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ijcmcrjournal · 2 years

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Case Report of Disseminated Pseudomonas Infection with Superadded Burkholderia Infection – A Battle Lost! by Sangita K*

Abstract

Pseudomonas aeruginosa is a gram-negative pathogen, that often causes nosocomial pneumonia in hospitalized patients. Most of these patients have risk factors for pseudomonas infection. Although uncommon, there have been case reports of previously healthy individuals who developed Community-Acquired Pneumonia (CAP) caused by P. aeruginosa. Such cases have often rapidly progressive course and prove fatal. We, hereby, report a case of pseudomonas pneumonia in a 29-year-old immunocompetent patient, who developed disseminated infection and superinfection with yet another nosocomial pathogen, Burkholderiacepacia, eventually leading to septic shock and death, despite appropriate antibiotic therapy.

Keywords: Infection; Bacteremia; Pneumonia; Antibiotics; Healthy

Introduction

Community-Acquired Pneumonia (CAP) due to pseudomonas aeruginosa in a previously healthy individual is rare. Pseudomonas is a gram-negative, aerobic organism which generally infects patients with structural lung diseases like cystic fibrosis and Chronic Obstructive lung Disease (COPD) and immunocompromised host [1]. We report a rare case of P. aeruginosa CAP in a young female without risk factors that progressed to necrotizing pneumonia, with formation of cavities. Further, there was dissemination of infection to other organs resulting in metastatic abscesses in liver and spleen, superinfection with Burkholderiacepacia, eventually leading to septic shock, Multi-Organ Dysfunction Syndrome (MODS) and death, despite being treated with appropriate antibiotics.Such a case of disseminated pseudomonas infection is hitherto not described in the literature.

Case Report

A 22-year-old previously healthy lady was admitted to our hospital with history ofhigh-grade fever for 7 days accompanied by cough, productive of scanty yellowish sputum for 5 days. She had also noticed swelling of both legs, three days prior to the admission. She had undergone caesarian section 3 months prior and remained asymptomatic till 1 week prior to hospital admission. She did not have past history of any significant medical ailment and addictions. On examination, she had pallor and bilateral pitting pedal edema. There was no cyanosis, clubbing or generalized lymphadenopathy. She was febrile, pulse rate was 124/minute, regular, blood pressure was 112/70 mm Hg and respiratory rate was 22/minute with accessories working. Breath sounds were vesicular type and were diminished at both bases. SaO2 while breathing ambient air was 92%. Abdomen was fatty and there was no organomegaly. Other systems were normal.

On admission, her hemoglobin was 6.4gm/dl, mean corpuscular volume (MCV) 77.8 fl, WBC count 2,300/µL (52% neutrophils with toxic granules, 36% lymphocytes, 12% monocytes) and platelet count 51,000/cu mm. Evaluation of the cause of anemia revealed serum iron – 34.8mcg/dl, serum ferritin – 564 mcg/L, serum folic acid –5.6ng/ml, serum B12 - 442pg/ml, reticulocyte count of 0.8%, normal adult pattern hemoglobin electrophoresis and negative Direct Coomb’s Test (DCT). Renal function test was normal. Liver function test revealed serum bilirubin – 1.72 mg/dl, alanine transferase (ALT)-27.9U/L, Aspartate Transferase (AST) 40.8U/L, alkaline phosphatase (ALP)-284.4U/L, total serum protein 6.1g/dl, serum albumin- 2.07 g/dl, serum globulin – 4.03g/dl. Her coagulation tests revealed prothrombin time–13.2, control-11 secs, International Normalized Ratio (INR) 1.54 and activated partial thromboplastin time – 26.9 sec, control-24.6. C- Reactive Protein (CRP)was 29.24 mg/dl. Her viral markers (HBsag, HIV 1 and ll and HCV antibodies) were non-reactive. Her antinuclear antibodies (ANA) and antibodies to double-stranded DNA (dsDNA) were negative. Mantoux skin test was negative. Urine routine examination showed 10 to 12 pus cells/ high power field and 274.6mg/dl of protein.Her serial laboratory investigations were as tabled in the Table 1.

Chest radiograph showed left mid zone pneumonia (Figure 1) while Contrast Enhanced Computed Tomography (CECT) of thorax showed multiple small nodules and cavities in both lungs with mild left pleural effusion (Figures 2a-2d). Echocardiography was normal. Abdominal ultrasound showed hepatosplenomegaly with imaging features suggestive of multiple abscesses in liver largest measuring 6 cm x 4 cm and largest splenic abscess measuring 4 x 3.5 cm with moderate ascites while Contrast Enhanced Computed Tomography (CECT) abdomen confirmed the above findings and additionally showed few small abscesses in the right kidney (figures 3a-3d).

Her blood culture sent on the day of admission grew gram negative bacilli, pseudomonas aeruginosa (BACTEC method), which showed sensitivity to meropenem, imipenem, ciprofloxacin and piperacillin-tazobactum and resistance to amikacin, colistin, cefepime, cefaperazone-sulbactum and tigecycline. She was treated with intravenous piperacillin-tazobactum 4.5 g thrice a dayand levofloxacin 500 mg once a dayfor 10 days with other supportive measures. However, she continued to get high grade fever spikes (104 to 105F). A second blood culture sent on day 8 of admission grew Burkholderiacepacia sensitive to meropenem and ciprofloxacin. Her antiobiotic therapy was escalated to intravenous meropenem 1 g tidand oral trimethoprim/ sulfamethoxazole (80/400 mg). She, however, went into septic shock needing double vasopressor support. Shelater developed multiorgan dysfunction syndrome (MODS) and Disseminated Intravascular Coagulation (DIC) and succumbed to her illness. A final diagnosis of community acquired pseudomonas pneumonia with dissemination with metastatic abscesses with superadded Burkholderia infection leading to MODS was made.

