Management of Refractory Chronic Obstructive Pulmonary Disease: A Review

Chronic obstructive pulmonary disease (COPD) is a common condition with an estimated prevalence of 12% in adults over the age of 30 years worldwide. COPD is a leading cause of morbidity and mortality globally, with a substantial economic and social burden. There are an estimated 3 million deaths annually due to COPD. However, most of the patients with COPD respond to routine interventions like bronchodilator therapy, assessing supplemental oxygen needs, smoking cessation, vaccinations, and pulmonary rehabilitation. There is a significant number of patients who unfortunately progress to have persistent symptoms despite these interventions. Refractory COPD is not yet formally defined. Patients with severe persistent symptoms or exacerbations despite appropriate care can be considered to have refractory COPD. Managing refractory COPD needs a multidimensional approach. In this review article, we will discuss essential interventions like ensuring adequate inhaler techniques, exploring the need for non-invasive ventilatory support, use of chronic antibiotics and phosphodiesterase inhibitors to advanced therapies like bronchoscopic lung volume reduction surgery, and the upcoming role of anti-IL5 agents in managing patients with refractory COPD. We will also discuss non-pharmacologic interventions like psycho-social support and nutritional support. We will conclude by discussing the palliative care aspect of managing patients with refractory COPD. Through this review article, we aim to better the approach to managing patients with refractory COPD and discuss new upcoming therapies.

DbGTi: Thermostable trypsin inhibitor from Dioscorea bulbifera L. ground tubers: assessment of antioxidant and antibacterial properties and cytotoxicity evaluation using zebrafish model

Oxidative stress disorders and diseases caused by drug-resistant bacteria have emerged as significant public health concerns. Plant-based medications like protease inhibitors are growing despite adverse effects therapies. Consecutively, in this study, trypsin inhibitors from Dioscorea bulbifera L. (DbGTi trypsin inhibitor) ground tubers were isolated, purified, characterized, and evaluated for their potential cytotoxicity, antibacterial, and antioxidant activities. DbGTi protein was purified by Q-Sepharose matrix, followed by trypsin inhibitory activity. The molecular weight of the DbGTi protein was found to be approximately 31 kDa by SDS-PAGE electrophoresis. The secondary structure analysis by circular dichroism (CD) spectroscopy revealed that the DbGTi protein predominantly comprises β sheets followed by α helix. DbGTi protein showed competitive type of inhibition with Vmax = 2.1372 × 10-1 μM/min, Km = 1.1805 × 102 μM, & Ki = 8.4 × 10-9 M and was stable up to 70 °C. DbGTi protein exhibited 58 % similarity with Dioscorin protein isolated from Dioscorea alata L. as revealed by LC-MS/MS analysis. DbGTi protein showed a non-toxic effect, analyzed by MTT, Haemolytic assay and in vivo studies on zebrafish model. DbGTi protein significantly inhibited K. pneumoniae and has excellent antioxidant properties, confirmed by various antioxidant assays. The results of anti-microbial, cytotoxicity and antioxidant assays demonstrate its bioactive potential and non-toxic nature.

Differential Gene Expression Profiles Involved in the Inflammations Due to COVID-19 and Inflammatory Bowel Diseases and the Investigation of Predictive Biomarkers

Gastrointestinal manifestations in COVID-19 were attributed to 74-86% of the hospitalised patients due to severe or prolonged pathogenesis. Though it is a respiratory disease, the impact it elicits on the gastrointestinal tract and brain are intense. Inflammatory bowel disease including Crohn's disease and ulcerative colitis are idiopathic inflammatory disorders of the gastrointestinal tract. The intrinsic mechanisms involved in gut inflammations due to a respiratory viral disease can be deciphered when the gene expression profiles of COVID-19 and IBD are compared. The current study utilises an integrated bioinformatics approach to unravel them. The publicly available gene expression profiles of colon transcriptomes infected with COVID-19, Crohn's disease and Ulcerative colitis were retrieved, integrated and analysed for the identification of differentially expressed genes. The inter-relational analysis along with gene annotation and pathway enrichment detailed the functional and metabolic pathways of the genes during normal and diseased conditions. The protein-protein interactions deduced from the STRING database and the identified hub genes predicted potential biomarker candidates for COVID-19, Crohn's disease and ulcerative colitis. The inflammatory response pathways were upregulated and enrichment of chemokine signalling, altered lipid metabolism, coagulation and complement cascades were seen in all three conditions along with impaired transport mechanisms. CXCL11, MMP10, and CFB are predicted to be overexpressed biomarkers, whilst GUCA2A, SLC13A2, CEACAM, and IGSF9 as downregulated novel biomarker candidates for colon inflammations. The three miRNAs hsa-miR-16-5p, hsa-miR-21-5p, and hsa-miR-27b-5p exhibited significant interactions with the upregulated hub genes and four long non-coding RNAs NEAT1, KCNQ1OT1, and LINC00852 capable of regulating miRNA were also predicted. This study offers significant information on the underlying molecular mechanisms of inflammatory bowel disease with identification of potential biomarkers.

Response to insecticides and underlying mechanisms of resistance in the field populations of Aedes aegypti Linnaeus (Diptera: Culicidae) in Puducherry, India

Background & objectives

Mosquito-borne diseases are major threats to human health worldwide. Successful control of vector mosquitoes requires periodic updates on their response to the insecticides that are in use. Different classes of neurotoxic insecticides have been used in vector control programs. Ae. aegypti and Ae. albopictus are the primary vectors of dengue and have developed resistance to organophosphates and synthetic pyrethroids that are used in vector control programs. Monitoring insecticide pressure and studying the underlying mechanisms of resistance in the field populations of Aedes aegypti are important to formulate resistant management strategies for their control programs.

Methods

Aedes aegypti were collected from study sites Lawspet and Abishegapakkam and F1 progeny was subject to biochemical assays to determine the enzyme activity. Insecticide susceptibility tests were conducted to determine vector susceptibility/resistance to malathion and deltamethrin. Adult dried mosquitoes were subjected to multiplex PCR to detect point mutation in the VGSC gene.

Results

Insecticide susceptibility test results revealed that Aedes aegypti is resistant to malathion and incipient resistance to deltamethrin has emerged. It was observed that β-esterase and monoxygense activity were significantly higher in Lawspet sample than the laboratory strain, whereas it was comparatively lower in Abishegapakkam sample than laboratory strain. Multiplex PCR assays showed no kdr mutation in all Ae. aegypti strains.

Interpretation & conclusion

Monitoring insecticide resistance in Ae. aegypti would help the local health authorities to implement a rationalized approach for insecticide use in vector control.

