Cutaneous fungal infections in the elderly

Prevalence of Large Fiber Neuropathy in Nondiabetic Older Adults Seeking Routine Foot Care

BACKGROUND

Older adults qualifying for routine foot care (RFC) under the Medicare program are often diagnosed with diabetes, peripheral artery disease (PAD), or neuropathy. Specifically, large fiber neuropathy (LFN) has been shown to increase during the aging process, rendering patients more susceptible to unperceived trauma because of loss of protective sensation and an increased fall risk because of balance deficits. This study assessed the prevalence of LFN as diagnosed by the timed vibration test (TVT) in the nondiabetic segment of the Medicare population seeking RFC. A comparison was made between this group and those patients identified with PAD.

METHODS

A retrospective electronic medical record review of Medicare patients seeking RFC (Current Procedural Terminology codes 11720, 11721, and 11055) was conducted in a community health center-based podiatry clinic over a 5-year period. The prevalence of LFN as diagnosed by the TVT (International Statistical Classification of Diseases, Tenth Revision code G62.9 and TVT ≤4 sec at the hallux) and PAD as diagnosed per Medicare class findings for vascular impairment (International Statistical Classification of Diseases, Tenth Revision codes I70.203 and I73.9) was identified in nondiabetic Medicare patients seeking RFC.

RESULTS

The prevalence of LFN and PAD within the nondiabetic Medicare population seeking RFC was found to be 21.1% (91 of 431) and 27.6% (119 of 431), respectively. There was a 6.5% difference between the proportions of the LFN and PAD groups, which was significantly different (P = .026, confidence interval = 0.77-12.2%). A total of 10.9% of the population was found to have LFN and PAD concurrently. There was no significant difference between the ages of patients in the LFN and PAD groups (P = .36, standard deviation [SD] = 1.65), the LFN and LFN/PAD groups (P = .3, SD = 1.95), or the PAD and LFN/PAD groups (P = .07, SD = 1.95).

CONCLUSIONS

LFN and PAD are both present in substantial proportions in nondiabetic Medicare patients seeking RFC. The prevalence of LFN in this at-risk population highlights the importance of accurate diagnosis and implementation of preventative measures designed to mitigate unperceived foot trauma and potential falls. This is especially relevant, as neuropathy in geriatric patients has been associated with earlier mortality.

Cutaneous Fungal Infections in Older Adults

The population of older adults continues to increase in the United States, leading to a concomitant increase in cutaneous disease. Fungal disease, specifically, commonly affects this population but often goes undiagnosed for too long. It is therefore important that providers be aware of common fungal pathogens, recognizable symptoms of disease, and treatment options. This article discusses 3 groups of pathogens: dermatophytes, Candida species, and Pityrosporum species, all of which cause a host of conditions that can be debilitating for older adults.

Demographic and Socioeconomic Factors Associated with Fungal Infection Risk, United States, 2019

Diagnosis disproportionately affected minority and low-income populations, underscoring the need for broad public health interventions.

Fungal infections cause substantial rates of illness and death. Interest in the association between demographic factors and fungal infections is increasing. We analyzed 2019 US hospital discharge data to assess factors associated with fungal infection diagnosis, including race and ethnicity and socioeconomic status. We found male patients were 1.5–3.5 times more likely to have invasive fungal infections diagnosed than were female patients. Compared with hospitalizations of non-Hispanic White patients, Black, Hispanic, and Native American patients had 1.4–5.9 times the rates of cryptococcosis, pneumocystosis, and coccidioidomycosis. Hospitalizations associated with lower-income areas had increased rates of all fungal infections, except aspergillosis. Compared with younger patients, fungal infection diagnosis rates, particularly for candidiasis, were elevated among persons > 65 years of age. Our findings suggest that differences in fungal infection diagnostic rates are associated with demographic and socioeconomic factors and highlight an ongoing need for increased physician evaluation of risk for fungal infections.

Tinea Pedis in Underrepresented Groups: An All of Us Database Analysis

BACKGROUND

Tinea pedis is the most common form of dermatophytosis resulting in interdigital infections. All of Us (AoU) is a National Institute of Health initiative with an emphasis on patient populations traditionally underrepresented in biomedical research.

OBJECTIVES

Our objective was to evaluate the burden of tinea pedis in underrepresented groups in the United States, utilizing the novel AoU research program.

METHODS

We analyzed AoU Registered Tier dataset version 5, which includes data collected between May 30, 2017 and April 1, 2021. We conducted a cross-sectional analysis linking survey and electronic health record (EHR) data to estimate the prevalence of tinea pedis in underrepresented groups.

RESULTS

AoU data release includes 329,038 participants. Of these, 251,597 (76.5%) had electronic health record data and 6,932 had tinea pedis (overall prevalence, 2.76%; 95% CI, 2.69-2.82). Multivariate analyses revealed that, compared with White participants, Black and Hispanic participants had a higher adjusted odds of tinea pedis (OR, 1.29; 95% CI, 1.20-1.38 and OR, 1.38; 95% CI, 1.28-1.48, respectively). Higher adjusted odds of tinea pedis were observed in underrepresented groups defined by: age >=75 years (OR, 1.45; 95% CI, 1.33-1.57), LGBTQ status (OR, 1.17; 95% CI, 1.09-1.27), less than a high school education (OR, 1.22; 95% CI, 1.11-1.34), income <$35 000 (OR, 1.09; 95% CI, 1.02-1.16), and physical disability (OR, 1.56; 95% CI, 1.08-1.24).