Discussion

This patient was diagnosed to have severe Community-Acquired Pneumonia (CAP) due to P. aeruginosa, which was complicated by secondary hematogenous spread causing metastatic abscess in liver and spleen and MODS involving cardiovascular, hematologic and respiratory systems. Injury to thealveolar epithelium causes release of proinflammatory cytokines into the circulation which are ultimately responsiblefor septic shock. During treatment, she developed superadded secondary infection with Burkholderiacepacia. Pseudomonas aeruginosa is a gram-negative aerobic bacterium that causes several types of infections including wound, urinary tract, and respiratory tract infections. It is a common pathogenicbacteria in hospital acquired pneumonia, and is usually seen in patients who have structural lung disease, or are immunocompromised [1]. However, it is rarely identified as a cause of pneumonia in previously healthy individuals, accounting for 0.4–6.9% of the reported cases of CAP requiring hospitalization [2] and 1.8–8.3% CAP requiring Intensive Care Unit (ICU) admission [3]. Several studies [4,5] found that fatal P. aeruginosa pneumonia in healthy patients was associated with exposure to contaminated hot tubs. Harris et al.[6] reported a case of P. aeruginosapneumonia in a chronic asthmatic patient who was using a home humidifying device that contained water contaminated with P. aeruginosa.Other risk factors identified in various studies include bronchiectasis, cystic fibrosis, chronic heart failure, smoking, malnutrition and immunocompromised status [7]. Our patient was a home maker and there was no history of any of the above risk factors. Few studies have reported prior infection with Influenza A to be a risk factor for P. aeruginosa infection. Influenza viral infection causes respiratory epithelial cell dysfunction and apoptosis by disruption of protein synthesis and thus allowing increased bacterial adherence and invasion [1,8]. Occupational exposure in health care workers may also be a risk factor [9]. Our patient, prior to hospital admission, did not have any risk factor for pseudomonas infection. Compared to pneumonia caused by other pathogens,P. aeruginosa CAP runs a fulminant course, shows rapid dissemination and has poor prognosis[1].Semerci SYet al reported a case of hepatic and splenic abscess in a preterm infant caused by P.aeruginosa[11].Govan et al reported a case of a previously healthy 49-year-old man who died within 12 hoursofhospital admission. P. aeruginosa was subsequently isolated both from sputum and blood samples taken at the time of admission and from postmortem specimens of his lung, liver and spleen [2,12].

In a review of literature by Hatchette et al from 1966 to 2000, he reported 11 cases of P aeruoginosa[10]. Further Maharaj S et al did a review of nine cases indexed in PubMed from 2001to 2016 of which 3 were complicated by sepsis with MODS [2]. However, none of these cases were complicated by metastatic abscess formation.Predilection for the Right Upper Lobe (RUL) was seen in two-thirds of the cases of P. aeruginosaCAP described by Hatchette et al[10] and in 7 out of 9 cases by Maharaj S et al [2]. P. aeruginosais an aerobic bacterium and upper lobes provide a more favorable environment due to higher ventilation to perfusion ratios [2]. However, our patient had bilateral, multifocal involvement with cavitation in CT thorax while the chest radiograph initially showed only left mid zone involvement. As P.aeruoginosa is an invasive pathogen, and causes thrombotic endarteritis, pneumonia rapidly progresses to necrosis, with coalescing of these foci into cavities. Surprisingly the total leucocyte count was normal on admission, despite the fact that the infection was disseminated. However, there was neutrophilic leukocytosis with toxic granules seen in the neutrophils and CRP was very high suggestive of bacterial infection.Later, she went to develop neutropenic sepsis. The leucocyte count may be variable (high, normal or low) as reported by Hatchette et al [10].The current guidelines from the Infectious Diseases Societyof America(IDSA) suggest that patients with CAP who are hospitalizedin the ICU and or have risk factors like structural lung diseases, immunocompromised status, prior use of antibiotics before admission, should receive a macrolide or a fluoroquinoloneplus cefotaxime or ceftriaxone or a beta-lactam–beta-lactamase inhibitor [13].Our patient was treated as per the protocol for treatment of pseudomonas pneumonia with antipseudomonal antibiotic(piperacillin-tazobactum and clarithromycin which was escalated to meropenem, clarithromycin and co-trimoxazole), considering the possibility of emergence of resistant strains during the therapy. This was also in accordance with the antibiotic sensitivity pattern. Though earlier studies showed better prognosis in younger patients, ourpatient unfortunately did not respond to the treatment.