Role of Therapeutic Anticoagulation in COVID-19: The Current Situation

Thrombotic complications from COVID-19 are now well known and contribute to significant morbidity and mortality. Different variants confer varying risks of thrombotic complications. Heparin has anti-inflammatory and antiviral effects. Due to its non-anticoagulant effects, escalated-dose anticoagulation, especially therapeutic-dose heparin, has been studied for thromboprophylaxis in hospitalized patients with COVID-19. Few randomized, controlled trials have examined the role of therapeutic anticoagulation in moderately to severely ill patients with COVID-19. Most of these patients had elevated D-dimers and low bleeding risks. Some trials used an innovative adaptive multiplatform with Bayesian analysis to answer this critical question promptly. All the trials were open-label and had several limitations. Most trials showed improvements in the meaningful clinical outcomes of organ-support-free days and reductions in thrombotic events, mainly in non-critically-ill COVID-19 patients. However, the mortality benefit needed to be more consistent. A recent meta-analysis confirmed the results. Multiple centers initially adopted intermediate-dose thromboprophylaxis, but the studies failed to show meaningful benefits. Given the new evidence, significant societies have suggested therapeutic anticoagulation in carefully selected patients who are moderately ill and do not require an intensive-care-unit level of care. There are multiple ongoing trials globally to further our understanding of therapeutic-dose thromboprophylaxis in hospitalized patients with COVID-19. In this review, we aim to summarize the current evidence regarding the use of anticoagulation in patients with COVID-19 infection.

The Impact of Anxiety and Depression in Chronic Obstructive Pulmonary Disease

Patients with COPD (chronic obstructive pulmonary disease) are at a higher risk of comorbid conditions such as anxiety and/or depression, which in turn increase their symptom burden and rehospitalizations compared to the general population. It is important to investigate the pathophysiology and clinical implications of mental health on patients with COPD. This review article finds that COPD patients with anxiety and/or depression have a higher rehospitalization incidence. It reviews the current screening and diagnosis methods available. There are pharmacological and non-pharmacologic interventions available for treatment of COPD patients with depression based on severity. COPD patients with mild depression benefit from pulmonary rehabilitation and cognitive behavioral therapy, whereas patients with severe or persistent depression can be treated with pharmacologic interventions.

Mosquito Diversity in an Experimental Township in Tamil Nadu, India

To glean more information on mosquito diversity and distribution in Auroville, a cross-sectional study was carried out by mapping the distribution of water bodies and habitats supporting immature stages on the one hand and the distribution of water bodies/habitats supporting mosquito immature stages on the other. A satellite image covering an area of 8.08 km2 was overlaid with a grid of 500 × 500 m. Fifteen modules were selected and the area of each module served as the sampling site for the entomological survey. Adult and larval stages were sampled. Diversity indices were analyzed to compare mosquito diversity. Rarefaction estimations were used to compare abundance and richness of the mosquito species between different zones. In total, 750 mosquito larvae and 84 resting adults were sampled. Eighteen species of mosquitoes belonging to 11 subgenera and 7 genera were documented. Genera included Aedes (Johann Wilhelm Meigen 1818, Diptera, Culicidae), Anopheles (Johann Wilhelm Meigen 1818, Diptera, Culicidae), Armigeres (Theobald 1901, Diptera, Culicidae), Culex (Carl Linnaeus 1758, Diptera, Culicidae), Lutzia (Theobald 1903, Diptera, Culicidae), and Mimomyia (Theobald 1903, Diptera, Culicidae). Of the 18 mosquito species identified, 8 species are new records for Auroville. The Alpha (α) biodiversity indices show that the mosquito fauna is diverse (S = 18; DMg = 2.732 [95% CI: 2.732-2.732]). The Shannon-Weiner (H' = 2.199 [95% CI: 2.133-2.276]) and Simpson indices (λ = 0.8619 [95% CI: 0.8496-0.8723]) measured species richness, evenness, and dominance. The values of these indices suggest high species richness, evenness, and dominance. Prevailing conditions can provide suitable environment for establishment of different mosquito species in this ecosystem. Given the sociodemographic characteristics of this area, research on mosquito diversity and risk of vector-borne diseases will be of great use.

Meta-analysis of the microbial biomarkers in the gut - lung crosstalk in COVID-19, community acquired pneumonia and Clostridium difficile infections

Respiratory infections are the leading causes of mortality and the current pandemic COVID-19 is one such trauma that imposed catastrophic devastation to the health and economy of the world. Unraveling the correlations and interplay of the human microbiota in the gut- lung axis would offer incredible solutions to the underlying mystery of the disease progression. The study compared the microbiota profiles of six samples namely healthy gut, healthy lung, COVID-19 infected gut, COVID-19 infected lungs, Clostridium difficile infected gut and community acquired pneumonia infected lungs. The metagenome datasets were processed, normalized, classified and the rarefaction curves were plotted. The microbial biomarkers for COVID-19 infections were identified as the abundance of Candida and Escherichia in lungs with Ruminococcus in the gut. Candida and Staphylococcus could play a vital role as putative prognostic biomarkers of community acquired pneumonia whereas abundance of Faecalibacterium and Clostridium are associated with the Clostridium difficile infections in gut. A machine learning random forest classifier applied to the datasets efficiently classified the biomarkers. The study offers an extensive and incredible understanding of the existence of gut lung axis during dysbiosis of two anatomically different organs.

Prognostic indicators and outcomes of hospitalised COVID-19 patients with neurological disease: An individual patient data meta-analysis

Background

Neurological COVID-19 disease has been reported widely, but published studies often lack information on neurological outcomes and prognostic risk factors. We aimed to describe the spectrum of neurological disease in hospitalised COVID-19 patients; characterise clinical outcomes; and investigate factors associated with a poor outcome.

Methods

We conducted an individual patient data (IPD) meta-analysis of hospitalised patients with neurological COVID-19 disease, using standard case definitions. We invited authors of studies from the first pandemic wave, plus clinicians in the Global COVID-Neuro Network with unpublished data, to contribute. We analysed features associated with poor outcome (moderate to severe disability or death, 3 to 6 on the modified Rankin Scale) using multivariable models.

