Clinical and Immunological Factors That Distinguish COVID-19 From Pandemic Influenza A(H1N1)

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of coronavirus disease 2019 (COVID-19), is a global health threat with the potential to cause severe disease manifestations in the lungs. Although COVID-19 has been extensively characterized clinically, the factors distinguishing SARS-CoV-2 from other respiratory viruses are unknown. Here, we compared the clinical, histopathological, and immunological characteristics of patients with COVID-19 and pandemic influenza A(H1N1). We observed a higher frequency of respiratory symptoms, increased tissue injury markers, and a histological pattern of alveolar pneumonia in pandemic influenza A(H1N1) patients. Conversely, dry cough, gastrointestinal symptoms and interstitial lung pathology were observed in COVID-19 cases. Pandemic influenza A(H1N1) was characterized by higher levels of IL-1RA, TNF-α, CCL3, G-CSF, APRIL, sTNF-R1, sTNF-R2, sCD30, and sCD163. Meanwhile, COVID-19 displayed an immune profile distinguished by increased Th1 (IL-12, IFN-γ) and Th2 (IL-4, IL-5, IL-10, IL-13) cytokine levels, along with IL-1β, IL-6, CCL11, VEGF, TWEAK, TSLP, MMP-1, and MMP-3. Our data suggest that SARS-CoV-2 induces a dysbalanced polyfunctional inflammatory response that is different from the immune response against pandemic influenza A(H1N1). Furthermore, we demonstrated the diagnostic potential of some clinical and immune factors to differentiate both diseases. These findings might be relevant for the ongoing and future influenza seasons in the Northern Hemisphere, which are historically unique due to their convergence with the COVID-19 pandemic.

A unique immune signature of serum cytokine and chemokine dynamics in patients with Zika virus infection from a tropical region in Southern Mexico

OBJECTIVES

To describe the kinetics of circulating cytokines and chemokines in humans with ZIKAV infection.

METHODS

Serum levels of different immune mediators in patients with ZIKAV infection were measured at distinct stages of the disease, as well as in culture supernatants from human monocytes infected with a clinical ZIKAV isolate. We also looked for clinical features associated with specific immune signatures among symptomatic patients.

RESULTS

We evaluated 23 ZIKAV-infected patients. Their mean age was 32 ± 8.3 years and 65% were female. ZIKAV patients showed elevated IL-9, IL-17A, and CXCL10 levels at acute stages of the disease. At day 28, levels of CCL4 and CCL5 were increased, whereas IL-1RA, CXCL8 and CCL2 were decreased. At baseline, IL-7 was increased among patients with headache, whereas CCL2, and CCL3 were decreased in patients with bleeding and rash, respectively. Our clinical ZIKAV isolate induced a broad immune response in monocytes that did not resemble the signature observed in ZIKAV patients.

CONCLUSIONS

We showed a unique immune signature in our cohort of ZIKAV-infected patients. Our study may provide valuable evidence helpful to identify immune correlates of protection against ZIKAV.

High performance of rapid influenza diagnostic test and variable effectiveness of influenza vaccines in Mexico

OBJECTIVES

To evaluate the performance of rapid influenza diagnostic tests (RIDT) and influenza vaccines' effectiveness (VE) during an outbreak setting.

METHODS

We compared the performance of a RIDT with RT-PCR for influenza virus detection in influenza-like illness (ILI) patients enrolled during the 2016/17 season in Mexico City. Using the test-negative design, we estimated influenza VE in all participants and stratified by age, virus subtype, and vaccine type (trivalent vs quadrivalent inactivated vaccines). The protective value of some clinical variables was evaluated by regression analyses.

RESULTS

We enrolled 592 patients. RT-PCR detected 93 cases of influenza A(H1N1)pdm09, 55 of AH3N2, 141 of B, and 13 A/B virus infections. RIDT showed 90.7% sensitivity and 95.7% specificity for influenza A virus detection, and 91.5% sensitivity and 95.3% specificity for influenza B virus detection. Overall VE was 33.2% (95% CI: 3.0-54.0; p = 0.02) against any laboratory-confirmed influenza infection. VE estimates against influenza B were higher for the quadrivalent vaccine. Immunization and occupational exposure were protective factors against influenza.

