Case Report: Alternaria alternata keratitis

Background

Alternaria spp are ubiquitous pigmented filamentous fungi that can cause opportunistic human infections. These molds can be found in healthy individuals and the most frequently observed clinical manifestations are skin infections, ocular mycosis, rhinosinusitis, among others. Immunosuppression (both local and systemic) as well as contact or trauma with contaminated matter are important risk and predisposing factors for ocular mycosis. Accurate diagnosis with microscopy and culture is crucial since infections by filamentous fungi are sight-threatening, and clinically indistinguishable from bacterial disease. In general terms, conventional antifungal drugs are effective.

Case Presentation

We report a case of Alternaria alternata keratitis after ocular trauma with biological material in a 44-year-old man's functional single eye, which had a good clinical and functional evolution after topical therapy with voriconazole.

Conclusion

This case accounts the importance of thinking about other etiological diagnoses in infectious keratitis refractory to the established therapy and with a history of trauma with biological material.

Major adverse cardiac events in critically ill COVID-19 patients

Background

Critically ill patients hospitalized with COVID-19 are at high risk of developing major adverse cardiac events (MACE).

Purpose

This study aimed to identify independent predictors of MACE after intensive care unit (ICU) admission which could be used to identify high-risk patients who may benefit from preventive strategies.

Methods

We retrospectively analyzed patients consecutively admitted to an ICU with COVID-19 and followed them for a median period of 7 months. Patients admitted due to trauma or emergent surgery were excluded. Logistic regression analysis was performed to evaluate which clinical characteristics predicted MACE. MACE was defined as all-cause ICU mortality, new-onset heart failure, acute coronary syndrome, ventricular arrythmias, pulmonary embolism, myocarditis, and stroke (ischemic or hemorrhagic).

Results

A total of 297 patients was included in the analysis. Median age was 62 (IQR 17) years, and most patients were male (198 patients, 66.7%). From a total of 297 patients, 108 (36.4%) developed at least one MACE: ICU all-cause mortality (92 patients, 31.0%), new-onset heart failure (27 patients, 9.1%), acute coronary syndrome (7 patients, 2.4%), ventricular arrythmias (7 patients, 2.4%), pulmonary embolism (13 patients, 4.4%), myocarditis (4 patients, 1.3%), and stroke (5 patients, 1.7%).

Univariate logistic regression analysis showed that the clinical variables associated with MACE were male sex, older age, APACHE II score, SAPS II score, hypertension, hyperlipidemia, known coronary artery disease, heart failure, new-onset atrial fibrillation, need for invasive mechanical ventilation, duration of mechanical ventilation, and vasopressor use. In multivariate logistic regression analysis, we found that the MACE's independent predictors were older age, higher APACHE II score, and new-onset atrial fibrillation. Main results are presented in Table 1.

Conclusion(s)

Among critically ill COVID-19 patients, older age, higher APACHE II score, and new-onset atrial fibrillation independently predicted MACE.

Funding Acknowledgement

Type of funding sources: None.

Atrial fibrillation in COVID-19 patients admitted to an intensive care unit: prevalence and prognosis

Background

The association between atrial fibrillation (AF) and prognosis has been studied in non-COVID-19 patients, but few studies reflect the reality of critically ill COVID-19 patients admitted to a general intensive care unit (ICU).

Purpose

This study sought to investigate the relationship between previous and new-onset AF in COVID-19 patients admitted to an ICU and prognosis.

Methods

We retrospectively analyzed patients consecutively admitted to an ICU with COVID-19 and followed them for a median period of 7 months. Patients admitted due to trauma or emergent surgery were excluded from the analysis. Three groups were identified: without AF (G1), with prior history of AF (G2), and with new-onset AF (G3). Groups were compared, with special interest regarding ICU mortality, duration of mechanical ventilation, length of hospitalization, major adverse cardiac events (MACE), and re-hospitalization. MACE was defined as all-cause ICU mortality, new-onset heart failure, acute coronary syndrome, ventricular arrhythmias, pulmonary embolism, myocarditis, and stroke (ischemic or hemorrhagic).

Results

A total of 297 patients was included in the analysis: without AF (248 patients, 83.5%), with prior history of AF (15 patients, 5.1%), and with new-onset AF (34 patients, 11.4%). Median age was 62 (IQR 17) years, and most patients were male (198 patients, 66.7%).

