Through self-assembly, environmentally friendly cellulose nanocrystals (CNCs) can form films with a photonic crystal structure whose pitch size can be adjusted in a variety of ways at the fabrication stage. Moreover, the films exhibit response performance to multiple stimuli, which offers extensive applications. Poly(ethylene glycol) (PEG) and CNCs combine to form a smaller chiral nematic domain that develops a solid film with a uniform spiral structure when slowly dried. By changing the composition of CNCs and PEG, flexible and flat photonic composite films with uniform structural colors from blue to red are prepared. Benefiting from the change in pitch size by insertion and detachment of water molecules into the chiral nematic structure, CNCs films and CNC-PEG composite films exhibit a reversible structural color change in response to different humidity. In addition, the chiral nematic films formed by the combination of glycerol and CNCs have a reversible stimulation response to hydrochloric acid gas. Similarly, adjusting the ratio of glycerol can control the pitch size of the films and, thus, the reflective color. In summary, the pitch size of the photonic crystal structure of the films can be precisely tuned by regulating the additive ratio, and the two prepared films have reversible responses to humidity and hydrochloric acid gas, respectively. The CNC-based films show promise in the application of colorimetric biosensors. Many creatures in nature have unique and bright structural colors, such as butterfly wings, crustacean shells, bird feathers, and cephalopod skins ,2. AnimaCellulose nanocrystal-based colorimetric biosensors with structural colors are very promising due to their biocompatibility, biodegradability and non-toxicity. Thus, they play an important role in environmental monitoring, medical diagnostic tools and foodstuff processing safety applications. Cellulose nanocrystal (CNC) is commonly prepared by sulfuric acid hydrolysis of natural cellulose and generally has an anisotropic rod shape (diameter 3–20 nm) with a negatively charged surface  so that 4, Si(OMe)4, 1,2-bis(trimethoxysilyl)ethane, 1,2-bis(triethoxysilyl)ethane [Furthermore, the introduction of additives in the colloidal CNC suspensions can obtain the tunable pitch of CNC and thus control the photonic band gap, and the additives bind to CNC nanorods, participating in self-assembly and forming chiral nematic structures. Various additives such as Si(OEt)l)ethane ,14, monol)ethane ,16,17, wl)ethane ,19, silvl)ethane ,21 were l)ethane ,23, CNC However, a few studies show that, in addition to humidity, CNC-based nanocomposites have a broad and rapid effect on environmental stimulation ,25. ThisIn this work, through scanning electron microscopy (SEM), polarization optical microscopy (POM), UV–visible spectroscopy, and other comprehensive characterization methods, the CNC-PEG and CNC-glycerol composite films with response properties to humidity and hydrochloric acid vapor, respectively, are explored. Herein, through the cell ultrasonic method and the addition of PEG, the pitch of the chiral nematic phase structure in the solid film can be adjusted, and the color of the CNCs film can be controlled to obtain a composite film with a tunable photonic band gap . The colsinoreagent.com, accessed on 1 August 2022); Sulfuric acid, 98% concentration, and Glycerol, analytical Pure, were provided by Beijing Chemical Reagent .Microcrystalline cellulose (MCC), PEG and dialysis bags, molecular weight 800–14,000, were purchased from Sinopharm Chemical Reagent  and added it to the above. Then, we slowly added the sulfuric acid while stirring to prevent the microcrystalline cellulose from agglomerating in the sulfuric acid. The stirred suspension was poured into a round bottom flask and stirred at a constant speed in a constant temperature water bath. The microcrystalline cellulose was hydrolyzed in the acid. The reaction temperature was 40 °C, the reaction times were 2 h, 2.5 h, 3 h, 3.5 h and 4 h and the acid-concentration-to-acid ratio was 1 g:17.5 mL. After the hydrolysis reaction was completed, the hydrolyzed solution was poured into a beaker and added to a volume of 5-times ionized water, which stopped the reaction, and it was left to stand. We discarded the supernatant, centrifuged the remaining suspension at 8000 r/min for 5 min and washed and centrifuged it several times. Once we took it out, we put it into a dialysis bag with a molecular weight of 8000–14,000 for dialysis for 3–4 days until the pH of the suspension was 5–6. Then, the suspension was taken out in a translucent state and placed in a beaker for use.The CNC suspension prepared above was concentrated to a mass fraction of 2.3 wt%, and the cells were sonicated with 200 W power in an ice-water bath. The sonication times were 1 min, 3 min, 5 min, 7 min, 10 min, 15 min and 20 min. Then, we took 3.5 mL from the CNC suspension at different ultrasonic times and added them into a plastic Petri dish with a diameter of 3.5 cm, and the CNC film was prepared by self-assembly.By mixing the aqueous CNC suspension with a mass fraction of 2.3 wt% that has been treated with cell ultrasonic for 1 min and PEG aqueous solution with a mass fraction of 5 wt%, the mass ratios of the CNC suspension to the PEG aqueous solution were 10:0, 9:1, 8:2, 7:3 and 6:4. After mixing, it was further stirred at room temperature for 24 h. Then, 3.5 mL of the mixed solution was poured into a plastic Petri dish with a diameter of 3.5 cm, and the CNC-PEG composite film was prepared by self-assembly.Next, 0 mg, 9 mg, 15 mg, 21 mg, 30 mg and 45 mg of glycerol were added to the aqueous CNC suspension (3 g) with a mass fraction of 2.3 wt%, respectively, and mixed at room temperature for 12 h. Then, the mixed solution was poured into a plastic Petri dish with a diameter of 3.5 cm, and the CNC-glycerol composite film was prepared by self-assembly. hitachi-hightech.com, accessed on 1 August 2022). For each formulation, the width and length of approximately 500 particles were measured from the TEM image using ImageJ. A VarianCary50BIOUV visible spectrophotometer was used to record the ultraviolet–visible spectrum of the composite films in a wavelength range of 200–1100 nm . The transmission spectrum was collected by installing a separate FLMS so that the surface of the FLMS was perpendicular to the beam path. We measured the FLMS in at least 10 different locations. The Hitachi S-4800 was used to observe the cross-sections of CNCs, CNC-PEG and CNC-glycerol composite film by FE-SEM. The working distance of the composite FLMS was 1 kV, and the probe current was 10 µA. The fractured sample was clamped in a thin sample, the mounting bracket was separated, and a 5 nm gold-palladium coating was applied using an agar HR sputtering coater. The composite membrane was observed on a POM microscope BX-51 .The morphology of the CNC samples was studied by transmission electron microscope (TEM). A 0.001 wt % CNC aqueous suspension was deposited and stained with 2% ferric chloride on a carbon-coated grid. Specimens were observed using a Hitachi HT7700 model in a high contrast mode under a 100 kV transmission electron microscope (Herein, a CNC suspension was prepared using the acid hydrolysis approach. As determined by TEM, the as-prepared CNC is rod-shaped with a length between 200 and 300 nm and a diameter within 20–30 nm, respectively a. The poFor the self-assembly process in the CNC suspensions, when the solution concentration is low at the beginning, CNC molecules are stably dispersed in the aqueous solution with a disordered arrangement, and the solution does not show structural color at this time a. It conThe pitch of the CNC film can be controlled by subjecting the CNC suspension to different times of ultrasonic treatments, thereby controlling its reflection wavelength. As the ultrasonic time increases a–f, the However, the brittle nature of neat CNC film limits its applications. To improve the flexibility of CNC film, the PBG was introduced into the CNC suspension that had been properly ultrasonic treatments. In addition, the pitch of the cholesteric structure can be regulated by controlling the amount of PBG, which means the structure color of the film can be adjusted. With the increase in PEG content, the color of the composite film first turns yellow and then blue. The color change in the CNC-PEG composite film with different mass ratios was analyzed by transmission spectra a. The reTo understand the relationship between the structure and color of CNC-PEG composite film with different mass ratios and to clarify the mechanism of controllable iridescence, SEM and POM are performed on the neat CNC and CNC-PEG films. As shown in The CNC and CNC-PEG composite films exhibit response performance to humidity . The CNCBy introducing glycerol into the aqueous CNC suspension, it is also possible to modulate the pitch and thus control the structural color. The CNC-glycerol films were prepared by introducing glycerol with different ratios into the CNC suspension. The SEM characterization and POM characterization are carried out, and the results are shown in 0.5 as the representative, it is stored in a closed space filled with hydrochloric acid gas for different periods of time (0.5 became red. After removing hydrochloric acid gas and drying the CNC-G0.5 composite film, the composite film can recover from red to its original color. CNC-G0.5 composite film has a reversible stimulation response to hydrochloric acid gas and can be repeated many times, so the reversibility is good. The red-shifted structural color of CNC-glycerol composite film is mainly because when the composite film is in a space filled with hydrochloric acid gas, the molecules of hydrochloric acid gas can diffuse into the periodic lamellae of CNC-glycerol composite film, resulting in the expansion of the spiral lamellae and an increase in the pitch, which makes the reflection wavelength and structural color red-shift. When the hydrochloric acid is removed, the hydrochloric acid gas molecules entering the composite film diffuse out, causing the pitch of the film to decrease and the reflection wavelength and structure color to recover.According to the hygroscopic property of glycerol, the stimulation response performance of CNC-glycerol composite films to hydrochloric acid gas was investigated. Taking CNC-G of time . We can In summary, stimulus-responsive and iridescent CNC-PEG and CNC-glycerol composite films were successfully prepared. Additionally, their pitch could be adjusted by subjecting the CNC suspension to different lengths of ultrasonic treatments and changing the amount of additives. The structure color covered the entire visible spectrum. By evaporating the CNC suspension, the self-assembled chiral nematic phase structure could be retained in the film, showing vivid color in a certain wavelength range due to the Bragg reflection. To this end, the conditions for preparing CNC film were explored, and a CNC suspension with a concentration of 2.3 wt% was selected and slowly evaporated at room temperature. The ultrasonic treatment and the addition of PEG or glycerol could regulate the pitch and thus control the reflection wavelength. Due to the reversible swelling and dehydration of the chiral nematic phase structure, when the RH was between 50% and 100%, the CNC-PEG composite film showed reversible structural color changing. By changing the composition of CNCs and PEG, the film could produce different humidity response properties. The CNC-glycerol film has a reversible stimulation response to hydrochloric acid gas, and similar to CNC-PEG film, it presented a stimulus response of diversified color changes by simply adjusting the additive content. This CNC-based low-cost responsive photonic material will have important applications in colorimetric biosensors, optically active ingredients, inks and decorative coatings.