CONCLUSIONS

Our findings are consistent with overall age, and gender-specific prevalence estimates from prior epidemiologic studies, validating the scientific consistency of the new AoU database. Additionally, there may be an increased burden of tinea pedis among Black and Hispanic individuals.

Recurrent candidal intertrigo: challenges and solutions

Intertrigo is a common inflammatory dermatosis of opposing skin surfaces that can be caused by a variety of infectious agents, most notably candida, under the effect of mechanical and environmental factors. Symptoms such as pain and itching significantly decrease quality of life, leading to high morbidity. A multitude of predisposing factors, particularly obesity, diabetes mellitus, and immunosuppressive conditions facilitate both the occurrence and recurrence of the disease. The diagnosis of candidal intertrigo is usually based on clinical appearance. However, a range of laboratory studies from simple tests to advanced methods can be carried out to confirm the diagnosis. Such tests are especially useful in treatment-resistant or recurrent cases for establishing a differential diagnosis. The first and key step of management is identification and correction of predisposing factors. Patients should be encouraged to lose weight, followed up properly after endocrinologic treatment and intestinal colonization or periorificial infections should be medically managed, especially in recurrent and resistant cases. Medical treatment of candidal intertrigo usually requires topical administration of nystatin and azole group antifungals. In this context, it is also possible to use magistral remedies safely and effectively. In case of predisposing immunosuppressive conditions or generalized infections, novel systemic agents with higher potency may be required.

Using a polymerase chain reaction as a complementary test to improve the detection of dermatophyte fungus in nails

BACKGROUND

Dermatomycoses are a group of pathologic abnormalities frequently seen in clinical practice, and their prevalence has increased in recent decades. Diagnostic confirmation of mycotic infection in nails is essential because there are several pathologic conditions with similar clinical manifestations. The classical method for confirming the presence of fungus in nail is microbiological culture and the identification of morphological structures by microscopy.

METHODS

We devised a nested polymerase chain reaction (PCR) that amplifies specific DNA sequences of dermatophyte fungus that is notably faster than the 3 to 4 weeks that the traditional procedure takes. We compared this new technique and the conventional plate culture method in 225 nail samples. The results were subjected to statistical analysis.

RESULTS

We found concordance in 78.2% of the samples analyzed by the two methods and increased sensitivity when simultaneously using the two methods to analyze clinical samples. Now we can confirm the presence of dermatophyte fungus in most of the positive samples in just 24 hours, and we have to wait for the result of culture only in negative PCR cases.

CONCLUSIONS

Although this PCR cannot, at present, substitute for the traditional culture method in the detection of dermatophyte infection of the nails, it can be used as a complementary technique because its main advantage lies in the significant reduction of time used for diagnosis, in addition to higher sensitivity.

Cutaneous fungal infections in the elderly

This article summarizes the common, superficial, cutaneous, fungal infections that are found in older adults. The epidemiology, classic appearance, and current treatments of these fungal infections are discussed. These common skin pathogens occur in many older adults.

Cutaneous fungal infections in the United States: Analysis of the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS), 1995-2004

BACKGROUND

Dermatophyte infections lead to high costs and differentially affect certain groups. Previous population studies have been limited in size, duration, and representativeness.

METHODS

Using the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (1995-2004), a cross-sectional analysis of ambulatory visits in the USA was performed. Outpatients presenting with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)-coded diagnoses of tinea unguium, tinea corporis/manuum, tinea pedis, tinea capitis, and tinea cruris were identified. Trends, descriptive epidemiology, and point prevalence estimates for these conditions were determined using stratification and standardization.

RESULTS

There was an estimated average of 4,124,038 +/- 202,977 annual visits for dermatophytoses during the study period. Tinea unguium, tinea corporis, tinea pedis, tinea capitis, and tinea cruris represented 23.2%, 20.4%, 18.8%, 15.0%, and 8.4%, respectively, of such infections; 71.6% of tinea unguium visits occurred among those older than 45 years. Tinea capitis was significantly more common among the black than the white population (prevalence odds ratio = 12.4; 95% confidence interval, 9.9-15.7). Ineffective treatment of tinea pedis, tinea corporis, and tinea cruris with polyenes, such as nystatin, commonly occurred.

CONCLUSIONS

Improved healthcare provider education is needed to ensure judicious antidermatophyte drug management. Further studies, including proven diagnoses via fungal microscopy and culture, are needed to explain the prevalence discrepancy of tinea capitis among black children and tinea unguium in older adults, focusing on preventable risk factors.

