COVID-19 associated mucormycosis: A Descriptive Multisite Study from India

BACKGROUND AND AIMS

Mucormycosis is an invasive fungal infection and carries a significant morbidity and mortality. A number of cases of mucormycosis have been reported in association with COVID-19. In this study, a consortium of clinicians from various parts of India studied clinical profile of COVID-19 associated mucormycosis (CAM) and this analysis is presented here.

METHODS

Investigators from multiple sites in India were involved in this study. Clinical details included the treatment and severity of COVID-19, associated morbidities, as well as the diagnosis, treatment and prognosis of mucormycosis. These data were collected using google spreadsheet at one centre. Descriptive analysis was done.

RESULTS

There were 115 patients with CAM. Importantly, all patients had received corticosteroids. Diabetes was present in 85.2% of patients and 13.9% of patients had newly detected diabetes. The most common site of involvement was rhino-orbital. Mortality occurred in 25 (21.7%) patients. On logistic regression analysis, CT scan-based score for severity of lung involvement was associated with mortality.

CONCLUSION

Universal administration of corticosteroids in our patients is notable. A large majority of patients had diabetes, while mortality was seen in ∼1/5th of patients, lower as compared to recently published data.

Psychological symptoms among healthcare workers handling COVID-19 patients

INTRODUCTION

Healthcare workers serve as the frontliners against the coronavirus 2019 disease (COVID-19) and this puts them most at risk of infection as they attend to numerous patients with unknown status. This study aimed to examine stress, anxiety, and depression among healthcare workers caring for COVID-19 patients in Sarawak General Hospital (SGH), Malaysia.

MATERIALS AND METHODS

This cross-sectional observational study conducted in SGH during the pandemic with an online self-administered questionnaire composed of two parts, the socio-demographic characteristics, and the Depression Anxiety Stress Scale (DASS).

RESULTS

A total of 105 healthcare workers responded to this study. A questionnaire in both Bahasa Melayu and English was used. The findings showed that all healthcare workers had mild anxiety, with the majority experiencing mild stress (57.1%), and almost half of the respondents experiencing mild depression (41%). Female subjects had a significant higher mean score in anxiety level and stress level compared to male subjects (10.0±3.20 vs. 8.6±2.93, p<0.05; 14.1±4.76 vs. 10.7±3.70, p<0.05, respectively). Staff who were transferred from other units to handle COVID-19 cases experienced more psychological symptoms. There were significant correlations between the depression, anxiety and stress levels among the healthcare workers and the number of children they had (r=0.739, p=0.001; r=0.642, p=0.001; r=1, p =0.001 respectively). However, the stress level among the healthcare workers was reversely correlated with their years of working experience (r=-0.199, p=0.042).

CONCLUSION

This study identified some socio-demographic factors associated with increased levels of stress, anxiety and depression among the healthcare workers during pandemic, which may lay ground for future interventions.

Urodynamics in patients with multiple sclerosis: A consensus statement from a urodynamic experts working group

AIMS

Urodynamics (UDS) is often indicated for multiple sclerosis (MS) patients either at presentation to specialized medical centers or after failure of conservative management of lower urinary tract dysfunction (LUTD). However, the ideal moment and context to indicate this exam in this group of patients remain controversial. We aimed to establish a consensus panel to address the role of UDS in MS patients.

METHODS

A panel representing urology, rehabilitation medicine, and neurology skilled in neuro-urology participated in a consensus-forming project using a Delphi method to reach consensus on the role of UDS in MS patients.

RESULTS

In total, five experts participated. All panelists participated in the four phases of the consensus process. Consensus was reached if ≥70% of the experts agreed on recommendations. To facilitate a common understanding among all experts, a face-to-face consensus meeting was held in Florence in September 2017 and then with a follow-up teleconference in March 2018. By the end of the Delphi process, formal consensus was achieved for 100% of the items and an algorithm was then developed in a face-to-face meeting in Philadelphia in August 2018. The final expert opinion recommendations were approved by the unanimous consensus of the panel.

CONCLUSIONS

UDS represents an important diagnostic tool for MS patients and is particularly useful to evaluate the pattern of LUT dysfunction in high-risk patients. There is a lack of high-evidence level studies to support an optimal urodynamic long-term follow-up protocol.

P82 Pelvic neurophysiological and urodynamics findings in patients with sacral-level tarlov cysts

Objectives

Sacral Tarlov cysts (TC) are frequent incidental findings on spinal MRI. Controversy remains regarding their ability to cause nerve root compression. Pelvic neurophysiological and urodynamics testing provides information about sacral nerve root involvement.

Design

Case series

Subjects

Patients with MRI evidence of sacral (S1, 2 or 3) TC seen in the Uro-neurology Department between 2011 and 2018.

Methods

Clinical, neurophysiological and urodynamics data were reviewed.