CONCLUSIONS

The RIDT was useful to detect influenza cases during an outbreak setting. Effectiveness of 2016/17 influenza vaccines administered in Mexico was low but significant. Our data should be considered for future local epidemiological policies.

Colgajo microquirúrgico de músculo gracilis para cobertura de palma y dorso de mano tras revascularización

Presentamos el caso de un varón de 28 años de edad que sufrió el atrapamiento y la avulsión cutánea de la palma y dorso de la mano izquierda con arrancamiento de todos los pedículos vasculo-nerviosos a la altura del canal carpiano. Presentaba una fractura metafisaria de la falange proximal del quinto dedo, fractura diafisaria del tercer metacarpiano y avulsión de la piel del pulgar a la altura de la articulación trapeciometacarpiana. Las fracturas se fijaron con agujas. Tras la revascularización del pulgar y reparación microquirúrgica de los pedículos avulsionados, el 5.° dedo y la piel de la palma y del dorso, evolucionaron a la necrosis. Una semana después se realizó el desbridamiento de la necrosis y la cobertura con un colgajo microvascular de músculo gracilis, anastomosado a la arteria cubital termino-lateralmente. Cinco días después el colgajo se cubrió con un injerto de piel de espesor parcial.

El postoperatorio trascurrió sin complicaciones. El paciente comenzó la rehabilitación a la 4.a semana tras revascularización. 28 meses tras la intervención presenta un rango de movimiento de los dedos trifalángicos y muñeca completos, rigidez en pulgar (IF 30°-90°, MCF 20-60°). La sensibilidad era de 20 mm en el test de discriminación a los dos puntos en los dedos trifalángicos y, anestesia en el pulgar. La fuerza de prensa era del 79,6% (43 kg/54 kg) respecto a la mano sana.

El colgajo microquirúrgico del músculo gracilis constituye una excelente opción para cobertura en mano, al permitir el deslizamiento de los tendones. Además, mediante el uso de presoterapia, se consigue un excelente resultado estético, en un único tiempo, muy superior al conseguido con colgajos fasciocutáneos.

Complicaciones del tratamiento quirúrgico del síndrome del túnel del carpo con el sistema “KnifeLight®”

Los autores presentan una serie de complicaciones derivadas del uso del sistema “KnifeLigth®”, instrumento diseñado para el tratamiento quirúrgico del síndrome del canal carpiano de una forma mínimamente invasiva.

Material y Método: Se presentan seis casos de complicaciones derivadas del uso del instrumental “KnifeLigth®”, remitidos para tratamiento. Hubo dos casos de liberación incompleta, tratados mediante revisión quirúrgica e interposición con colgajo graso hipotenar, dos casos de lesiones parciales del mediano, tratadas de forma conservadora, un caso de sección de un nervio comisural tratado con injerto nervioso y colgajo graso hipotenar y una sección completa del nervio mediano reconstruida con injertos nerviosos, cobertura con vena autóloga y oponenteplastia.

Resultados: Todos los pacientes refirieron mejoría tras el tratamiento recibido, con un seguimiento mínimo de un año. Los casos de sección incompleta del ligamento anular del carpo evolucionaron como un caso primario estándar. Las secciones nerviosas reconstruidas con injertos nerviosos recuperaron sensibilidad de protección y experimentaron mejoría de la clínica de dolor.

Conclusiones: Si bien las técnicas mínimamente invasivas presentan algunas ventajas respecto a la técnica abierta, la severidad de las complicaciones derivadas de la falta de visión nos hacen ser reticentes a utilizarlas. Por otro lado, la interposición de grasa vascularizada o la cobertura con vena autóloga, constituyen técnicas de elección en cirugías secundarias de nervios.

A technique for arthroscopic all-inside suturing in the wrist

A technique for arthroscopic all-inside suturing in the wrist is presented. The procedure allows placement of the knot inside the joint without additional incisions. We have applied it in cases of dorsal, foveal and coronal tears of the triangular fibrocartilage. No special instrument is required apart from a Tuohy needle.

