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Background: Prickly pear juices are considered as valuable ingredient for sports and energy drinks due to its higher amino acids contents, minerals and attractive red color. Hence, prickly pear fruit has received renewed interest for the production of juice. Up to date, relatively little work has been reported regarding the manufacturing of prickly pear products. Enzyme has proved to be the key element for producing clear and stable fruit juice. The present study aimed to optimize the processing parameters for enzymatic clarification of prickly pear juice. The results of this investigation are expected to provide the suitable process technology for the production of prickly pear juice with better retention of betalain content and color value. Methods: Prickly pear pulp was treated with pectinase enzyme at different concentrations (0.01-0.09%), incubation temperatures (40-60°C) and incubation time (60-180 min). The effect of enzymatic treatments on clarity, color index, betalain content and ascorbic acid content of juice were studied through response surface methodology by employing second order central composite rotatable design. Result: Response surface analysis determined the optimum condition for clarifying prickly pear juice as 0.036% enzyme concentration, 46°C incubation temperature and 112 min incubation time. At this condition, it was predicted to produce the prickly pear juice with clarity of 48.59% T, color index of 0.603 abs, betalain content of 542.93 mg/L of juice and ascorbic acid content of 9.35 mg/100 g with the desirability of 0.780. [ABSTRACT FROM AUTHOR]

Fully matured fresh guava fruits (Lucknow-49) were precooled at 10 °C for 1 h and pretreated with 500-ppm benomyl for 5 min. The fruits were packed in 25-µm and 50-µm LDPE bags with active modified atmosphere packaging of 3% O2+5% CO2, 6% O2+5% CO2 and 9% O2+5% CO2 gas concentrations and stored at 5 ± 1 °C and 10 ± 1 °C temperatures as well as non-packaged as control. The shelf life of guava could be increased up to 42 days by packaging in 50-µm LDPE bags with a gas concentration of 9% O2 +5% CO2 and stored at 10 °C without much change in physical, biochemical and sensory characteristics. Physico-chemical changes viz., PLW, pulp to peel ratio, firmness, TSS, total sugar, ascorbic acid and titratable acidity were observed minimum for fruits packed in 50-µm LDPE bags at 3% O2+5% CO2 gas concentration at 5 °C storage temperature, but sensory score decreased drastically after 21 days of storage. Chilling injury was observed for the fruits packed at 5 °C storage temperature after 21 days of storage, and it was severe in 25-µm LDPE bag at later stage. Control fruits over-ripened with the highest weight loss (12.47%) on 6 days of storage and discarded from the storage. [ABSTRACT FROM AUTHOR]

Cooking quality of dehusked splits is influenced by the dehulling method, in particular, by the pre-milling treatments. The effects of four enzymatic hydrolysis parameters, i.e., enzyme concentration (2-60 mg/100 g dry matter), incubation time (3-15 h), incubation temperature (40-60°C) and tempering water pH (4.0-6.0) on cooking time of pigeon pea dhal were optimized using response surface methodology. Three kinds of enzymes, i.e., xylanase, pectinase, and cellulas were used in combination for enzymatic pre-treatment. A quadratic model satisfactorily described the dehulling efficiency with high value for the coefficient of determination R2 (0.9062). It predicted a minimum cooking time of 21.91 min at enzyme concentration of 37.8 mg/100 g dry matter, incubation time 8.69 min, incubation temperature 48.5°C and pH 5.49 of tempering water. Cooking time at optimum condition was observed to be 21.50 min and the predicted values of cooking time showed 2.19% deviation from the experimental values. Results of the study revealed that cooking time of enzyme treated dhal could be decreased by 19.77% compared to the oil treated dhal. [ABSTRACT FROM AUTHOR]