Patients with a prior history of AF were older [median (IQR), G1 60 (16), G2 71 (12), G3 67 (15) years, p=0.001], were more likely to have a history of coronary artery disease (G1 4.9%, G2 26.7%, G3 11.8%, p=0.002), and history of heart failure (G1 6.5%, G2 33.3%, G3 17.6%, p<0.001). Patients with new-onset AF had a longer duration of mechanical ventilation [median (IQR), G1 9 (13), G2 11 (16), G3 18 (12) days, p<0.001), longer ICU length of stay [median (IQR), G1 12 (10), G2 13 (12), G3 19 (15), p=0.001], higher ICU mortality rate (G1 27.0%, G2 33.3%, G3 58.8%, p=0.001), and higher rate of MACE (G1 31.9%, G2 33.3%, G3 70.6%, p<0.001), compared to the other groups. There were no differences regarding sex distribution, other baseline comorbidities, need for invasive mechanical ventilation, vasopressor use, and re-hospitalization rates among groups. Most AF patients were treated with beta-blockers (39.6%) and amiodarone (77.1%), but only 68.8% of patients received anticoagulation (G2 92.9%, G3 58.8%), which may reflect that physicians underestimate the prognosis of new-onset AF.

In multivariate analysis, new-onset AF (OR 3.07, 95% CI 1.42–6.67, p=0.005) and older age (OR 1.07, 95% CI 1.04–1.09, p<0.001) remained independent predictors of ICU mortality. Main results are presented in Table 1. Kaplan-Meier survival curves are presented in Figure 1.

Conclusion(s)

This study shows that critically ill COVID-19 patients with AF present a worse prognosis compared to patients without AF, and new-onset AF is an independent predictor of ICU mortality and MACE.

Funding Acknowledgement

Type of funding sources: None.

Prognostic value of cardiac troponin in critically ill COVID-19 patients

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Among patients with COVID-19, there is a high prevalence of cardiovascular disease and myocardial injury from the infection, especially in critically ill patients.

Purpose

This study sought to investigate the relationship between elevated admission high-sensitive troponin I in COVID-19 patients admitted to an intensive care unit (ICU) and prognosis.

Methods

We retrospectively analyzed patients consecutively admitted to an ICU with COVID-19, with a median follow-up of 10 months. Patients who were diagnosed with acute coronary syndrome, either died or were discharged within 48 hours of admission, and who did not have a cardiac troponin measurement in the first 48 hours, were excluded.

Two groups were identified, with normal troponin and with elevated troponin. Groups were compared, with special interest regarding in-hospital mortality, duration of mechanical ventilation, in-hospital diagnosis of heart failure, and length of hospitalization. Global mortality (in-hospital and during follow up) and re-hospitalization were compared. To compare survival, a Kaplan-Meier curve with log rank test was performed.

Results

From a total of 219 patients, after applying the exclusion criteria, 100 patients were included in the analysis, mean age was 62.9 ±12.5 years, and 74% were male.

Troponin was normal in 77% of patients and elevated in 23%. Median troponin was 11 (IQR=26) ng/L (reference range <34 ng/L).

Patients with elevated troponin were older (66.5 ±12.0 vs 61.6 ±12.5 years, p=0.036). Gender, comorbidities, vasopressor use, and APACHE II score were similar among groups. Patients with elevated troponin presented a higher ICU mortality (16.9% vs 47.8%, p=0.002) and higher global mortality (22.1% vs 47.8%, p=0.016). Re-hospitalization rates, ICU length of stay and duration of mechanical ventilation were similar among groups.

In multivariate analysis, after adjustment for age and APACHE II score, an elevated troponin remained an independent predictor of ICU mortality (OR=3.40, 95% CI 1.08-10.4, p=0.036), but not an independent predictor of global mortality (OR=2.75, 95% CI 0.86-8.80, p=0.087).

Kaplan-Meier analysis (Figures 1 and 2) showed that patients with elevated troponin had higher ICU (p=0.008) and global mortality (p=0.008) when compared to patients with normal admission troponin.

Conclusion(s)

The present study shows that elevated high-sensitive cardiac troponin I at admission predicts ICU and global mortality in critically ill COVID-19 patients. Cardiac troponin is as easy-to-use tool that may help to identify patients who benefit from tighter monitoring both during hospitalization and after discharge.