cepacia is a member of a group known as B. cepacia complex which includes nine differentrecognized genomovars. It is a gram-negative, glucose-non-fermenting, aerobic bacillus and causes acute systemic infection and “cepacia syndrome” which is progressive necrotizing pneumonia [14].It is associated with infections in patients with underlying lung disease, like cystic fibrosis, chronic granulomatous disease, immunocompromised individuals, hospitalized patients and drug addicts [15].Outbreaks may occur due to contaminated antiseptics, disinfectants, ventilators and other types of medical equipment [14]. Also, person-to-person spread has also been documented.In a study by Bressler et al, among ICU patients without cystic fibrosis, bacteremia due to B. cepacia was associated with renal failure requiring dialysis, recent abdominal surgery, bronchoscopies, tracheostomy, and presence of a central line [16]. In a study by Huang et al, most patients had seriouscomorbidities including diabetes mellitus, Chronic Obstructive Pulmonary Disease (COPD), malignancy and congestive heart failure [15]. Our patient had central line insertion and was transferred to Intensive Care Unit (ICU). She,thus having two risk factors.The organism was sensitive to meropenem and co-trimoxazole. As she had overwhelming infection, resulting in metastatic infection in liver, splenic and renal infection, she succumbed to her illness.To our knowledge, this is the first report of pseudomonas pneumonia complicated by metastatic abscesses (liver, spleen and kidney), secondary infection with B. cepacia and MODS.

Conclusion

Pseudomonas aeruginosa, can cause CAP. The disease, although described in immunocompromised patients and with underlying risk factors, can also occur in apparently healthy individuals. The initial symptoms may not be precise enough for a specific diagnosis. Though earlier studies have shown predilection for right upper zone, pseudomonas pneumonia can be bilateral and tend to become necrotizing with cavity formation. CT thorax can demonstrate coalescing of infectiousfoci into cavities and is recommended when the initial radiograph is not contributory. The infection can disseminate to other organs as in our case and ultimately lead to septic shock despite appropriate antibiotic therapy. Superadded infection with other pathogens can also occur. Physicians must, therefore, keep this possibility in mind while diagnosing CAP, especially if there is associated septic shock and treat the patient early with anti-pseudomonal antibiotics.

For more information about Article : https://ijclinmedcasereports.com/

https://ijclinmedcasereports.com/ijcmcr-cr-id-00136/ https://ijclinmedcasereports.com/pdf/IJCMCR-CR-00136.pdf

#Infection #Bacteremia #Pneumonia #Antibiotics #Healthy #Sangita #IJCMCR #clinical studies

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incorrect-marauders · 3 years

Conversation

Sirius: My favourite song is that Scottish song...1000 Miles?

Remus: It's 500 Miles, but he says he'll walk 500 more...so I see the confusion.

#harry potter #hp #marauders #wolfstar #remus lupin #sirius black #incorrect quotes #source: overheardlondon #mod: McG

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incorrect-professors · 4 years

Conversation

McGongall: So what have you planned for the future?

Harry: Um, lunch?

McGonagall: No, I mean long term.

Harry: Dinner?

#harry potter #hp #minerva mcgonagall #incorrect quotes #source: ?#mod: McG #100 #200 #300 #400 #500 #600

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piyotycho · 3 years

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Zero and Alice for a commission. Zero is an OC created by Eri (http://croctus.tumblr.com), Alice is an OC created by Snicket McG. (http://snickers-sketchbook.tumblr.com).

#commission #color

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doctorfoxtor · 3 years

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everyday is Friday the 13th when you're studying

100 days of productivity

day 13

RS/CVS

NIPPV has best effect between pH 7.25-7.35; but generally trial NIPPV before tubing unless imminent or current respiratory collapse (or other indications such as failure to protect airway)

constrictive pericarditis vs tamponade: differentiate with y-descent of JVP; this is *absent* in tamponade, but otherwise they are clinically very similar

in the absence of thromboembolic events, pts with bioprosthetic valve replacements *do not need* warfarin (low dose aspirin sufficient)

asthma ICS dose: budesonide: low dose < 400 mcg; mod dose 400-800 mcq; high dose >800 mcg

ICS dose conversion: budesonide = beclomethasone, multiply budesonide dose x2 to get fluticasone dose

Rheum/Derm

pseudoxanthoma elasticum: AR mutation in ABCC6 (ATP-binding cassette transporter) skin: cutaneous laxity + yellow papules in flexural regions; eyes: blue sclerae + peau d'orange of Bruch's membrane + retinal angioid streaks; GIT: upper GI bleed!; CVS: accelerated atherosclerosis w/ consequent IHD/CVA/PAD; rheum: demineralisation w/ reduced circulating pyrophosphate

microscopic polyangiitis and GPA cause kidney involvement with equal frequency; HSP causes IgA nephropathy with much less frequency (and much less severity)

tinea incognita = tinea corporis that has had topical steroid tx; may show florid fungal growth without characteristic tinea lesions (skin scraping w/ KOH stain is sufficient to dx)

inclusion body myositis (not to be confused with hereditary inclusion body myopathies): most common inflammatory muscle disease in adults! → sporadic, nonheritable progressive asymmetric weakening and wasting of both proximal and distal muscle groups (may mimic ALS but is a myopathy rather than a neuropathy and NCS/bloods will reflect that, eg, ↑CPK in IBM)

CNS

floaters + flashes of light = vitreous detachment

important ddx for Wernicke encephalopathy: cerebellar stroke. Do NOT forget the CT brain!

neuromyelitis optica: differentiate from MS w/ anti-NMO IgGs (such as anti-aquaporin 4 (AQP4) and anti-myelin oligodendrocyte glycoprotein (MOG))

pons = horiPONStal gaze palsy

SCD: T2-weighted hyperintensity of affected areas (dorsal column, lat corticospinal tracts, spinocerebellar tracts)