Ischemic monomelic neuropathy (IMN) is a relatively uncommon and under-recognized complication of vascular access creation for arteriovenous (AV) fistula in hemodialysis patients. They usually develop distal muscle weakness, sensation loss, and severe acute pain without muscle necrosis soon after AV fistula creation. Physicians should be aware of this condition as prompt diagnosis and timely vascular interventions are necessary to save the limbs and prevent permanent functional disability. Once the diagnosis of IMN is made, the patients will need emergent ligation of the fistula to restore the distal perfusion. We report a case of a 59-year-old male patient with End-stage Renal Disease on hemodialysis who developed severe pain, weakness, and loss of sensation in the left arm a few hours after left brachiocephalic vascular access creation. He was subsequently diagnosed with ischemic monomelic neuropathy and underwent emergent AV fistula ligation. Symptoms were relieved immediately after the ligation., Competing Interests: Conflict of interest None., (© 2023 Greater Baltimore Medical Center.)

Modern medicine has made tremendous advancements and succeeded in increasing longevity through adequate screening and diagnosis and various new therapeutic approaches. However, alternative medicine is a branch of health care practicing different traditional and unconventional, potentially hazardous therapies to treat commonly known ailments. Standard low-dose vitamin C, ie, 500-1000 mg, is approved in medical conditions like methemoglobinemia, scurvy, burns and also helps iron absorption in anemia. However, toxic doses carry high nephrotoxicity potential like in our case. We present a 74-year-old Caucasian female falling victim to one such alternative therapy leading to acute kidney injury requiring lifelong hemodialysis. She had endometrial cancer and received 100 gm of intravenous vitamin C weekly through a provider for the last 6 weeks as part of this alternate approach to cure her cancer. Upon admission, the serum creatinine level was elevated at 8.2 mg/dl, which subsequently did not improve with conservative management. Renal biopsy revealed diffuse acute tubular injury with polarized microscopy demonstrating calcium oxalate crystals. While her blood vitamin C levels were high, the serum oxalate level was normal. She ended up requiring renal replacement therapy permanently. Alternative medicine continues to be a significant health care hazard with the potential to cause unwanted irreversible nephrotoxicity. Public attention is necessary at various social levels to counter the detrimental outcomes of alternative medicine.

Coronavirus disease 2019 (COVID-19) is an infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It is known to cause a myriad of symptoms ranging from mild respiratory illness to severe pneumonia and acute respiratory distress. Since its discovery in late 2019 in Wuhan, China, the virus has caused a devastating worldwide pandemic. Although COVID-19 most commonly causes respiratory symptoms, complications such as hypercoagulability are now known to occur in some patients. In this case report, we present a COVID-19 patient that suffered a stroke and was found to have an aortic thrombus. In this case report, we discussed hypercoagulability, venous and arterial thrombosis in COVID-19 patients. We hope to highlight the importance of monitoring laboratory markers of hypercoagulability and thromboembolism symptoms in COVID-19 patients and encourage appropriate prophylaxis and treatment with anticoagulants when necessary. It is unclear whether or not a causal relationship exists given the nature of the syndrome. However, given the growing number of reported cases physicians should maintain awareness of this possible complication when evaluating COVID-19 patients., Competing Interests: Conflict of interest None., (© 2022 Greater Baltimore Medical Center.)

Coronavirus Disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) primarily affects the lungs and can lead to acute respiratory distress syndrome (ARDS). The ongoing global pandemic has created healthcare and economic crisis for almost every nation of the world. Though primarily affecting the lungs, it has also affected the kidney in various ways including acute kidney injury (AKI), proteinuria, and hematuria. It has been increasingly shown that African American (AA) individuals affected with COVID-19 and presenting with AKI and nephrotic-range proteinuria are very susceptible to focal segmental glomerulosclerosis (FSGS). The APOL-1 gene, associated with the African American population, has been increasingly recognized as a risk factor for FSGS affected with COVID-19. Our case highlights a similar case of COVID-19 in a 65-year-old AA descendant with biopsy-proven FSGS and genetically confirmed APOL-1 alleles., Competing Interests: The authors have no conflicts of interest to declare., (Copyright © 2021 Sasmit Roy et al.)