Results

13 patients (9 females, mean age54/SD13.1) were included. Symptoms were urgency/incontinence (n=8), hesitancy/urinary retention (n=7), bowel complaints (n=4), sexual complaints (n=3), back pain (n=5), genital/pelvic pain (n=6), genital numbness (n=5), impaired sensation of bladder fullness (n=2), lower limb (LL) pain/hypoesthesia (n=6), LL weakness (n=2). The following neurophysiological abnormalities were seen: anal sphincter EMG (n=10) evidence for reinnervation (n=8), pudendal sensory evoked potentials (SEPs) (n=6) absent response (n=1), S2 and S3 dermatomal SEPs (n=6) absent response (n=2), sympathetic skin response (n=6) absent response (n=3). Findings in cystometry (n=5) were: detrusor underactivity (n=2), detrusor after-contraction (n=1), equivocal obstructed voiding (n=1) and reduced bladder compliance (n=1).

Conclusions

Abnormal results in urodynamics and pelvic neurophysiology suggest involvement of the somatic and autonomic sacral innervation. Further studies are required to explore any association between structural changes on MRI and functional changes in urodynamics and neurophysiology.

Lithium in patients with amyotrophic lateral sclerosis (LiCALS): a phase 3 multicentre, randomised, double-blind, placebo-controlled trial

Background

Lithium has neuroprotective effects in cell and animal models of amyotrophic lateral sclerosis (ALS), and a small pilot study in patients with ALS showed a significant effect of lithium on survival. We aimed to assess whether lithium improves survival in patients with ALS.

Methods

The lithium carbonate in amyotrophic lateral sclerosis (LiCALS) trial is a randomised, double-blind, placebo-controlled trial of oral lithium taken daily for 18 months in patients with ALS. Patients aged at least 18 years who had ALS according to the revised El Escorial criteria, had disease duration between 6 and 36 months, and were taking riluzole were recruited from ten centres in the UK. Patients were randomly assigned (1:1) to receive either lithium or matched placebo tablets. Randomisation was via an online system done at the level of the individual by block randomisation with randomly varying block sizes, stratified by study centre and site of disease onset (limb or bulbar). All patients and assessing study personnel were masked to treatment assignment. The primary endpoint was the rate of survival at 18 months and was analysed by intention to treat. This study is registered with Eudract, number 2008-006891-31.

Findings

Between May 26, 2009, and Nov 10, 2011, 243 patients were screened, 214 of whom were randomly assigned to receive lithium (107 patients) or placebo (107 patients). Two patients discontinued treatment and one died before the target therapeutic lithium concentration could be achieved. 63 (59%) of 107 patients in the placebo group and 54 (50%) of 107 patients in the lithium group were alive at 18 months. The survival functions did not differ significantly between groups (Mantel-Cox log-rank χ² on 1 df=1·64; p=0·20). After adjusting for study centre and site of onset using logistic regression, the relative odds of survival at 18 months (lithium vs placebo) was 0·71 (95% CI 0·40–1·24). 56 patients in the placebo group and 61 in the lithium group had at least one serious adverse event.

Interpretation

We found no evidence of benefit of lithium on survival in patients with ALS, but nor were there safety concerns, which had been identified in previous studies with less conventional designs. This finding emphasises the importance of pursuing adequately powered trials with clear endpoints when testing new treatments.

Funding

The Motor Neurone Disease Association of Great Britain and Northern Ireland.

Dysmyelinating neuropathy in benign form of megalencephalic leukoencephalopathy with subcortical cysts: a novel observation from south India

A 37-year-old gentleman presented with macrocephaly since early childhood and progressive impairment of motor and cognitive functions. Magnetic resonance imaging revealed extensive white matter involvement and frontotemporal subcortical cysts. Absent ankle jerk and abnormal nerve conduction study raised a possibility of associated peripheral neuropathy. Sural nerve biopsy was suggestive of dysmyelinating neuropathy. This report serves to expand the clinical spectrum of this rare leukodystrophy.

Diffusion-weighted imaging and proton MR spectroscopy in the characterization of acute disseminated encephalomyelitis

INTRODUCTION

Acute disseminated encephalomyelitis (ADEM) is usually a monophasic illness characterized by multiple lesions involving gray and white matter. Quantitative MR techniques were used to characterize and stage these lesions.

METHODS

Eight patients (seven males and one female; mean age 19 years, range 5 to 36 years) were studied using conventional MRI (T2- and T1-weighted and FLAIR sequences), diffusion-weighted imaging (DWI) and proton magnetic resonance spectroscopy (MRS). Apparent diffusion coefficient (ADC) values and MRS ratios were calculated for the lesion and for normal-appearing white matter (NAWM). Three patients were imaged in the acute stage (within 7 days of the onset of neurological symptoms) and five in the subacute stage (after 7 days from the onset of symptoms).

