Dry Membranes Research Articles

Point-of-care ultrasound to assess volume status and pulmonary oedema in malaria patients

PurposeFluid management is challenging in malaria patients given the risks associated with intravascular fluid depletion and iatrogenic fluid overload leading to pulmonary oedema. Given the limitations of the physical examination in guiding fluid therapy, we evaluated point-of-care ultrasound (POCUS) of the inferior vena cava (IVC) and lungs as a novel tool to assess volume status and detect early oedema in malaria patients.MethodsTo assess the correlation between IVC and lung ultrasound (LUS) indices and clinical signs of hypovolaemia and pulmonary oedema, respectively, concurrent clinical and sonographic examinations were performed in an observational study of 48 malaria patients and 62 healthy participants across age groups in Gabon.ResultsIVC collapsibility index (CI) ≥ 50% on enrolment reflecting intravascular fluid depletion was associated with an increased number of clinical signs of hypovolaemia in severe and uncomplicated malaria. With exception of dry mucous membranes, IVC-CI correlated with most clinical signs of hypovolaemia, most notably sunken eyes (r = 0.35, p = 0.0001) and prolonged capillary refill (r = 0.35, p = 0.001). IVC-to-aorta ratio ≤ 0.8 was not associated with any clinical signs of hypovolaemia on enrolment. Among malaria patients, a B-pattern on enrolment reflecting interstitial fluid was associated with dyspnoea (p = 0.0003), crepitations and SpO2 ≤ 94% (both p < 0.0001), but not tachypnoea (p = 0.069). Severe malaria patients had increased IVC-CI (p < 0.0001) and more B-patterns (p = 0.004) on enrolment relative to uncomplicated malaria and controls.ConclusionIn malaria patients, POCUS of the IVC and lungs may improve the assessment of volume status and detect early oedema, which could help to manage fluids in these patients.

Synthesis of Kraton/Polyaniline Ionomer Composite Membrane as Cu (II) Ion Selective Membrane Electrode

Background: Kraton/polyaniline ionomer is synthesized and further characterized by electrochemical studies to check the redox properties of the material. Ion exchange capacity, proton conductivity, and selectivity of the synthesized membrane were determined. And found that the membrane was selective for Cu (II) ions. Methods: The dry Kraton membranes were weighed and kept in 25 mL of 10 % prepared aniline solution in a conical flask for 5, 10, 15, and 20 minutes below 10 0C for socking. The prepared solution of 30 mL of 0.1 M potassium peroxydisulfate was added in a conical flask at constant stirring below 10 0C for half an hour. Finally, the aluminum foil-covered conical flask was kept in the refrigerator for 24 h and modified Kraton membranes were weighed again before carrying out further studies. Results: The membrane was characterized by some physicochemical methods like SEM, TGA, T-IR, IEC, proton conductivity and selectivity sorption studies. An ionomeric membrane of Kraton polymer was developed as reported earlier. Kraton membrane showed the IEC of 1.9 meq·g-1. The FTIR spectrum of Kraton/PANI film reveals that weight loss up to 400°C may be found because of the thermal degradation of composite substances. Conclusion: Ion-selective potentiometric was carried out using the self-prepared ion-selective membrane electrode. The membrane was prepared by solution casting method. The membrane was characterized by some physicochemical methods like SEM, TGA, T-IR, IEC, proton conductivity and selectivity sorption studies. On the basis of selectivity studies, the composite material was found selective for Cu (II) ion. A copper ISME was successfully fabricated using the solution casting method. The ISME possessed good selectivity, linearity, working pH range, and response time which was also used as an indicator electrode for the titration of copper using EDTA.

Using Dry Human Amniotic Membrane in Secondary Intention Wound Healing After Urological Cancer Surgery: The First Randomized Clinical Trial in Iran

Background: Wound healing is a complex process and in some patients, it is a long process. Due to the presence of various underlying diseases in patients with cancer, this process is delayed, and as a result, the rate of complications increases. Therefore, some materials are needed to accelerate wound healing. Nowadays efficacy of dry human amniotic membrane in burn wounds and chronic wounds is proven; however, no studies have been performed on the effect of this tissue in the treatment of surgical wounds. Objectives: This study aimed at evaluating the efficacy of dry human amniotic membrane in the secondary repair of urological cancer surgery wounds. Methods: In this randomized clinical trial from January 2018 to June 2020, 40 patients who underwent urological cancer surgery and secondary intention wound healing were selected and randomly divided into 2 groups of 20 patients. In the case group, the dry human amniotic membrane was used for dressing wounds, and in the control group, normal dressing without an amniotic membrane was performed. Complications such as infection, sepsis, and reoperation, as well as the duration of wound healing and hospitalization of patients at intervals of 1 week, 1, and 3 months, were compared between the 2 groups. Results: The 2 groups matched in terms of gender, age, and wound location. The mean duration of hospitalization and wound healing was significantly lower in the case group (P &lt; 0.05). The rate of complications was higher in the control group but was not significant. Conclusions: Dry human amniotic membranes due to the accelerated wound healing process and fewer complications could be a good choice for secondary healing of wounds after urological cancer surgery.