Cardiovascular disease in critically ill COVID-19 patients

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

It is now well known that patients with COVID-19 have a high prevalence of cardiovascular disease. COVID-19 is also associated with a substantial degree of cardiovascular involvement. However, the impact of cardiovascular disease (CVD) and cardiovascular risk factors on the natural history of COVID-19 is much less characterized.

Purpose

To characterize the prognostic impact of CVD and cardiovascular risk factors in COVID-19 patients admitted to an Intensive Care Unit (ICU).

Methods

We retrospectively analyzed patients consecutively admitted to an ICU with COVID-19, with a median follow-up of 10 months. Patients who either died or were discharged in the first 48 hours of admission were excluded.

Three groups were identified: (1) established CVD – presence of either heart failure, coronary artery disease and/or peripheral artery disease; (2) at higher risk of CVD – arterial hypertension, dyslipidemia, diabetes mellitus and/or smoking, in the absence of established CVD; and (3) at lower risk of CVD – i.e. none of the above.

Groups were compared, with special interest regarding in-hospital mortality, duration of mechanical ventilation, length of hospitalization. Global mortality (in-hospital and during follow up), and re-hospitalization were also compared. To compare survival, a Kaplan-Meier and multivariate Cox regression analysis were performed.

Results

Overall, 219 patients were identified, mean age was 62.1 ±11.9 years, 67.1% were male, 71 (32.4%) died in the ICU, 78 (35.6%) died during follow-up, and 14 (6.4%) were re-hospitalized.

30 patients (13.7%) had established CVD, 144 (65.8%) were at higher risk of CVD, and 45 (20.5%) were at lower risk of CVD. Patients with established CVD were older than patients at higher risk of CVD, and both were older than patients at lower risk (68.0 ±8.4 vs 62.0 ±11.3 vs 56.0 ±13.0 years, p <0.001). ICU mortality was 56.7%, 30.6%, and 22.2% for patients with established CVD, at higher risk of CVD, and at lower risk of CVD, respectively (p = 0.005). Re-hospitalization rate, ICU length of stay, and duration of mechanical ventilation were similar among groups.

Patients with established CVD were at significantly higher risk of ICU mortality (HR 2.42, 95% CI 1.08-5.46, p = 0.033), and higher risk of global mortality (HR 2.16, 95% CI 1.03-4.52, p = 0.042), compared to patients at higher and lower risk of CVD; in patients at higher and lower risk of CVD, ICU and global mortality was similar. In multivariate Cox regression, after adjusting for age and risk scores, established CVD was not an independent predictor of mortality. Kaplan-Meier survival curves are presented in figures 1 and 2.

Conclusion(s)

Almost 80% of patients admitted to an ICU with COVID-19 had established or were at higher risk of CVD. Patients with established CVD have a higher risk of death, although its presence is not an independent predictor of death.

A systematic review of the complications of high-risk third molar removal and coronectomy: development of a decision tree model and preliminary health economic analysis to assist in treatment planning

Coronectomy is an alternative surgical technique for the management of high-risk third molars. It involves the removal of the crown of a tooth and the deliberate retention of the roots, thereby avoiding injury to the inferior alveolar nerve (IAN). Previous studies have suggested that it reduces the risk of nerve injury when compared with surgical extraction. The purpose of this study was to systematically review the incidence of complications following coronectomy such as IAN injury, pain, dry socket, infection, root migration, and need for re-operation. A comparative cost analysis of coronectomy and surgical extraction was done based on the results of the review. This provides an insight into the economic implications of the two procedures. A search through the MEDLINE database via Ovid, PubMed, Scopus, EMBASE via Ovid, and Web of Science, was carried out to extract randomised and non-randomised controlled trials. Four studies fulfilled the inclusion criteria. A meta-analysis was conducted to measure the overall effect of each outcome. The pooled odds ratio (OR) for IAN injury was 0.16 (95% CI 0.01 to 0.39). Coronectomy reduced this risk by 84%. Dry socket may occur less frequently following coronectomy whereas infection did not show a higher incidence with either intervention. Root migration was found to occur in 13%-85% of cases and the average incidence of re-operation was 2.2%. The ratio of the average costs was 1.12 favouring coronectomy if cone-beam computed tomography (CBCT) was not done prior to the procedure. If a scan was taken routinely for coronectomy, the cost ratio marginally favoured extraction. Coronectomy reduced the risk of nerve injury in high-risk third molars. Definitive conclusions, however, cannot be made for outcomes such as the need for re-operation, which may alter the cost ratio of coronectomy:extraction, as higher quality studies with longer follow-up are needed.