Sagittal rotational malunions of the distal radius: the role of pure derotational osteotomy

Sagittal rotational malunion after distal radius fractures was identified in eight patients by the presence of a "hinge" point on the volar cortex on the lateral radiograph, and the ulnar head being shorter than the anterior lip of the radius on the posterior-anterior radiograph. The surgical correction consisted of preplating the distal fragment with a volar locking plate before an osteotomy through the "hinge" point, and correcting the dorsal tilt of the distal fragment. Any dorsal defect was filled with cancellous bone graft from the olecranon. Pain, range of motion and grip all improved. Disabilities of arm, shoulder and hand score changed from 54 to six. Dorsal sagittal tilt improved by 26 degrees , from -23 degrees to +3 degrees . Ulnar variance improved by 3 mm, from +1.5 to -1.5 mm, becoming identical to the opposite side. A pure derotational osteotomy corrected the apparent shortening of the radius and restored the volar tilt.

High prevalence of infections in patients with systemic lupus erythematosus and pulmonary haemorrhage

The main objective of this study is to describe the presence of infections in patients with pulmonary haemorrhage and systemic lupus erythematosus. Patients with systemic lupus erythematosus and pulmonary haemorrhage were thoroughly evaluated in the first 48 hours with imaging plus bronchoscopy and bronchoalveolar fluid analysis. If needed, videoassisted thoracoscopy and lung biopsy were performed too. In all, search for bacterial, mycobacterial and fungal infections proceeded. Appropriate blood, bronchoalveolar fluid and tissue cultures were taken. Patients were treated with antibiotics and corticosteroids in case of infection. Otherwise, they received initial intravenous methylprednsiolone pulses for 3 days as standard therapy for pulmonary haemorrhage in systemic lupus erythematosus. Additional treatment with immunosuppressives was further decided by the treating physicians. Fourteen events in 13 patients were evaluated. In eight events (57%), an infection was demonstrated. Aetiological agents included Pseudomonas sp. and Aspergillus fumigatus. Four patients died, three of them because of the pulmonary infection and one because of cerebral haemorrhage secondary to severe systemic hypertension, 48 hours after methylprednisolone treatment. Patients with systemic lupus erythematosus and pulmonary haemorrhage have a high prevalence of infections. The influence of pulmonary haemorrhage in the setting of systemic lupus erythematosus needs further study to establish adequate treatment and to reduce the high mortality of this complication.

Vascularised corticoperiosteal grafts from the medial femoral condyle for difficult non-unions of the upper limb

The vascularised corticoperiosteal graft was introduced by Sakai and Doi, in 1991, as a means to achieve bony union under unfavourable conditions. We present our experience with this vascularised graft, taken from the femoral condyle, in six patients with difficult non-unions (5) or other bony problems (1) in the upper limb. In five cases, a long bone defect--two humeral, two ulnar and one radial--was involved. All had had between three and seven previous operations. Two of the non-unions were secondary to infection. The others had had conventional grafting on two or three previous occasions each. In the sixth case, a corticoperiosteal graft was used to promote healing in a combined carpometacarpal and intercarpal dislocation with a very poor bed. All of the grafts survived without complications and all of the bones healed radiologically in less than three months. Three patients achieved a normal range of motion and two obtained a functional range of motion with only slight limitations. The carpometacarpal arthrodesis was healed soundly at five weeks.

The effect of biomass burning on respiratory symptoms and lung function in rural Mexican women

BACKGROUND

The use of biomass as a cooking fuel is commonplace in developing countries and has been associated with chronic bronchitis and obstructive airway disease.

METHODS

A cross-sectional survey was done in the village of Solis, close to Mexico City. Lifelong nonsmoking women 38 yr of age or older (n=841) completed a questionnaire on respiratory symptoms and illnesses and on cooking fuel use, and performed spirometry in their homes. Particulate matter concentration was measured with a nephelometer in the kitchen for 1 h, while the subject was cooking.

RESULTS

The peak indoor concentration of particulate matter (PM10, particles with a diameter of 10 microm or less) often exceeded 2 mg/m3. Compared with those cooking with gas, current use of a stove burning biomass fuel was associated with increased reporting of phlegm (27 vs. 9%) and reduced FEV1/FVC (79.9 vs. 82.8%). Levels of FEV1 were 81 ml lower and cough was more common (odds ratio, 1.7; 95% confidence interval, 1.0-2.8) in women from homes with higher PM10 concentrations. All women found with moderate airflow obstruction (Global Initiative for Chronic Obstructive Lung Disease stage II and above) were cooking with biomass stoves.