Haem/Onc

Stauffer syndrome: renal cell ca associated nonmetastatic hepatobiliary dysfunction (cholestatic enzyme pattern, elevated platelets/PT, hepatosplenomegaly, NORMAL bilirubin, NO jaundice)

GIT

FAP: the second most common cause of death after colorectal cancer is duodenal cancer

Whipple's disease: tx with 1-1.5 yrs of ampicillin or cotrimoxazole or doxy+HCQS, then assess, then continue tx if necessary

Psych/Toxo

sertraline specifically is used for agoraphobia due to best cost-effect ratio; other SSRIs are second line

long-term lithium side effects: LITHIUM: Leukocytosis, Intracranial hypertension, Tremor/Teratogen, Hair loss/Hypothyroid/Hyperparathyroid, Increased Urine (N-DI), Metabolic syndrome

other than hypokalaemia, other precipitating factors for digitoxicity include hypernatraemia, hypomagnesaemia and hypothermia

Misc

bezlotoxumab → C. diff toxin B

suvratoxumab → S. aureus alpha toxin

#100 days of productivity #studyblr #studying #medicine #medblr #mine #long post

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hpfemslash-minifest · 5 years

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HP Femslash MiniFest August/September prompts are here!

Massive apologies, friends and followers, for our tardiness this time around. Headmistress McG was not pleased and house points have been deducted accordingly. This month we’ve cooked up three prompts we hope you’re as excited for as we are! Our trope this time around is Magical Creatures. Our seasonal prompt is Changes. Our wildcard prompt is Broomstick. Our AO3 collection is now open for submissions.

As a reminder, this cycle we are partnering with @flonksfest so if you write any of these prompts for Fleur & Tonks don’t forget to tag both fests! And if you’re not already following them, you should hop on over there for some femslash good-ness!

The timeline for this fest will be:

August 9 - Mod prompts post & AO3 collection opens

September 31 - Last day to submit for this cycle

October 1 - Round up post released

One quick programming note: Upon mod reflection we will not be continuing to maintain follower prompts on AirTable. Instead, we invite our followers to give scenario prompts through our askbox instead. These will be posted directly to our Tumblr and hopefully get more views/spark inspiration for our followers a little easier than having to visit an external page. All scenario prompt guidelines still apply, minus the timelines, and you can review them here.

Please be sure to review our updated FAQs and Rules. Remember that all followers/creators under 18 CANNOT interact with or create any works rated M or E for this fest.

All works will be compiled into a master post at the end of the cycle. We are so excited to see the brilliance you create!

#hp femslash #hp femslash minifest #aug/sept 2019 #magical creatures #changes #broomstick

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blogroof250 · 2 years

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Resident Evil 4 Hd Movie Patch

Resident Evil 4 Hd Movie Patch Notes

Donation Points system. This mod is not opted-in to receive Donation Points. Drivers actiontec gateway. Some mods to make the original port of RE4 more hd, will require a beefy computer with good ram (ie 8-32GB would be perfect for best results) also be aware cause the file size of the zip is 3GB lol. MINIMUM Requirements. Download Resident Evil 4 PC HD Movie CutScenes Patch 1.1 with hash 1483a8cc19cf5fafa117b727cb2873 and name Resident Evil 4 PC HD Movie CutScenes Patch 1.1. Resident Evil 4 PC (2007) with HD cutscenes Texture Patch 2.0 Arhum MK. Download MATRIXCN 720p HD RESIDENT EVIL 4 MOVIE PACK torrent or any. Some mods to make the original port of RE4 more hd, will require a.

Capcom has released a new beta patch for Resident Evil 4: Ultimate HD Edition that introduces a new mouse control scheme, increases master volume level and fixes various bugs. In order to download this beta patch, you’ll need to follow the guide below. You can also find below the complete changelog of this beta patch. Enjoy!

From your Steam ‘LIBRARY’ list, right-click on Resident Evil 4 / Biohazard 4 and select ‘Properties’

Select the ‘BETAS’ tab.

Type RE4BETAoptin (case-sensitive) in the ‘Enter beta access code’ field and then click CHECK CODE.

Now, select “beta-public – 1.0.1” from the pull-down menu and click CLOSE.

Wait for the Steam client to finish downloading the 3.4MB patch

Launch Resident Evil 4 / Biohazard 4 and verify that 1.0.1 is visible on the bottom right section of the ‘Press any key’ title screen.

Texture patch for Resident Evil 4 (PC) created by Albert Marin Garau. It's compatible with all versions of the game. Since the original textures suck you NEED this patch, it makes the game look a lot better. It's really easy to install, too. Just open ResidentEvil4Pc-Text1.exe and extract the files in your Resident Evil 4/Biohazard 4 folder. Click to download: Download resident evil 4 ultimate hd edition patch 1.0.6 adobe Download songs computer memory card resident evil 4 ultimate hd edition patch 1.0.6 download adobe - resident evil 4 ultimate hd edition patch 1.0.6 download adobe. GRISOFT Company AVG Free Edition 7.5.446 Name Mehul S/N. Ultradev 4 4.0 Name Shane McG S/N.

Changelog

Changes:

Removed mouse acceleration from Keyboard & Mouse controller setup screen. “AIM MODE” option is now present instead, and mouse sensitivity settings have been re-tuned to accommodate new setting.

Users can now choose between two mouse control schemes: “CLASSIC” and “MODERN.” MODERN setting makes the aiming utilizing native mouse functionality while “Classic” setting retains previous calibration from the original game.