Kondo effect under the influence of spin-orbit coupling in a quantum wire

The analysis of the impact of spin-orbit coupling (SOC) on the Kondo state has generated considerable controversy, mainly regarding the dependence of the Kondo temperatureTKon SOC strength. Here, we study the one-dimensional (1D) single impurity Anderson model (SIAM) subjected to Rashba (α) and Dresselhaus (β) SOC. It is shown that, due to time-reversal symmetry, the hybridization function between impurity and quantum wire is diagonal and spin independent (as it is the case for the zero-SOC SIAM), thus the finite-SOC SIAM has a Kondo ground state similar to that for the zero-SOC SIAM. This similarity allows the use of the Haldane expression forTK, with parameters renormalized by SOC, which are calculated through a physically motivated change of basis. Analytic results for the parameters of the SOC-renormalized Haldane expression are obtained, facilitating the analysis of the SOC effect overTK. It is found that SOC acting in the quantum wire exponentially decreasesTKwhile SOC at the impurity exponentially increases it. These analytical results are fully supported by calculations using the numerical renormalization group (NRG), applied to the wide-band regime, and the projector operator approach, applied to the infinite-Uregime. Literature results, using quantum Monte Carlo, for a system with Fermi energy near the bottom of the band, are qualitatively reproduced, using NRG. In addition, it is shown that the 1D SOC SIAM for arbitraryαandβdisplays a persistent spin helix SU(2) symmetry similar to the one for a 2D Fermi sea with the restrictionα=β.

African histoplasmosis in a Guinea Bissau patient with HIV-2: Case report and review

African histoplasmosis is the relatively unknown infection by Histoplasma capsulatum var. duboisii. It is endemic to Central and West Africa, generally involving the skin with potential for systemic dissemination, and has been described mainly in immunocompetent hosts. We present the case of a 30-year-old Bissau-Guinean man with HIV-2 infection known for 16 years, irregularly treated, admitted with two weeks of fever, diarrhoea and cutaneous lesions. Examination revealed multiple subcutaneous nodes, Molluscum contagiosum-like lesions, generalized lymphadenopathy and painful palpation of the left iliac fossa. Laboratory tests showed severe nonhaemolytic anaemia and CD4+ count of 9/mm3, with normal creatinine and hepatic enzymes. Chest roentgenogram was unremarkable and a research for Mycobacterium tuberculosis by GeneXpert® was negative. Nonetheless, given the lack of further diagnostic tools, a presumptive diagnosis of disseminated tuberculosis was made, and the patient was started on tuberculostatic and antiretroviral drugs. Despite initial improvement, a national shortage of antiretrovirals precluded further treatment, with worsening of the clinical picture, namely an increase in the number and dimensions of the skin lesions. An excisional biopsy of a subcutaneous nodule revealed Histoplasma capsulatum var. duboisii. Unfortunately, due to the unavailability of antifungals, the patient died one week later. To our best knowledge, this is the first confirmed case of an HIV infected patient with African histoplasmosis in Guinea-Bissau.

Epidemiologia das infeções fúngicas superficiais em Portugal - revisão de 3 anos (2014-2016)

Introdução: As infeções fúngicas superficiais são as dermatoses infeciosas mais frequentes e a sua incidência continua a aumentar. Os dermatófitos são os principais agentes causais apresentando, contudo, uma distribuição geográfica variável.Material e Métodos: O presente estudo teve como objetivo a caracterização epidemiológica das infeções fúngicas superficiais diagnosticadas nos Serviços/Unidades de Dermatologia pertencentes ao Serviço Nacional de Saúde Português entre janeiro de 2014 e dezembro 2016 através da análise retrospetiva dos resultados das culturas realizadas durante esse período.Resultados: Foram estudados 2375 isolamentos, pertencentes a 2319 doentes. O dermatófito mais frequentemente isolado foi o Trichophyton rubrum (53,6%), tendo sido o principal agente causal da tinha da pele glabra (52,4%) e das onicomicoses (51,1%). Relativamente às tinhas do couro cabeludo, globalmente o Microsporum audouinii foi o agente mais prevalente (42,6%), seguido do Trichophyton soudanense (22,1%). Enquanto na área metropolitana de Lisboa estes dermatófitos foram os principais agentes de tinha do couro cabeludo, nas regiões Norte e Centro o agente mais frequente foi o Microsporum canis (58,5%). Os fungos leveduriformes foram os principais responsáveis pelas onicomicoses das mãos (76,7%).Conclusão: Os resultados deste estudo estão globalmente concordantes com a literatura científica. O Trichophyton rubrum apresenta-se como o dermatófito mais frequentemente isolado em cultura. Na tinha do couro cabeludo, na área metropolitana de Lisboa, as espécies antropofílicas de importação assumem particular destaque.