Euglycemic DKA Associated With SGLT2 Inhibitors

Background: DKA associated with SGLT2 inhibitors also known as Euglycemic DKA (EDKA) is a rare condition characterized by milder degrees of hyperglycemia with a blood glucose level < 200 mg/dl. Unfortunately, this unusual feature can often lead to missed or delayed diagnosis with potential life-threatening outcomes. Clinical Case: The patient is a 53-year-old Caucasian male with PMH of type 2 diabetes mellitus treating with Metformin and Empagliflozin. He presented to the emergency room with shortness of breath, flu-like symptoms, and decreased oral intake for a couple of days. Vital signs at presentation were: Temperature 98.2 °F, pulse rate 108 beats/min, respiratory rate 28 breaths/min, and blood pressure 134/72 mmHg. He was alert but ill-looking, moderately dehydrated with dry mucus membranes. The rest of the physical examination was unremarkable at the time of admission. In the initial blood work, sugar was found to be mildly elevated (163mg/dl), and hemoconcentration besides mild pre-renal acute kidney injury was detected. He was also found infected by the COVID-19 virus without hypoxemia or signs of pneumonia. Arterial blood gases showed metabolic acidosis with an elevated anion gap (PH 7.21, CO2 39.93mmHg, HCO3− 10mEq/L, anion gap 21mEq/L). Urine analysis was positive for ketones and glucose. After ruling out other causes of metabolic acidosis by screening for alcohols, salicylates, acetaminophen, lactic acid, and urine toxicology; the diagnosis of EDKA was made. He was treated with a 3L bolus of IV normal saline and an insulin drip with dextrose solution started as per the protocol based on his glucose levels and promptly admitted to the intensive care unit (ICU). Serial blood tests showed gradual resolution of ketoacidosis and anion gap normalized after 36 hours when insulin drip was stopped and replaced by subcutaneous insulin therapy. Conclusion: SGLT2 inhibitors increase the urinary excretion rate of glucose and subsequent fall in plasma glucose level. Thus, In the absence of exogenous insulin use, increase glucagon release resulting in upregulation of lipolysis and activation of the ketogenesis. Factors such as low oral intake, concurrent infection, and alcohol use can also exacerbate the process. Timely diagnosis of EDKA can be a challenge for physicians unfamiliar with this class of medications, additionally, ketone studies and blood gas analyses are not part of the routine workup for diabetic patients in the emergency department. We recommend all first-line care providers to consider ketosis in ill patients with diabetes and metabolic acidosis, despite the normal or near-normal serum glucose levels. EDKA is mainly a diagnosis of exclusion, but treatment is not different from DKA; correcting dehydration by using intravenous fluids and then, initiating insulin drip along with dextrose-containing solutions, and frequent monitoring of serum anion gap.

Double the Battle: Two Cases of Irreversible Endocrinopathies in Patients Already Fighting Metastatic Cancer