Results

We included 83 studies (31 unpublished) providing IPD for 1979 patients with COVID-19 and acute new-onset neurological disease. Encephalopathy (978 [49%] patients) and cerebrovascular events (506 [26%]) were the most common diagnoses. Respiratory and systemic symptoms preceded neurological features in 93% of patients; one third developed neurological disease after hospital admission. A poor outcome was more common in patients with cerebrovascular events (76% [95% CI 67–82]), than encephalopathy (54% [42–65]). Intensive care use was high (38% [35–41]) overall, and also greater in the cerebrovascular patients. In the cerebrovascular, but not encephalopathic patients, risk factors for poor outcome included breathlessness on admission and elevated D-dimer. Overall, 30-day mortality was 30% [27–32]. The hazard of death was comparatively lower for patients in the WHO European region.

Interpretation

Neurological COVID-19 disease poses a considerable burden in terms of disease outcomes and use of hospital resources from prolonged intensive care and inpatient admission; preliminary data suggest these may differ according to WHO regions and country income levels. The different risk factors for encephalopathy and stroke suggest different disease mechanisms which may be amenable to intervention, especially in those who develop neurological symptoms after hospital admission.

A Deep Learning Framework for Earlier Prediction of Diabetic Retinopathy from Fundus Photographs

Diabetic patients can also be identified immediately utilizing retinopathy photos, but it is a challenging task. The blood veins visible in fundus photographs are used in several disease diagnosis approaches. We sought to replicate the findings published in implementation and verification of a deep learning approach for diabetic retinopathy identification in retinal fundus pictures. To address this issue, the suggested investigative study uses recurrent neural networks (RNN) to retrieve characteristics from deep networks. As a result, using computational approaches to identify certain disorders automatically might be a fantastic solution. We developed and tested several iterations of a deep learning framework to forecast the progression of diabetic retinopathy in diabetic individuals who have undergone teleretinal diabetic retinopathy assessment in a basic healthcare environment. A collection of one-field or three-field colour fundus pictures served as the input for both iterations. Utilizing the proposed DRNN methodology, advanced identification of the diabetic state was performed utilizing HE detected in an eye's blood vessel. This research demonstrates the difficulties in duplicating deep learning approach findings, as well as the necessity for more reproduction and replication research to verify deep learning techniques, particularly in the field of healthcare picture processing. This development investigates the utilization of several other Deep Neural Network Frameworks on photographs from the dataset after they have been treated to suitable image computation methods such as local average colour subtraction to assist in highlighting the germane characteristics from a fundoscopy, thus, also enhancing the identification and assessment procedure of diabetic retinopathy and serving as a skilled guidelines framework for practitioners all over the globe.

Trends in the Epidemiology and Outcomes of Pneumocystis Pneumonia among Human Immunodeficiency Virus (HIV) Hospitalizations

Introduction: Pneumocystis Pneumonia (PCP) is a common opportunistic infection among people living with the human immunodeficiency virus (HIV). This study’s objective was to assess temporal trends in PCP epidemiology among hospitalized patients with HIV/AIDS in the US and to compare data for hospitalizations with HIV with PCP to those without PCP. Methods: The national inpatient sample (NIS) data were analyzed from 2002−2014. The discharge coding identified hospitalized patients with HIV or AIDS and with or without PCP. Results: We identified 3,011,725 hospitalizations with HIV/AIDS during the study period; PCP was present in 5% of the patients with a diagnosis of HIV. The rates of PCP progressively declined from 6.7% in 2002 to 3.5 % in 2014 (p < 0.001). Overall mortality in patients with HIV was 3.3% and was significantly higher in those with PCP than without PCP (9.9% vs. 2.9%; p < 0.001). After adjusting for demographics and other comorbidities, PCP had higher odds of hospital mortality 3.082 (OR 3.082; 95% CI, 3.007 to 3.159; p < 0.001). Conclusion: From 2002 to 2014, the rate of PCP in HIV patients has decreased significantly in the United States but is associated with substantially higher mortality.

Impact of atrial fibrillation on in-hospital outcomes among hospitalizations for cardiac surgery: an analysis of the National Inpatient Sample

The short-term impact of atrial fibrillation (AF) on cardiac surgery hospitalizations has been previously reported in cohorts of various sizes, but results have been variable. Using the 2005-2014 National Inpatient Sample, we identified all adult hospitalizations for cardiac surgery using the International Classification of Diseases, Ninth Revision, Clinical Modification as any procedure code and AF as any diagnosis code. We estimated the impact of AF on inpatient mortality, length of stay (LOS), and cost of hospitalization using survey-weighted, multivariable logistic, accelerated failure-time log-normal, and log-transformed linear regressions, respectively. Additionally, we exact-matched AF to non-AF hospitalizations on various confounders for the same outcomes. A total of 1,269,414 hospitalizations were noted for cardiac surgery during the study period. Coexistent AF was found in 44.9% of these hospitalizations. Overall mean age was 65.6 years, 40.9% were female, mean LOS was 11.6 days, and inpatient mortality was 4.5%. Stroke rate was lower in AF hospitalizations (1.8% vs 2.1%, p<0.001). Mortality was lower in the AF (3.9%) versus the non-AF (5%) group (exact-matched OR or emOR=0.48, 95% CI 0.29 to 0.80, p<0.001; 987 matched pairs, n=2423), with similar results after procedural stratification: isolated valve replacement/repair (emOR=0.38, p<0.001), isolated coronary artery bypass graft (CABG) (emOR=0.33, p<0.001), and CABG with valve replacement/repair (emOR=0.55, p<0.001). A 12% increase was seen in LOS in the AF subgroup (exact-matched time ratio=1.12, 95% CI 1.10 to 1.14, p<0.001) among hospitalizations which underwent valve replacement/repair with or without CABG. Hospitalizations for cardiac surgery which had coexistent AF were found to have lower inpatient mortality risk and stroke prevalence but higher LOS and hospitalization costs compared with hospitalizations without AF.

Virulence, MLST analysis, and antimicrobial resistance of Campylobacter coli isolated from broiler chickens in Tamil Nadu, India

Background

Campylobacter species are the zoonotic bacteria and the most common cause of foodborne gastroenteritis around the world. The link between human campylobacteriosis and infected poultry consumption has been well established.

Aims

In this study, we aimed to isolate Campylobacter spp. from chicken and characterize them with molecular methods.

Methods

Totally, 241 chicken caecal mucosal scrapings were collected from five districts of Tamil Nadu. Bacterial isolation was done by plating on blood-free Campylobacter selective medium with supplements. Campylobacter species were identified by multiplex PCR and Campylobacter coli isolates were tested for 11 virulence genes by PCR. C. coli isolates were typed based on seven housekeeping genes multilocus sequence typing (MLST) scheme. The antimicrobial susceptibility was determined by a microdilution resazurin assay.