CONCLUSION

Women cooking with biomass fuels have increased respiratory symptoms and a slight average reduction in lung function compared with those cooking with gas.

CD8+ cell noncytotoxic anti-HIV response: restoration by HAART in the late stage of infection

Highly active antiretroviral therapy (HAART) is currently the best HIV infection management strategy. However, its effects on the CD8+ T cell noncytotoxic anti-HIV response (CNAR) are not well known. We investigated if HAART has different effects on CNAR in patients at the intermediate and late stages of HIV infection. Untreated healthy HIV-infected subjects with a mean CD4+ T cell count of 606 cells/microl were examined as a reference group. Plasma viral load, CD4+ T cell count, and CNAR activity were measured at baseline and regular intervals for at least 48 weeks following initiation of HAART. Baseline CNAR activity in all subjects correlated inversely with viral load and directly with CD4 T+ cell counts. The level of CNAR in the latestage group was significantly lower than in the intermediate-stage and the healthy reference group (p < 0.01). Following initiation of HAART, substantial increases in CD4+ T cell counts and decreases in viral loads were observed in both groups, indicating treatment success. CNAR activity was found to be increased significantly during HAART, but only in the late-stage group (p < 0.01). This increase in CD8+ cell function was seen within 4 weeks of treatment initiation and resulted in levels of CNAR activity almost equal to those observed in the healthy reference subjects. Our findings suggest a beneficial effect on CNAR in those individuals with reduced activity, typically in late-stage infection.

Survival of patients with chronic obstructive pulmonary disease due to biomass smoke and tobacco

RATIONALE

Women exposed chronically to biomass develop airflow limitation, as tobacco smokers do, but their clinical profile and survival have not been described in detail.

OBJECTIVE

To determine the clinical profile, survival, and prognostic factors of chronic obstructive pulmonary disease associated with biomass exposure and tobacco smoking.

METHODS

During a 7-yr period (1996-2003), a consecutive series of 520 patients were recruited and followed up at the COPD Clinic of the National Institute of Respiratory Diseases. Prognostic factors of survival were evaluated taking into account the interaction between sex and exposure.

MEASUREMENTS

Spirometry, arterial blood gases and oxygen saturation, body mass index, exercise capacity, and health-related quality of life were performed at baseline. The main outcome was survival.

MAIN RESULTS

A total of 481 patients were followed up. The patients in the biomass group, mainly women (84%), were older and shorter and had a greater body mass index than those in the tobacco group (p < 0.0001). Airflow obstruction was more severe in smokers (p < 0.001). Quality of life and distance walked showed similar abnormalities in both groups. In the multivariable Cox regression analysis including an interaction term exposure-sex, we found that age (relative risk [RR], 1.02; 95% confidence interval [CI], 1.02-1.07), FEV(1) as percentage of predicted (RR, 0.96; 95% CI, 0.96-0.99), body mass index (RR, 0.95; 95% CI, 0.90-1.01), and oxygen saturation (RR, 0.96; 95% CI, 0.92-0.99) were predictors of mortality but not exposure or sex.

CONCLUSIONS

Women exposed domestically to biomass develop chronic obstructive pulmonary disease with clinical characteristics, quality of life, and increased mortality similar in degree to that of tobacco smokers.

Técnica para el tratamiento de la malunión intra-articular del radio mediante osteotomías con control artroscópico

El propósito de este trabajo es presentar un método para realizar las osteotomías intraarticulares con control visual.

Método: Utilizamos los abordajes dorsales clásicos de artroscopia (3-4, 6-R) además de un portal volar radial (VR). Para visualizar la articulación radiocarpiana recurrimos sólo a la tracción sin irrigar con agua. Las osteotomías se efectuaron con osteotomos de 4 mm introducidos por los portales y bajo control visual por la óptica del artroscopio. Una vez finalizada la refractura se movilizaron y fijaron los fragmentos desplazadas mediante tornillos o placas, obteniendo en todos los casos escalones próximos a 0mm.