Abstract Immune Checkpoint Inhibitors (ICI) have been approved since 2011 to treat patients with advanced solid and hematological malignancies and have had remarkable results. However, case reports of endocrine adverse events are becoming increasingly reported and can be fatal if not recognized early. Here we present two unique cases of rare endocrinopathies after the use of ICIs. A 47 year old male with metastatic melanoma presented with nausea, vomiting, polyuria, polydipsia of 5 days. Three weeks prior, he was started on nivolumab and ipilimumab. On presentation, he was tachycardic and tachypneic. Lab work was remarkable for a glucose of 676, Na 129, K 6.2, CO2 6, Cr 2.43 (baseline of 1.1) and beta-hydroxybutyrate of 11.7 with elevated HgA1c of 7.1%. DKA was diagnosed and fluids and insulin drip were started. Further work up revealed a normal cortisol level, TFTs and C-peptide &amp;lt;1 consistent with new-onset type I diabetes mellitus in the setting of two ICI agents. Patient was started on insulin regimen. An 81 year old female with metastatic bladder cancer on Pembrolizumab was admitted with 2 weeks of fatigue, positional dizziness and dyspnea. She recently presented with hyperkalemia attributed to dehydration. On admission, she was hypotensive with a blood pressure of 81/59 with normal heart rate and no fever. She had dry mucous membranes on exam but no abnormal skin. Further work up revealed an AM cortisol of &amp;lt;1, ACTH of 458 and positive Cosyntropin stim test, consistent with primary adrenal insufficiency. CT-Abdomen Pelvis did not reveal any acute adrenal masses. She was started on hydrocortisone at discharge with fludrocortisone due to hypotension. ICIs are categorized as target programmed death-1 receptor inhibitors (PD-1) nivolumab, pembrolizumab, cemiplimab, programmed death-ligand 1 inhibitors (PDL1) atezolizumab, avelumab, durvalumab and cytotoxic T-lymphocyte associated protein-4 (CTLA-4) iplimumab. Immune checkpoint proteins are T-cell surface receptors that cause inhibition when they bind to their ligands to limit the immune response. Tumors manipulate these inhibitory pathways to evade rejection. ICIs no longer halt the immune response and result in effective cancer treatment. However, a robust immune response can go on to attack healthy tissue resulting in endocrinopathies such as hypophysitis, hypo-or hyperthyroidism, diabetes mellitus or adrenal insufficiency. Acute hypocortisolemia or thyroid storm can be fatal if not identified acutely. Current guidelines recommend baseline screening with TFTs, morning cortisol and ACTH and screening monthly thereafter in patients on ICIs. In this report, we present two unique cases of irreversible endocrinopathies in patients treated with ICI who developed type I diabetes and primary adrenal insufficiency. These cases warn physicians to be vigilant with patients on ICI and consider the possibility of life-threatening endocrinopathies.

Graves’ Disease Induced Severe Hypercalcemia

Introduction: Hyperthyroidism is a well-known non-parathyroid hormone-mediated cause of hypercalcemia. Hypercalcemia associated with thyrotoxicosis is usually asymptomatic. Increased osteoclastogenesis is one of the mechanisms underlying this etiology. Hyperthyroidism is associated with mild to moderate levels of hypercalcemia in approximately 20% of patients, but severe hypercalcemia is rare. We report a case of a male with Grave’s disease-induced symptomatic severe hypercalcemia. Clinical Case: A 36-year-old male with type 2 diabetes mellitus and arterial hypertension who was transferred from another institution to our Emergency Department due to suspected primary hyperparathyroidism for Endocrinology Services evaluation. Family history is non-contributory. Patient reports palpitations, irritability, and unintentional weight loss of approximately fifty pounds in nine months. One month ago, he started with constipation, anxiety, depression, abdominal discomfort, nausea, and vomiting for which decided to seek medical attention. Physical examination was remarkable for tachycardia, dry mucous membranes, and goiter. Laboratory tests showed lipase 69 U/L (13-60U/L), albumin-corrected calcium 14.3 mg/dL (8.8-10.3mg/dL), phosphorus 3.30 mg/dL (2.4-4.2mg/dL), magnesium 1.58 mg/dL (1.8-2.2mg/dL), creatinine 1.38 mg/dL (0.90-1.30 mg/dL), alkaline phosphatase 77 IU/L (43-115IU/L), iPTH 4 pg/mL (11-67pg/mL), PTHrp <0.4 pmol/L (≤4.2pmol/L), 25-OH vitamin D 32.1 ng/mL (30-100ng/mL), 1,25-dihydroxyvitamin D <5.0 pg/mL(19.9-79.3pg/mL), hemoglobin 11.6 g/dL (14-18g/dL), negative serum and urine protein electrophoresis, TSH 0.003 uIU/mL (0.45-5.33 uIU/mL), free T4 2.80 ng/dL (0.71-1.85ng/dL), total T3 2.57 ng/mL (0.80-2.00ng/mL), TSI: 486% (<140%), urine calcium 24hr 525mg/day (100-300mg/day). Thoracic and abdominopelvic CT scan without contrast was unremarkable for masses, adenopathies, osseous lesions, or acute abdominal processes. Patient was treated with IV isotonic saline and methimazole 10mg oral daily with resolution of symptoms. Finally, diagnosed with Graves’ disease as the cause of hypercalcemia after ruling out other etiologies. He was discharged home with calcium levels 10.8 mg/dL, normal renal function, methimazole, and follow up with Endocrinology Services. Conclusion: This is a case of an atypical presentation of hyperthyroidism-induced symptomatic hypercalcemia. It is important to consider hyperthyroidism in the differential diagnoses of severe hypercalcemia. Prompt suspicion is essential due to the effective treatments available for Graves’ disease. Early treatment of hypercalcemia is important for quick resolution of symptoms and decreased associated mortality.