Results

The prevalence of C. coli and C. jejuni were 14.94% (36/241), and 3.32% (8/241), respectively. The virulence genes flaA, flaB, cadF, cdtA, cdtB, cdtC, ciaB, and ceuE were present in all 36 C. coli isolates, pldA and racR genes were present in 58.33% (21/36), and 16.67% (6/36) of the isolates, respectively, and dnaJ was present in only one isolate. Two novel sequence types (ST-10872, ST-11031) were found in this study. Though different STs were identified, all the STs belonged to the same clonal complex of ST-828. All 14 C. coli isolates showed 100% resistance to nalidixic acid, and higher resistance to tetracycline (92.8%), erythromycin (71.4%), clindamycin (71.4%), and azithromycin (64.2%) was noticed. All C. coli isolates were sensitive to chloramphenicol, and higher sensitivity to ciprofloxacin (78.5%), and gentamicin (71.4%) was observed.

Conclusion

The present study demonstrated that C. coli is more prevalent in broilers than C. jejuni in Tamil Nadu. The presence of C. jejuni and C. coli in chicken caecal samples from the slaughterhouse are indicative of the possibility of public health hazards.

Nivar cyclonic impacts on mollusk habitat destruction in Parangipettai, southeast coast of Tamil Nadu, India: A case study

Tropical storms form in the Bay of Bengal every year during the pre-monsoon season, affecting the coastal communities and the marine ecosystem. On November 25, 2020, severe cyclone Nivar impacted the southeast coast of Tamil Nadu, causing massive damage to marine benthic species. The study found that the Nivar cyclone's high velocity wind impacted tidal currents and damaged sediment compartments. This phenomenonhas immensely affected the benthic communities of Mudasalodai, Parangipettai, Puthupettai, Samiyarpettai, and Kumarapettai. Post-Nivar cyclone observations revealed massive bivalve and gastropod mortality. The two molluscan species lost their habitats due to the tremendous cyclone effect. More than 1 lakh Mactra violacea were emigrated from Parangipettai and 5 lakh Turritella acutangula and T. attenuata were emigrated from Samiyarpettai. Thus, the Nivar cyclone severely damaged mollusk habitats along India's southeast coast. The severe cyclonic storm Nivar disrupted the southeast coast of India, with losses amounting to over $600 million.

Fungal infections in hematopoietic stem-cell transplant patients: a review of epidemiology, diagnosis, and management

The advent of bone marrow transplant has opened doors to a different approach and offered a new treatment modality for various hematopoietic stem-cell-related disorders. Since the first bone marrow transplant in 1957, there has been significant progress in managing patients who undergo bone marrow transplants. Plasma-cell disorders, lymphoproliferative disorders, and myelodysplastic syndrome are the most common indications for hematopoietic stem-cell transplant. Despite the advances, invasive fungal infections remain a significant cause of morbidity and mortality in this high-risk population. The overall incidence of invasive fungal infection in patients with hematopoietic stem-cell transplant is around 4%, but the mortality in patients with allogeneic stem-cell transplant is as high as 13% in one study. Type of stem-cell transplant, conditioning regimen, and development of graft-versus-host disease are some of the risk factors that impact the risk and outcomes in patients with invasive fungal infections. Aspergillus and candida remain the two most common organisms causing invasive fungal infections. Molecular diagnostic methods have replaced some traditional methods due to their simplicity of use and rapid turnaround time. Primary prophylaxis has undoubtedly shown to improve outcomes even though breakthrough infection rates remain high. The directed treatment has seen a significant shift from amphotericin B to itraconazole, voriconazole, and echinocandins, which have shown better efficacy and fewer adverse effects. In this comprehensive review, we aim to detail epidemiology, risk factors, diagnosis, and management, including prophylaxis, empiric and directed management of invasive fungal infections in patients with hematopoietic stem-cell transplant.

Spontaneous intercostal artery bleeding in a patient with alcohol-induced liver cirrhosis

Spontaneous intercostal artery bleeding is a rare disease seen in cirrhosis and can present with hemodynamically significant blood loss anemia, hypotension, and shock. Transcatheter arterial embolization is an effective treatment for severe cases.

Radiation-Induced Lung Injury-Current Perspectives and Management

Radiotherapy plays an important role in the treatment of localized primary malignancies involving the chest wall or intrathoracic malignancies. Secondary effects of radiotherapy on the lung result in radiation-induced lung disease. The phases of lung injury from radiation range from acute pneumonitis to chronic pulmonary fibrosis. Radiation pneumonitis is a clinical diagnosis based on the history of radiation, imaging findings, and the presence of classic symptoms after exclusion of infection, pulmonary embolism, heart failure, drug-induced pneumonitis, and progression of the primary tumor. Computed tomography (CT) is the preferred imaging modality as it provides a better picture of parenchymal changes. Lung biopsy is rarely required for the diagnosis. Treatment is necessary only for symptomatic patients. Mild symptoms can be treated with inhaled steroids while subacute to moderate symptoms with impaired lung function require oral corticosteroids. Patients who do not tolerate or are refractory to steroids can be considered for treatment with immunosuppressive agents such as azathioprine and cyclosporine. Improvements in radiation technique, as well as early diagnosis and appropriate treatment with high-dose steroids, will lead to lower rates of pneumonitis and an overall good prognosis.

A Unique Case of Spontaneous Pneumomediastinum in a Patient With COVID-19 and Influenza Coinfection

Spontaneous pneumomediastinum is reported in patients with coronavirus disease-2019 (COVID-19) and influenza infection independently, usually associated with noninvasive and mechanical ventilation. We report a case of spontaneous pneumomediastinum in a patient with COVID-19 and influenza coinfection. A 58-year-old male admitted with shortness of breath, diagnosed with COVID-19 and influenza infection. A computed tomography angiogram showed pneumomediastinum. He was treated conservatively with 15 L of oxygen, remdesivir, convalescent plasma, and oseltamivir. The case is being reported for its uniqueness since this is the first documented case of spontaneous pneumomediastinum in COVID-19 and influenza coinfection.

Clostridium Difficile and Noncirrhotic Hyperammonnemia in a Patient With COVID-19 Infection

Clostridium difficile is a bacterial infection that usually presents with diarrhea and is mostly associated with previous antibiotics use. Patients with coronavirus disease 2019 (COVID-19) generally have respiratory symptoms but can also present with diarrhea. Noncirrhotic hyperammonemia is an infrequent presentation and is treated with lactulose. We report the case of a 40-year-old male who was admitted to our hospital with abdominal pain, diarrhea, shortness of breath, and confusion. During hospitalization, the patient tested positive for COVID-19 and C. difficile, and oral vancomycin was administered. His kidney functions improved, but he remained confused. His ammonia levels were elevated, and he was not treated with lactulose due to ongoing diarrhea secondary to C. difficile infection.

