Features and evaluation of mucormycosis in COVID-19 patients from two referral hospitals in Iran.

OBJECTIVES: The present study aimed to assess the features, clinical characteristics, and species diversity among patients admitted to referral Hospitals for SARS-CoV-2 pneumonia and mucormycosis in Tehran, Iran, and the relationship between seasonal and species diversity was considered. METHODS: Confirmed COVID-19 patients with a positive reverse-transcriptase real-time (rRT-PCR) test for SARS-CoV2 were primarily included based on clinically suspected mucormycosis infection and confirmed by histopathology and mycology examination of biopsy specimens. The PCR technique was performed by the amplification of the high-affinity iron permease 1 (FTR1) gene for identification and discrimination between Rhizopus arrhizus and non- Rhizopus arrhizus isolates. In contrast, species identification of non-Rhizopus arrhizus was performed by sequencing of ITS rDNA region. RESULTS: Rhino-sino-orbital mucormycosis was identified in the majority of cases (n = 33), with 66 % and 34 % of the cases involving male and female patients, respectively. Rhizopus arrhizus was found to be the most prevalent (84.6 %), followed by Mucor circinelloides (7.6 %). Rhizopus arrhizus was the most prevalent species and present in all the seasons; however, Mucor circinelloides was only present in the autumn. The overall mortality of the total population was 24.6 % (16/ 65); the mortality rates occurring in patients diagnosed with rhino-sino-orbital infection and rhino-sinusal form were 21.4 % and 25 %, respectively. CONCLUSION: CAM can be a serious complication of severe COVID-19, especially in patients with uncontrolled diabetes. It is important to monitor the epidemiology of mucormycosis to raise awareness of the disease and improve diagnosis, treatment and prognosis, particularly in the setting of pandemic.

Publication bias in otorhinolaryngology meta-analyses in 2021.

INTRODUCTION: One concern in meta-analyses is the presence of publication bias (PB) which leads to the dissemination of inflated results. In this study, we assessed how much the meta-analyses in the field of otorhinolaryngology in 2021 evaluated the presence of PB. METHODS: Six of the most influential journals in the field were selected. A search was conducted, and data were extracted from the included studies. In cases where PB was not assessed by the authors, we evaluated the risk of its presence by designing funnel plots and performing statistical tests. RESULTS: Seventy-five systematic reviews were included. Fifty-one percent of them used at least one method for assessing the risk of PB, with the visual inspection of a funnel plot being the most frequent method used. Twenty-nine percent of the studies reported a high risk of PB presence. We replicated the results of 11 meta-analyses that did not assess the risk of PB and found that 63.6% were at high risk. We also found that a considerable proportion of the systematic reviews that found a high risk of PB did not take it into consideration when making conclusions and discussing their results. DISCUSSION: Our results indicate that systematic reviews published in some of the most influential journals in the field do not implement enough measures in their search strategies to reduce the risk of PB, nor do they assess the risk of its presence or take the risk of its presence into consideration when inferring their results.

Evaluation of the quality of clinical guidelines for prophylaxis of venous thromboembolism in urological surgeries by the AGREE II review instrument.

Background and Aims: Venous thromboembolism (VTE) is the most common cause of death during the first 30 days after surgery. There is not any study which critically evaluated clinical guidelines related to VTE prophylaxis in urological surgeries. Therefore, in this study, we decided to evaluate related clinical guidelines using the AGREE II instrument to take a positive step towards improving the care of these patients. Methods: The latest version of all available clinical guidelines related to the topic of VTE prophylaxis in urological surgeries until 2021 was searched. Four appraisers, including one urologist, one cardiologist, one epidemiologist, and one MD who had prior knowledge of working with the AGREE II tool and international articles in this field appraised selected clinical guidelines. Using the AGREE II review tool, clinical guidelines were critically evaluated. Then, the score of six domains of AGREE II for each guideline was calculated and compared with each other, and the relationship between the domains was measured by Kendall's correlation test. To determine the reliability of the test, interclass correlation coefficients were calculated for all indicators. Results: Items were rated on a 7-point scale from 1 (strongly disagree) to 7 (strongly agree). NICE, CHEST, and EAU guidelines obtained the highest scores from the Overall Assessment criteria by scoring 6, 5.75, and 5.25, respectively. There was only a correlation between the score of Overall Assessment criterion with "Applicability" domain, with Kendall's correlation coefficient of 0.867 and p = 0.015. The domains of "Clarity and presentation" and "Scope and purpose" obtained the highest standardized scores by getting 84.49% and 75.69%, respectively, and "Applicability" with 30.04% obtained the lowest standardized score. Conclusion: In this study, NICE, CHEST, and EAU guidelines are suggested as clinical guidelines by obtaining the highest scores from Overall Assessment criterion.

Distinguishing Characteristics of COVID-19-Associated Mucormycosis; a Case Series.