Polyglandular Autoimmune Syndrome Type II in a Patient Presenting With Hypotension After Acute Illness

Introduction: Polyglandular Autoimmune Syndrome Type II (PAS-2) is a rare disorder characterized by two or more endocrine diseases (primary adrenal insufficiency, autoimmune thyroid disease, type 1 diabetes). Of these, the most common is autoimmune thyropathy, followed by Type 1 Diabetes (1). These endocrinopathies rarely have concurrent onset. This case reports a 22-year-old male, recently recovered from severe pneumonia, who presented to the Emergency Department in acute adrenal crisis and was diagnosed with PAS-2. Case: A 22-year-old male with past medical history of celiac disease presented with abdominal discomfort, nausea, vomiting, fatigue and dizziness for 1–2 weeks. Review of systems included a 20-pound weight loss over several months. Recent history included a hospitalization at another facility three weeks prior for pneumonia and septic shock requiring admission to the ICU and vasopressor treatment. He was not discharged on any medications. He was afebrile with heart rate of 105/min, blood pressure 78/48 mm Hg and BMI of 17.2. Physical exam revealed dry mucous membranes and mild diffuse abdominal tenderness. Skin was warm and dry without hyperpigmentation. Laboratory values included sodium 123 (135 - 146 mmol/L), potassium 6.8 (3.3 - 4.8 mmol/L), glucose 47 (70 - 100 mg/dL), TSH 37.67 (0.3 - 5.00 uIU/mL), and FT4 0.7 (0.7 - 1.7 ng/dL). He was started on fluids and intravenous hydrocortisone. Cortisol and ACTH levels drawn prior to the initiation of steroids resulted at 0.6 (6–20 mcg/dl) and 977 (9 - 46 pg/mL) respectively. Additional labs included: aldosterone < 1 ng/dL, 21 hydroxylase antibody positive, TPO antibody > 1000 (0 - 100 Units) and GAD-65 antibody > 47 IU/mL (<5 IU/mL). Levothyroxine was initiated after hydrocortisone. Blood glucose was elevated during hospitalization, peaking at 227 mg/dL. He was discharged on prednisone, fludrocortisone and levothyroxine. At 2 week follow up, he reported overall improvement in health and was pleased with a weight gain of 12 lbs. Blood glucose remained mildly elevated (123 - 143 mg/dL). Conclusion: The patient had pneumonia and septic shock septic at an outside hospital three weeks prior to presentation. There was no record of steroid administration or suspicion of adrenal insufficiency. We postulate that his severe illness contributed to significant depletion of his adrenal reserve, and therefore he presented to our facility a short time later in overt adrenal crisis. Adrenal crisis is unusual to be the first presentation of PAS-2. It is important to have a high index of suspicion for adrenal insufficiency and PAS-2 in patients presenting with severe illness or hypotension who have known autoimmune disorders. Reference: 1. Kahaly, G.J., Frommer, L. Polyglandular autoimmune syndromes. J Endocrinol Invest. 2018; 41: 91–98.

Treatment-Resistant Hypercalcemia Secondary to Ectopic PTH Hypersecretion From Disseminated Ovarian Cancer

Background: Hypercalcemia of malignancy (HCM) can present secondary to hypersecretion of parathyroid hormone (PTH)-related protein (PTHrP) from malignant tumors, but rare cases of HCM have also been documented due to inappropriate PTH secretion from ectopic neoplasms. Here, we report an unusual case of HCM due to hypersecretion of PTH from a disseminated mucinous ovarian adenocarcinoma. Case Presentation: A 45-year-old female presented with confusion, constipation, fatigue, and abdominal pain two weeks after total abdominal hysterectomy with bilateral salpingo-oophorectomy and suboptimal debulking of a newly discovered left ovarian mucinous adenocarcinoma with metastasis to the bladder, parametrium, vagina, right ovary, and rectosigmoid. Subsequent CT revealed numerous bilateral pulmonary nodules, hilar adenopathy, liver lesions, and abdominal adenopathy. On exam, she was tachycardic and hypertensive with diaphoresis, dry mucous membranes, respiratory distress, guarded abdominal tenderness, and altered mental status. Her labs were significant for a serum calcium of 21.7 mg/dL, creatinine of 1.93 mg/dL, ferritin of 2,379 ng/mL, leukocytosis of 21.9 bil/L, PTH of 1,061 pg/mL, and PTHrP of 29 pmol/L. Ectopic PTH secretion was highly suspected after negative parathyroid ultrasound. Pamidronate (60 mg IV), calcitonin (200 U IM), and fluid resuscitation were unable to normalize her serum calcium, resulting in the need for dialysis and subsequent continuous renal replacement therapy. Further intervention with denosumab (120 mg SQ), etelcalcetide (5 mg IV), and cinacalcet (60 mg PO) was also attempted. Serum calcium began to decline, but repeat PTH resulted greater than 2,500 pg/mL. Unfortunately, the patient died just one week into her hospital course from septic shock and multi-organ system failure. Discussion: Hypercalcemia of malignancy typically arises from tumor secretion of PTHrP, cytokine release from osteolytic metastases, or tumor production of calcitriol. In cases of hypercalcemia due to excess PTH secretion, primary parathyroid etiologies are typically considered while ectopic PTH-secreting tumors are rare. PTH staining of biopsy specimens and total body sestamibi scan may prove useful in the early detection and treatment of these tumors, but HCM offers a poor prognosis with mean survival of 2 to 3 months and in-hospital mortality of 6.8%. Currently, there are only three cases in the reported literature of ectopic PTH-induced hypercalcemia related to ovarian cancer. To our knowledge, this is the fourth reported case. Conclusion: Ectopic PTH-secreting tumors carry a poor prognosis and should be considered in cancer patients presenting with PTH-associated hypercalcemia. Biopsy staining for PTH and total body sestamibi scan may assist in the early detection of these tumors, but current treatment strategies offer suboptimal outcomes.

