Acute Invasive Rhino-Orbital Mucormycosis in a Patient With COVID-19-Associated Acute Respiratory Distress Syndrome.

Acute invasive fungal rhinosinusitis is a rare, although highly morbid, infection primarily affecting immunosuppressed individuals. The same population is at particularly high risk of complications and mortality in the setting of SARS-CoV-2 infection and coronavirus disease 2019 (COVID-19)-related acute respiratory distress syndrome. The authors present a case of acute invasive fungal rhino-orbital mucormycosis in a patient with COVID-19 and discuss the prevalence, diagnosis, and treatment of fungal coinfections in COVID-19. Prompt recognition, initiation of therapy, and consideration of the challenges of rapidly evolving COVID-19 therapy guidelines are important for improving patient survival.

Measures of gene expression in sputum cells can identify TH2-high and TH2-low subtypes of asthma.

BACKGROUND: The 3-gene signature of periostin, chloride channel accessory 1 (CLCA1), and Serpin ß2 (SERPINB2) in airway epithelial brushings is used to classify asthma into TH2-high and TH2-low endotypes. Little is known about the utility of gene profiling in sputum as a molecular phenotyping method. OBJECTIVE: We sought to determine whether gene profiling in sputum cells can identify T(H)2-high and T(H)2-low subtypes of asthma. METHODS: In induced sputum cell pellets from 37 asthmatic patients and 15 healthy control subjects, PCR was used to profile gene expression of the epithelial cell signature of IL-13 activation (periostin, CLCA1, and SERPINB2), TH2 genes (IL4, IL5, and IL13), and other genes associated with airway TH2 inflammation. RESULTS: Gene expression levels of CLCA1 and periostin, but not SerpinB2, were significantly higher than normal in sputum cells from asthmatic subjects. Expression levels of IL-4, IL-5, and IL-13 were also significantly increased in asthmatic patients and highly correlated within individual subjects. By combining the expression levels of IL-4, IL-5, and IL-13 in a single quantitative metric ("T(H)2 gene mean"), 26 (70%) of the 37 asthmatic patients had T(H)2-high asthma, which was characterized by more severe measures of asthma and increased blood and sputum eosinophilia. TH2 gene mean values tended to be stable when initial values were very high or very low but fluctuated above or below the T(H)2-high cutoff when initial values were intermediate. CONCLUSION: IL-4, IL-5, and IL-13 transcripts are easily detected in sputum cells from asthmatic patients, and their expression levels can be used to classify asthma into T(H)2-high and T(H)2-low endotypes.

Primary Practice Emphasis Area and Diversity Among Board-Certified Ophthalmologists.

PURPOSE: To describe the ophthalmology primary practice emphasis area by underrepresented in medicine (URiM) status using the American Board of Ophthalmology (ABO) Diplomates database. DESIGN: Retrospective cohort study. METHODS: The study was based on a retrospective review of the ABO database from 1992 to 2020. The datapoints recorded included age at time of graduation and at time of certification, sex/gender, self-reported race/ethnicity, year of graduation and of certification, region of practice in the United States, and the self-reported primary practice emphasis area within ophthalmology. The URiM cohort included self-identified Black, Hispanic/Latinx, American Indian and Alaska Native, and Native Hawaiian and Other Pacific Islander individuals. Statistical analysis was conducted using Pearson χ2, Student t, and Fisher exact tests. RESULTS: A total of 575 (10.1%) ophthalmologists self-identified as URiM, vs 5132 (89.9%) as non-URiM. Diplomates who were URiM were more likely to be female and to be older at the time of ABO certification than those who were not URiM (P < .001). Over time, there was a steady decrease in the percentage of diplomates who were URiM (P < .001). There was a statistically significantly higher percentage of URiM ophthalmologists who reported glaucoma as their primary area of emphasis (P = .039) and non-URiM ophthalmologists who reported oncology, pathology, international, or genetics (P = .015), but no significant differences in the remaining subspecialties (P ≥ .123). CONCLUSIONS: There were modest differences in reported ophthalmology primary practice emphasis areas between URiM and non-URiM ABO diplomates. Despite efforts to increase diversity in ophthalmology, the percentage of graduating URiM ABO diplomates has decreased over the past 2 decades.

Retinal emboli after cervicopetrous junction internal carotid artery pseudoaneurysm stenting.

PURPOSE: To describe acute and chronic retinal ischemic changes following an internal carotid artery pseudoaneurysm stenting procedure, and to review current evidence for risk factors and management of post-procedural retinal ischemic events. OBSERVATION: A 50-year-old man presented with a 3-month history of pulsatile tinnitus, headache, and intermittent blurry vision. A CT angiogram of head and neck showed bilateral cervicopetrous internal carotid artery (ICA) pseudoaneurysms. The patient underwent successful repair with angioplasty and stenting of the flow-limiting high-grade (>95%) stenosis of his left high cervical ICA. On post-operative day 1, the patient reported monocular vision loss with a large central scotoma. He was found to have a central macular area of retinal whitening and multiple areas of perivascular retinal whitening on exam, concerning for retinal artery occlusions secondary to peri-procedural emboli. Dual antiplatelet therapy was started and a stroke evaluation was performed. Two months later, his visual acuity in the affected eye was counting fingers and his left eye fundus examination was notable for multiple areas of scattered hemorrhages, microaneurysms, and retinal exudates in the distribution of prior retinal ischemia. OCT imaging revealed atrophic changes in the left macula. Subsequently, the patient completed stage-2 repair of the left ICA pseudoaneurysm followed by uncomplicated repair of the right ICA. Four months later, his left eye visual acuity and retinal findings remained stable. CONCLUSIONS AND IMPORTANCE: Post-procedure retinal emboli and ischemia are important, vision threatening possible ocular complications for patients undergoing carotid vascular and endovascular procedures.

The relationship between air pollutants and maternal socioeconomic factors on preterm birth in California urban counties.

BACKGROUND: Preterm birth is the leading cause of perinatal morbidity and mortality in the U.S. and disparities among racial and ethnic groups persist. While etiologies of preterm birth have not been fully elucidated, it is probable that environmental and social factors play a role. OBJECTIVE: We hypothesized that there is an interactive association between exposure to fine particulate matter (PM2.5) or ozone (O3) and neighborhood socioeconomic factors that increase the risk of preterm birth. METHODS: We conducted a retrospective study using geocoded birth certificate data between 2007 and 2011, daily ambient air quality data on PM2.5 and O3, and American Community Survey (2007-2011 5-year estimates) data to assess census tract-level socioeconomic factors in California urban counties. RESULTS: Our study found a small positive association between maternal exposures to PM2.5 and O3 and preterm birth that varied by gestational exposure period. In mixed-effects models, we found an increase in the risk of preterm birth for a one-unit change in PM2.5 averaged across the entire pregnancy (AOR = 1.02, 95% CI: 1.01, 1.02) and O3 during 3-months pre-pregnancy (AOR = 1.03, 95% CI: 1.02, 1.04). Interaction between census tract-level factors and air pollutants showed an increase in the risk of preterm birth among mothers living in higher socioeconomic areas, though, a fixed cohort bias sensitivity analysis showed these associations were not significant. SIGNIFICANCE: These findings substantiate previous studies that showed associations between air pollution and preterm birth, even as pollution levels have decreased. This study has important implications for policy decisions and may help inform research on potential mechanisms of preterm birth.