Digital health technologies may support the management and prevention of disease through personalized lifestyle interventions. Wearables and smartphones are increasingly used to continuously monitor health and disease in everyday life, targeting health maintenance. Here, we aim to demonstrate the potential of wearables and smartphones to (1) detect eating moments and (2) predict and explain individual glucose levels in healthy individuals, ultimately supporting health self-management. Twenty-four individuals collected continuous data from interstitial glucose monitoring, food logging, activity, and sleep tracking over 14 days. We demonstrated the use of continuous glucose monitoring and activity tracking in detecting eating moments with a prediction model showing an accuracy of 92.3% (87.2–96%) and 76.8% (74.3–81.2%) in the training and test datasets, respectively. Additionally, we showed the prediction of glucose peaks from food logging, activity tracking, and sleep monitoring with an overall mean absolute error of 0.32 (+/−0.04) mmol/L for the training data and 0.62 (+/−0.15) mmol/L for the test data. With Shapley additive explanations, the personal lifestyle elements important for predicting individual glucose peaks were identified, providing a basis for personalized lifestyle advice. Pending further validation of these digital biomarkers, they show promise in supporting the prevention and management of type 2 diabetes through personalized lifestyle recommendations. Type 2 diabetes (T2D) is a top-10 leading cause of disability-adjusted life years (DALYs) in the last decade, and it is anticipated to affect more than 7% of the world population by 2030 ,5,6,7,8.The implementation of lifestyle medicine with sustained lifestyle behavior change necessitates a personalized approach, including personalized diagnosis and diet, physical activity and stress management, self-empowerment, motivation, participation, and health literacy . IncreasWearable technologies, including smartphones and smartwatches, are increasingly utilized in the healthcare domain for the development of so-called digital biomarkers ,25,26. TThe current study set out to demonstrate a proof of principle for detecting eating moments with CGM, as well as predicting and explaining glucose levels based on contextual factors, such as sleep, activity, and diet in a personalized manner, ultimately supporting health self-management and prevention of T2D. Therefore, we performed an observational study with 24 healthy adult volunteers who conducted continuous self-monitoring for two weeks in a real-life setting. The volunteers wore a CGM device for glucose monitoring and a smartwatch for monitoring physical activity and sleep and logged their food intake via a mobile food diary app. The study evaluated how well the probability of having an eating moment can be predicted based on continuously measured glucose, sleep, and activity data. Personalized insight into eating moments can form the basis for personalized advice on the timing of eating. In addition, passive detection of eating moments has the potential to notify individuals to fill out the food diary and to improve compliance with data collection. Additionally, personal glucose prediction models were created to model the effects of physical activity, dietary intake, and sleep on individual glucose levels. How well the glucose levels can be predicted based on personal lifestyle behavior, including dietary intake, sleep, and activity data, was evaluated since personalized insights into the effects of lifestyle behavior on glucose levels can support an individual in keeping glucose levels within a healthy range.2, and conditions that would not allow the use of a continuous glucose monitoring system, such as a skin allergy or eczema. All participants gave written, informed consent.Twenty-four healthy volunteers with an affinity for nutrition and health research were included in this observational pilot study. Participants were eligible for study participation if they were aged 20–65, owned a smartphone, and had a finger-prick glucose value < 7.8 mmol/L after eight hours of fasting during screening to exclude for unknown type 2 diabetes. Exclusion criteria were having type 2 diabetes, body mass index > 30 kg/mHowAmI app  on their smartphones, and were instructed in the use of all devices and apps. The study consisted of 14 days of self-monitoring in a real-life setting. The self-monitoring devices were the Abbott FreeStyle® Libre™ Pro  continuous glucose monitoring (CGM) device and the Philips Elan wristband . The factory-calibrated CGM device was worn on the upper arm and measured subcutaneous interstitial glucose concentrations every fifteen minutes. Participants were blinded to their glucose values. Glucose data were stored on the CGM devices, which were collected at the end of the study. Glucose measurements from the first day were excluded to allow for the stabilization of the sensor. The Elan wristband collected data via a raw green spectrum photoplethysmogram (PPG) sensor and accelerometer. Data were regularly offloaded by participants using ElanControl software  and transferred to Philips after the study. Proprietary algorithms were used to translate the raw data into sleep, energy expenditure, ACN, and heart rate. The HowAmI app was used for collecting food intake. The app was custom-built to provide the functionality to record the exact date and time of the recorded meals. The HowAmI app uses the MyFatSecret food database and back-end  to record food intake and connects to a custom, parallel back-end database to record the time stamp for each meal. This same database was used to collect and store data from the continuous glucose monitor. Helpdesk support was available throughout the study. Participants could follow their regular lifestyle during the study. The study protocol was approved by the Medical Ethics Committee Brabant (NL68969.028.19). The study was performed in accordance with the Declaration of Helsinki and good clinical practice and registered at the Netherlands Trial Register: NL7117.At inclusion, participants were equipped with self-monitoring devices, installed the custom-built Android- and iOS-compatible After data collection, all subsequent data processing, analysis, and visualization were performed using R, version 4.1.2. We used packages ggplot 3.3.5, xgboost 1.5.0.2, caret 6.0–90, pracma 2.3.8, and treeshap 0.1.1 ,38,39,40We created an appropriate dataset for the detection of meals in a multi-step process consisting of data aggregation and feature engineering. Several engineered features were created from continuous glucose sensor data that matched the sampling interval of the glucose sensor. We created lag, lead, the difference of the lead (1st to 6th order), the difference of the log lead (1st to 6th order), lagged difference of the lead (1st to 6th order), standard deviation and mean of the lead up to 90 min, standard deviation and mean of the lag up to the 90 min, standard deviation and mean from a 90 min lag to a 90 min lead, relative standard deviations of the 90 min lead and lag, the ratio between the standard deviation of the lead and the lag, and the ratio between the 90 min lead and lag maximum and minimum values. No other modalities were used in the meal detection dataset. The target variable was given as a classification label, where the positive class denotes that food was taken at that respective time point, and the negative class denotes that no food was taken. A time point was considered to be of the positive class if the meal contained any carbohydrates; the time points immediately preceding and following food intake were also considered to be of the positive class to account for inaccuracies in diary annotation and the time it took to consume the food.A similar approach was taken to create a suitable dataset for the prediction of glucose. Data were first aggregated to deal with varying sampling intervals across the different modalities. The items of any meal that were eaten within 15 min were combined to form a single meal. For each meal, total calories, as well as calories from fat, protein, and carbohydrates, were calculated. From this, the fractions of calories from fat, protein, and carbohydrates were also derived. Additionally, energy expenditure, acceleration (movement), and heart rate features collected from the Elan wristband were aligned to the collection interval of the continuous glucose sensor (once every 15 min) and then aggregated to match the frequency of the glucose measurements before being joined. Sleep and sleep stage information were subsequently joined so that each glucose value was associated with sleep feature values from the closest preceding period of sleep, but no more than 28 h earlier.Subsequently, we created new features from all aggregated and joined data (except sleep-related data) by averaging the values for all features over rolling periods of 30, 60, and 90 min as well as 2, 3, 8, and 24 h. In the case of caloric intake, energy expenditure, and activity, these features were created by taking the rolling sum instead of the rolling average.The final datasets were created from this data by selecting the longest stretch of uninterrupted data that was available from every included participant with a minimal stretch of 24 h. For this purpose, we defined ‘uninterrupted data’ as periods where data from all modalities were available without a break in the glucose sensor measurements and no break in the activity or food intake measurements. In addition, the total length of combined stretches per participant needed to exceed 7 days to allow sufficient data for training and test sets.The training set for the glucose prediction model contained all available data for each participant apart from those from the last 3 days; these were kept separate for the testing set. The training dataset for the meal detection model was more limited; we used the first 4 days of data for each participant for training purposes and kept a subsequent 3-day period as the training set. The training dataset for the meal detection model was kept intentionally smaller to imitate a practical situation where only limited data can be obtained because of the participant burden of keeping a food intake diary.In the case of both models, the test dataset was used to estimate model generalizability but not for any other purposes.gain, as a measure of improvement in accuracy, was used to rank feature importance during RFE [For both models, we used recursive feature elimination (RFE) with 10-fold cross-validation to obtain the smallest set of features that would still perform similarly to the full feature set. This step was undertaken to simplify the model for easier interpretation and reduce overfitting. In this procedure, we used xgboost as the underlying model to drive feature selection; ring RFE . A fixedFor the final glucose prediction model, the model hyperparameters were tuned by minimizing the mean absolute error using random search with 10-fold cross-validation. The target variable was the log-transformed glucose value. The