Vitamin D Levels as a Marker of Severe SARS-CoV-2 Infection

The SARS-CoV-2 virus may cause severe infection, which is associated with diverse clinical manifestations. Vitamin D has immunomodulating properties and may enhance the body's defense system against invading pathogenic organisms. The aim was to assess 25(OH)D3 levels in patients hospitalized for severe infection from the SARS-CoV-2 virus and explore the relationship between 25(OH)D3 and outcomes. In a group of 88 patients hospitalized for severe infection from the SARS-CoV-2 virus and a control group matched for age and sex, the levels of 25(OH)D3 were analyzed. Levels of 25(OH)D3 were 17.36 ± 8.80 ng/mL (mean ± SD) compared with 24.34 ± 10.34 ng/mL in patients with severe SARS-CoV-2 infection and the control group, respectively, p < 0.001 (Student's t-test). 25(OH)D3 levels were significantly related to outcomes, i.e., survival as opposed to non-survival, as more patients with 25(OH)D3 deficiency (0-10 ng/mL) and insufficiency (10-20 ng/mL) had a fatal outcome as compared with those with vitamin D sufficiency (p < 0.001, chi-square test, p < 0.001, Fisher's exact test). Levels of 25(OH)D3 were inversely related to C-reactive protein (CRP), ferritin, d-dimer, and fibrinogen levels (p < 0.001, linear regression analysis, beta coefficient of variation, -0.176, -0.160, -0.178, and -0.158, respectively). Vitamin D deficiency observed in severe SARS-CoV-2 infection was related to disease outcomes.

Interferon gamma-induced protein 10 (IP-10) for the early prognosis of the risk for severe respiratory failure and death in COVID-19 pneumonia

OBJECTIVES

Elevated concentrations of soluble urokinase plasminogen activator receptor (suPAR) predict progression to severe respiratory failure (SRF) or death among patients with COVID-19 pneumonia and guide early anakinra treatment. As suPAR testing may not be routinely available in every health-care setting, alternative biomarkers are needed. We investigated the performance of C-reactive protein (CRP), interferon gamma-induced protein-10 (IP-10) and TNF-related apoptosis-inducing ligand (TRAIL) for predicting SRF or death in COVID-19.

METHODS

Two cohorts were studied; one discovery cohort with 534 patients from the SAVE-MORE clinical trial; and one validation cohort with 364 patients from the SAVE trial including also 145 comparators. CRP, IP-10 and TRAIL were measured by the MeMed Key® platform in order to select the biomarker with the best prognostic performance for the early prediction of progression into SRF or death.

RESULTS

IP-10 had the best prognostic performance: baseline concentrations 2000 pg/ml or higher predicted equally well to suPAR (sensitivity 85.0 %; negative predictive value 96.6 %). Odds ratio for poor outcome among anakinra-treated participants of the SAVE-MORE trial was 0.35 compared to placebo when IP-10 was 2,000 pg/ml or more. IP-10 could divide different strata of severity for SRF/death by day 14 in the validation cohort. Anakinra treatment decreased this risk irrespective the IP-10 concentrations.

CONCLUSIONS

IP-10 concentrations of 2,000 pg/ml or higher are a valid alternative to suPAR for the early prediction of progression into SRF or death the first 14 days from hospital admission for COVID-19 and they may guide anakinra treatment.

TRIAL REGISTRATION

CLINICALTRIALS

gov, NCT04680949 and NCT04357366.

Development and validation of SCOPE score: A clinical score to predict COVID-19 pneumonia progression to severe respiratory failure

Most patients infected with SARS-CoV-2 (COVID-19) experience mild, non-specific symptoms, but many develop severe symptoms associated with an excessive inflammatory response. Elevated plasma concentrations of soluble urokinase plasminogen activator receptor (suPAR) provide early warning of progression to severe respiratory failure (SRF) or death, but access to suPAR testing may be limited. The Severe COvid Prediction Estimate (SCOPE) score, derived from circulating concentrations of C-reactive protein, D- dimers, interleukin-6, and ferritin among patients not receiving non-invasive or invasive mechanical ventilation during the SAVE-MORE study, offers predictive accuracy for progression to SRF or death within 14 days comparable to that of a suPAR concentration of ≥6 ng/mL (area under receiver operator characteristic curve 0.81 for both). The SCOPE score is validated in two similar independent cohorts. A SCOPE score of 6 or more is an alternative to suPAR for predicting progression to SRF or death within 14 days of hospital admission for pneumonia, and it can be used to guide treatment decisions.