Conclusiones: Este procedimiento permite realizar la partición de los fragmentos por los trazos originales de fractura. La clave de esta intervención es realizar la artroscopia sin agua (técnica seca) que permite una visión nítida y la ejecución de las osteotomías sin extravasación de agua, ni pérdidas de visión.

[Severity of dyspnea during exercise: similarities and differences between patients with COPD or pulmonary fibrosis]

To understand the mechanisms leading to dyspnea during exercise and to identify possible predictive factors, we compared dyspnea at rest (baseline)and during exercise in 27 patients with chronic obstructive pulmonary disease (COPD) and 39 pulmonary fibrosis (PF) patients. We also compared spirometry and blood gases at rest and after exercise,which consisted of a 12-minute walking test (12 WT). Heart rate and oxygen saturation (SaO2) were recorded every two minutes during the 12 WT. Distance walked was also recorded. Although dyspnea changed during the 12 WT in both groups (p < 0.001),the maximum level of dyspnea reached in the two groups was not statistically different. COPD patients walked farther than did PF patients (782 +/- 182 m vs. 618 +/- 225 m, respectively;p = 0.002) and paused less often during the 12 WT than did PF patients(0.18 +/- 0.55 vs. 0.82 +/- 1.55, respectively; p <0.05). After adjusting for diagnosis, age, sex, baseline dyspnea,distance walked and pauses during the 12 WT, we found that only SaO2 was significantly related to severity of dyspnea during exercise. We conclude that there are important differences in degree of dyspnea experienced during exercise by COPD and PF patients and that SaO2 is the only variable that predicts severity of dyspnea.

Bacteriology in burn patients undergoing mechanical ventilation

In this paper the authors introduce a retrospective study of the incidence of infectious processes in the Burns Unit of the Cruces Hospital (Bilbao), in those patients treated between 1995 and 1998, and who needed, for different reasons, mechanical ventilatory support. The most common microorganisms found in wound cultures, plugged telescoping catheter and blood cultures and analyse variations throughout the stay in the Burns Unit are described.

Dynamic rhinoplasty for the plunging nasal tip: functional unity of the inferior third of the nose

To achieve permanent results for the correction of a drooping nasal tip, it is important to understand the mechanism responsible for the caudal rotation of the tip when a person speaks or smiles. This mechanism can be considered to depend on a "functional unity" formed by three components: (1) the cartilaginous framework (alar cartilages and accessories acting as a single structure); (2) muscular motors (m. levator labii superioris alaeque nasi and depressor septi nasi); and (3) gliding areas (apertura piriformis, the valvular mechanism between the upper lateral cartilages and alar cartilages, the lax tissue of the nasal dorsum, and the membranous septum). We describe a new anatomical and functional concept responsible for the plunging of the nasal tip. When a person smiles, the functional unit is activated by a combination of two forces acting simultaneously in opposite directions that rotate the tip caudally and elevate the nasal base. The levator moves the alar base upward and the depressor pulls the tip caudally. To correct the drooping tip, the transcartilaginous incision is extended laterally, and the lateral portion of the alar arch is dissected free from the skin and the mucosa, thus exposing the accessory cartilages. The arch is then severed at the level of the accessories to allow the cephalad rotation of the domes. The muscle insertions are dissected free from the accessories and a section of the muscle and, if necessary, the accessory cartilages, is removed. From January of 1991 onward, 312 patients have had this ancillary procedure performed in addition to the basic rhinoplasty technique.

Primary Vibrio vulnificus bacteremia in a liver transplant recipient after ingestion of raw oysters: caveat emptor

Vibrio vulnificus is responsible for severe infections in chronically ill patients. Organ transplant recipients are also at risk for severe infections due to V vulnificus. We report here the first case of V. vulnificus primary bacteremia due to raw shellfish consumption in a liver transplant recipient. All transplant patients should be cautioned against consuming uncooked seafood and warned about the risk of severe Vibrio infections from seemingly innocuous wounds acquired in a salt water environment.

Clindamycin hypersensitivity appears to be rare

BACKGROUND

A patient developed a generalized confluent erythematous papular rash after a single injection of clindamycin preoperatively. The literature from two small studies suggested a 10% incidence of cutaneous eruptions to clindamycin which seemed too high.