hyperparameter tuning procedure for the meal detection model minimized the classification error using grid search with 10-fold cross-validation. Grid search was chosen over random search because of the propensity for overfitting and its reduced computation time because of a smaller amount of training data compared to the glucose prediction model.treeshap package. This algorithm was defined using a mathematical game theoretic approach that is explained in detail by Lundberg et al. [findpeaks algorithm of the pracma package, we identified peaks for all subjects where the glucose value was higher than at least the For the glucose prediction model, Shapley values were calculated for all data points in the training dataset by using the implementation of the algorithm described in Lundberg et al.  and provg et al. . These S2. Of the 24 participants, 17 participants were female (71%). All individuals had non-fasting blood glucose in the normal range below 7.8 mmol/L during screening, which excluded people with unknown diabetes. A minimal length of uninterrupted data periods for 24 h from all continuous data sources was selected for each individual to guarantee sufficient data quality. Additionally, at least three days of test data and three days of training data were required to ensure sufficient power to perform the analysis. Applying these two criteria resulted in a dataset with 11 individuals with 4–11 days of training data and three days of testing data that was selected for further analysis  of 22 +/−9.4 kg/manalysis .Detecting eating moments can support food logging, for example, through AI-driven notifications, thereby reducing the risk of erroneous reporting. We developed an extreme gradient boosting machine model to predict the probability of having an eating moment in healthy individuals. Eating moments were predicted in segments of 30 min based on continuously collected interstitial glucose, sleep, and activity data over three days per participant. After model training, accuracy, specificity, and sensitivity were calculated using a hold-out test dataset. The final model showed an accuracy, specificity, and sensitivity of 92.3% (87.2–96%), 98.9% (97–100%), and 90.8% (86.4–94.9%), respectively. The accuracy, specificity, and sensitivity in the test dataset of another three days per individual were 76.8% (74.3–81.2%), 60.3% (33.3–82.6%), and 78.4% (74.3–84.1%), respectively. The glycemic response is highly personal, depending on biological and contextual factors, such as lipid metabolism, muscle mass, nutrition, stress, activity, and sleep. The individual glycemic response may, thus, vary between and within individuals. Here, we applied an extreme gradient boosting machine approach with the subject number as a random variable to allow personalized models to predict glucose levels from contextual factors in real time. Continuous glucose levels for three days were predicted from 72 features engineered around nutrition, activity, and sleep over different periods . An overall mean absolute error (MAE) of 0.32 (+/−0.04) mmol/L for the training data and 0.62 (+/−0.15) mmol/L for the test data was obtained. The final model contained 17 features after feature selection, covering activity, nutrition, sleep, and unexplained, subject-specific features. The influence of the different features is summarized in In this study, we aimed to prove the feasibility of using real-life CGM data combined with contextual data to make predictions on an individual basis in healthy persons. First, we showed the ability to predict eating moments using interstitial glucose. Second, we showed the ability to predict and explain current interstitial glucose values using contextual data, including those relating to food intake, physical activity, and sleep.Dietary intake assessment is challenging since common methods are susceptible to misreporting. Several technological innovations currently focus on image recognition of meal photographs, eating action detection, and biochemical sensors that are targeted at specific nutrition-associated metabolite concentrations in non-invasive biofluids such as urine and sweat . These iPersonalized nutrition is gaining momentum in science to support health maintenance and disease prevention, especially prevention of chronic, lifestyle-related diseases such as type 2 diabetes ,30,45. WThe overview of the final, overall feature influence confirmed the importance of physical activity, dietary intake, and sleep in determining glucose values ,52,53,54The strength of this study is the real-world design, maximizing the ecological validity of the observations. However, neither above-described applications of remote monitoring technologies can be realized without proper data quality. Therefore, only participants with a professional affinity for nutrition research and care were included. Indeed, the data from food logs appeared very complete, although this was not directly verifiable with reference data. Still, from the 24 participants, only 11 individuals had good-quality multimodal data for three consecutive days from the HowAmI app, the wristband, and the continuous glucose monitor . For theIn this study, we explored the feasibility of data generated from current, wearable technologies for detecting eating moments and predicting the impact of physical activity, sleep, and dietary intake on continuous glucose levels in healthy volunteers. We showed that, pending further validation in a larger population, both eating moments and the influence of contextual lifestyle factors on glucose can potentially be predicted on an individual level. By opening up the ‘black box’ using SHAP, to our knowledge, this is the first study taking the step towards personalized, real-time lifestyle recommendations based on continuous health monitoring data. Eventually, the application of digital biomarkers that predict glucose from contextual factors is to drive personalized, continuous feedback on lifestyle factors to improve or maintain glucose homeostasis, thereby preventing the development of T2D.The ease of use of wearable technologies is key for good data quality to allow for application in remote clinical trials, self-management, or remote care. Under everyday life conditions, we showed the feasibility of detecting eating moments to support food intake monitoring. Additionally, we showed how machine learning methods can be used to understand and explain individual relations between contextual lifestyle factors and interstitial glucose concentrations. Pending further validation, it is envisioned that these technologies will support self-management to maintain a healthy glucose metabolism through personalized lifestyle recommendations. Especially when combined with the early detection of insulin resistance and understanding of the biological cause for glucose derailment, the possibility exists that, in the future, meaningful digital biomarkers may provide the feedback and motivation to enable individuals to achieve the required lifestyle behavior change, ultimately allowing them to maintain health, prevent disease development, and reduce the economic burden of chronic diseases such as T2D.


The most common causes of perioperative hypersensitive reactions are neuromuscular blocking drugs, latex, and antibiotics, although there are other more emerging causative agents. Allergic reactions to Patent Blue V (PBV) dye have been reported. Most of them are mild and presented with blue coloration of cutaneous plaque. The PBV dye is widely used in the identification of sentinel lymph nodes in patients with breast cancer and other malignancies. Here, we present a case of 33-year-old patient with carcinoma of the breast proposed for sentinel lymph node and skin-sparing mastectomy with severe, life-threatening anaphylaxis which occurred immediately after PBV dye was injected, with cardiopulmonal resuscitation and prolonged refractory hypotension. The patient was without previous exposure to PBV and signs of skin rash, erythema, or bronchospasm, making the diagnosis and management of such cases challenging. Skin tests were performed on all drugs used in premedication and induction of anesthesia and PBV showed positive at IDT of 1:10. Physicians must always think of possible adverse reaction to PBV and for the potential risk of anaphylactic reaction immediately after the dye is injected, during anesthesia and other procedures. Although the most common causes of perioperative anaphylactic reactions are neuromuscular blocking drugs 70%), latex 10%), and antibiotics, there are other more emerging causative agents 0%, and a. The Pat0%, latexWe present an unusual case of severe anaphylaxis to PBV dye with atypical clinical features in a young woman with carcinoma of the right breast.A 33-year-old patient with carcinoma of the right breast proposed for sentinel lymph node and skin sparing mastectomy, followed by reconstruction with prosthesis, had a history of iodine, cefalexine and trastuzumab allergies. The patient had one previous surgery without complications and no prior medical contact with PBV dye.After anesthetic induction and endotracheal intubation, the surgeon applied 1 mL of Patent Blue V Sodium Guerbet 2.5%, diluted to 2 mL with normal saline, subcutaneously into the retromamilar peritumoral region of the breast for the identification of the sentinel lymph node and massaged the application site. Immediately after injection of the PBV dye, the patient developed volume refractory hypotension of 50/30 mmHg, bradycardia with 30–45 beats per minute, desaturation, and skin goosebumps, without signs of skin rash, erythema, urticaria, edema, or bronchospasm. These symptoms required prompt treatment and we started with intravenous administration of diluted epinephrine, first fractionated total of 1 mg, then continuous infusion of 0.8 mg/h. The patient also received boluses of norepinefrine 0.01 mg/ml, 250 mg of hydrocortisone, 100 mg of ranitidine, 20 mg of chloropyramine, 2 mg of athropine, 3000 mL of crystalloids, and 500 mL of colloids. For 20 min after application of the PBV dye, the patient remained in severe hypotension and bradycardia, and ventricular fibrillation rhythm occurred. Following immediate cardiopulmonal resuscitation with cardiac massage for 1 min and defibrillation using 200 J, we managed the conversion in the sinus rhythm at around 120 beats per minute. The patient received treatment with 300 mg of amiodarone, 60 mL of bicarbonates, and electrolyte correction, and then an arterial cannula and urinary catheter were placed with invasive blood pressure measurement. Surgical intervention was not performed, and the patient was transported to the intensive care unit (ICU) intubated, hypotensive 75/45 mmHg, on continuous infusion of epinephrine 0.5 mg/h, and normal skin with mild cervical edema. After 1 h of admission to ICU, the patient was extubated, promptly awake, without any neurocognitive deficit. During the first 8 h in the ICU, the patient was very hemodynamically unstable, with tachycardia up to 150 beats per minute and hypotension with systolic pressure of 70–90 mmHg, on continuous infusion