Diffuse alveolar hemorrhage associated with ustekinumab treatment

PURPOSE

A case of diffuse alveolar hemorrhage (DAH) occurring as a reaction to ustekinumab therapy is reported.

SUMMARY

After starting ustekinumab for treatment of psoriatric arthritis, a 46-year-old female presented with flu-like symptoms and cough with blood-tinged sputum that had begun 1 week previously. Her initial computed tomography scan of the chest demonstrated bilateral ground-glass opacities. On bronchoscopy, the bronchoalveolar lavage (BAL) return became bloodier from sample 1 to samples 2 and 3. Her BAL fluid was more than 90% hemosiderin-laden macrophages, a finding consistent with DAH. We ruled out infectious etiologies and other common vasculitis conditions that can cause DAH. A diagnosis of ustekinumab-induced DAH was made due to a temporal relationship between initiation of the drug and the patient's presentation and the absence of infection and other alternate diagnosis. Prior case reports including ustekinumab-induced pneumonitis, interstitial lung disease with a granulomatous component, and lupus syndrome have been reported, with this being the first case of DAH in a patient undergoing treatment of psoriatic arthritis.

CONCLUSION

A 46-year-old woman developed DAH during ustekinumab treatment. Symptoms abated after drug discontinuation and supportive treament. Clinicians must remain mindful of this rare complication of ustekinumab use in order to avoid potential delays in appropriate DAH treatment.

Metabolic and molecular modelling of zebrafish gut biome to unravel antimicrobial peptides through metagenomics

Recently efforts have been taken for unravelling mysteries between host-microbe interactions in gut microbiome studies of model organisms through metagenomics. Co-existence and the co-evolution of the microorganisms is the significant cause of the growing antimicrobial menace. There needs a novel approach to develop potential antimicrobials with capabilities to act directly on the resistant microbes with reduced side effects. One such is to tap them from the natural resources, preferably the gut of the most closely related animal model. In this study, we employed metagenomics approaches to identify the large taxonomic genomes of the zebra fish gut. About 256 antimicrobial peptides were identified using gene ontology predictions from Macrel and Pubseed servers. Upon the property predictions, the top 10 antimicrobial peptides were screened based on their action against many resistant bacterial species, including Klebsiella pneumoniae, Pseudomonas aeruginosa, Staphylococcus aureus, E. coli, and Bacillus cereus. Metabolic modelling and flux balance analysis (FBA) were computed to conclude the antibiotic such as tetracycline, cephalosporins, puromycin, neomycin biosynthesis pathways were adopted by the microbiome as protection strategies. Molecular modelling strategies, including molecular docking and dynamics, were performed to estimate the antimicrobial peptides' binding against the target-putative nucleic acid binding lipoprotein and confirm stable binding. One specific antimicrobial peptide with the sequence "MPPYLHEIQPHTASNCQTELVIKL" showed promising results with 53% hydrophobic residues and a net charge +2.5, significant for the development of antimicrobial peptides. The said peptide also showed promising interactions with the target protein and expressed stable binding with docking energy of -429.34 kcal/mol and the average root mean square deviation of 1 A⁰. The study is a novel approach focusing on tapping out potential antimicrobial peptides to be developed against most resistant bacterial species.

Trends in Prevalence and Outcomes of Cannabis Use Among Chronic Obstructive Pulmonary Disease Hospitalizations: A Nationwide Population-Based Study 2005-2014

Background: Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of mortality in the United States. Due to the ongoing legalization of cannabis, its acceptance, availability, and use in the in-patient population are on the rise. In this retrospective study, we investigated the association of cannabis use with important outcomes in COPD hospitalizations. Methods: The National Inpatient Sample (NIS) data were analyzed from 2005 to 2014. The primary outcome of interest was the trends and outcomes of cannabis use among COPD hospitalizations, including in-hospital mortality, pneumonia, sepsis, and respiratory failure. Results: We identified 6,073,862 hospitalizations, 18 years of age or older, with COPD using hospital discharge codes. Of these, 6,049,316 (99.6%) were without cannabis use, and 24,546 (0.4%) were admitted with cannabis use. The majority of COPD hospitalizations with cannabis use were aged 50-64 (60%). Cannabis use was associated with lower odds of in-hospital mortality (odds ratio [OR] 0.624 [95% confidence interval (CI) 0.407-0.958]; p=0.0309) and pneumonia (OR 0.882 [95% CI 0.806-0.964]; p=0.0059) among COPD hospitalizations. Cannabis use also had lower odds of sepsis (OR 0.749 [95% CI 0.523-1.071]; p=0.1127) and acute respiratory failure (OR 0.995 [95% CI 0.877-1.13]; p=0.9411), but it was not statistically significant. Conclusions: Among hospitalized patients with a diagnosis of COPD, cannabis users had statistically significant lower odds of in-hospital mortality and pneumonia compared to noncannabis users. The association between cannabis use and these favorable outcomes deserves further study to understand the interaction between cannabis use and COPD.

From genomes to molecular dynamics - A bottom up approach in extrication of SARS CoV-2 main protease inhibitors

The recent pandemic Coronavirus disease-19 outbreak had traumatized global countries since its origin in late December 2019. Though the virus originated in China, it has spread rapidly across the world due its firmly established community transmission. To successfully tackle the spread and further infection, there needs a clear multidimensional understanding of the molecular mechanisms. Henceforth, 942 viral genome sequences were analysed to predict the core genomes crucial in virus life cycle. Additionally, 35 small interfering RNA transcripts were predicted that can target specifically the viral core proteins and reduce pathogenesis. The crystal structure of Covid-19 main protease-6LU7 was chosen as an attractive target due to the factors that there were fewer mutations and whose structure had significant identity to the annotated protein sequence of the core genome. Drug repurposing of both recruiting and non recruiting drugs was carried out through molecular docking procedures to recognize bitolterol as a good inhibitor of Covid-19 protease. The study was extended further to screen antiviral phytocompounds through quantitative structure activity relationship and molecular docking to identify davidigenin, from licorice as the best novel lead with good interactions and binding energy. The docking of the best compounds in all three categories was validated with molecular dynamics simulations which implied stable binding of the drug and lead molecule. Though the studies need clinical evaluations, the results are suggestive of curbing the pandemic.