OBJECTIVE

Describe a patient with clindamycin hypersensitivity and determine the incidence of hospital-wide adverse drug reactions from clindamycin from 1995-1997.

METHODS

At a tertiary care center, utilizing the Department of Pharmacy records, the incidence of adverse drug reactions was determined with (1) voluntary physician reporting, (2) Health Information Management chart reviews and adverse drug reaction coding, and (3) chart reviews by the Pharmacy and Therapeutics Committee of adverse drug reactions.

RESULTS

(I) A 50-year-old patient developed a generalized raised, erythematous rash that worsened over 3.5 days until hydrocortisone was administered. Immediate skin tests with clindamycin were negative. (2) From 3,896 administrations of clindamycin from April 1995 to October 1997, 14 (0.47%) adverse drug reactions occurred but 7 were confounded by other medications also being administered.

CONCLUSION

(1) Adverse drug reactions to clindamycin are much lower than reported 25 years ago with an incidence < 1%. (2) A patient who previously had experienced facial edema and a generalized rash after receiving clindamycin and a cephalosporin 6 years ago and who was considered allergic to cephalosporins, was found to be clindamycin allergic when she received a preoperative dose of clindamycin.

Factors influencing the sequelae of high tension electrical injuries

The purpose of this study was to conduct a retrospective analysis of the clinical spectrum, treatment and morbidity of the patients who have suffered high tension electrical injuries with current passage through their body (59 patients). Voltage, localization and surgical treatment seem to be the main factors influencing the lesion and the morbidity. The following points were considered: (1) Is there any relation between known factors such as voltage and the localization of the points of contact with the incidence and the type of complications and sequelae? (2) Do the observations show that wound management and the excision of dead tissues is the most adequate? From factors studied in our patients (voltage, point of entry and pathway of current, associated multiple trauma or flame burns, surgical treatment) we have found that the voltage does not have any influence on the severity of the wound nor on the percentage of sequelae (cataracts, limb amputation, neurologic complications). The current pathway, as well as its points of entry, does not show any relation with the presence of renal failure, cardiac arrhythmia and cataracts. A clear relationship between the point of entry of the current and the appearance of neurologic injury with presence of paralysis and permanent regional anaesthesia at the same level was observed. The presence of associated burns was not related to any other complications or sequelae. For those patients whose length of contact has been shorter we find a lower rate of amputations despite having associated limb fractures. Fasciotomy incisions appear to confer benefit as this series shows that this procedure decreases the rate of limb amputations.

Exposure to biomass smoke and chronic airway disease in Mexican women. A case-control study

A case-control study was performed in women older than 40 yr of age to evaluate the risk of cooking with traditional wood stoves for chronic bronchitis and chronic airway obstruction (CAO). The subjects were recruited from patients attending a referral chest hospital in Mexico City. We selected 127 patients with chronic bronchitis or CAO, of which 63 had chronic bronchitis alone, 23 had CAO alone (FEV1 less than 75% of predicted), and 41 had both chronic bronchitis and CAO (cases). Four control groups were selected: 83 patients with pulmonary tuberculosis, 100 patients with interstitial lung diseases, 97 patients with ear, nose and throat ailments, and 95 healthy visitors to the hospital (controls). Exposure to wood smoke, assessed as any or none, and as hour-years (years of exposure multiplied by average hours of exposure per day) was significantly higher in cases than in controls. Crude odds ratios for wood smoke exposure were 3.9 (95% CI, 2.0 to 7.6) for chronic bronchitis only, 9.7 (95% CI, 3.7 to 27) for CAO plus chronic bronchitis, and 1.8 (95% CI, 0.7 to 4.7) for CAO only. Differences in exposure to wood smoke persisted after adjusting by stratification and logistic regression for age, income, education, smoking, place of residence, and place of birth. Risk of chronic bronchitis alone and chronic bronchitis with CAO increased linearly with hour-years of cooking with a wood stove; odds ratios for exposure to more than 200 hour-years compared with nonexposed were 15.0 (95% CI, 5.6 to 40) for chronic bronchitis only and 75 (95% CI, 18 to 306) for chronic bronchitis with CAO. The findings support a causal role of domestic wood smoke exposure in chronic bronchitis and chronic airflow obstruction.