The epidemic of obesity in children and adolescents in the world

The prevalence of obesity has reached alarming levels, affecting virtually both developed and developing countries of all socio-economic groups, irrespective of age, sex or ethnicity. Concerning childhood obesity, it has been estimated that worldwide over 22 million children under the age of 5 are severely overweight, and one in 10 children are overweight. This global average reflects a wide range of prevalence levels, with the prevalence of overweight in Africa and Asia averaging well below 10% and in the Americas and Europe above 20%. The proportion of school-age children affected will almost double by 2010 compared with the most recently available surveys from the late 1990s up to 2003. In the European Union, the number of children who are overweight is expected to rise by 1.3 million children per year, with more than 300,000 of them becoming obese each year without urgent action to counteract the trend. By 2010 it is estimated that 26 million children in E.U. countries will be overweight, including 6.4 million who will be obese. Moreover, in the U.S.A. the prevalence of obesity in adolescents has increased dramatically from 5% to 13% in boys and from 5% to 9% in girls between 1966-70 and 1988-91. In this review paper we present the epidemiology of obesity in children and adolescents, including prevalence rates, trends, and risk factors associated with this phenomenon.

Unequivocal morphological diagnosis of fungi in morphologically abnormal nails

AIMS

To analyse the prevalence of fungi in abnormal nails by morphological diagnosis. Prevalence studies of onychomycoses in temperate climate zones have yielded widely varying rates, possibly reflecting the confounding effects of referral bias, sampling specificity and intrinsic sensitivity of the diagnostic techniques employed.

METHODS AND RESULTS

The method employed to identify fungi in nails entailed primary fixation using a non-formaldehyde-based coagulative fixative (BoonFix; Finetec, Japan) and microwave-enhanced processing to histology, followed by staining the paraffin sections with periodic acid-Schiff, using haematoxylin as a routine counterstain. The results of 990 nail samples were tabled for statistical analysis related to gender, patient age and diabetes mellitus status. In four of the 990 (< 1%) analysed cases the diagnosis was found to be equivocal using the method employed. These cases were jointly reviewed for definitive diagnosis. The overall prevalence of invasive hyphal structures was found to be 606/990 (approximately 61%). The relative risk for fungal infection in morphologically abnormal nails was found to be higher for persons < 20 years old or diabetic patients aged > or = 71 years.

CONCLUSIONS

The 61% positivity rate for fungi found justifies systematic direct submission of samples from abnormal nails for histological confirmation in order to avoid unwarranted treatment.

Un nuevo enfoque sobre la epidemiología de las onicomicosis

Onychomycoses represent a group of nail affections caused by one or more fungi. Whether aging represents a risk factor for developing onychomycosis, remains a question. In the present work, we studied the variations in frequency and prevalence of onychomycoses and non-mycotic onychodystrophies according to age. Our results show that there is an increase in the frequency and prevalence of onychomycoses and non-mycotic onychodystrophies predominantly in patients over forty years of age.

Dimethyl sulfoxide targets phage RNA polymerases to promote transcription

Dimethyl sulfoxide (DMSO) is a "universal" solvent in pharmaceutical sciences and cell biology. DMSO was previously reported to facilitate in vitro transcription of chromatin and supercoiled plasmid, with the underlying mechanism being attributed to the alteration of the template structure. Here, we demonstrated that low concentrations of DMSO significantly increase the phage polymerase-catalyzed RNA synthesis when the naked and short PCR products were used as templates, suggesting that DMSO promotes transcription through additional mechanism(s). Interestingly, SP6 RNA polymerase was more sensitive to the DMSO stimulation than T7 RNA polymerase, suggesting that the polymerase is an important target for DMSO stimulation of RNA synthesis. Consistent with this finding, we also showed that DMSO dramatically elevated the RNA polymerase activity. This elevated activity is explained by altered polymerase structure as reflected by a change in intrinsic fluorescence. Furthermore, DMSO was shown to simultaneously accumulate both the abortive and full-length transcripts, leading us to conclude that the DMSO-altered polymerase structure primarily encodes an enhanced activity at the stage of transcription initiation. DMSO-induced alteration of the polymerase structure and function highlights a potentially generalized mechanism in interpreting the molecular action of this popular solvent.

Dermatofitosis con lesiones concurrentes a distancia. Importancia pronóstica y terapéutica

INTRODUCTION

Recurrence and a lack of treatment response are common in dermatophytosis. In patients with cutaneous and concurrent toenail lesions, often only the former are investigated, which may result in inappropriate treatment due to misdiagnosis.

METHODS

Between January 2000 and April 2004, we prospectively studied the presence of dermatophytic fungi in lesions other than those prompting the consultation to further investigate the diagnosis.

RESULTS

We prospectively identified 61 patients with dermatophytosis and concurrent lesions caused by the same fungus at sites distant from the primary lesion. Concurrent lesions occurred in 15.9% of culture-confirmed dermatophyte infections. Thirty-six patients (59%) consulted for skin lesions located at sites other than that of the primary lesion in the foot. The most frequently identified species was Trichophyton rubrum (50/61, 82%).

CONCLUSIONS

Localization of all the lesions, as well as isolation and identification of the causative fungus, are essential to establish the prognosis and choose the most appropriate antifungal agent, route of administration, and duration of treatment in dermatophytosis.