48-year-old with Altered Mental Status and Respiratory Failure: A Case Report

IntroductionThe differential diagnosis for altered mental status and respiratory failure is broad. Careful physical examination, appropriate use of diagnostic tools, and accurate interpretation and correlation of test results are important for piecing together the puzzle of a patient with altered mental status that emergency physicians commonly face. In certain cases, such as this one, rapid diagnosis and management is crucial for improving patient morbidity and mortality.Case PresentationA 48-year-old male with altered mental status and respiratory failure presented to the emergency department after being found unconscious on his porch. Vital signs were notable for temperature 105.5 °F, blood pressure 202/102 millimeters of mercury, pulse 126 beats per minute, respiratory rate 30 breaths per minute, and oxygen saturation 91% on room air. Physical examination revealed an obese male lying in bed awake in severe distress with labored breathing and unable to converse. His physical examination was significant for dry mucous membranes, tachycardia, and bilateral lower extremity 1+ pitting edema. He also appeared to have Kussmaul respirations with severe tachypnea, but his breath sounds were clear to auscultation bilaterally. On further examination, the patient appeared to have intravenous (IV) injection markings along his arms suggesting the possibility of IV drug use.DiscussionWith limited history, the only context clues initially available to assist in the diagnosis were abnormal vital signs and physical examination. The patient was tachycardic, hyperthermic, hypertensive, hypoxic, and tachypneic with altered mental status; he eventually required endotracheal intubation for hypoxic respiratory failure. The complexity of his condition prompted a large list for the differential diagnoses. Toxidromes, endocrine abnormalities, infectious process, cardiac and/or renal etiologies, and neurological pathology such as a cerebrovascular accident were considered. In the case of this patient, urgent diagnosis and management was crucial to prevent further decompensation and improve his outcome.

Analysis of Ionic Domains on a Proton Exchange Membrane Using a Numerical Approximation Model Based on Electrostatic Force Microscopy.

Understanding the ionic channel network of proton exchange membranes that dictate fuel cell performance is crucial when developing proton exchange membrane fuel cells. However, it is difficult to characterize this network because of the complicated nanostructure and structure changes that depend on water uptake. Electrostatic force microscopy (EFM) can map surface charge distribution with nano-spatial resolution by measuring the electrostatic force between a vibrating conductive tip and a charged surface under an applied voltage. Herein, the ionic channel network of a proton exchange membrane is analyzed using EFM. A mathematical approximation model of the ionic channel network is derived from the principle of EFM. This model focusses on free charge movement on the membrane based on the force gradient variation between the tip and the membrane surface. To verify the numerical approximation model, the phase lag of dry and wet Nafion is measured with stepwise changes to the bias voltage. Based on the model, the variations in the ionic channel network of Nafion with different amounts of water uptake are analyzed numerically. The mean surface charge density of both membranes, which is related to the ionic channel network, is calculated using the model. The difference between the mean surface charge of the dry and wet membranes is consistent with the variation in their proton conductivity.