“GAME RESET” in “RETRY OR RELOAD” has been relabeled to “RETURN TO MAIN MENU”

Relabeled “POST PROCESS” in graphics option to ‘COLOR FILTER’

Master volume level increased.

Bug fixes:

Fixed ready-knife delay when using mouse and keyboard.

Calibrated animation speed at which pottery, lamps, boxes, barrels etc. fall apart when frame rate is set to 60fps. Set pieces getting destroyed during cutscenes such as the castle gate and gazebo have also been recalibrated.

Fixed an issue with the character performing quick turns when pressing aim while turning.

Reduced possible audio desynchronization during cutscenes.

Fixed texture on Ada’s Blacktail (Bottle cap)

Fixed flickering or prolonged black screen during active gameplay on the Water level in Mercenaries Mode.

Fixed problem with Krauser’s bow in Mercenaries Mode Castle level.

Fixed problem with enemies not spawning (Garrador, Leader Cultist etc.) in Mercenaries Mode Castle Level.

Fixed the speed at which hens lay eggs when frame rate is set to 60fps.

Removed green flashing screen that appeared after pre-rendered cutscenes.

Fixed Leon’s distorted voice when roundhouse-kicking Verdugo while he’s frozen.

Fixed flickering in the first custscene of chapter 5-1.

Mine cart QTE difficulty reduced for PRO level difficulty.

Restored the blue light bloom effect from the merchant’s torch.

John Papadopoulos

Resident Evil 4 Hd Movie Patch Note

John is the founder and Editor in Chief at DSOGaming. He is a PC gaming fan and highly supports the modding and indie communities. Before creating DSOGaming, John worked on numerous gaming websites. While he is a die-hard PC gamer, his gaming roots can be found on consoles. John loved - and still does - the 16-bit consoles, and considers SNES to be one of the best consoles. Still, the PC platform won him over consoles. That was mainly due to 3DFX and its iconic dedicated 3D accelerator graphics card, Voodoo 2. John has also written a higher degree thesis on the 'The Evolution of PC graphics cards.' Contact: Email

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gingertodgers · 6 years

Note

Happy winter times, McG! Not sure if you have any slots left, but if you have I'd love to request a little something for my lovely co-mods: @tdcat and @unadulteratedstorycollector. I was thinking Drarry + gingerbread house + non-fetishised eating + competitive streak. Regardless of if you pick this one up, thanks for making the yuletide gay!

Harry Potter/Draco Malfoy - 11th December in the HP Secret Santa(Hello darling frankly, thank you for the ask and being such a warm and positive part of fandom this year xxx Merry Christmas to the truly wonderful @hdconsentfest mods, @tdcatsblog and @unadulteratedstorycollector!)Headmistress McGonagall sighed with disappointment when she saw the two students waiting in her office.

Potter was flushed, a stripe of icing sugar obscuring his famous scar and dusting the hair pulled back from his face.

Malfoy was even paler than usual, the green edible glitter staining his finger tips and a rouge jelly-tot lodged in the collar of his robes the only sign that he’d ever even heard the words “food fight”.

“Mr Potter, Mr Malfoy,” she said, taking a seat. “Professor Flitwick informs me that you are the pair responsible for disrupting the Gingerbread Hogwarts Tournament?”

“He started it-”

“Potter was the one who-”

“Gentlemen,” McGonagall raised a hand. “I am not interested in the whys and wherefores of this regrettable situation. My concern lies with the younger students who saw hours of hard work destroyed by your selfish and tediously predictable actions.”

To their credit, both men looked immediately concerned.

“Are the firsties alright?” Potter asked. “We didn’t mean to frighten anyone, Headmistress.”

“It was supposed to be a bit of fun,” said Malfoy, leaning forward and dislodging the rouge jelly-tot. “Some casual banter among friends. I am very sorry that it got so-”

“Banter,” Potter snorted, causing Malfoy to sit up straight again.

“Yes banter, Potter.”

“Alright,” Potter held up both hands, smirking as he mouthed “banter” to himself.

“Do we have a problem, Potter?” demanded Malfoy, his voice laced with sugar and poison. “Perhaps I am mispronouncing the word, should I deploy a soft “ahhh” or is it the German-”

“I don’t know Malfoy, maybe you should check with your boyfriend. Seeing as you clearly picked it up from him.”

“My… I don’t have a boyfriend.”

“He’s lying,” Potter turned to inform the Headmistress, who in turn reassured Potter that she really, really, did not care. “You do, I saw you with Ben in Hogsmeade,” Potter turned back to Malfoy. “There’s no way you started using words like “banter” on your own.”

“I assume you are talking about Ben,” said Malfoy, glaring at Potter. “Pansy’s boyfriend.”

“A likely- what? He’s… Pansy boyfriend.”

“Exactly.”

“But you were in Hogsmeade…”

“With Pansy.”

“Oh.”

“Quite.”

Silence fell as the two men stared at one another. Malfoy appeared to be trying not to smile while Potter turned purple and nervously playing with the hem of his own jumper.

Sensing that they might be here for a while, the Headmistress sat back and summoned her emergency biscuits.

#gt secret santa #secret santa #frnklymrshnkly #unadulteratedstorycollector #tdcat #drarry #draco malfoy #harry potter #minerva mcgonagall #christmas #gingerbread

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incorrect-marauders · 3 years

Conversation

James: What does your gut tell you?

Sirius: 'Go ask Remus, he'll know what to do'.