of epinephrine 0.5 mg/h and boluses of norepinephrine 0.02 mg iv. After that, the patient demanded support with continuous infusion of epinephrine 0.05–0,3 mg/h for a total of 44 h. Within the first 24 h, the patient received 7800 mL of intravenous fluid, and spontaneous diuresis of greenish blue urine was 4700 ml, which stayed greenish blue for 36 h. The patient was discharged from the ICU at Day 3 in good condition. No tryptase assay was done.Seven weeks later, at the allergy department, skin and challenge tests were performed on all drugs used in premedication and induction of anesthesia , and results were negative. These medications were allowed for use, and the risk of anaphylactic reaction was not higher than other members of the population. We also tested Patent Blue V sodium Guerbet 2.5% using the following protocol: skin prick test (SPT) 1:10, 1:1, and intradermal skin test (IDT) 1:1000, 1: 100, 1:10. The Patent Blue V sodium Guerbet 2,5% was positive at IDT of 1:10.After 3 months, the patient was reoperated without the use of blue dye and with all the other drugs used in the first surgery, without complications. Instead of sentinel lymph node, the surgeon performed an axillary dissection.Our case is an example of atypical life-threatening anaphylactic reaction that presented with severe and prolonged hypotension refractory to epinephrine, without signs of skin rash, erythema, urticaria, edema, or bronchospasm.The most common triggers of drug-induced allergic reactions during surgery are neuromuscular relaxants, antibiotics, anesthetic induction drugs, opioids, colloids, NSAIR, topical antiseptics, and latex . All druThis patient never had contact with medical blue dye. In most reported cases there was a lack of previous exposure to PBV dye , 11, 13.The incidence of anaphylactic reaction of any severity associated with PBV dye is about 0.1%–2.8% , 12, 13.Reactions to PBV dye usually consist of skin lesions (blue coloration of the cutaneous plaque) and hypotension, but respiratory symptoms are uncommon. Reactions tend to occur 15–30 min after the dye is injected and onset is faster for more serious reactions , 10. In Although anaphylaxis usually presents as an acute episode, the mast cell can release mediators and support anaphylaxis for hours . PBV dyeAnaphylactic shock after PBV dye injection remains a serious adverse event and warrants awareness . ImmediaAll surgical patients should give consent for adverse reactions to PBV dye preoperatively . PhysiciThe original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.SMŠ, IKZ performed the anesthesia and ICU treatment. AŽ, MP, AŠ and TT provided supervision and participated in the literature review and in drafting the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The incorporation of nHA into the polymeric blend matrix resulted in a rather irregular structure and the crystallization became more difficult. The addition of nHA improved the density and tensile and flexural strength of the PLA/PCL matrix (0% nHA). However, with increasing nHA content, the PLA/PCL/nHA biocomposites became more porous. In addition, the density, flexural strength, and tensile strength of the PLA/PCL/nHA biocomposites decreased with increasing nHA concentration. The PLA/PCL/nHA biocomposites with 10% nHA had the highest mechanical properties with a density of 1.39 g/cm3, a porosity of 1.93%, a flexural strength of 55.35 MPa, and a tensile strength of 30.68 MPa.Hydroxyapatite has the closest chemical composition to human bone. Despite this, the use of nano-hydroxyapatite (nHA) to produce biocomposite scaffolds from a mixture of polylactic acid (PLA) and polycaprolactone (PCL) using cold isostatic pressing has not been studied intensively. In this study, biocomposites were created employing nHA as an osteoconductive filler and a polymeric blend of PLA and PCL as a polymer matrix for prospective usage in the medical field. Cold isostatic pressing and subsequent sintering were used to create composites with different nHA concentrations that ranged from 0 to 30 weight percent. Using physical and mechanical characterization techniques such as Fourier transform infrared spectroscopy (FTIR), X-ray diffraction (XRD), scanning electron microscopy (SEM), and density, porosity, tensile, and flexural standard tests, it was determined how the nHA concentrations affected the biocomposite’s general properties. In this study, the presence of PLA, PCL, and nHA was well identified using FTIR, XRD, and SEM methods. The biocomposites with high nHA content showed intense bands for symmetric stretching and the asymmetric bending vibration of PO Bone fractures caused by cancer, traffic accidents, bone tumors, or aging are incapable of self-healing. These bone fractures require interventional therapy with implants or bone grafts in order to heal and regenerate. Bone tissue engineering has garnered interest due to its inherent advantages for the healing of bone fractures.Important components of bone tissue engineering are scaffolds that can provide dynamic circumstances for cell growth. Scaffolds must be biocompatible and biodegradable, possess appropriate mechanical qualities and pore sizes, and have pores that are well-connected ,2,3. TheMoreover, internal fixation devices made from metal may be utilized for the repair of bone fractures. Metallic materials such as stainless steel, CoCr alloys, Ti, and Ti alloys have a lot of good properties that mean they are utilized for bone implants. These properties include high fracture toughness, corrosion resistance, high strength, high hardness, and biocompatibility. However, the inadequate interfacial adhesion between metallic implants and tissue or bone results in the creation of a non-adhesive layer and movement at the implant tissue interface. This results in the failure of using metal implants to treat bone fractures. Furthermore, metallic implants have a substantially greater modulus of elasticity than bone, which can result in stress shielding. Consequently, osteoporosis, osteolysis, and secondary fractures will occur. During the implantation process, toxic effects induced by ions released from metallic implants represent a major problem ,7,8,9,10Presently, only a few polymer biomaterials are now available that are non-toxic, absorbable, and FDA-approved for use as scaffolding materials in medical applications. Among these, biomaterials with strong biocompatibility and biodegradability include polylactic acid (PLA) and polycaprolactone (PCL) ,12. PLA PLA is a brittle material that degrades quickly in body fluids . TherefoHydroxyapatite (HA) is known as the most common mineral found in bones and teeth. Because HA chemicals account for approximately 65% of bone, they are an interesting candidate for a synthetic bone composite. HA is a bioactive ceramic material that is extensively utilized in various biomedical applications, primarily as orthopedic implant materials and in the creation of dentistry materials ,22,23.w/w and 35% HA had better osteoinduction, viability, and biocompatibility qualities [Pijamit et al. utilize PLA/PCL/HA to be the biocomposite material for manufacturing 3D printing filaments. HA in the PLA/PCL/15HA mixture is used for producing the greatest compressive strength (82.72 ± 1.76 MPa). Furthermore, it was observed that HA also provided higher bone cell proliferation . Fabricaualities . Fitriyaualities .The use of additive manufacturing techniques to create scaffolds has been the subject of numerous investigations. The benefits of the additive manufacturing-based process for scaffold fabrication include closeness to the final dimensions, precision, and the capability of generating complex geometries, as well as low processing costs. The disadvantages that come along with this method are limited product size, relatively small dimensions, poor mechanical properties, the requirement of post-processing, which is expensive and time-consuming, residual stress, high surface roughness, frequently clogged nozzles, clumping, and the presence of delamination of the layers on the final product ,25,26.To overcome these problems, this research uses the cold isostatic pressing method to make biocomposites from PLA/PCL/nHA as a scaffold material. Prior to machining or sintering, powdered materials can be compacted via cold isostatic pressing to create a solid, uniform mass. The main advantage of cold isostatic pressing is the ability to produce products with more complex shapes. In addition, distortion and cracking due to non-uniform stresses are greatly reduced ,28,29. AAl Bakri et al. found that the pressing process also affects the characteristics of the zirconia toughness alumina (ZTA) composite that is manufactured. CIP provides superior mechanical qualities compared to uniaxial pressing. Compared to the uniaxial pressing method, composites compacted using the CIP method exhibit superior characteristics at lower sintered temperatures . The pro2.5Co2.4Al0.1 and LaNi5, and manganese powder. In their research, they utilized the isostatic cold pressure technique to generate materials containing a mixture of amorphous boron powder, crystalline aluminum, and LaB6–TiB2 composites under 0.6 GPa of pressure and sintering at 1000 °C [The results suggest that high hydrostatic pressures can be employed to reduce synthesis temperature and generate nanostructured ceramics and manganates with predetermined oxygen nonstoichiometry. The cold isostatic pressing affects manganate synthesis and increases the contact area, which mechanically activates the grains and amplifies the solid-phase sintering processes . Akimov  1000 °C . The dec 1000 °C .Cold isostatic pressing has not been intensively investigated as a method for producing scaffolds from PLA, PCL, or nHA biocomposites. This research was conducted to determine the effect of the concentration of HA used on the physical and mechanical properties of biocomposites with a PLA/PCL matrix prepared using the cold isostatic pressure method.The properties of the polycaprolactone (PCL) and polylactic acid (PLA) used in this study are shown in The percentages of nHA composition used in this study were 0, 10, 20, and 30 wt%. The PLA/PCL/nHA biocomposite formulation is presented in The sintering technique was then performed on the green body formed at 150 °C for 2 h using a digital drying oven .The developed PLA/PCL/nHA biocomposites were evaluated using FTIR, X-ray diffraction, scanning electron microscopy (SEM), and density, porosity, tensile, and flexural techniques.