Sepsis management demands early diagnosis and timely treatment that includes source control, antimicrobial therapy, and resuscitation. Currently employed diagnostic tools are ill-equipped to rapidly diagnose sepsis and isolate the offending pathogen, which limits the ability to offer targeted and lowest-toxicity treatment. Cutting edge diagnostics and therapeutics in development may improve time to diagnosis and address two broad management principles: (1) source control by removing the molecular infectious stimulus of sepsis, and (2) attenuation of the pathological immune response allowing the body to heal. This review addresses novel diagnostics and therapeutics and their role in the management of sepsis.

Syndrome of Inappropriate Secretion of Antidiuretic Hormone (SIADH) is one of the most common causes of hyponatremia in hospitalized patients. The distinct aetiologies and co-morbidities associated with hyponatremia pose substantial challenges in identifying and managing this disorder. Several infectious causes of SIADH are reported but hyponatremia associated with SIADH and influenza virus infection is less commonly seen. We present a case of hyponatremia associated with influenza, which was subsequently diagnosed as SIADH. CAsE REPORtA 75-year-old paraplegic male presented to the Emergency Department complaining of non productive cough and chest pain for one day. Chest pain was generalized, moderate in intensity and exacerbated by cough. No additional symptoms were reported. He did not take any medications and denied smoking, alcohol consumption or drugs. He was paraplegic due to a gunshot wound injury at lumbar region of the back several years ago. He was afebrile, had a blood pressure of 107/69 mmHg, heart rate of 87 beats per minute and respiratory rate of 18 breaths per minute with oxygen saturation of 98% on room air. Physical exam was only significant for diminished muscle strength 0/5 in lower extremities bilaterally and absent deep tendon reflexes. Laboratory findings were significant for a white blood cell count of 19,340/µl with a left shift deviation (87.2% neutrophils) and serum sodium (Na) of 130 mEq/l. Baseline serum Na was 137 mEq/l noted on prior admission for a urinary tract infection four months ago. Kidney function test was normal. A chest x-ray did not show any infiltrates or masses. Urine legionella antigen test was negative. Electrocardiogram showed no abnormality. Rapid flu test was positive for influenza type A. Cultures of urine, sputum and blood were negative for any microbial pathogen. He was started on oseltamivir 75 mg twice daily and fluid restriction was recommended for hyponatremia. Urine work up was significant for a high urine osmolarity of 631 mOsm/kg, low serum osmolality of 261 mOsm/kg with normal urine electrolytes including urinary sodium 46mEq/l. Thyroid stimulating hormone and morning cortisol levels were normal. Chest and brain computed tomography scans were unremarkable. Since all workup for pulmonary and central nervous system disorders remained negative, the patient was diagnosed as having SIADH due to underlying Influenza A virus infection. Patient was followed up after three weeks in the clinic. Leukocytosis was resolved and repeat sodium levels were found to be normal.

Study Objective According to the National Health and Nutrition Examination Survey (NHANES) data from 2003-2006 the prevalence of folic acid deficiency in the United States has decreased from 16% to 0.5% since the dietary folic acid fortification program started in the late 1990s. Routine testing for folic acid deficiency remains quite common in the workup of anemia, dementia, alcoholism and other high risk populations. The objective for this study were to determine the prevalence of folic acid deficiency in order to analyze whether routine testing for deficiency should be discouraged or targeted to specific patient populations. In addition to this, we want to assess the economic burden that folic acid level testing adds to the high cost of care of our health system. Methods Cross sectional chart review of all adults tested for folic acid level from March 2014 to March 2015 from the Hospital and Ambulatory Care Center of the Community Hospital was undertaken. Folic acid deficiency was defined as ≤4ng/dl. Folic acid level were further classified as low (≤10ng/dl ), intermediate (10-20ng/dl) and high (>20ng/dl). Age, race, body mass index, hemoglobin, mean corpuscular volume levels and billing details were recorded of all patients and information was also collected regarding known conditions correlated to the folic acid levels including Vitamin B12 deficiency( <300 ng/dl), dementia, alcoholism, pregnancy malabsorption, sickle cell disease, bariatric surgery, inflammatory bowel syndrome, and drug therapy with HAART (Highly Active Anti-Retroviral Therapy) , TMP-SMX(Trimethoprim/sulfamethoxazole), phenytoin, valproic acid and/or methotrexate (Table 1). Statistical testing using t-test, logistic / linear regressions with α level at 0.05 was used for analysis of data. Results A total of 957 charts of patients who were tested for folic acid between March 2014 to March 2015 at our Heath- Care System were reviewed. 413 (43%) patients were male and 544 (57%) were female. There were 394 (41 %) Hispanics, 325 (34%) African American, 202 (21%) Caucasian and 36 (4%) were from other ethnicity. The mean age was 59.7 years and a mean Hb was 11. 6 g/ dl. Mean folic acid level was 14.5 ng/dl. 16 patients from total of 957 (2 %) had folic acid deficiency with value ≤4ng/dl . Additional results from the study are described in Table 1, Table 2 and Table 3. Conclusion The prevalence of folic acid deficiency was 2%, About 33,000 dollars per year were used to identify such a low prevalent disease which can be treated at a low cost (2 cents/day) by oral supplementation. Low levels of folic acid were statistically associated with male sex, African American race, dementia and coexistence of vitamin B12 deficiency. Empiric supplementation of folic acid and possibly limiting testing for folic acid level to this group of patients may represent a more cost effective strategy. Disclosures No relevant conflicts of interest to declare.

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Background: As the severe acute respiratory syndrome coronavirus 2 demonstrates greater sickness in people with obesity, extracorporeal membrane oxygenation rescue is increasingly being used in this patient population. An appropriate body mass index threshold where the use of extracorporeal membrane oxygenation for this viral syndrome would not be a useful therapy remains unknown and matter of ongoing debate. Case: We describe a case of acute respiratory distress syndrome secondary to coronavirus disease 2019 infection in setting of super morbid obesity (body mass index 73.9 kg/m2) with the successful use of extracorporeal membrane oxygenation. To our knowledge, this is the heaviest patient to survive coronavirus disease 2019 with venovenous extracorporeal membrane oxygenation so far. Conclusions: While extracorporeal membrane oxygenation in obese patients must be carefully considered in coronavirus disease 2019 acute respiratory distress syndrome, a multidisciplinary care team effort is a requisite for a successful outcome in case like ours.