Neuromyelitis Optica or Devic disease is changed to Neuromyelitis Optica spectrum disorder to include more diverse neurological and autoimmune manifestations. This is a severe relapsing autoimmune demyelinating disorder commonly affecting the optic nerve and spinal cord. It has been reported as either the first manifestation of SLE or as a coexisting condition with other autoimmune disorders commonly included but not limited to SLE and SS. We discussed a case of a 49-year-old female patient who was initially presented with a left-sided weakness that rapidly progressed to quadriparesis and bladder dysfunction within a few days. She had positive autoimmune serology tests for SLE posing a diagnostic challenge as SLE is associated with neurological manifestations. Due to a lack of definitive diagnostic criteria for SLE, presence of AQP-4 antibodies in CSF, and evidence of longitudinal extensive transverse myelitis in MRI cervical spine, we conclude that she has Neuromyelitis Optica spectrum disorder with probable SLE. It is possible that she may develop more signs and symptoms of SLE with time and will need close follow up. Timely diagnosis and prompt treatment are vital to decrease morbidity and mortality, as done in our case. The patient was started on high-dose steroids with significant improvement in her symptoms. These patients may need early treatment with plasmapheresis and long-term follow-up with immunotherapy to prevent relapse. There are few case reports in the literature, and more information is needed to understand and better diagnose NMO with coexisting SLE., Competing Interests: No potential conflict of interest was reported by the author(s)., (© 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group on behalf of Greater Baltimore Medical Center.)

Immune checkpoint inhibitor-related neurotoxicity causing Guillain Barre Syndrome is relatively uncommon. We discussed an 80-year-old patient with known systemic lupus erythematosus who presented with lower extremity weakness, areflexia and then progressed to respiratory muscle and upper extremity weakness after receiving immunotherapy with checkpoint inhibitors for metastatic bladder cancer. With the increasing use of immunotherapy for the management of cancer, awareness of neurological autoimmune side effects is essential. Immune checkpoint inhibitor-mediated GBS can be severe and fatal if not diagnosed promptly. The hospitalists, neurologists, and oncologists should be aware of neurotoxicity related to immune checkpoint inhibitor therapy requiring a multidisciplinary approach to patient care. Prompt initiation of immunosuppressive therapy is required for the management of immune checkpoint inhibitor-related neurotoxicity., Competing Interests: No potential conflict of interest was reported by the authors., (© 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group on behalf of Greater Baltimore Medical Center.)

Paget-Schroetter syndrome or effort thrombosis is a relatively rare primary spontaneous thrombosis of upper extremity deep veins secondary to entrapment of axillary subclavian veins from an abnormality of the thoracic outlet. It is commonly seen in young adults who lift heavy weights or strenuous use of the upper extremities during athletic activities. Repetitive microtrauma to the subclavian vein secondary to narrow costoclavicular space and strenuous activities leads to intimal layer inflammation, hypertrophy, fibrosis, and coagulation cascade activation. Management of Paget-Schroetter syndrome differs from the venous thrombosis of the lower extremity as treatment includes anticoagulation, thrombolysis, and surgical decompression. Early recognition and timely management are required to prevent significant disability from post-thrombotic syndrome and long-term morbidity from recurrent thromboembolism and pulmonary embolism. Internists and emergency physicians should be aware of the disease's presentation, treatment options, and early referral to vascular surgeons since prompt initiation of appropriate treatment will have better outcomes than delayed treatment. We discussed a case of a 31-year-old female who lifts heavyweight at work, presented with right arm swelling and pain for 2 weeks, and diagnosed with axillary subclavian vein thrombosis secondary to thoracic outlet obstruction. She received a high-dose heparin drip followed by catheter-directed thrombolysis and underwent surgical decompression of axillary subclavian vein via resection of the first rib, subclavius muscle resection, partial anterior scalenectomy, and venolysis. In our review of the literature, randomized controlled studies lack the efficacy and safety of surgical decompression. However, the results are promising based on accumulated experience from vascular surgery experts and small case series. Extensive studies are needed further to delineate the protocol for the management of Paget-Schroetter syndrome.