−1 to 4000 cm−1. X-ray diffraction (XRD) analysis was a non-destructive technique for investigating crystalline materials that was used to identify the crystalline phases in a material by looking at its crystal structure [In the PLA/PCL/nHA biocomposite, the functional groups constituting the material as well as the orientation of the molecular chain were identified using the Fourier transform infrared (FTIR) technique . The funtructure . The PLAtructure . To makeThe actual density, theoretical density, and void volume (%) of PLA/PCL/nHA biocomposites were determined using studies by Satapathy et al. (2017)  and TaibTensile strength was measured using PLA/PCL/nHA biocomposites specimens in accordance with the American Society for Testing and Materials (ASTM) D3039. In this study, the specimens for the tensile test were rectangular in shape, with dimensions of 250 mm × 25 mm × 3 mm. Aluminum tabs were fastened at the ends of the specimen to provide proper grip, prevent gripping damage, and ensure deep failure at the gauge length. A 50 kN load cell and a clip-on-type MTS extensometer with a gauge length of 25 mm were used to measure load and strain. A loading rate of 2 mm/min was used for testing. The flexural and tensile tests in this study used the HT-2402 Series Computer Universal Testing Machine from Hung Ta Instrument Co., Ltd., Sammutprakarn, Thailand, with five replications, and the average data were analyzed.3 peaks in the biocomposite specimens demonstrate that polylactic acid (PLA) was present. Meanwhile, the C–O, C=O, and CH2 peaks indicate the presence of polycaprolactone (PCL) in the biocomposite specimens. The existence of PO43− and O–H peaks in the biocomposite specimens indicates that nano-hydroxyapatite (nHA) is present [43− stretch band is around 1156–1000 cm−1 and the O–H bend is in the range of 950–910 cm−1. Following the O–H bend, a band at 631 cm−1 showing the extension of the hydroxyl group (OH-) in nHA was also detected in all biocomposite samples. In this study, all of the biocomposite specimens showed a weak O–H stretch in the range of 3160–3640 cm−1 [−1 indicates a CH2 asymmetric stretch. A peak between 2880 and 2975 cm−1 shows a CH3 symmetrical stretch [3 in specimens of 0, 10, 20, and 30% at peaks of 1373, 1335, 1332, and 1336 cm−1, respectively. Thus, the C=O and C–O stretches are measured at 1760–1670 cm−1 and 1100–1000 cm−1 [ present ,46,47. T640 cm−1 ,49,50. T stretch ,52. FTIRThe biocomposite specimens in this investigation demonstrated all of the peaks that were representative of nHA, PCL, and PLA. Furthermore, the findings of this investigation revealed no novel peaks in the spectrum. This suggests that the two polymers and nano-hydroxyapatite have a weak interaction and are fully incompatible. The results of this study are in accordance with the results of research conducted by Hassanajili et al., Shojaei et al., and Åkerlund et al. Based on the FTIR spectra, they found that there is a weak interaction between PLA, PCL, and HA, which indicates that they are completely incompatible. The carbonyl groups shifted, indicating that PLA, PCL, and HA interact with each other ,46,47.−1, which were associated with the symmetric stretching vibration of PO43− and the asymmetric bending vibration of PO43−. The findings in this study are similar to the results of research conducted by Bernardo et al. They made 3D filament from a biocomposite of PLA and HA. Their results showed that with a higher concentration of HA used, the FTIR spectra showed bands with stronger intensities at 1026 and 563 cm−1, representing a symmetric stretching vibration of PO43− and asymmetric bending vibration of PO43−, respectively [ectively .X-Ray diffraction (XRD) was utilized to identify the biocomposites’ crystallized phases  within tThe lack of crystal peaks in the PLA/PCL blend (0% nHA) suggests that an amorphous structure is generated. When PCL is incorporated into PLA, a disordered structure is formed, making crystallization more difficult .In this investigation, the PLA/PCL/nHA biocomposite exhibited amorphous phase dominance, as evidenced by the broadening of peaks between 2 thetas 10.00° and 40.00° for all nHA content variations . This occurred because the integration of nHA into the PCL and PLA matrix resulted in a less homogeneous structure and essentially no crystalline phase formation. The reason for this is that the addition of HA interferes with the arrangement of the PLA and PCL molecules, preventing crystal formation . In addiThe surface morphology of biocomposite samples has been examined using a scanning electron microscope (SEM). However, in specimens with 0% nHA, the EDX graph only found C and O peaks. Aside from this, with more nHA added, the atomic (%) of Ca and P also increased . The SEMThe studies of Cardoso et al. and Doyle et al. also showed similar results to this study. The agglomeration of nHA particles in the polymer matrix is caused by dispersion problems that occur during the mixing process in the raw materials ,61. Acco3, respectively. Adding nHA to the PLA/PCL matrix resulted in lower porosity than the sample without nHA (0%). This is because the nHA within the PLA/PCL matrix is strongly bound and is believed to be involved in the chemical changes that occur during biocomposite fabrication. During the process, nHA is adsorbed into the PLA/PCL matrix to fill voids and increases in density as the porosity of the biocomposite decreases [ecreases . The finecreases . Meanwhiecreases .The porosity of the biocomposite specimens increased as the concentration of nHA used increased. This occurred because the addition of nHA inhibited sintering for the matrix (PLA/PCL), resulting in the formation of pores in the biocomposite specimens . Further3, while biocomposites with a 10% nHA concentration produced the highest density, 1.39 g/cm3. The density of the biocomposite decreases as the nHA content increases from 10% to 30%. This is due to the wettability and clustering of nHA as the reinforcement particles [3, which is nearly equivalent to that of human cortical bone density [2O3/HA bio-nanocomposite.The density of biocomposite specimens decreases as porosity rises ,68. The articles . The bio density . This exFurthermore, the density of the specimen with low HA is relatively identical to the density values noted in the theory. The increase in HA concentration resulted in the difference between the measured density and the theoretical density increasing .The tensile strength of the PLA/PCL matrix (0% nHA) increased with the addition of nHA . This isConsequently, the surface fracture strength and energy of the biocomposite specimen increase. Furthermore, as the concentration of nHA rises, the size of the voids form when the polymer matrix disintegrates from the nHA particles. When this happens, significant cracks begin to occur. In addition, the increased agglomeration of nHA particles resulting from uneven dispersion reduces the biocomposite’s strength ,74,75,76Dehestani et al. found that as the content of HA increased, the tensile strength and ductility of iron–hydroxyapatite composites dropped. The higher the HA content, the more unequal the HA particle dispersion in the Fe matrix and the lower the tensile strength of the biocomposite. The magnitude of the decrease in mechanical properties obviously depends not only on the content of HA but also on the distribution of HA dispersed in the Fe matrix and the particle size of the HA used . AccordiWhen the HA concentration is 30 percent or less, the tensile strength of the HA/PEEK composite is greater than that of cortical bone (50 MPa). The 40% HA/PEEK composite’s tensile strength, however, was less than 50 MPa, rendering it incompatible with cortical bone . AccordiFlexural strengths of 0%, 10%, 20%, and 30% of specimens were 30.21 MPa, 55.35 MPa, 47.99 MPa, and 45.67 MPa, respectively. The highest flexural strength (55.35 MPa) was obtained in biocomposite specimens containing 10% nHA. The flexural strength of the biocomposite specimens decreases as the nHA concentration increases from 10% to 30%. A rise in nHA concentration results in significant nHA agglomeration in the matrix. Consequently, a propagating fracture may form as a result of stress concentration, which subsequently readily results in brittle failure. Furthermore, the addition of nHA with a concentration of 10% gave a suitable stiff phase in the matrix made of a mixture of PCL and PLA. The use of nHA with the right concentration can limit deformation and mobility in the matrix, resulting in high flexural strength .Aldabib et al. explained that the homogeneous distribution of nHA particles within the biocomposite can be linked to the increased flexural strength of the biocomposite specimen at lower nHA concentrations. The flexural strength increases as the dispersion of nHA particles improves . As prevFurthermore, the higher concentration of nHA resulted in the formation of a lot of pore content in the composite specimen . ComparaThe investigation findings are aligned with Ferri et al.’s research. Their findings show that the higher the concentration of HA used, the lower the flexural strength of the PLA/HA composite. Flexural strength is reduced as a result of the biocomposites’ greater stiffness produced by the increased HA concentration. Furthermore, when HA concentration increases, particle aggregation becomes more possible, and the nucleating effect becomes less evident. As a result, the cracking probability is increased because HA aggregates perform as crack initiators . Accordi−1, which were associated with a symmetric stretching vibration of PO43− and asymmetric bending vibration of PO43−, respectively. The PLA/PCL/nHA biocomposites lack crystal peaks, indicating that the resulting structure is amorphous. A broadening of the peak between 2 thetas of 10.00° and 40.00° on the XRD diffractogram indicated an increase in the distance between PLA layers. The spacing between PLA layers increased, indicating a more amorphous phase in these PLA/PCL/nHA biocomposites, whereas the addition of nHA led to a less uniform structure and made crystallization more difficult. The nHA  was evenly distributed throughout the biocomposite. However, nHA agglomerations of diverse sizes were seen in biocomposites with higher nHA content.The PLA/PCL/nHA biocomposites were successfully prepared via the cold isostatic pressing method. The biocomposites obtained via isostatic cold pressing, PCL, PLA, and nHA bands, were well identified using the FTIR test. The different band intensities are affected by the concentration of nHA used. The biocomposites with high nHA content showed intense bands at 1047 and 551 cm3) and the smallest porosity (1.93%).The addition of nHA improves the density and tensile and flexural strength of the PLA/PCL matrix (0% nHA). However, by increasing nHA content, the PLA/PCL/nHA biocomposites became more porous. In addition, the density of the PLA/PCL/nHA biocomposites decreased linearly as the nHA concentration increased. The PLA/PCL/nHA biocomposites with 10 wt% nHA exhibited the highest density (1.39 g/cmThe flexural and tensile strength of the PLA/PCL/nHA biocomposite decreased with decreasing density. The tensile strength of biocomposite specimens decreased when the nHA concentration exceeded 10 wt% because the nHA particles were not well dispersed. Furthermore, the increase in the concentrations of nHA led to a decrease in flexural strength. Flexural strength is reduced as a result of the biocomposites’ greater stiffness produced by the increased nHA concentration. The highest tensile and flexural strength were found in PLA/PCL/nHA biocomposites with 10 wt% nHA, with a tensile and flexural strength of 30.68 MPa and 55.35 MPa, respectively.