April 2021 Critical Care Case of the Month: Abnormal Acid-Base Balance in a Post-Partum Woman

No abstract available. Article truncated after first page. History of Present Illness: A 29-year-old healthy woman, who is 8 weeks postpartum, presented to the emergency department with severe shortness of breath, fast shallow breathing, nausea, several episodes of nonbloody nonbilious emesis, abdominal pain and malaise for 1 week. The patient delivered a healthy boy at full-term by spontaneous vaginal delivery. Her pregnancy was uneventful. She denied smoking or use of alcohol. Physical Exam: On presentation to the emergency department her blood pressure was found to be 121/71, temperature 36.8°C, pulse 110 beats per minute, respiratory rate 20 breaths per minute and SpO2 saturation of 99% while breathing ambient air. Physical exam was remarkable except for dry mucous membranes, sinus tachycardia, and tachypnea with mild epigastric tenderness with light palpation. Which of the following should be done? 1. Complete blood count (CBC) 2. Metabolic panel 3. Chest x-ray 4. Arterial blood gases (ABGs) 5. All of the above …

Sapovirus Gastroenteritis in a Lung Transplant Recipient

Introduction Diarrhea is a common complaint in lung transplant recipients but has significant consequences with increased morbidity from dehydration, medication toxicity and allograft dysfunction. Etiologies range from side effects to infection, malignancy, and graft-versus-host disease. The most common causes of infectious diarrhea in this population are Clostridium difficile, cytomegalovirus (CMV), and norovirus. Norovirus is well known to cause prolonged viral shedding and chronic diarrhea in lung transplant recipients and limited case reports in renal transplant recipients suggest that sapovirus may present similarly. Case Report A 53-year-old woman with excellent allograft function at seven months following right single lung transplant was admitted with gastroenteritis and acute kidney injury. She reported diffuse abdominal cramps and distension, nausea, vomiting, watery diarrhea, and headache for five days prior to presentation. Notable home medications included tacrolimus, prednisone, azithromycin, itraconazole, atovaquone, and valganciclovir. Examination revealed normal vital signs, dry mucus membranes and a distended abdomen with diffuse tenderness. Laboratory studies showed a white blood cell count of 3.7 K/μL with 56% lymphocytes and elevated creatinine of 1.65 mg/dL. Tacrolimus level was 9.8 ng/mL. Non-contrasted CT of the abdomen and pelvis did not show any acute intraabdominal pathology. The patient was treated with intravenous fluids and broad-spectrum antibiotics while awaiting additional workup including an undetectable CMV DNA viral load and negative testing for COVID-19, serum cryptococcal antigen, stool Giardia antigen, ova and parasites, Shigatoxin and Clostridium difficile antigen and toxin. A multiplex PCR gastrointestinal panel detected the presence of sapovirus. Antibiotics were discontinued and the patient experienced progressive improvement in symptoms and renal function by day 3. Summary To our knowledge, this is the only case report of sapovirus-related gastroenteritis in a lung transplant recipient, emphasizing the need to maintain a high index of suspicion for both common and uncommon etiologies of diarrhea in transplant recipients. Though sapovirus is not an uncommon cause of self-limited viral gastroenteritis in healthy individuals, it may present with a severe and prolonged course in transplant patients and can result in significant morbidity.

Photoexpansion of Biobased Polyesters: Mechanism Analysis by Time-Resolved Measurements of an Amorphous Polycinnamate Hard Film.

Cinnamate-based polyesters were synthesized, including poly(4-hydroxycinnamic acid), poly(4-hydroxy-3-methoxycinnamic acid), poly(3-hydroxycinnamic acid) (P3HCA), and hyperbranched poly(3,4-dihydroxycinnamic acid) (PdHCA). These materials were further processed into hard and dry membranes by casting and underwent photoreactions by ultraviolet (UV) light. The photodeformation behavior of the linear and hyperbranched polyester containing membranes with cinnamate derivatives in the main chain was observed macroscopically and microscopically. The PdHCA and P3HCA membranes were amorphous and exhibited photodeformations. The PdHCA surface visibly contracts, which is a typically observed phenomenon in photoresponsive polymers; however, the P3HCA surface showed a unique photoexpansion behavior. Time-resolution infrared spectroscopy of the P3HCA film revealed trans-to-cis isomerism in the polymer main chains that bent convexly as a result of photoexpansion of the UV-irradiated regions. Furthermore, photomasking created a micropattern on the P3HCA film, which supported the photoexpansion mechanism of the P3HCA film.