Isolated Radial Vein Thrombosis: Upper Extremity Deep Vein Thrombosis in a Patient With COVID-19 Infection

In general, upper extremity deep vein thrombosis (DVT) is less common than lower extremity DVT. Among upper extremity DVT cases, most of them are due to secondary causes like indwelling catheters, cancer, surgery, trauma or immobilization by plaster casts, pregnancy, oral contraceptives, and estrogen. Patients with coronavirus disease 2019 (COVID-19) infection are known to have coagulation dysfunction and a high incidence of DVT, mostly in the lower extremities; however, upper extremity DVT has been rarely reported. We present a rare case of upper extremity DVT in COVID-19 infection. A 56-year-old male with no significant past medical history was admitted with acute respiratory failure due to COVID-19 pneumonia. During hospitalization, he developed right upper extremity swelling, and an ultrasonogram showed right radial vein thrombosis. He was initially started on low molecular weight heparin (LMWH) and was discharged on apixaban. Patients with COVID-19 infection who develop DVT are recommended treatment with a direct oral anticoagulant (DOAC) for three months.

Hematologic disorders associated with COVID-19: a review

Coronavirus disease 2019 is caused by severe acute respiratory syndrome coronavirus 2. Primarily an infection of the lower respiratory tract, it is now well known to cause multisystem abnormalities. Hematologic manifestations constitute a significant area of concern. Severe acute respiratory syndrome coronavirus 2 infects monocytes and endothelial cells leading to a complex downstream cascade, cytokine storm, and eventual intravascular thrombosis. Coronavirus disease 2019 causes lymphopenia, neutrophilia, and thrombocytopenia. Prophylactic anticoagulation is vital in patients with coronavirus disease 2019, as its effect on the coagulation system is associated with significant morbidity and mortality. The disease can cause both arterial and venous thromboses, especially pulmonary embolism and pulmonary microthrombi. A high index of suspicion is indispensable in recognizing these complications, and timely institution of therapeutic anticoagulation is vital in treating them. Virus-induced disseminated intravascular coagulation is uncommon but shares some similarities to sepsis-induced disseminated intravascular coagulation. Marked elevations in hematologic biomarkers such as lactate dehydrogenase, D-dimer, ferritin, and C-reactive protein are associated with worse outcomes. Understanding the pathophysiology and recognizing factors associated with poor prognosis are crucial in improving patient outcomes with coronavirus disease 2019.

A Case of Hemothorax as Manifestation of Thoracic Endometrial Syndrome

Thoracic endometriosis is a rare progression of a mostly benign disease of ectopic endometrial activity involving the pleura and lung. This is a case of a young female who presented with progressive shortness of breath and was found to have significant anemia. Further investigations showed a massive right-sided pleural effusion and ascites. Subsequent thoracentesis and pelvic diagnostic laparoscopy showed a hemorrhagic pleural effusion and ascites, along with dense pelvic adhesions. Pathology was consistent with endometriosis. Patient improved on leuprolide acetate and norethindrone. This case illustrates an important consideration in the differential of a reproductive-age female with new onset shortness of breath and anemia.

Disseminated Mycobacterium abscessus infection and native valve endocarditis

Mycobacterium abscessus is a rapidly growing mycobacterium. It rarely causes disseminated infection or endocarditis. A 55-year-old male with a history of hepatitis C, liver cirrhosis, intravenous drug use (last use was four years ago), and chronic back pain presented with a three-week history of a right calf nodular lesion. He did not have a fever, chills, rash, dyspnea, or cough. Laboratory data showed mild leukocytosis. Computed tomography of the chest revealed bilateral cavitating nodules. Skin biopsy, sputum, and blood cultures grew Mycobacterium abscessus. Therapy with meropenem, tigecycline, and amikacin was initiated. He was re-admitted with worsening lower back pain. A lumbar magnetic resonance imaging showed destructive changes of L4 and L5 vertebral bodies concerning for osteomyelitis. Blood culture and bone biopsy grew Mycobacterium abscessus again. An echocardiogram was performed due to persistent bacteremia, which revealed large vegetation on the tricuspid valve and small vegetation on the mitral valve. Therapy was changed to eight weeks of amikacin, with cefoxitin and imipenem for twelve months based on drug susceptibility. Treatment of disseminated Mycobacterium abscessus is challenging due to antibiotic resistance. Typically, multidrug therapy is warranted with at least three active drugs. In severe valvular endocarditis, valve replacement may be required.

Computational gene expression profiling in the exploration of biomarkers, non-coding functional RNAs and drug perturbagens for COVID-19

The coronavirus disease, caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), is a global health crisis that is being endured with an increased alarm of transmission each day. Though the pandemic has activated innumerable research attention to decipher an antidote, fundamental understanding of the molecular mechanisms is necessary to halt the disease progression. The study focused on comparison of the COVID-19 infected lung tissue gene expression datasets -GSE155241 and GSE150316 with the GEO2R-limma package. The significant up- and downregulated genes were annotated. Further evaluation of the enriched pathways, transcription factors, kinases, noncoding RNAs and drug perturbations revealed the significant molecular mechanisms of the host response. The results revealed a surge in mitochondrial respiration, cytokines, neurodegenerative mechanisms and deprived oxygen, iron, copper, and glucose transport. Hijack of ubiquitination by SARS-CoV-2, hox gene differentiation, histone modification, and miRNA biogenesis were the notable molecular mechanisms inferred. Long non-coding RNAs such as C058791.1, TTTY15 and TPTEP1 were predicted to be efficient in regulating the disease mechanisms. Drugs-F-1566-0341, Digoxin, Proscillaridin and Linifanib that reverse the gene expression signatures were predicted from drug perturbations analysis. The binding efficiency and interaction of proscillaridin and digoxin as obtained from the molecular docking studies confirmed their therapeutic potential. Two overlapping upregulated genes MDH1, SGCE and one downregulated gene PFKFB3 were appraised as potential biomarkers candidates. The upregulation of PGM5, ISLR and ANK2 as measured from their expressions in normal lungs affirmed their possible prognostic biomarker competence. The study explored significant insights for better diagnosis, and therapeutic options for COVID-19.

Communicated by Ramaswamy H. Sarma

A Child with Enlarged Extremities - A Case of Macrodystrophia Lipomatosa

Macrodystrophia lipomatosa (ML) is a rare, non-hereditary, developmental anomaly that occurs because of the progressive proliferation of all mesenchymal elements of single or multiple digits or entire extremity, with a disproportionate increase in fibroadipose tissue. Commonly one or few digits of an extremity will be enlarged and present as macrodactyly or as enlarged limb. Lower limb involvement is more common and frequently unilateral. The diagnosis of ML is made by accurate clinical assessment and imaging modalities, such as plain X-ray, computed tomography scan, magnetic resonance imaging, and confirmed by histopathological study. In this case, we described a 10-year-old child who was brought to us with enlarged upper and lower extremities and was diagnosed as a case of ML with the help of clinico-radiological studies and presented here because of focal gigantism involving all four limbs, which is very rare.