#harry potter #hp #marauders #wolfstar #sirius black #james potter #remus lupin #incorrect quotes #source: the big bang theory #mod: McG

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incorrect-professors · 3 years

Conversation

Harry: Is there a giftshop?

Dumbledore: Harry, this is the afterlife.

Harry:

Dumbledore: Of course there's a giftshop.

#harry potter #hp #marauders #albus dumbledore #deathly hallows #incorrect quotes #source: the good place #mod: McG #100 #200 #300

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hpconsentfest · 6 years

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Consent Fest: Prompting Guidelines

Prompting will open on 1 November and close 21 February to give newcomers to the fest ample time to participate.

On 1 November a notice that prompting is open will be posted to DW and tumblr. Prompters will submit prompts anonymously through a Google Form that will be shared on 1 November.

Remember: Whether it’s communicated through words, eye contact, gestures, or any variety of magical means that you dream up, we’re here to create a platform to showcase exactly how sexy explicit consent is!

To help get your cogs whirring, here are 2 sample prompts:

Prompt: Harry and Draco have been leading up to this moment for a while, but as per usual, neither of them have actually talked about it. A very nervous Harry starts a beautifully awkward conversation, and the rest is history.* Any Extra Information: glasses!Draco is a bonus Squicks/dislikes: tentacles Maximum Rating: any rating

Prompt: Minnie McG's sexual health and well-being classes* Any Extra Information: re-sorting Squicks/dislikes: character bashing Maximum Rating: R

Prompting Guidelines:

1) Anyone can prompt—you do not need to submit fic/art to H/D Consent Fest to be eligible.

2) The more the merrier! Submit as many prompts as you can think up!

3) Only one prompt per form.

4) Creators can claim their own prompts.

5) Creators are welcome to claim additional prompts once they have submitted.

6) Prompts must include the following info:

Prompt (scenario, vague premise, etc) Any Extra Information Squicks/dislikes Maximum Rating

We look forward to seeing your imaginative prompts!

Don’t hesitate to contact your mods if you have any questions! Just email: [email protected]

* Thanks to @unadulteratedstorycollector and @gingertodgers respectively for sharing their creative sample prompts!

#consent fest #mod post #guidelines #prompting #harry potter #drarry #drarry squad #consent is sexy

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alternislatronemhq · 4 years

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hello everyone! here’s a sample application that you can reference if you need any help with your own application. Since apps are OFFICIALLY OPEN, I can’t wait to see what all of you genius, creative beauties come up with!

Congrats, Kate, you have been accepted to AL for the role of Minerva McGonagall (FC: Tea Leoni). We loved your enthusiasm for and portrayal of Minnie McG. Blah blah blah it would be weird to compliment myself some more here ha ha ha. Please send in your blog (no sideblogs for first characters, please) in the next 24 hours and be sure to take a look at our new player checklist. Welcome home, we’re so excited to have you join the family!

OOC

name — Kate age — 26 pronouns — she/her timezone — EST activity level — REDACTED. any questions? — why is McG so cool?

IC Overview

name — Minerva McGonagall faceclaim — tea leoni, the bae age — 49 gender — cis-female, she/her sexuality — heterosexual patronus — a calico cat; maybe unusual for someone who seems as straightforward as strict Minerva, but there are many more layers to her than her students would ever imagine. the calico cat makes a perfect patronus for her, especially considering her animagus form, and she’s quite fond of it. boggart — oddly enough, minerva’s boggart is a bible on fire. growing up the daughter of a minister, minerva has a complicated relationship with religion, but the bible on fire represents the loss of her most deeply held convictions, as well as the breaking of her relationship with her beloved father.

IC In Depth

personality traits —

+ intelligent — it is minerva’s talent for seeing to the heart of things that makes her such an excellent asset to the Order. She has the ability to cut through bullshit when she’s dealing with people and is well respected for her academic insights, particularly in transfiguration. this ability to be both academic and interpersonal is an amazing feat. + moralistic — minerva has deep convictions, and she fights for them. maybe it’s because she was a minister’s daughter, but she has a very black and white way of thinking when it comes to light vs dark, and the strength of her conviction is what makes her such an excellent leader for the auror. - stubborn — minerva can be very pigheaded sometimes. because she’s so intelligent and knows it, she has an impossible time believing that she could be wrong. once she makes up her mind about something, good luck trying to get her to change it, even if changing it is necessary for her to move forward. - standoffish — minerva has never been the warmest person. she doesn’t have problems being around people, but that doesn’t mean she feels comfortable immediately opening up to them. she keeps many of the people in her life at arms’ length, preferring to hide behind the persona she’s built of strict professor, and this causes her to miss out on some really rich relationships.

character biography —

minerva’s six when her mother tells her that the unexplainable things she can do is magic. her mother confessed to her father, afraid that her three children wouldn’t be able to keep this secret, and though it shocks the muggle minister, he moves past it. still, minerva’s mother isobel relies heavily on her to help her hide the accidental magic her brothers can perform, not wanting to overwhelm her father. minerva is a thoughtful and shrewd young girl, and she picks up on the tensions that exist between her parents, despite the fact that they love one another. she vows never to keep the truth of who she is a secret the way her mother did.

