1, 3, 5, and 7 at home or in hospital. The primary and secondary outcome measurements were polysomnographic parameters of sleep-disordered breathing and sleep architecture.Results:Of the 58 patients completed the study, 38 patients had OSA (apnea hypopnea index [AHI] >5) with median preoperative AHI of 18 events per hour and 20 non-OSA patients had median preoperative AHI of 2. AHI was increased after surgery in both OSA and non-OSA patients (P < 0.05), with peak increase on postoperative N3 (OSA vs. non-OSA, 29 [14, 57] vs. 8 [2, 18], median [25th, 75th percentile], P < 0.05). Hypopnea index accounted for 72% of the postoperative increase in AHI. The central apnea index was low (median = 0) but was significantly increased on postoperative N1 in only non-OSA patients. Sleep efficiency, rapid eye movement sleep, and slow-wave sleep were decreased on N1 in both groups, with gradual recovery.Conclusions:Postoperatively, sleep architecture was disturbed and AHI was increased in both OSA and non-OSA patients. Although the disturbances in sleep architecture were greatest on postoperative N1, breathing disturbances during sleep were greatest on postoperative N3.

A 51-year-old man with end-stage renal disease presented with extensive necrotic ulcers and eschar on both legs.

Intestinal parasitic infestation has been a major public health problem throughout the world, particularly in developing countries owing to unhygienic living conditions. Early and accurate diagnosis as well as improvement in detection rates of intestinal parasites is of prime importance in limiting the incidence of parasitic infestations and decreasing the disease burden. In the present study, we introduce a novel gauze filtration technique to improve the detection rates of intestinal parasites. The technique is simple, inexpensive and time-saving. Detection rate is 96.5% compared to the sedimentation technique, which was considered as the gold standard. This technique can be utilized in peripheral laboratory settings with limited resources and untrained personnel.

A 32 year old female presented with a 4 year history of on and off dry scaly lesions in the webspaces. KOH mount of the skin scrapings was positive for fungal hyphae. The fungus was isolated on Sabouraud dextrose agar and identified as Cylindrocarpon lichenicola. The patient was treated and responded to itraconazole.

SummaryVascular hyperpermeability contributes to morbidity in inflammation. Current methodologies for in vivo assessment of permeability based on extravasation of Evans Blue (EB)-bound albumin are cumbersome and often lack sensitivity. We developed a novel infrared fluorescence (IRF) methodology for measurement of EB-albumin extravasation to quantify vascular permeability in murine models. Vascular permeability induced by endotoxaemia was examined for all solid organs, brain, skin and peritoneum by IRF and the traditional absorbance-based measurement of EB in tissue extracts. Organ IRF increased linearly with increasing concentrations of intravenous EB (2.5–25 mg/kg). Tissue IRF was more sensitive for EB accumulation compared to the absorbance-based method. Accordingly, differences in vascular permeability and organ EB accumulation between lipopolysaccharide-treated and saline-treated mice were often significant when analysed by IRF-based detection but not by absorbance-based detection. EB was detected in all 353 organs analysed with IRF but only in 67% (239/353) of organs analysed by absorbance-based methodology, demonstrating improved sensitivity of EB detection in organs with IRF. In contrast, EB in plasma after EB administration was readily measured by both methods with high correlation between the two methods (n=116, r2=0.86). Quantitation of organ-specific EB-IRF differences due to endotoxin was optimal when IRF was compared between mice matched for weight, gender, and age, and with appropriate corrections for organ weight and EB plasma concentrations. Notably, EB-IRF methodology leaves organs intact for subsequent histopathology. In summary, EB-IRF is a novel, highly sensitive, rapid, and convenient method for the relative quantification of EB in intact organs of treatment versus control mice.