Aspergillus plays a predominant role both in human and veterinary medicine. From a “One Health” perspective, infections by Aspergillus spp. often represent a public health problem linked to specific occupational categories that could have a greater risk of inhaling spores and developing any respiratory disease. This preliminary investigation allowed to acquire information about the spread of Aspergillus spp. in avian livestock of the Umbria region , their sensitivity to antifungals, and the presence of mycotoxins in the considered farms. Environmental, feed, animal, and human samples were collected for mycological investigations; chemical analyses were also performed in feed samples. Moreover, prevalence estimated of the fungal isolates were provided for each individual farm sampled. Direct fungal identification was possible in 298 out of the 559 total samples; 162 of the samples were positive for Aspergillus spp. Mycotoxins were detected in 5 out of the 21 feed samples collected. All the aspergilli tested for antifungal susceptibility were resistant to fluconazole. The results obtained show how much the genus Aspergillus is widespread in the investigated farms; therefore, the poultry livestock represents a favorable environment for the maintenance and spread of fungal spores and their potential transmission to animals and humans.Among the fungi responsible for deep mycosis, the genus  In the last decades, mycoses have acquired a considerable clinical importance. Nowadays, human mortality due to invasive fungal infections is comparable to that induced by tuberculosis or malaria worldwide ,2,3. TheDeep and systemic mycoses play a more worrying role in public health, given their incidence, their clinical evolution, and their often difficult therapeutic management . FurtherAspergillus plays a preponderant role among the fungi responsible for deep mycosis; in particular, A. fumigatus can be responsible of bronchopulmonary allergic forms, especially in humans, worsening the clinical signs in patients with asthma, cystic fibrosis, or Chronic Pulmonary Aspergillosis (CPA). Allergic Bronchopulmonary Aspergillosis (ABPA) is still underestimated from a diagnostic point of view; its clinical or radiological features are confused with pulmonary tuberculosis, especially in developing countries. In industrialized countries, the estimated incidence of the disease is very high . From a pathogenesis perspective, recurrent exposure to high concentrations of A. fumigatus spores is the most cited risk factor in the development of ABPA, even if not the only one [A. fumigatus is associated with deep fungal respiratory infections, almost exclusively in birds [Aspergillus spp. is also mentioned in cases of dog rhinitis, mycosis of the guttural pockets in horses, bovine abortions and pneumonia in dolphins; however, these clinical conditions are uncommon [Aspergillus spp. can have an impact to public health. In particular, they represent a problem linked to specific occupational fields because some workers  could have a greater risk of inhaling spores and developing any respiratory conditions [The genus only one ,7. Also in birds : exposurin birds . Aspergiuncommon ,11. The uncommon . Therefonditions .Aspergillus spp. spread in some avian farms of the Umbria region ; (ii) their sensitivity to common antifungals; (iii) the presence and spread of mycotoxins in feed samples. The data obtained have been useful to understand the potential risk of spreading and transmitting fungal spores and air-borne mycotoxins to workers operating in the poultry sector.Particularly, thanks to a multidisciplinary approach, this investigation provided information relating to: (i) Through the involvement of the territorial Veterinary Services, eight poultry farms located in the Umbria region were selected for the investigations as follows: four intensive farms in the province of Perugia, three intensive farms, and one rural farm in the province of Terni. All farms were constantly monitored for the main infectious diseases, such as Influenza, West Nile Disease, and salmonellosis.Gallus gallus) were raised indoors, in sheds ranging from 400 to 800 m2 , and ducks (Anas platyrhynchos) were bred in stables with a surface of about 40 m2 and the possibility of access to outdoor parks , litter, and soil; feed samples, directly collected from the silos and the feeders inside the sheds; animal samples, represented by respiratory mucosal swabs and pools of trachea, lungs, and air bags of birds found dead in the investigated farms; and human samples, represented by nasal swabs from farm workers.For the isolation and the identification of The collection was planned on a monthly basis, in two periods of the year, one colder and one warmer: January–April and June–September. All the samples were stored in sterile containers until their transfer to the laboratory.For mycotoxins analysis, to ensure representativeness of the entire feed lot, sampling was conducted according to EU Commission Regulation (EC) n. 152/2009.Aspergillus spp. and Penicillium spp. For air and swabs samples, the gravity sedimentation method settling plates exposed for 20 min, and plating by dilution were the techniques used. For air samples, plates were incubated at 25 ± 1 °C in aerobiosis, whereas for swabs the incubation was performed at 37 ± 1 °C in aerobiosis, according to the laboratory standards provided for fungi. The observation of the colonies was performed within 72–96 h.A quantitative mycological analysis was carried out at the IZSUM for the air monitoring and for the surface swabs. Czapek agar (CZA) stimulating the growth of xerophilic species deeply colonizers of substrates was used as a selective reference medium for A qualitative mycological examination was performed at UNIPV for litter, soil, and feed samples. The method used was direct-plating onto CZA. Plates were incubated at 25 ± 1 °C in aerobiosis, prolonging the incubation until 14 days in order to detect the slower growing strains too, and Petri plates replicates were constantly observed at low magnification (4×).A qualitative mycological examination was carried out at IZSUM from collected animal organs or human nasal swabs, as previously described. Samples were direct-plated onto CZA and incubated at 25 ± 1 °C and 37 ± 1 °C in aerobiosis. Colonies were daily observed within 72–96 h.In accordance with the specific monographs, the morphological identification of the isolated aspergilli was carried out through the evaluation of their macroscopic and microscopic features such as growth rate, shape, texture, colour, pigments or exudates of the colonies, micro-morphology of the conidiophores and the conidia, and any other fruiting organs and cellular organelles.They were morphologically analysed according to Klich M. A. , and als®, Valencia, CA, USA) following the initial analysis step with Lysozyme Buffer : the evaluation of the M.I.C.  ensure compliance with CLSI recommendation [A total of 12 strains were subjected to DNA extraction for molecular typing using QIAamp DNA mini kit  were set at 0.0020, 0.025, and 0.050 mg/kg for Aflatoxin B1, Ochratoxin A, and Zearalenone, respectively. After shredding in slurry form, the samples were extracted by MeOH/H2O (80/20 v:v) and purified with Immunoaffinity columns (IAC), which ensured maximum specificity and allowed concentrations to be reached well below the levels set by current EU regulations: Directive 2002/32/EC of the European Parliament and Commission Recommendation (EU) 2016/1319. The instrumental determination was carried out by Ultra High Performance Liquid Chromatography couplet with fluorescence detector (UHPLC-FLUO).The presence of mycotoxins in 21 poultry feed samples collected from the investigated farms was evaluated by IZSUM using an ISO 17025  accreditA descriptive analysis of the obtained information was carried out considering the farms and the types of samples. In addition, the prevalence and the relative 95% confidence interval (95% CI) for each tested farm were calculated.A. fumigatus ones).The antifungal susceptibility of the isolated aspergilli from the animals and the environment as well as the possible presence of mycotoxins in the feed samples examined were evaluated , 38 animal samples, 46 feed samples, and 81 human samples .Aspergillus spp.: in particular, 26 (5%), 5 (0.9%), and 3 (0.5%) of them were identified as members of A. fumigatus complex, A. flavus complex, and black aspergilli (A. niger complex), respectively.Fungal growth was recorded in 298 out of the 559 total samples 53%, . As specA. fumigatus complex grown velvety onto CZA appeared green to blue to greyish in colour and edged in white, with a cream-colored reverse , 5 A. flavus complex strains, and 3 A. niger complex strains. The consensus sequences obtained showed significant similarity with those registered in the Westerdijk Fungal Biodiversity Institute database for A. fumigatus, A. flavus, and A. niger , 5-fluorocytosine , and anidulafungin, micafungin, and caspofungin .The results of the antifungal susceptibility testing are shown in 1, Ochratoxin A and Zearalenone) was carried out on 21 out of 46 feed samples, and 5 of them, all collected at the rural farm using self-produced feed, presented mycotoxins at concentrations above LOQs. In four of them Aflatoxin B1 was detected while in the other one both Aflatoxin B1 and Zearalenone were found. Although, the concentrations of the mycotoxins  were below the limits established by current EU legislation the presence of these molecules  is of high concern.The investigation on mycotoxins , with a high percentage if compared with the total of fungi observed (54%). This evidence agree with data emerged from other studies carried out in some European countries [A. fumigatus, 5 A. flavus, and 3 A. niger has been sequenced from environmental, feed, animal, and human samples with significant similarity to the sequences deposited in the specific database. The importance of these three species was given according to the literature data about respiratory fungal diseases in humans and animals [Fungal species are widespread in the avian livestock investigated (53%). In particular, the genus ountries ,22. Combnalysed 2%, with a animals .Aspergillus spp. in a total of 72 collected ones. Despite the small amount of the investigated farms, the high prevalence of fungal growth, approximately 50% in the “C” intensive farm, encourages similar studies.In seven investigated farms the prevalence of aspergilli ranging from 19% to 43%; only in the remaining one no aspergilli were isolated, even if this intensive farm was the less sampled . The only rural farm showed a prevalence of 28%, with 20 positive samples for Aspergilli. Storage in silos can prevent the mycotoxins production as long as biosafety guidelines will be respected. Mycotoxins can spread as free air-borne particles or through spores as vectors, thus becoming inhalable for animals and workers with serious health implications [In the present survey, the rural poultry farm used a self-produced feed, stored on the floor of a room adjacent to the stables where the poultry were raised, whereas in the intensive farms the commercial feed was stored in silos. Feed storage in an environment without monitoring in temperature, humidity, ventilation, or the presence of fungal spores can easily allow its contamination by molds, including mycotoxin-producing ications . The mycAspergillus spp. and 6/18 (33%) as A. fumigatus  and A. flavus . These fungi were found in the upper respiratory tract, but no cases of deep mycoses were reported. Despite this, all the strains subjected to antifungal susceptibility showed high percentages of resistance to common antifungals, especially fluconazole (100%) [In a total of 81 human nasal swabs, 20 25%) showed fungal growth, 18/20 (90%) has been identified as % showed e (100%) . PeriodiFinally, further studies are necessary including more farms with different management  to improve the monitoring of fungi and correlate the isolated strains with those of human origin, especially considering the resistance to common antifungal molecules.Aspergillus species (particularly belonging to sections Nigri and Flavi) are also highly used for enzyme production, food fermentations, biotechnology, and production of pharmaceuticals [Many euticals . In indu