Impact of a Positive Viral Polymerase Chain Reaction on Outcomes of Chronic Obstructive Pulmonary Disease (COPD) Exacerbations

Introduction: More than 15 million adults in the USA have chronic obstructive pulmonary disease. Chronic obstructive pulmonary disease (COPD) places a high burden on the healthcare system. Many hospital admissions are due to an exacerbation, which is suspected to be from a viral cause. The purpose of this analysis was to compare the outcomes of patients with a positive and negative respiratory virus panel who were admitted to the hospital with COPD exacerbations. Methods: This retrospective cohort study was conducted in the Geisinger Healthcare System. The dataset included 2729 patient encounters between 1 January 2006 and 30 November 2017. Hospital length of stay was calculated as the discrete number of calendar days a patient was in the hospital. Patient encounters with a positive and negative respiratory virus panel were compared using Pearson’s chi-square or Fisher’s exact test for categorical variables and Student’s t-test or Wilcoxon rank-sum tests for continuous variables. Results: There were 1626 patients with a total of 2729 chronic obstructive pulmonary disease exacerbation encounters. Nineteen percent of those encounters (n = 524) had a respiratory virus panel performed during their admission. Among these encounters, 161 (30.7%) had positive results, and 363 (69.3%) had negative results. For encounters with the respiratory virus panel, the mean age was 64.5, 59.5% were female, 98.9% were white, and the mean body mass index was 26.6. Those with a negative respiratory virus panel had a higher median white blood cell count (11.1 vs. 9.9, p = 0.0076). There were no other statistically significant differences in characteristics between the two groups. Respiratory virus panel positive patients had a statistically significant longer hospital length of stay. There were no significant differences with respect to being on mechanical ventilation or ventilation-free days. Conclusion: This study shows that a positive respiratory virus panel is associated with increased length of hospital stay. Early diagnosis of chronic obstructive pulmonary disease exacerbation patients with positive viral panel would help identify patients with a longer length of stay.

Clinical and Radiologic Findings of Acute Necrotizing Encephalopathy in Young Adults

Acute necrotizing encephalopathy after an acute febrile illness, although initially described exclusively in the pediatric age group, has been recently shown to have an adult onset as well. In this study, we describe 10 patients (16 years of age or older) with acute necrotizing encephalopathy. In our study, bilateral thalamic involvement with the trilaminar pattern of diffusion restriction on MR imaging was the predominant finding seen in all of the patients reviewed. Ancillary findings of cerebral white matter, brain stem, and cerebellum involvement with sparing of the basal ganglia were also noted. A poorer outcome was observed in patients with a higher degree of thalamic involvement. The cause of an underlying infection was identified in 4 patients (dengue in 3 and influenza in 1). Overall, a sizeable portion of young adults with acute necrotizing encephalopathy have shown a poorer outcome, with dengue being an important underlying trigger in an endemic region.

A case of secondary tension pneumothorax in COVID-19 pneumonia in a patient with no prior history of lung disease

Complications that arise in patients with severe COVID-19 pneumonia are acute respiratory distress syndrome, often leading to mechanical ventilation, shock requiring vasopressors, acute kidney injury, stroke, thromboembolic phenomena, and myocardial injury. To date, there are four cases of tension pneumothorax in patients with COVID-19, published in literature. We present a 33-year-old man with no prior history of lung disease who was admitted to our hospital on account of hypoxic respiratory failure secondary to COVID-19 pneumonia. During his hospitalization, he developed sudden onset of chest pain which worsened with coughing. A chest X-ray showed a right-sided pneumothorax with left-sided mediastinal shift. He required placement of chest tubes with eventual resolution of the pneumothorax several days later. This case highlights the need for clinical recognition, consideration of differential diagnoses, prompt evaluation, appropriate imaging, and management of this severe life-threatening unusual complication of COVID-19 pneumonia.

Molecular modelling analysis of T219A mutant envelope protein revealed novel virulence enhancing factors in Dengue virus isolated from Kerala state, India

Dengue virus (DENV) is an emerging health threat and its envelope glycoprotein E, is involved in the anchoring and fusion mechanisms. Anchoring followed by conformational changes of E-protein are responsible for the fusion and entry of DENV into host. The variation in the conformation of the E-protein due to mutations, results in its altered binding with antibodies (Abs) and also its receptors. This leads to failure of neutralization of DENV and enhance the infection. In our earlier studies we have identified T219A mutation in the E-protein of DENV and the present study is focused on the impact of this mutation on the conformation of E-protein and also its binding variation with Abs and Fc-γ receptor. A comparative molecular modelling studies of wild type and T219A mutant E-proteins revealed that, the mutation induced several conformational variations in the E-protein and resulted in the variable binding orientation with altered affinities. Further, the mutation was also observed to enhance the fusion mechanism by Fc-γ receptors that mediate the efficient entry of DENV into host cell through altered membrane fusion mechanism. Such conformational variations of E-protein could be the responsible factors for enhanced virulence of DENV infections.

A Review of the Incidence Diagnosis and Treatment of Spontaneous Hemorrhage in Patients Treated with Direct Oral Anticoagulants

Anticoagulation carries a tremendous therapeutic advantage in reducing morbidity and mortality with venous thromboembolism and atrial fibrillation. For over six decades, traditional anticoagulants like low molecular weight heparin and vitamin K antagonists like warfarin have been used to achieve therapeutic anticoagulation. In the past decade, multiple new direct oral anticoagulants have emerged and been approved for clinical use. Since their introduction, direct oral anticoagulants have changed the landscape of anticoagulants. With increasing indications and use in various patients, they have become the mainstay of treatment in venous thromboembolic diseases. The safety profile of direct oral anticoagulants is better or at least similar to warfarin, but several recent reports are focusing on spontaneous hemorrhages with direct oral anticoagulants. This narrative review aims to summarize the incidence of spontaneous hemorrhage in patients treated with direct oral anticoagulants and also offers practical management strategies for clinicians when patients receiving direct oral anticoagulants present with bleeding complications.