In this study, condensation of 2-amino-5-chlorobenzoic acid with benzoyl chloride afforded 2-benzamido-5-chloro benzoic acid which on cyclization with different primary amines yielded the corresponding 6-chloro-2-phenyl-3-substituted quinazolin-4(3H)-ones (V1–V8). The reaction was monitored by thin layer chromatographic analysis. The structure of the synthesized compounds was confirmed by spectral studies and elemental analysis. All these compounds were screened for their anti-inflammatory, antiproliferative and antimicrobial activities. Anti-inflammatory activity was done by rat paw oedema method. Compounds V6 and V5 showed a good percentage inhibition of inflammation at the 2nd and the 3rd h, respectively. Antiproliferative activity was carried out by MTT assay against Chang liver, Hep2 and HeLa cell lines. Compounds V1, V5 and V8 showed antiproliferative activity at low concentrations. The minimum inhibitory concentrations (MIC) of the synthesized compounds against Pseudomonas aeruginosa, Staphylococcus aureus, Escherichia coli, Candida albicans and Aspergillus flavus was studied by microdilution assay. Compound V4 was found to be a potent antimicrobial agent against the organisms tested. Further, it was selected for time kill study. These data revealed that the compounds containing chloro- and/or fluoro-substituted phenyl ring or N,N-dimethyl ethyl substitutions in the quinazolin-4(3H)-ones led to increase of their biological activities.

Sporotrichosis caused by the fungus Sporothrix schenckii has been widely reported from the northern Himalayan belt and the north eastern region of India. Three autochthonous cases of lymphocutaneous sporotrichosis from east and south districts of Sikkim are reported. Fluid aspirate from the nodulo-ulcerative lesions were sent for cytology and fungal culture. S. schenckii was isolated on culture and cytological examination in all three cases showed granulomatous reaction. Thermal dimorphism was demonstrated and animal pathogenicity testing was performed. Saturated solution of potassium iodide was used for treatment and the last case was treated with itraconazole and potassium iodide. Awareness of this disease and an extensive environmental study is required to understand the actual burden of this disease.

PURPOSE: Endophthalmitis due to Pyrenochaeta romeroi has not been reported in literature (PubMed, Medline). We report an interesting case of P. romeroi causing chronic endophthalmitis in an immunocompetent lady.METHODS:Retrospective interventional case report. A 25-year-old immunocompetent lady presented with pain and redness in the left eye of 1-month duration. Her best-corrected visual acuity was 6/6 and 6/18 in the right and the left eyes, respectively. Slit-lamp examination of the left eye showed a corneal stromal scar, fibrinlike material in the anterior chamber, few retrolental cells, and normal fundus examination. RESULTS:Aqueous taps on two occasions were negative for bacteria and fungi on routine smear, culture, and nested polymerase chain reaction. As inflammation recurred despite intravitreal voriconazole and amikacin injections, a lensectomy with vitrectomy was done. During vitrectomy, dense flocculent material was seen in the pars plana with only scleral indentation. The flocculent material grew a rare filamentous fungus called P. romeroi. The left eye underwent retinal detachment surgery with silicone oil insertion for a giant retinal tear at 2 months of follow-up. At 6 months of follow-up, her vision in the left eye was stable at 6/24 (Snellen) with no ocular inflammation.CONCLUSION:P. romeroi may need to be added in the list of rare fungi, which cause chronic endophthalmitis.

Yeasts produce killer toxin, which gives them a selective advantage against susceptible yeasts. In this study we isolated 8 various non-pathogenic yeasts from 12 different food products and detected killer toxin activity in them against a clinical isolate of Cryptococcus neoformans by chloroform exposure method. The experiment was performed in two sets that had 3 replicates each. The first set plates and the second set plates were exposed to chloroform once and twice respectively. Among the 8 yeasts, 5 yeasts namely Sachharomyces cerevisiae, Candida pintolopesii, Candida tropicalis, Pichia anomala and Dekkera spp. showed significant amount of killer toxin activity against Cryptococcus neoformans in all the replicates, followed by candida parapsilosis and Trichosporon asahii, which showed killer toxin activity only in two of the three replicates. Geotrichum candidum showed no killer toxin activity. Killer toxin activity was observed in vitro in non-pathogenic yeast strains against medically important Cryptococcus neoformans. Keywords: Yeasts; Killer toxin; Chloroform exposure. © 2010 JSR Publications. ISSN: 2070-0237 (Print); 2070-0245 (Online). All rights reserved. DOI: 10.3329/jsr.v2i2.4159 J. Sci. Res. 2 (2), 407-411 (2010)