eleven and minerva’s time at hogwarts is a breath of fresh air. away from the mounting tensions at her home, she thrives in gryffindor, making close friends who sustain her. she’s almost sorted into ravenclaw like her mother, but she takes after the rest of her mother’s Ross family in being sorted into gryffindor. she plays for the house team and thrives at her academics, but most especially transfiguration. it’s her friendship with poppy pomfrey and alastor moody that really defines her time at hogwarts, though. they’re the two people she relies on most in this world, despite the fact that poppy’s in a different house and alastor drives her up the wall sometimes.

seventeen and minerva follows her dream of working for the ministry. the summer before she begins, however, she returns home to spend some time with her family, where she falls in love with a local muggle. their summer romance is a whirlwind, and minerva is too besotted to recognize that her relationship with dougal breaks all of those pledges that she made to herself so many years ago. it isn’t until he proposes marriage that minerva realizes how far she’s gone, and after a very frank conversation with her father, minerva breaks it off, not wanting to repeat the mistakes that her mother made.

minerva throws herself into work with the ministry, but she’s not really happy there. she spends almost all of her time wondering if she made a mistake, if maybe she lost the one real chance at love that she would get in her life. after a couple of years of this, minerva resigns and decides to take dumbledore’s offer to teach at hogwarts. before she begins her first year, she hears on a visit home that dougal has married a local muggle girl. it’s as if a spell that had been cast over minerva is lifted, and suddenly she feels in her heart that she’s free of the pull of her first love.

minerva’s twenty five and poppy makes an offhand comment about how perfect alastor and minerva would be for each other if they could just stop being so damn stubborn. minerva is embarrassed, blushing and protesting that they could never be more than friends, but a seed is planted, and it doesn’t take long for it to sprout and grow. finally, it comes to be too much for her to handle, and she begins to drop hints to alastor, hints that all seem to go unnoticed. eventually she has to pluck up the courage to be obvious about it, and to her surprise, alastor reciprocates. they settle into life as a married couple and begin a family, but that doesn’t stop either of them from doing what they feel is their duty for their world.

they both fight when dumbledore forms the order of the phoenix, and minerva is happy to be lieutenant to dumbledore here just as she is at hogwarts. the war is a nasty time, one that minerva would gladly forget if she could, but when it’s over and the dust settles, dumbledore comes to her, alastor, and kingsley with the truth. this is only a reprieve, a rest period between two battles, and they must be prepared for voldemort’s inevitable return. dumbledore needs to focus on hunting horcruxes with sirius, so he leaves the three of them in charge of the order, minerva acting as leader. she’s not sure how she feels about such an important role, but minerva mcgonagall has never been one to shirk her duty, so she sets her mind to it and marches forward.

plot ideas — either for the broader group plot or for your specific character

I’d love to see minerva as a mother. i’ve left some of that purposely vague because of the inclinations/opinions of the moody player, but I think this would be a fascinating dynamic to explore between these two incredible fighters. how do they balance being parents while also being leaders of a revolution? what is it like for them to be parents when for so long they’ve been teachers?

MMM MCMOODY — such an underrated and wonderful ship, and as the mod for this group, I just had to establish it. alastor and minerva are the only two people I see being strong willed enough to complement one another, and I’m beyond excited to see how these two pigheaded stubborn individuals navigate the reality of marriage alongside leading the order.

minerva does not give a DAMN about politics, but I’d be super interested to see a plot that drags her into them somehow. how does she handle dealing with people like dolores umbridge or barty crouch sr? does she agree with alastor’s thoughts on the azkaban dementors issue, or does she have other ideas? does he pull her into writing up a proposed bill because he’s rubbish at that sort of thing? is she offered a seat on the wizengamot and suddenly alongside her teaching duties has to worry about actual lawmaking? so many possibilities.

OH MAN minnie is such a stubborn and narrow minded individual at times. she has a tendency to make snap judgements about people, and it’s hard to get her to change her mind. I’d love to see a dynamic where she makes a rash judgement about a student (likely slytherin) who goes on to be a death eater, and then has to come to terms with the reality that it was her actions that solidified that path -- maybe if she had been a little kinder and not expected this student to go dark they wouldn’t have.

extra —

headcanons

minerva is the heir to an ancient scottish clan of witches, the ross clan. the ross clan has their own heritage of magic that is passed down through the generations, typically through the women. minerva’s mother turned her back on it when she married robert, but minerva learns about it from her grandmother and continues the lineage.

#al:accepted #harry potter rp #hp rp #marauders era rp #marauders rp #sample application #minerva mcgonagall

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consultatiiladomiciliu-ro · 3 years

Text

COVID19 wiki - Dispozitive de filtrare a sangelui si anticoagulante in boala SARS-cov2

Citeste articolul pe https://consultatiiladomiciliu.ro/covid19-wiki-dispozitive-de-filtrare-sangelui-si-anticoagulante-boala-sars-cov2/

COVID19 wiki - Dispozitive de filtrare a sangelui si anticoagulante in boala SARS-cov2

Dispozitive de investigație

Dispozitive de purificare a sângelui

Mai multe filtre extracorporale de purificare a sângelui (de exemplu, CytoSorb, oXiris, Seraph 100 Microbind, Spectra Optia Aferesis) au primit autorizație de utilizare de urgență de la FDA pentru tratamentul pneumoniei COVID-19 severe la pacienții cu insuficiență respiratorie. Dispozitivele au diverse scopuri, inclusiv utilizarea în terapia de substituție renală continuă sau în reducerea nivelului de citokine proinflamatorii. [365]