RESULTS

ADC values in NAWM were in the range 0.7-1.24 x 10(-3) mm/s2 (mean 0.937 +/- 0.17 mm/s2). ADC values of ADEM lesions in the acute stage were in the range 0.37-0.68 x 10(-3) mm/s2 (mean 0.56 +/- 0.16 mm/s2) and 1.01-1.31 x 10(-3) mm/s2 (mean 1.24 +/- 0.13 mm/s2) in the subacute stage. MRS ratios were obtained for all patients. NAA/Cho ratios were in the range 1.1-3.5 (mean 1.93 +/- 0.86) in the NAWM. NAA/Cho ratios within ADEM lesions in the acute stage were in the range 0.63-1.48 (mean 1.18 +/- 0.48) and 0.29-0.84 (mean 0.49 +/- 0.22) in the subacute stage. The ADC values, NAA/Cho and Cho/Cr ratios were significantly different between lesions in the acute and subacute stages (P < 0.001, P < 0.027, P < 0.047, respectively). ADC values were significantly different between lesions in the acute (P < 0.009) and subacute stages (P < 0.005) with NAWM. In addition, NAA/Cho and Cho/Cr ratios were significantly different between lesions in the subacute stage and NAWM (P < 0.006, P < 0.007, respectively).

CONCLUSION

ADEM lesions were characterized in the acute stage by restricted diffusion and in the subacute stage by free diffusion and a decrease in NAA/Cho ratios. Restricted diffusion and progressive decrease in NAA/Cho ratios may help in staging the disease.

Hepatic myelopathy: a rare complication following extrahepatic portal vein occlusion and lienorenal shunt

A 19-year-old gentleman presented with slowly progressive spastic paraparesis, 2 years after the therapeutic lienorenal shunt for portal hypertension secondary to cirrhosis and portal vein occlusion. After 2 years of initial evaluation, the motor functions had not worsened further. He did not have any obvious clinical or EEG features of hepatic encephalopathy. Other causes for myelopathy were ruled out. Contribution of portal vein occlusion to portosystemic shunting has not been reported previously in patients with 'hepatic myelopathy.' This uncommon complication needs to be considered in patients with shunt surgery for relieving portal hypertension.

The overall effectiveness of prophylaxis in severe haemophilia

The aim of this retrospective review was to assess the overall effectiveness of prophylaxis when compared with on-demand treatment of haemophilic patients. Twenty-five children (22 with severe haemophilia A and three with severe haemophilia B) were evaluated. Five haemophilia A patients received primary prophylaxis (instituted before the onset of any joint bleed) while the other 17 haemophilia A and all three haemophilia B patients were on secondary prophylaxis. We compared factor usage, number of bleeding episodes, emergency room (ER) visits and hospitalizations while on prophylaxis to those while on demand therapy. All subjects were male, the median age at time of review was 11.4 years and at start of prophylaxis was 4.5 years. Thirteen of the 25 patients (52%) required indwelling venous catheters for access, seven of these had one or more (one-six) episodes of line sepsis. Haemophilia A patients received an average of 23.8 U kg(-1) (20-30 U kg(-1)) of recombinant factor VIII three times a week while haemophilia B patients received 50 U kg(-1) recombinant FIX twice weekly. There was a significant reduction in the mean number of major bleeds on prophylaxis from 15.5 to 1.9 per year and a significant decrease in target joints, ER visits and hospitalizations. Although factor usage per year was higher on prophylaxis, there was an overall reduction in number of bleeds and resultant decrease in hospitalizations and ER visits. By preventing new target joints, prophylaxis can lead to reduction in long-term morbidity and a better quality of life despite increased central lines and higher factor usage.

Comparative efficiency of commercial and improvised spacer device in acute bronchial asthma

OBJECTIVE

To compare the efficacy of a commercial spacer device versus an improvised spacer device in delivering aerosolized beta-2 agonist through metered dose inhaler in an acute exacerbation of bronchial asthma.

DESIGN

Randomized controlled trial.

SETTING

Urban tertiary care teaching hospital.

METHODS

60 children between 1 to 12 years of age with acute asthma were prospectively enrolled and randomized into two groups. Detailed history, clinical evaluation and appropriate laboratory investigations were recorded on a pretested proforma. One group received inhaled salbutamol using metered dose inhaler via commercial spacer device (Group 1), while the other received it via improvised spacer device (Group II). The response was sequentially assessed after 20, 40 and 60 minutes of institution of therapy.

RESULTS

The two groups were comparable with respect to various parameters at presentation (p > 0.05). All the outcome parameters showed a significant improvement with time in both groups (p < 0.05). There was no statistical difference between the response in the two groups (p< 0.05).

CONCLUSION

Metered dose inhaler with improvised spacer device is equivalent in efficacy and a more cost effective alternative to metered dose inhaler with commercial spacer for administration of beta-2 agonist in acute asthma.