Obstructive sleep apnea (OSA) is presumed to be a risk factor for postoperative morbidity and mortality, but the current evidence is incomplete. This retrospective matched cohort study tested the hypothesis that OSA is a risk factor for the development of postoperative complications.Hospital ethics approval was obtained for the conduct of this study. The patients who were selected for the study were18 yr of age, diagnosed preoperatively with OSA, and scheduled to undergo elective surgery. A cohort of surgical patients without OSA was used as a comparator group based on a one-to-one match. Matching criteria included gender, age difference5 yr, type of surgery, and a5 yr difference between two surgery dates. Summary data are presented and conditional logistic regression was used to identify risk factors for postoperative complications.The 240 pairs of study subjects aged 57 +/- 13 yr included 184 (77%) males and 56 (23%) females. The OSA patients had a higher mean body mass index relative to their non-OSA counterparts (35 +/- 9 vs 28 +/- 6 kg . m-2, respectively) and a higher frequency of co-morbidities, including hypertension (48% vs 36%, respectively) and obesity (61% vs 23%, respectively). Also, the incidence of postoperative complications in the OSA patients was significantly greater (44% OSA group vs 28% non-OSA group; P0.05). The most commonly observed between-group difference was oxygen desaturation90% (17% OSA group vs 8% non-OSA group). The OSA patients who did not use home continuous positive airway pressure (CPAP) devices prior to surgery but required the use of a CPAP device after surgery had the highest rate of complications. Conditional logistic regression was used to diagnose OSA and pre-existing stroke as significant risk factors for developing postoperative complications. The hazard ratio for OSA was 2.0 (1.25-3.19).Patients with diagnosed OSA have an increased incidence of postoperative complications, the most frequent being oxygen desaturation.

The aim of the present study was to analyse the sustain release of Chlorhexidine with Chitosan and to investigate the antimicrobial activity of 2% Chlorhexidine gel, 2% Chitosan gel and their combination against Candida albicans and Enterococcus faecalis. Sustain release of Chlorhexidine with Chitosan was determined using UV spectrophotometer. Then the inoculae of these organisms were used to make the lawn culture on sabouraud's dextrose agar and blood agar plates. Wells were prepared in these lawn cultures and filled with 2% Chlorhexidine gel, 2% Chitosan gel and their combination. The agar plates were incubated overnight at 37 degrees C and the zone of inhibition was examined after 48 h. Release of Chlorhexidine with Chitosan was better than plain Chlorhexidine release. Combination of Chlorhexidine and Chitosan showed maximum inhibitory zone for C. albicans (25.2 mm) and E. faecalis (26.0 mm). Plain Chlorhexidine gel showed intermediate inhibitory zone for C. albicans (20.6 mm) and E. faecalis (21.4 mm) and plain Chitosan gel showed minimum inhibitory zone for C. albicans (16.6 mm) and E. faecalis (11.0 mm). Carbopol which served as control did not have any antimicrobial effect. The present study suggests that 2% Chlorhexidine gel in combination with 2% Chitosan gel has the highest antimicrobial effect against C. albicans and E. faecalis compared with 2% Chlorhexidine gel or 2% Chitosan gel alone.

SummaryThe hypothesis that prothrombin (FII) protects coagulation factor Va (FVa) from proteolytic inactivation by activated protein C (APC) was tested using purified proteins. FII dose-dependently protected FVa from APC proteolysis under conditions where competition of proteins for binding to negatively-charged phospholipid surface was not relevant (i.e. either at high phospholipid vesicle concentrations or using soluble dicaproylphosphatidylserine at levels below its critical micellar concentration). Cleavages in FVa at both Arg506 and Arg306 by APC were inhibited by FII. FII did not alter the amidolytic activity of APC towards chromogenic oligopeptide substrates or inhibit FVIIIa inactivation by APC, implying that the FII-mediated protection of FVa from APC proteolysis was due to the ability of FII to inhibit protein-protein interactions between FVa and APC. FII also protected FVa from inactivation by Gla-domainless APC, ruling out a role for the APC Gla domain for these observations. To identify domains of FII responsible for the observed phenomenon, various forms or fragments of FII were employed. Biotin-PheProArg-CMK-inhibited meizothrombin and fII-fragment 1•2 protected FVa from proteolysis by APC. In contrast, no significant protection of FVa from APC cleavage was observed for Gladomainless-FII, prethrombin-1, prethrombin-2, FII fragment 1 or active site inhibited-thrombin (DEGR-thrombin). Overall, these data demonstrate that the Gla domain of FII linked to kringle 1 and 2 is necessary for the ability of FII to protect FVa from APC cleavage and support the general concept that assembly of the FII activation complex (FXa•FVa•FII•lipid surface) protects FVa from APC inactivation so that the procoagulant, thrombin generating pathway can act unhindered by APC. Only following FII activation and dissociation of the FII Gla domain fragments from the FII-ase complex, can APC inactivate FVa and down-regulate thrombin generation.