Kratom mainly grows in Southeast Asia. It is widely used for pain management and opioid withdrawal, which is available online for cheaper prices. Alkaloids extracted from kratom such as mitragynine and 7-hydroxy mitragynine exhibit analgesic properties by acting through µ receptors. Commonly reported side effects of kratom include hypertension, tachycardia, agitation, dry mouth, hallucinations, cognitive and behavioral impairment, cardiotoxicity, renal failure, cholestasis, seizures, respiratory depression, coma, and sudden cardiac death from cardiac arrest. Rhabdomyolysis is a less commonly reported lethal effect of kratom. Limited information is available in the literature. In this article, we present a case of a 45-year-old female who is overdosed with kratom and presented with lethargy, confusion, transient hearing loss, and right lower extremity swelling and pain associated with weakness who was found to have elevated creatinine phosphokinase. She was diagnosed with rhabdomyolysis, compartment syndrome, multiorgan dysfunction including acute kidney injury, liver dysfunction, and cardiomyopathy. She underwent emergent fasciotomy and required hemodialysis. Her renal and liver function subsequently improved. We described the case and discussed pharmacology and adverse effects of kratom toxicity with a proposed mechanism and management. We conclude that it is essential for emergency physicians, internists, intensivists, cardiologists, and nephrologists to be aware of these rare manifestations of kratom and consider a multidisciplinary approach.

Fat embolism syndrome is a relatively infrequent presentation in sickle cell thalassemia patients. It most commonly occurs in long bone fractures in the setting of trauma. However, nonorthopedic trauma and nontraumatic cases have been reported to contribute to fat embolism. The fat embolic syndrome is an underdiagnosed, life-threatening, and debilitating complication of sickle-β-thalassemia-related hemoglobinopathies. It is primarily seen in milder versions of sickle cell disease, including HbSC and sickle cell β-thalassemia, with the mild prior clinical course without complications; hence, diagnosis can be easily missed. Pathogenesis of fat embolic syndrome is a combination of mechanical obstruction from fat globules released into systemic circulation at the time of bone marrow necrosis and direct tissue toxicity from fatty acids and inflammatory cytokines released from fat globules. Prompt diagnosis and early initiation of treatment can reduce morbidity and mortality and result in better outcomes and prognosis. Red cell exchange transfusion is the mainstay of therapy with mortality benefits. Overall mortality and neurological sequelae continue to be high despite increased red cell exchange transfusion in the last few years. In this article, we discussed a case of a 34-year-old male patient with a history of sickle cell thalassemia and avascular necrosis of the hip, who presented with fever, hypoxia, encephalopathy, and generalized body aches, found to have thrombocytopenia and punctate lesions on magnetic resonance imaging brain, which led to the diagnosis of the fat embolism syndrome. Only a few sickle cell β-thalassemia with fat embolic syndrome cases have been reported.

Ewing sarcoma is typically seen in children involving long bones. Although well described, its presentation in extraskeletal tissues is relatively rare and is classified as an Ewing sarcoma family of tumors. They are mostly curable when they occur in children. An extraskeletal Ewing sarcoma in adults is uncommon, limiting the experience in adult oncologists. The biopsy is essential for definitive diagnosis, which shows small round blue cells that must be differentiated from lymphoma, embryonal rhabdomyosarcoma, and small cell carcinoma. Management is multimodal, involving surgery, radiation for local treatment of primary tumor, and systemic chemotherapy. A multidisciplinary approach, coupled with risk-adapted intensive neoadjuvant and adjuvant multi-agent chemotherapies and other modalities such as radiation and surgery for control of the primary site and metastatic disease, is needed. The primary multidrug chemotherapy regimen consists of alternating cycles of vincristine/doxorubicin/cyclophosphamide (VDC) and ifosfamide/etoposide (IE) given every 2 weeks with growth factor support. Prognosis and the 5-year survival rate are better for localized than the metastatic disease, and in metastatic disease, it is better for patients with lung metastasis than other metastatic disease sites. We describe a rare extraskeletal tumor arising from a lung that tested positive for Ewing sarcoma, also known as Askin's tumor in a young adult. In our case, the tumor rapidly metastasized locally to involve the thoracic spine causing paraparesis. Timely diagnosis and early management are essential to improve outcomes. We also present how treatment can be delayed due to sepsis and emphasize the careful multispecialty approach's importance., Competing Interests: None to declare., (Copyright 2020, Pokal et al.)