Accurate evaluation of hydrogen crossover in water electrolysis systems for wetted membranes

In fuel cell and electrolysis systems, hydrogen crossover is a phenomenon where hydrogen molecules (H2) permeate through a membrane, lowering the overall process efficiency and generating a potential safety risk. Many works have been reported to mitigate this undesired phenomenon, but it is yet difficult to accurately measure the rate of hydrogen crossover, particularly when the membrane is fully wetted in water. In this work, we investigated the pressure decay method as a simple, convenient, and low-cost method to characterize hydrogen crossover through wetted membranes for water electrolysis systems. Three different ion exchange membranes were analyzed: Nafion 212, Nafion 115, and in-house sulfonated poly(arylene ether sulfone). We rigorously confirmed our method and data by comparing it to the ANSI dataset with the current state-of-the-art equations of state (EOS) to account for the nonideality of high pressure hydrogen systems. The error from the gas non-ideality was less than 0.03%. As expected, the rate of hydrogen crossover showed high dependency on the temperature; more importantly, hydrogen crossover increased significantly when the membrane was fully soaked in water. For dry membranes, the proposed pressure decay method corroborated well with the literature data measured using other known methods. Moreover, for wetted membranes, the obtained data showed high similarity compared to the GC method which is currently the most reliable method in the literature. We attempted to predict the hydrogen permeability of wetted membranes using the solution diffusion model. The model based on the given thermodynamic parameters overestimated the hydrogen permeability, which can be used to estimate the ion channel tortuosity.

Strange Behavior in a Transgender Teenager.

1. Salvador R. Maffei, MD* 2. Andrea Dean, MD* 1. *Baylor College of Medicine, Texas Children’s Hospital, Houston, TX A 12-year-old transmale ( transgender male or transmale is the term used for a person who is assigned female at birth [and is, usually, XX genotype] but who identifies as male) presents to the emergency department (ED) from an inpatient psychiatric facility for evaluation of new gait abnormalities and decreased oral intake. He initially presented to the ED 2 weeks earlier with acute onset of confusion, agitation, and suicidal ideation in the setting of a recent disclosure of his gender identity to family and classmates without their acceptance. After medical evaluation for toxic ingestion and intracranial abnormality, he was referred for inpatient psychiatric evaluation and was admitted for 2 weeks. While hospitalized he was started on chlorpromazine, haloperidol, risperidone, and escitalopram. Over the next 2 weeks he developed slowing and stiffening of movements, with progressively impaired motor function and cognitive abilities. For the past 3 days he has demonstrated mutism, minimal oral intake, tongue thrusting, and refusal to walk. At times he would hit himself in the forehead repeatedly. Symptoms did not improve with benztropine, amantadine, and lorazepam use, so he was transferred back to the ED for further evaluation. On presentation he is alert but nonverbal and does not follow commands. He is afebrile, his heart rate is 129 beats/min, and his blood pressure is 136/83 mm Hg. He has dry mucous membranes. There is an ecchymosis on his forehead, consistent with described self-injurious behavior. Cranial nerves, strength, and coordination cannot be assessed, but global hypertonia and lower extremity clonus are elicited. Laboratory evaluation demonstrates a serum sodium level of 151 mEq/L (151 mmol/L) (reference range, 135–145 mEq/L [135–145 mmol/L]) …

Empiric treatment of diarrhea in patient with HIV infection: a case report

Diarrhea is common opportunistic infection in patient with Human immunodeficiency virus (HIV) infection. Diarrhea in patient with HIV infection that contributes the negatively to quality of life. The etiology of diarrhea in patient with HIV infection is multifactorial include infectious, non-infectious, ART-association diarrhea. In addition, this diarrhea can be associated with empiric therapy. This article a 31 years old male patient with 3 days fatigue and diarrhea. Physical examination dry mucous membranes, abdominal pain especially in in the upper abdomen and increase small bowel peristalsis. Stool examination test doesn’t have blood, parasites, and fungi. Stool cultures for Salmonella, Shigella, Campylobacter organisms no presence. The treatment metronidazole oral 500 mg every 8 hours was again performed. Metronidazole is available for the management of diarrhea in patient with HIV that can’t be treated with other antibiotics.

Acute Unilateral Nonhemorrhagic Adrenal Infarction in Pregnancy

A 24-year-old woman, 30 weeks pregnant, presented to an emergency room with severe, sharp, constant abdominal pain in the left upper quadrant, which radiated to the back and was associated with nausea and vomiting. She appeared diaphoretic, with dry oral mucous membranes. Abdominal examination showed a gravid uterus, which was tender upon light palpation in the left upper area, with voluntary guarding. Genitourinary examination revealed a closed cervical os, with no blood in the vaginal vault. Abdominal magnetic resonance imaging revealed a T2-hypointense left adrenal gland (Fig.