Picrorhizae Rhizoma (PR) extract based on network pharmacology and molecular docking. The potential chemicals of PR were screened through the Traditional Chinese Medicine Systems Pharmacology (TCMSP) database and relevant literatures. Corresponding targets of active ingredients were found with the help of the UniProtKB database, and therapeutic targets for cancer action were screened with the help of the GeneCards database. We used Cytoscape software to construct the compound-target-pathway network of PR extract. We utilized the STRING database to obtain the protein-protein interaction (PPI) network. We used DAVID database combining Gene Ontology (GO) analysis and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis. Finally, molecular docking was employed for initial efficacy checking. We have identified 16 potential active components of PR through screening, involving 112 disease action targets. Utilizing the GeneCards database, 112 intersecting targets between PR extract and cancer were found, which mainly exerts anticancer effects by regulating tumor necrosis factor (TNF), recombinant caspase 3 (CASP3), c-Jun NH2-terminal kinase (JNK)/JUN, epidermal growth factor receptor (EGFR), and estrogen receptor-1 (ESR1) with some other target genes and pathways associated with cancer. The major anticancer species are prostate cancer, colorectal cancer, small cell lung cancer, etc. In the molecular docking study, herbactin had a strong affinity for TNF. Based on network pharmacology and molecular docking studies, PR and their compounds have demonstrated potential anticancer activities against several key targets. Our preliminary findings provide a strong foundation for further experiments with PR constituents.This study sought to explore the anticancer mechanism of  Picrorhizae Rhizoma (PR) is a perennial herb in the Scrophulariaceae family with a similar name to Rhizoma Coptidis (RC), and both are products of cold clearing heat and dampness, improving the removal of gastrointestinal dampness and treating dampness and dampness, which are the same herbal medicines for dampness and laxity and dysentery, distributed in Sichuan, Yunnan, Tibet, and Himalayas, with main birth in India. PR is mainly effective in clearing heat, etc. Modern pharmacology has shown that PR has antidiabetic [diabetic , blood gdiabetic , hepatopdiabetic , 4, protdiabetic , protectdiabetic , 7, and Simultaneously, PR extract has been found to have potential against a wide range of tumors and cancers such as renal cancer , esophagIn this study, the methods of network pharmacology and molecular docking were applied to predict the multitarget multipathway synergy of PR extract against cancer. Technically, the synergistic effects with multicomponents may target multipathways and multitargets as most of traditional Chinese medicine has been reported previously. And that artificial intelligence-based platforms such as network pharmacology and molecular docking offer new perspectives for studying and applying TCM in mainstream medicine within a limited amount of time and resources. This study comprehensively and systematically reveals their mechanism of action, which is of great significance for the development and utilization of anticancer efficacy of PR, and provides reference for basic and clinical cancer research. The study step flow diagram is presented in As per the hypothesis and objective of the study, we have used several bioinformatics software, tools, and reference databases during analyses .The active components of PR were identified from the Traditional Chinese Medicine Systems Pharmacology (TCMSP) database. The screening conditions were OB  ≥ 30% and DL (similarity of patent medicine) ≥ 0.18. After screening combined with literature mining, the reported active ingredients were collected for supplementation.TCMSP input into PR was used to search and curate compounds action targets. The targets of action of the active ingredient were imported into the UniProtKB database into corresponding gene names, and the human gene (“Homo sapiens”) was screened. If no information can be found in UniProtKB, use PubChem database to check the simplified molecular-input line-entry system (SMILES) number to Swiss Target Prediction database to predict the possible target information. Further, targets with a likelihood greater than 0.1 were filtered and duplicates were removed.Find keywords “cancer,” “neoplasm,” and “tumor” from the GeneCards database. Delete duplicate genes. The active components and disease targets of drugs were matched. Further, Venny (version 2.1) software was used to draw a Venn diagram to determine the potential anticancer targets according to active ingredients of PR.The obtained common anticancer targets were imported into STRING database in the form of gene symbols, the interactions between proteins were analyzed, and the protein-protein interaction (PPI) network diagram of PR extract core targets for the treatment of cancer was obtained. The species was selected as “Homo sapiens,” and PPI with a minimum interaction value (“minimum required interaction score”) > 0.4 were selected. Hide free dots, download PPI graphics, and save as “tsv.” format.Then, the Cytoscape software (version 3.8.2) was used to construct a network map of drug and disease targets to show the relationship between PR extract and various cancer targets, to explore the mechanism of the anticancer effect of PR extract.P values. Screening GOTERM_CC_DIRECT, GOTERM_BP_DIRECT, and GOTERM_MF_DIRECT, the top 15 for each of direct are summarized into a new table. KEGG pathway selects the top 20 data, all ordered in the order sample group, gene ratio, Q value, count, and description, where description is equivalent to term and Q value is equivalent to FDR. And output the results as a bubble plot in the ImageGP online sketch drawing software.The GO functional enrichment analysis was performed to further analyze the roles of target proteins of TCM compounds in gene function with a rough understanding of their differential gene enrichment. Then, KEGG pathway enrichment analysis was performed to know the genes and their pathway, which help to understand the significantly changed metabolic pathways under the experimental conditions. Active ingredient corresponding targets and cancer-related common targets were entered into the DAVID database. GO enrichment analysis of target genes and KEGG pathway enrichment analysis were performed. Data were downloaded and ranked from small to large based on the corrected The 3D chemical structure of PR extract was downloaded from PubChem. The crystal structures of target proteins were obtained from the Protein Data Bank. The key active ingredients and core targets after screening were subjected to molecular docking validation. The protein receptor was optimized by PyMOL software to remove the attached ligands, heteroatoms, and water molecules before docking , 15. ThePicrorhizae Rhizoma” compounds were retrieved, and 55 effective compounds were identified. A total of 10 active ingredients were screened based on OB ≥ 30% and DL ≥ 0.18. Six reported active ingredients were collected in combination with literature mining [Through TCMSP, “e mining . A totalThrough TCMSP data platform, UniProtKB database, and PubChem database, a total of 203 targets were collected from the 16 active ingredients of PR. After screening of human genes (“Homo sapiens”), there were 183 targets. The repeated targets in each compound were removed, and the gene names of 112 related targets were obtained.By using the GeneCards database, 29162 cancer genes  S1 were P value is less than 1.0e − 16. Among them, nodes represent proteins, and each edge indicates a protein-protein interaction relationship. The greater the number of lines, the stronger the association  items, 69 cellular component (CC) items, and 101 molecular function (MF) items. The top 15 items of each component were imported into ImageGP for visualization  signaling pathways. As shown in The role of PR extract in treatment was further verified by molecular docking technology and further verified the results of network pharmacology. A total of 30 key targets were screened using PPI networking and analyzed by Cytoscape. The average shortest path, intermediate number, and degree of freedom in the network are calculated. TNF, CASP3, JUN, EGFR, ESR1, and HSP90AA1 which are the top six proteins with a large intermediate number, large degree value, and small average shortest paths were chosen for molecular docking with the screened sixteen active components. Recorded docking scores indicated that all candidates displayed docking scores between 0.11 and -6.51 kcal/mol. According to AutoDock software, 0.11 kcal/mol displayed candidates have the lowest activity, where -6.51 kcal/mol displayed candidates which have the highest affinity for the specific target enzyme. When the binding energy of ligand and receptor is less than 0, it indicates that it can bind spontaneously. Then, select the best compound from each target and visualize it, as shown in β-Sitosterol can form hydrogen bonds with the amino acids of EGFR (MET-795), and HSP90AA1 (SER-72) residues combine to form hydrogen bonds. These interactions allow proteins to form stable compounds with compounds. The results suggest that the active ingredient herbacetin can form hydrogen bonds with the amino acid residues of TNF . (5S)-5,9-Dihydroxy-4-(4-hydroxyphenyl)-5,6-dihydro-1-benzoxo can form hydrogen bonds