Postpartum contraception needs of women with preterm infants in the neonatal intensive care unit

OBJECTIVES

To evaluate postpartum contraception experiences of mothers with premature infants in the neonatal intensive care unit (NICU), their knowledge of risk factors for preterm delivery and their interest in a family planning clinic located near the NICU.

STUDY DESIGN

This is a cross-sectional survey of English or Spanish-speaking women 18 or older whose premature neonate had been in the NICU for 5 days or more in a current stable condition.

RESULTS

A total of 95 women were interviewed at a median of 2.7 weeks postpartum (range 0.6-12.9). Approximately 75% of women were currently using or planning to use contraception, with 33% using less effective methods. Half of women reported they would obtain contraception at a family planning clinic near the NICU. Only 32% identified a short interpregnancy interval as a risk factor for preterm delivery.

CONCLUSION

Lack of knowledge of short interpregnancy interval as a risk factor for a future preterm delivery highlights the need to address postpartum contraception education and provision in this high-risk population.

Comparison of placental findings in type 1 and type 2 diabetic pregnancies

INTRODUCTION

The aim of this study is to compare placental pathology and related clinical parameters between gravidas with type 1 and type 2 pregestational diabetes.

METHODS

This is a retrospective cohort study of women with singleton gestations and pregestational diabetes who delivered at Women and Infants Hospital from 2003 to 2011. Pathology reports, maternal and neonatal outcomes were extracted and compared between the two groups.

RESULTS

In our cohort, 293 pregnancies were studied, including 117 with type 1 diabetes and 176 with type 2 diabetes. Women with type 1 diabetes had worse glycemic control during pregnancy, as characterized by higher HbA1c values and average fasting and postprandial blood sugars. More infants from the type 1 group were admitted to Neonatal ICU. Pregestational diabetes led to small for gestational age (SGA) placentas in nearly 20% pregnancies and large for gestational age (LGA) placentas in 30% of cases. Both groups shared similar incidences of preeclampsia and significant placental pathology related to uteroplacental (maternal) and fetal circulatory disorders; however, maternal decidual vasculopathy and placentas with insufficiency (fetal-to-placental weight ratio < 10th %tile) were more commonly found in placentas from women with type 2 diabetes.

DISCUSSION

Both types of pregestational diabetes have significant impact on placental growth and development. The comparison between the two groups suggests different pathogenetic mechanisms and may be helpful for better management of diabetic pregnancy.

Maternal perceptions of children's weight status

BACKGROUND

Several studies have addressed mothers' perceptions of their children's weight status; however, there is no investigation on Portuguese children (a country with one of the highest levels of children's overweight and obesity in Europe). The aim of this study was to quantify maternal misclassification of child weight status in a sample of Portuguese children aged 9 to 12 years, according to gender, family income, and maternal weight status, education level and age.

METHODS

Data were collected in a school-based study (school year 2009/2010) in northern Portugal with 499 urban children (236 girls; 47.3%). Body mass index was calculated from measurements of height and weight [body mass (kg)/height (m(2))]. Mothers' perceptions of child's weight status, age, height and weight were accessed by a questionnaire. Children's age, gender and socio-economic status were extracted from the schools' administrative record systems. Cohen's Kappa was used to analyse the misperceptions and the agreement between children's objectively measured weight status and mothers' perception of their child's weight status.

RESULTS

The prevalence of underweight, overweight and obesity in children was 4.6%, 25.5% and 6.4%, respectively. A proportion of 65.2% of underweight and 61.6% of overweight/obese children were misclassified by their mothers. For the majority of variables presented, the values of agreement were fair (k ranged from 0.257 to 0.486), but were statistically significant. Significant differences in the percentages of mothers who correctly classified their children's weight status were only found among the most educated in the overweight/obese group and among the normal-weight mothers in the underweight group.

CONCLUSIONS

Many mothers do not properly recognize their children's weight status and frequently underestimate their children's body size.