Isolation and characterization of an iridoid, Arbortristoside-C from Nyctanthes arbor-tristis Linn., a potential drug candidate for diabetes targeting α-glucosidase

Many parts of the plant Nyctanthes arbor-tristis Linn. are widely investigated for their biological properties. Purified Arbortristosides from seeds are reported as anticancer, anti-leishmania, anti-inflammatory, anti-allergic, immunomodulatory and antiviral. The present study elaborates on the isolation, structural and functional characterization of Arbortristoside-C and its inhibition properties against alpha-glucosidase, an important target for diabetes mellitus. Arbortristoside-C is purified from seeds of N. arbor-tristis by extraction using polar fractionation and chromatographic techniques. Arbortristoside-C has been characterized using Ultra Violet (UV), Mass (MS), Infra-Red (IR) and Nuclear Magnetic Resonance (NMR). Inhibition kinetics and Isothermal Titration Calorimetry (ITC) were used for activity and binding characteristics of acarbose and Arbortristoside-C using in-house purified α-glucosidase from Bos taurus. Modeling, docking and structural comparison with acarbose bound structure revealing the similar binding characteristics of Arbortristoside-C which include interaction with catalytic acid/base Aspartic acid residue. Cytotoxicity assay revealed that 100 µg/ml is the maximum toxic-free concentration of Arbortristoside-C. The purified Arbortristoside-C showed inhibition against mammalian α-glucosidase, suggesting its potential to treat Diabetes mellitus.

Paraganglioma of the middle mediastinum

A 60-year-old female was evaluated for significant weight loss, nausea, vomiting, and dysphagia. A computed tomography (CT) of the chest showed a 3 cm mass in the middle mediastinum. CT scan of the abdomen and pelvis revealed no abnormality. Positron emission tomography (PET) of the whole body revealed tracer uptake in the pre-carinal nodal mass. There were no other suspicious foci of tracer uptake. Mediastinoscopy and biopsy revealed a well-differentiated low-grade neuroendocrine tumor. She underwent sternotomy, and after careful mobilization of the great vessels, the middle mediastinal mass was successfully resected. Final pathology revealed a paraganglioma with no morphological signs to suggest malignancy. The right lower paratracheal lymph node did not show any tumor cells. She did well postoperatively.

Interstitial lung disease and diabetes

Diabetes mellitus (DM) is a chronic metabolic disease and its prevalence has been steadily increasing all over the world. DM and its associated micro and macrovascular complications result in significant morbidity and mortality. The microvascular complications are usually manifested as retinopathy, neuropathy, nephropathy and macrovascular complications generally affect the cardiovascular system. In addition to these complications, DM also affects the lungs because of its rich vascularity and abundance in connective tissue (collagen and elastin). DM has been found to cause microvascular complications and proliferation of extracellular connective tissue in the lungs, leading to decline in lung function in a restrictive pattern. Interstitial lung disease (ILD) includes a diverse group of disease conditions characterized by different degrees of inflammation and fibrosis in the pulmonary parenchyma. Idiopathic pulmonary fibrosis (IPF) is one of the common type of idiopathic interstitial pneumonia with a high mortality rate. IPF is characterized by chronic progressive fibrosis leading to progressive respiratory failure. In this review we focus on lung as the target organ in DM and the association of DM and ILD with special emphasis on IPF.

Structure-based drug designing towards the identification of potential anti-viral for COVID-19 by targeting endoribonuclease NSP15

The world is facing health and economic havoc due to the Corona Virus Disease-2019 (COVID-19) pandemic. Given the number of affected people and the mortality rate, the virus is undoubtedly a serious threat to humanity. By analogy with earlier reports about Severe Acute Respiratory Syndrome (SARS-CoV) and Middle East Respiratory Syndrome (MERS-CoV) - viruses, the novel Coronavirus' replication mechanism is likely well understood. The structure of an endoribonuclease (NSP15) of SARS-CoV-2 was reported recently. This enzyme is expected to play a crucial role in replication. In this work, attempts were made to identify inhibitors of this enzyme. To achieve the goal, high throughput in silico screening and molecular docking procedures were performed. From an Enamine database of a billion compounds, 3978 compounds with potential antiviral activity were selected for screening and induced fit docking that funneled down to eight compounds with good docking score and docking energy. Detailed analysis of non-covalent interactions at the active site and the apparent match of the molecule with the shape of the binding pocket were assessed. All the compounds show significant interactions for tight binding. Since all the compounds are synthetic with favorable drug-like properties, these may be considered for immediate optimization and downstream applications.

A Fatal Case of Coronavirus Disease 2019 (COVID-19) in a Patient With Idiopathic Pulmonary Fibrosis

The number of cases of coronavirus disease 2019 (COVID-19) has been exponentially increasing everyday. It is important to recognize the comorbidities and risk factors associated with this highly contagious and serious disease that has caused thousands of deaths worldwide. Patients with certain conditions like diabetes, hypertension, cardiovascular disease and chronic lung diseases have been reported to develop serious complications from COVID-19. Idiopathic pulmonary fibrosis (IPF) is a disease that is more prevalent in the elderly population, the same group that are more susceptible to serious complications from COVID-19. Our literature search did not reveal any review about COVID-19 in IPF patients. We report a patient with IPF who was exposed to COVID-19 from her spouse and died from its complications. This case would help to raise the awareness among IPF patients to follow the necessary precautions to reduce the risk of contracting the disease.

Crystallographic and calorimetric analysis on Pleurotus ostreatus lectin and its sugar complexes - promiscuous binding driven by geometry

Carbohydrate recognition is established as a property of lectins and implicated in many functions including immunity and defense against pathogens. Many lectins are characterized and proposed for various applications owing to the above said recognition. The crystal structure of a lectin from Pleurotus ostreatus has been determined and shown to be calcium dependent. The overall structure is a tandem repeat of two β-jelly roll domains, a new fold for lectins. The calcium dependence of sugar binding is analyzed in-detail through isothermal titration calorimetry. The serendipitous observation of malonate and glycerol, the intentional N-Acetyl-D-galactosamine, D-Galactose and L-Rhamnose binding to Pleurotus ostreatus lectin by Ca²⁺ coordination revealed that the binding site is promiscuous. Among these sugars, Rhamnose binding found to be thermodynamically most favourable. In all these structures, a vicinal diol motif, one at axial and the other at equatorial positions could be established as a specific requirement for binding. Interestingly, when compared with other calcium mediated lectin structures; this geometric requirement is found conserved. This observation could lead to the conclusion that lectins are not 'molecule specific' but 'geometry specific' so that any molecule not necessarily a sugar may be recognized by this lectin if the geometry exists.