Characterization of full term newborns with hypernatremic dehydration

The hypernatremic neonatal dehydration is a severe condition whose incidence has increased in recent years resulting in complications leading to the hospitalization of the newborn. Describe the clinical and laboratory characteristics of term-newborns with Hypernatremic Dehy dration diagnosis. Descriptive observational study of hospitalized term- newborns due to hypernatremic dehydration between a period from 2014 to 2016. Term newborns over 37 weeks with clinical signs of dehydration (dry mucous membranes, depressed fontanel, tear less crying, signs of the cutaneous pleat), and/or excessive weight loss greater than 7% and serum sodium greater than 145 mEq/L were included. Sociodemographic and biochemical variables were recorded for analysis. 43 neonates were included. 60.5 percent of their mothers were pri- miparous, 90 percent of neonates received exclusive breastfeeding, mothers reported breastfeeding problems in 76.7 percent. Incoming neonates reported weight loss compared to birth weight at 15.3% on average. 83.3% had public health insurance. 65.1% had dehydration clinical signs at entry and 83.5% transient neurological signs. The average sodium was 155 mEq/L at revenue. The sodium decrease in the first 24 hours of handling was 7.74 mEq/L (0.32mEq/L per hour). The correction of the hypernatremia was 55.8% by oral intake and 4 days hospital stay on average. The feeding's problems came up in a (76%), primiparous mothers in an (88.4%). 90.6 percent of this population administered exclusive breastfeeding, results that can help to alert the health professional to timely identification, warning signs, and early post-discharge control and preventive measures.

Interaction, structure and tensile property of swollen Nafion® membranes

Commercial Nafion® membranes are fabricated from an ionomer with strongly hydrophobic polytetrafluoroethylene (PTFE) backbone and strongly hydrophilic pendant sulfonic group. Understanding the difference in the phase separated structures for them in dry and solvent-swollen states is crucial for their optimal application and recycling. Structure changes in solvent swollen membranes were studied by Small angle X-ray scattering (SAXS), their thermodynamic origins from polymer-solvent interactions, solvent uptake and tensile properties were explored. Dry membranes have tightly packed backbone and crystallite, acting as the matrix that afford strong mechanic strength in tensile tests. Solvents that can swell both hydrophobic matrix and ionic clusters lead to high level of solvent uptake, evidenced from larger correlation lengths for both polymer matrix and ionic clusters, and the swollen membranes become soft and flexible. Semi-quantitative relationships to correlate polymer-solvent interactions, the length and distribution of structural domains, solvent uptake and tensile properties were presented. Dimethylacetamide as the primary solvent and 40% isopropanol-water as the binary solvent, both have intermediate difference in Hansen solubility with the PTFE backbone, can permeate into hydrophobic matrix and ionic clusters, resulting in the most swollen Nafion membranes. Based on correlation matrix analysis, we also found that solvents with larger molecule volume will benefit the elongation of swollen membranes.

Type II Diabetes Mellitus

Hyperosmotic hyperglycemic nonketotic (HHNK) state (also known as hyperosmolar hyperglycemic state) is a significant acute complication of type 2 diabetes mellitus, especially for those over 65 years of age. It is characterized by extreme hyperglycemia and hyperosmolarity with little ketosis. The main clinical effect of extreme hyperosmolarity is somnolence or confusion. The absence of severe ketonemia is attributed to residual insulin secretion that is sufficient to restrain lipolysis. HHNK state is marked by extreme dehydration, with both a marked deficit of free water and serious compromise of intravascular volume and tissue perfusion. Most patients with HHNK state have hypotension, extremely dry mucous membranes, and gross elevation of urea nitrogen and creatinine. Urinary tract infection, pneumonia, stroke, myocardial infarction, and sepsis may precipitate HHNK state. Elderly patients are particularly vulnerable because their thirst mechanisms are less sensitive to a rising serum osmolality. Fluid replacement is the most important component of therapy for HHNK state. Restoration of circulating volume is an urgent first priority and is accomplished by relatively rapid intravenous infusion of 2 L of 0.9% normal saline followed by 0.45% normal saline. Later, when plasma glucose levels have declined to 250 to 300 mg/dL, 5% dextrose in water is given. Insulin treatment is started soon after administration of isotonic saline. Potassium must be added to intravenous fluids to prevent hypokalemia caused by insulin action but should not be started until hypokalemia is proven, because potassium levels can be high initially. The mortality from the HHNK state is high, ranging from 10 to 20%, and is most often from the precipitating illness. This review contains 6 figures, 7 tables, and 73 references. Key words: dehydration, fluid deficit, hyperglycemia, hyperglycemic nonketotic state, hyperosmolar, hyperosmotic insulin, potassium, type 2 diabetes mellitus