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SCOPE score is composed of C-reactive protein, D dimers, ferritin, and interleukin-6

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Values of 6 or more predict 6-fold risk for severe respiratory failure or death

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SCOPE score predicts risk for severe respiratory failure or death comparable to suPAR

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Anakinra treatment when SCOPE is 6 or more provides lower odds of poor outcome

Pulmonary fibrosis and microscopic polyangiitis in a 75-year-old woman

We present a case of a 75-year-old woman who admitted in the internal medicine department for a recent onset of persisting moderate daily fever and fatigue that started 30 days prior to her hospitalization. Her past medical history is remarkable for mild pulmonary fibrosis, megaloblastic anaemia, and hypergammaglobulinaemia of no obvious causes. On presentation, she was febrile (38°C) and had high ESR and CRP levels, but most of her laboratory tests were within normal levels and had no signs of arthritis or rash. She was hospitalized for suspected lower urinary tract infection and started on antibiotics. During hospitalization, her renal function deteriorated together with microscopic haematuria, proteinuria and granular urine casts in urine analysis and her inflammation markers raised further. A renal biopsy revealed glomerulonephritis with pauci-immune crescents, and serology tests were positive for anti-MPO p-ANCA, both suggesting a diagnosis of microscopic polyangiitis (MPA). While high-dose methylprednisolone pulses and cyclophosphamide were introduced intravenously, there was no remission, but respiratory failure occurred that led to patient’s intubation and transfer to the ICU. She died a few days later due to septic shock. Asymptomatic pulmonary fibrosis can precede microscopic polyangiitis for several years and is associated with a poor prognosis.

Report of an atypical case of leishmaniasis presented as acute tonsillitis in an immunocompetent patient

Visceral leishmaniasis typically presents with symptoms such as fever, enlargement of the spleen and the liver, hypergammaglobulinaemia and infection of the bone marrow resulting in anaemia and leukopenia. The disease is sporadic in the countries of the Mediterranean basin. We report an unusual case of acute tonsillitis due to tonsillar leishmaniasis, in an immunocompetent 34-y-old male patient. Diagnosis was confirmed by serological tests and histopathological examination following biopsy of the right tonsil. The patient was successfully treated with liposomal amphotericin-B.

Prevalence of severe pelvic inflammatory disease and endometriotic ovarian cysts: a 7-year retrospective study

INTRODUCTION

The purpose of this study was to delineate the association between endometriosis and pelvic inflammatory disease (PID) and the prevalence of this coexistence.

MATERIALS & METHODS

The records of all patients with endometriotic ovarian cysts treated at the 3rd Department of Obstetrics and Gynecology of the University of Athens and in "Lito" Maternity Hospital of Athens from 2000 through 2007 were reviewed.

RESULTS

During this 7-year period 720 women underwent surgery due to endometriotic ovarian cysts. The average age was 40.9 years (range: 17-70). Median diameter of the cysts was 4.495 cm and 59% were located in the right ovary. PID was identified in 21 (2.9%) cases. The average age of these women was 31 years (range: 21-39). Half of the women presented with fever (10/21; 47.6%). Ultrasound examination was performed in all women, followed by laparoscopy. In 47.6% (10/21) the PID abscess was located in the right ovary and the rest (52.38%) in the left. The mean diameter of the endometriotic cysts in these women was 3.52 cm. Laparoscopy was the treatment of choice in all the women with the exception of five cases, where due to technical difficulties during laparoscopy, a laparotomy was performed. In all the cases with PID, abscesses were evacuated laparoscopically. No operative complications were observed.

CONCLUSIONS

Endometriosis and PID are two conditions that can easily confuse the physician in setting the diagnosis, especially in the situation where they co-exist. In our study we report that the prevalence of PID in women with endometriosis is sufficiently higher than the prevalence in the general population.