Importance: As the scientific community is in a marathon in finding out the cure for COVID-19, in this crisis, it is essential for the physicians not to forget about the basics. Due to the pandemic crisis, in many nursing homes and hospitals, there established new policies on decreasing unnecessary medications to minimize cross-contamination. Sometimes these policies are making providers avoid essential drugs such as Vitamins, including Vitamin D. In this paper, we try to emphasize the importance of Vitamin D in COVID-19 and respiratory viral patients., Relevance: Vitamin D helps in decreasing the 'pro-inflammatory cytokines' in the lungs and acts in immunomodulatory function, and 'also it will increase the anti-inflammatory, antiviral responses of the respiratory epithelial cells during infection.', Conclusion: Due to the highly contagious nature of COVID-19 and the increased morbidity and mortality with no appropriate therapy and vaccine, one must be cautious and do everything to help COVID-19 patients. In hospitals and other health care settings to decrease cross-contamination, holding other non-essential medications is taking place. Discontinuing Vitamins could increase the mortality and morbidity of those affected, especially in deficient/insufficient individuals. Obtaining serum 25 (OH) D levels in all patients with viral respiratory infections, especially COVID-19, could help in the detection and treatment of Vitamin D deficiency and potentially decrease recovery time and improve outcome. Even though evidence suggests that vitamin D has the anti-inflammatory, antiviral properties, randomized double-blinded controlled trials are needed to verify this further, and to understand Vitamin D and COVID-19 better., Abbreviations: Vitamin D receptor-VDR; 25(OH)D- 25 hydroxyvitamin D; 1,25 (OH)D-1,25 dihydroxy Vitamin D; 1α,25-dihydroxy Vitamin D-1,25[OH] 2 D or calcitriol; IU- International Units; Interferons stimulated genes- ISG; ARI- acute respiratory infection; RSV- respiratory syncytial virus; RTI- Respiratory tract infections; COPD-Chronic obstructive pulmonary disease; BMI-Basal metabolic index; USA-USA., Competing Interests: No potential conflict of interest was reported by the authors., (© 2020 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group on behalf of Greater Baltimore Medical Center.)

Background: Lung hydatid disease is an endemic problem in Mediterranean countries, and the ideal surgical management for it is still debated. In this prospective study, we aimed to evaluate the feasibility and safety of thoracoscopy in patients with lung hydatid disease. We studied the advantages of thoracoscopic procedure over posterolateral thoracotomy., Methods: A total of 32 patients with an uncomplicated, unilateral lung hydatid cyst were subjected to surgical treatment over a period of 5 years. Of the 32 patients, 18 were treated with thoracotomy and 14 with thoracoscopy. Observations were made with regard to duration and ease of operation, complications, hospital stay, return to activity, and recurrence., Results: The mean operative duration in the thoracoscopy group was 95.21 min compared to 137.77 min in thoracotomy group (P < 0.0001). Postoperative analgesia requirement was less in the thoracoscopic group (mean 4.92 days) compared to that in the thoracotomy group (mean 13.94 days; P < 0.0001). The intercostal drain was removed earlier in the thoracoscopic group (mean 5 days) than in the thoracotomy group (mean 8.83 days; P < 0.0001). The postoperative hospital stay was 8.35 days (mean) in thoracoscopic group and 18.77 days in the thoracotomy group (P < 0.0001). The most serious morbidity was wound infection, with three cases (16.66%) in the thoracotomy group and one (7.11%) in the thoracoscopy group. There was no operative mortality and no recurrence during the follow-up period., Conclusions: We strongly recommend the use of thoracoscopy as a primary tool for the management of uncomplicated, unilateral lung hydatid disease. Thoracoscopy offers a great advantage over open thoracotomy in terms of very low morbidity.