with the amino acid residues of CASP3 . Hederagenin can form hydrogen bonds with the amino acid residues of JUN (GLU-293), and ESR1 (LYS-416) and can bind well with the corresponding target proteins. β-sitosterol, hederagenin, picroside IV, scrophuloside A_QT, herbacetin, and other 16 anticancer active ingredients were confirmed. Among them, herbacetin belongs to flavonoids, which are widely distributed and have a variety of biological activities. It can induce apoptosis of HepG2 cells and play an anticancer role. Hederagenin belongs to triterpenoids, which have a wide range of physiological activities. Pharmacological properties have been shown to be anti-inflammatory and hepatoprotective from antitumor aspects. Hederagenin can inhibit gastric, cervical, and colon cancer cells [β-Sitosterol belongs to tetracyclic triterpenes and is a natural small molecule with antitumor effects. Scrophuloside A is a phenolic glycoside, and phenolic glycosides can also prevent tumors. Picroside I, picroside IV, picroside III, picroside II, catalpol, 6-feruloylcatalpol, and aucubin all belong to iridoids, which are widely distributed in traditional Chinese medicine.In this study, the method of network pharmacology was used to explore the complex network of multicomponent, multitarget, and multichannel anticancer potency of PR extract. First, several compound target databases and disease target databases were searched; 16 main active components and 112 anticancer and antitumor targets of PR extract were identified. Based on the network pharmacology method, picroside I, er cells –19. β-SiThirty key targets such as TNF, EGFR, CASP3, and ESR1 were identified. The pathways in the cancer signal pathway are closely related to the anticancer effect of PR extract. The binding activity was simulated based on molecular docking, and the results showed that all of them had binding activity. Currently, molecular docking has been widely used by academicians, drug developers, and pharmaceutical companies to assess the potency of compounds against target enzymes associated with diseases or disorders with minimal resources and time , 21. Nevβ-sitosterol, hederagenin, scrophuloside A_QT, picroside IV, and herbacetin have the highest correlation with the target pathway. These ingredients can play multiple roles in the human body to achieve the effect of disease prevention and treatment. Through the visualization of PPI protein network analysis and Cytoscape software, we can see that the key targets of PR extract on cancer are TNF, CASP3, JUN, EGFR, ESR1, HSP90AA1, PPARG, PTGS2, MTOR, etc. TNF is a tumor necrosis factor, which is a cytokine that can directly kill tumor cells, but has no obvious toxic effect on normal cells. It is also one of the most potent bioactive factors to kill tumors. It is produced by activated macrophages, NK cells, and T lymphocytes and can inhibit osteoblasts and stimulate osteoclasts. It can be used as a cytokine for tumor biotherapy [It is interconnected with many disease targets in the anticancer and antitumor target network of active components of PR. It can be seen from this that picroside I, otherapy . TNF is otherapy , 23. CASotherapy . Similarotherapy . Loss ofotherapy –28. ESR1otherapy , 30. HSPotherapy –36. It notherapy . PPARG iotherapy –41. PTGSotherapy –45. MTORotherapy  is a tarThrough GO enrichment analysis, it is known that the anticancer effect of PR of extract is related to the association of cytoplasmic membrane and enzymes. The cytoplasmic membrane is an extremely thin layer of membrane that surrounds the cell surface, mainly composed of membrane lipids and membrane proteins. The basic role of the cytoplasmic membrane is to maintain the relative stability of the intracellular microenvironment. It also participates in the external environment for the exchange of materials, energy, and information and overall plays an active role in both the survival and differentiation of cells. Of the 112 targets that we screened, 68 all had effects on the cytoplasmic membrane. Of the top 30 targets in degree value, 20 all had an effect on the cytoplasmic membrane.Δ32 deletion and human cytomegalovirus infection with colorectal cancer in Tunisia [According to KEGG pathway analysis, 27 target genes are associated with cancer pathways contributing to the development and proliferation of metastatic cancer. Of these, 11 target genes are associated with colorectal cancer, 10 target genes with prostate cancer, and 10 target genes with small cell lung cancer. Through literature, it is known that estrogen plays a role in liver and breast cancer. Estrogen protects against liver cancer through genomic pathways, rapid transduction pathways, noncoding RNAs, tumor microenvironment, estrogen metabolites, and inhibition of hepatitis infection and replication . The exp Tunisia . Kaposi  Tunisia , relieve Tunisia , inhibit Tunisia , suppres Tunisia , promote Tunisia , and pro Tunisia . In addiβ-sitosterol has strong binding force with EGFR and HSP90AA1. Overall, flavonoid herbacetin exhibited the highest binding or docking score against TNF . Analyzing the interaction mode between proteins and ligands, it can be concluded that the extracts of PR can bind well to these selected targets and obtain lower binding energy mainly by forming multiple hydrogen bonds. In addition, molecular docking models provide evidence for how these compounds act on targets to inhibit cancer. It is preliminarily confirmed that many effective components of PR play a therapeutic role on cancer through key targets.Based on molecular docking scores, herbacetin, (5S)-5,9-dihydroxy-4-(4-hydroxyphenyl)-5,6-dihydro-1-benzoxocin-2-one, picroside I_qt, and hederagenin comparatively exhibited strong binding affinity against TNF, and In this study, the therapeutic effects of PR extract on cancer and tumor were preliminarily analyzed by means of network pharmacology and molecular docking. The potential anticancer and antitumor targets, related signal pathways, and biological processes of PR extract were predicted. It is revealed that the anticancer and antitumor effects of PR are the result of the joint action of multiple components, multiple targets, and multiple pathways. Network pharmacology of traditional Chinese medicine is the development and integration of ancient Chinese medicine and modern medicine in the interdisciplinary fields of network, pharmacology, biology, and computer. In network visualization, the main active components, anticancer and antitumor targets, and pathways of PR extract can be deduced from a large array of data integrations and calculations, which provides a theoretical basis for anticancer and antitumor research. This study provides a theoretical basis for the anticancer and antitumor mechanism of PR extract and its future experimental verification, in order to serve as a reference for later drug development and clinical application.


The new coronavirus disease, in which 100,000 of people are infected in the world, appears in tables ranging from asymptomatic course to severe acute respiratory distress syndrome. Extracorporeal membrane oxygenation (ECMO) is one of the salvage treatments applied in intubated patients due to high mortality. However, since ECMO treatment is a complicated treatment, the gain loss rate should be determined well. We aimed to share two cases that we applied ECMO treatment in our clinic. Although we could not achieve a successful result, we believe that new experiences should be shared in order to better understand the place of ECMO in coronavirus disease 2019 treatment. The new coronavirus disease 2019 (COVID-19) has become a pandemic that has deeply affected the world. Although most of the COVID-19 cases are asymptomatic or have mild symptoms, some of the cases show acute respiratory distress syndrome (ARDS) symptoms, and some require mechanical ventilation (MV). Mortality in patients with MV needs remains high despite all treatments [Case 1 – A 76-year-old female patient was presented with only controlled hypertension disease. She had the symptoms of fever and cough. Due to the appearance of bilateral ground glass in her computed tomography (CT) scan, viral pneumonia was suspected and hydroxychloroquine sulfate, azithromycin, and oseltamivir were planned for 5 days. The first polymerase chain reaction (PCR) test was evaluated as SARS-CoV-2 positive. On the 2nd day of the treatment, the patient’s condition worsened, and she was admitted into our intensive care unit, and high dose of vitamin C, immune plasma, and tocilizumab  were added to the treatment. She was advised to lie in a prone position. On the 4th day of hospitalization, she had deep hypoxia and the patient was intubated under elective conditions. Venovenous ECMO was planned for the patient, as the condition severe ARDS did not improve due to viral pneumonia despite all treatments with P/F ratio below 100 [th day of ECMO treatment.elow 100 . ContinuCase 2 – A 48-year-old male patient was admitted with the symptoms of fever and cough. Due to the appearance of bilateral ground glass on CT, viral pneumonia was suspected and hydroxychloroquine, oseltamivir oral for 5 days was planned. Bone marrow biopsy test was done due to a suspected malignancy with white blood cell count of 74X103/µL. The first PCR test was negative, but the second test, which was taken after 48 h, was positive. However, during the follow-up period, the patient, whose oxygen saturation was 83% despite 5L/min through mask, was referred to our intensive care unit. The patient had increased respiratory difficulty and was taken under the support of MV. Rocuronium and demizolam infusion was initiated, and treatment with favipiravir, immunoglobulin, and imatinib was started for the patient whose biopsy was evaluated as chronic myeloid leukemia (CML). Venovenous ECMO treatment was planned on the 9th day of intubation [th day of ECMO, the patient developed sudden hypotension, metabolic acidosis, and P/F rate quickly dropped below 100. Laboratory results and images are shown in Despite treatments such as antiviral drugs, steroids, antibody drugs, lung protective strategies, and prone position, patients who are intubated for COVID-19 have a high mortality rate. For this reason, salvage therapies come to mind for patients with severe ARDS as ECMO, but the treatment is expensive and complicated. For these reasons, it is necessary to be selective about the indication. ECMO indications are respiratory insufficiency, P/F ratio below 100, MV time of <7 days, and age below 65 years . Some ofTaniguchi et al.  shared tIn the analysis of 32 ECMO cases shared by Jacobs et al. , 17 patiAlthough the success of ECMO is not as promising as in H1N1, more clinical experience is needed to clarify its role in the treatment of SARS-CoV-2-related ARDS. It can be preferred as a salvage treatment method for patients, considering the gain-loss ratio when appropriate.