Prevalence of acute hemoperitoneum in patients with endometriotic ovarian cysts: a 7-year retrospective study

INTRODUCTION

Endometriosis is a quite common condition in women of reproductive age. The purpose of this study is to delineate the association between hemoperitoneum and endometriosis.

MATERIALS & METHODS

The records of all patients with endometriotic ovarian cysts treated at the 3rd Department of Obstetrics and Gynecology of the University of Athens and at "Lito" Maternity Hospital of Athens from 2000 through 2007 were reviewed.

RESULTS

During this 7-year period 720 women underwent surgery due to endometriotic ovarian cysts. The average age was 40.9 years (range: 17-70). The median diameter of the cysts was 4.49 cm and 59% were located in the right ovary. Hemoperitoneum was identified in 16 (2.22%) of them. The average age of these women was 28.5 years (range: 22-44). Ten (62.5%) of these women presented with acute and strong abdominal pain and moderate signs of cardiovascular shock. The rest presented with abdominal pain and distension worsening at the onset of menses, nausea and/or vomiting and hemorrhagic fluid in the pelvis. Ultrasound examination was performed in all women and afterwards they underwent laparoscopy to identify the source of bleeding. In all cases a ruptured endometriotic cyst was found. In 68.8% (11/16) the ruptured cyst was located in the left ovary and the rest (31.2%) in the right. A thorough examination did not reveal any other sources of bleeding. No operative complications were observed.

DISCUSSION

The simultaneous occurrence of ascites and endometriosis is rare. A physician, though, must always take into consideration endometriosis in the differential diagnosis of ascites and acute abdominal pain or pelvic mass.

Miniplate osteosynthesis for fractures of the edentulous mandible: a clinical study 1989-96

Our 8 years experience of treating fractures of the edentulous mandible by miniplate osteosynthesis, is discussed. Forty patients (31 men and 9 women) aged 37 to 86 years (mean: 64.6 years, SD: +/- 14.07) with 67 fracture sites were treated. The surgical approach was mainly intraoral (37 out of 40 patients) without the use of intermaxillary fixation. The postoperative clinical and radiological findings are reported and discussed. The advantages of the method are of great importance since immediate postoperative opening of the mouth is permitted, as the fractured bones are anatomically stabilized by means of titanium miniplates and screws. Our results were felt to be satisfactory, with a reoperation rate of only 3.9% (two out of 51 operated fracture sites, 16 condylar fractures were treated conservatively). This allows us to propose intraoral miniplate osteosynthesis as a routine method of treatment in cases of edentulous mandibular fractures which are mainly seen in elderly people.

The role of estrogens in mastopathy and mammary cancer in perimenopausal women

Fibrocystic disease of the breast (FCD) is an exaggeration of the normal physiologic response to cyclic estrogen and progesterone stimulation. The disorder can persist, with much less severity, in the menopausal woman. Whether FCD predisposes to mammary cancer remains moot. A new steroidal agent, danazol, can eliminate nodosities in the majority of women with FCD. Thermography may identify women who are at greater risk because of increased heat production. Mammography should be employed in women with persistently abnormal thermograms, even though no suggestive breast masses are palpable. Needle biopsy or surgical biopsy should be undertaken whenever a firm indurated mass is palpated, regardless of negative findings with a thermogram or mammogram. In a series of 1548 women treated for 10,715 women-years, the incidence of breast cancer after prolonged estrogen therapy was not increased. Although estrogens and prolactin have been incriminated in the etiology of mammary cancer, no hard facts exist to confirm such allegations.

Fibrocytic breast disease: current status of diagnosis and treatment

Improved diagnostic procedures and use of a new steroidal agent, danazol (Danocrine), should reduce the need for surgical intervention in fibrocystic breast disease. Thermography, a non-invasive procedure that may be used with impunity, may help identify women at high risk. Mammography, which is useful in revealing malignancy in an early stage, should be done in women with tow consecutive abnormal thermograms. Biopsies should be performed, however, on suspicious, firm, irregular masses, regardless of results on thermography or mammography. Use of danazol may be advantageous not only in ameliorating pain and eliminating nodosities, but also in guiding the surgeon to the nodule that is unresponsive to treatment and therefore should be evaluated by biopsy.