Nanospongii/Nanoburetii

Nanospongii celulari obținuți din membrane plasmatice derivate din celule epiteliale pulmonare de tip II uman sau macrofage umane au fost evaluate in vitro. Nanospongii prezintă aceiași receptori proteici necesari de SARS-CoV-2 pentru intrarea celulară și acționează ca momeli pentru a lega virusul. În plus, toxicitatea acută a fost evaluată in vivo la șoareci prin administrare intratraheală. [366]

Antitromboticele in terapia SARS-cov2

COVID-19 este o boală sistemică care afectează negativ diferite sisteme de organe. O revizuire a hipercoagulopatiei COVID-19 descrie în mod adecvat atât microangiopatia, cât și formarea trombului local, precum și un defect sistemic de coagulare care duce la tromboza vaselor mari și complicații tromboembolice majore, inclusiv embolie pulmonară, la pacienții cu afecțiuni critice. [305] În timp ce sepsisul este recunoscut pentru a activa sistemul de coagulare, mecanismul precis prin care inflamația COVID-19 afectează coagulopatia nu este pe deplin înțeles. [306]

Mai multe studii de cohortă retrospective au descris utilizarea dozelor anticoagulante terapeutice și profilactice la pacienții spitalizați cu boală critică cu COVID-19. Nu s-a observat nicio diferență în mortalitatea de 28 de zile la 46 de pacienți tratați empiric cu doze anticoagulante terapeutice, comparativ cu 95 de pacienți cărora li s-au administrat doze standard de profilaxie a TVP, inclusiv la cei cu niveluri de dimeri D mai mari de 2 mcg / ml. În acest studiu, ziua 0 a fost ziua intubației, prin urmare, nu au evaluat toți pacienții care au primit anticoagulare terapeutică empirică în momentul diagnosticului pentru a vedea dacă progresul către intubație a fost îmbunătățit. [307]

Spre deosebire de constatările de mai sus, un studiu retrospectiv de cohortă a arătat o supraviețuire mediană de 21 de zile pentru pacienții care au nevoie de ventilație mecanică și care au primit anticoagulare terapeutică, comparativ cu 9 zile pentru cei care au primit profilaxie TVP. [308]

Trialul NIH

Ghidurile actuale includ profilaxia trombozei (de obicei cu heparină cu greutate moleculară mică [LMWH]) pentru pacienții spitalizați. Începând cu septembrie 2020, studiul NIH ACTIV include un braț (ACTIV-4) pentru utilizarea antitrombotice în ambulatoriu, în spital și în convalescență.

Cele 3 studii clinice adaptive din cadrul ACTIV-4 includ prevenirea, tratarea și abordarea coagulopatiei asociate COVID-19 (CAC). În plus, un obiectiv de a înțelege efectele CAC în rândul populațiilor de pacienți – internat, ambulatoriu și convalescent.

În decembrie 2020, studiul ACTIV-4 care înregistra pacienții cu afecțiuni critice cu COVID-19 care necesită asistență pentru unități de terapie intensivă a fost întrerupt din cauza potențialului de rău din acest subgrup. Dacă utilizarea dozei complete în comparație cu anticoagulantele cu doze mici duce la rezultate mai bune la pacienții spitalizați cu boală severă mai mică a COVID-19 rămâne o întrebare foarte importantă.

Scopul și medicamentele inițiale incluse în ACTIV-4 sunt:

Trialul ambulatoriu

Investigează dacă anticoagulantele sau terapia antitrombotică pot reduce complicațiile cardiovasculare sau pulmonare care pun viața în pericol la pacienții nou diagnosticați cu COVID-19 care nu necesită internare în spital. Participanții vor fi randomizați să ia fie un placebo, aspirină, fie o doză mică sau terapeutică de apixaban.

Trialul internati

Investighează o abordare care vizează prevenirea evenimentelor de coagulare și îmbunătățirea rezultatelor la pacienții spitalizați cu COVID-19. Dozele variate de heparină nefracționată sau LMWH vor fi evaluate în funcție de capacitatea de a preveni sau reduce formarea cheagurilor de sânge.

Trialul convalescentilor

Investighează siguranța și eficacitatea anticoagulanților și / sau antiplachetelor administrate pacienților care au fost externați din spital sau care sunt convalescenți în reducerea complicațiilor trombotice (de exemplu, IM, AVC, TVP, PE, deces). Pacienții vor fi evaluați pentru aceste complicații în termen de 45 de zile de la internarea în spital pentru COVID-19 moderat și sever.

Antitrombotice in curs de investigare

AB201

AB201 (ARCA Biopharma) este o proteină recombinantă anticoagulantă nematodică c2 (rNAPc2) care inhibă în mod specific complexul factorului tisular (TF) / factorul VIIa și are proprietăți anticoagulante, antiinflamatoare și potențiale antivirale. TF joacă un rol central în răspunsul inflamator la infecțiile virale. Studiul clinic de fază 2b / 3 (ASPEN-COVID-19) a început în decembrie 2020 la pacienții spitalizați cu COVID-19 de la Universitatea din Colorado. Studiul de fază 2b randomizează 2 regimuri de dozare AB201 comparativ cu heparina. Obiectivul principal este modificarea nivelului dimerului D de la momentul inițial la Ziua 8. Proiectarea fazei 3 a studiului este dependentă de rezultatele fazei 2b. [309]

#AB201 #anticoagulante #cheaguri #concentrator de oxigen portabil #filtre sange #oxigenoterapie la domiciliu

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