PURPOSE: Upper airway abnormalities carry the risk of obstructive sleep apnea (OSA) and difficult tracheal intubations. Both conditions contribute to significant clinical problems and have increased perioperative morbidity and mortality. We hypothesized that patients who presented with difficult intubation would have a very high prevalence of OSA and that those with unexpected difficult intubation may require referral to sleep clinics for polysomnography (PSG). METHODS: Patients classified as a grade 4 Cormack and Lehane on direct laryngoscopic view, and who required more than two attempts for successful endotracheal intubation, were referred to the study by consultant anesthesiologists at four hospitals. Apnea-hypopnea index (AHI) data and postoperative events were collected. Patients with AHI 5/h were considered positive for OSA. Clinical and PSG variables were compared using t-tests and 2 test. RESULTS: Over a 20-mo period, 84 patients with a difficult intubation were referred into the study. Thirty-three patients agreed to participate. Sixty-six percent (22 of 33) had OSA (AHI 5/h). Of the 22 OSA patients, 10 patients (64%) had mild OSA (AHI 5–15), 6 (18%) had moderate OSA (AHI 15/h), and 6 (18%) had severe OSA (AHI 30/h). Of the 33 patients, 11 patients (33%) were recommended for continuous positive airway pressure treatment. Between the OSA group and the non-OSA group, there were significant differences in gender, neck size, and the quality of sleep, but there were no significant differences in age and body mass index. CONCLUSIONS: Sixty-six percent of patients with unexpected difficult intubation who consented to undergo a sleep study were diagnosed with OSA by PSG. Patients with difficult intubation are at high risk for OSA and should be screened for signs and symptoms of sleep apnea. Screening for OSA should be considered by referral to a sleep clinic for PSG. (Anesth Analg 2008;107:915‐20)

Background Obstructive sleep apnea (OSA) is a major risk factor for perioperative adverse events. However, no screening tool for OSA has been validated in surgical patients. This study was conducted to develop and validate a concise and easy-to-use questionnaire for OSA screening in surgical patients. Methods After hospital ethics approval, preoperative patients aged 18 yr or older and without previously diagnosed OSA were recruited. After a factor analysis, reliability check, and pilot study; four yes/no questions were used to develop this screening tool. The four questions were respectively related to snoring, tiredness during daytime, observed apnea, and high blood pressure (STOP). For validation, the score from the STOP questionnaire was evaluated versus the apnea-hypopnea index from monitored polysomnography. Results The STOP questionnaire was given to 2,467 patients, 27.5% classified as being at high risk of OSA. Two hundred eleven patients underwent polysomnography, 34 for the pilot test and 177 for validation. In the validation group, the apnea-hypopnea index was 20 +/- 6. The sensitivities of the STOP questionnaire with apnea-hypopnea index greater than 5, greater than 15, and greater than 30 as cutoffs were 65.6, 74.3, and 79.5%, respectively. When incorporating body mass index, age, neck circumference, and gender into the STOP questionnaire, sensitivities were increased to 83.6, 92.9, and 100% with the same apnea-hypopnea index cutoffs. Conclusions The STOP questionnaire is a concise and easy-to-use screening tool for OSA. It has been developed and validated in surgical patients at preoperative clinics. Combined with body mass index, age, neck size, and gender, it had a high sensitivity, especially for patients with moderate to severe OSA.