Introduction: Since the emergence of COVID-19 pandemic, several articles have reported the co-existence of mucormycosis and COVID-19. This study aimed to distinguish the characteristics of COVID-19-associated rhinocerebral mucormycosis. Methods: In this case series, 18 patients with COVID-19-associated rhinocerebral mucormycosis and unique clinical manifestations and outcomes, who were referred to Amiralam Hospital, a tertiary otorhinolaryngology center, Tehran, Iran, during the COVID-19 era, were reported. Results: Eighteen patients with the mean age of 62.0 ± 11.6 (range: 42 - 83) years were studied (50% males). The mean time interval between diagnosis of COVID-19 and first manifestation of mucormycosis was 15.5 ± 9.7 days. The most common presenting symptom was facial paresthesia (72.2%). Fifty percent of patients developed frozen eye. Palatal necrosis was seen in 7 cases (38.8%). Remarkably, facial paralysis was observed in 5 (27.7%) patients. Another notable clinical picture was cavernous sinus thrombosis, seen in 7 patients. We also had two cases of carotid artery occlusion. Three patients, unfortunately, passed away. Conclusion: Rhinocerebral mucormycosis is one of the most important complications of COVID-19 patients, especially those with underlying diseases. It seems that the key to proper management of mucormycosis is early diagnosis and timely intervention, which could give a patient a chance to live more.

Risk Factors of COVID-19 Associated Mucormycosis (CAM) in Iranian Patients: A Single-Center Retrospective Study.

BACKGROUND: COVID-19 associated mucormycosis (CAM) has been known as one of the most severe post-COVID morbidities. OBJECTIVES: To describe CAM cases, identify possible risk factors, and report outcomes of patients. METHODS: This retrospective study was performed in Amir-Alam Hospital, Tehran, Iran between February 2020 and September 2021. Patients with mucormycosis who had an active or previous diagnosis of COVID-19 have been included. RESULTS: Of 94 patients with mucormycosis, 52 (33 men and 19 women; mean age: 57.0 ± 11.82 years) were identified with an active or history of COVID-19. Rhino-orbital, rhino maxillary, rhino-orbito cerebral subtypes of mucormycosis were detected in 6 (11.5%), 18(34.6%), and 28(53.8%) patients. As a control group, 130 (69 men and 61 women; mean age: 53.10 ± 14.49 years) random RT-PCR-confirmed COVID-19 patients without mucormycosis have been included. The mean interval between COVID-19 diagnosis and initial mucormycosis symptoms was 16.63 ± 8.4 days (range 0-51). Those in the CAM group had a significantly more severe course of COVID-19 (OR = 3.60, P-value < 0.01). Known history of previous diabetes mellitus (OR = 7.37, P-value < 0.01), smoking (OR = 4.55, P-value < 0.01), and history of receiving high-dose corticosteroid pulse therapy because of more severe COVID-19 (P-value = 0.022) were found as risk factors. New-onset post-COVID hyperglycemia was lower in the CAM group (46.2% vs. 63.8%; OR = 0.485, P-value = 0.028). After treatment of the CAM group, 41(78.8%) of patients recovered from mucormycosis. The mean ages of the expired patients in the CAM group were significantly higher than those who recovered from mucormycosis (66.18 ± 9.56 vs. 54.56 ± 11.22 years; P < 0.01); and COVID-19 disease was more severe (P = 0.046). CONCLUSION: Either active or history of COVID-19 can cause an increase in the risk of mucormycosis development. Some of the most important risk factors are the medical history of diabetes mellitus, smoking, and high-dose corticosteroid therapy. CAM is important possible comorbidity related to COVID-19, which could make the post-COVID conditions more complicated. More research and studies with greater sample sizes among different ethnicities are needed to explore the association between COVID-19 and mucormycosis.

Factors related to successful closed nasal bone reduction: a longitudinal cohort study.

Fracture of the nasal bone is the most common facial fracture because the nose is the most protruding part of the facial skeleton. Standard treatment is nasal reduction, which may cause patients significant pain and stress. Closed nasal reduction may be unsuccessful because of old fractures, despite physical examination being compatible with a new fracture. This study aimed to investigate factors influencing the success of closed nasal reduction. A total of 80 patients with isolated nasal bone fractures who opted for closed reduction under local anaesthesia were included. Demographic features, days from trauma, and findings of physical examination and lateral nasal X-rays were assessed. Significant nasal bone movement with significant improvement in the deformity was considered a successful reduction. An absence of, or minimal, nasal bone movement was considered unsuccessful. The mean (SD) age of the patients was 28.4 (11.5) the youngest being 15. A total of 56 patients had successful nasal reduction. Younger age (p = 0.021), absence of periorbital ecchymosis (p = 0.042), and no fracture line on lateral nasal X-ray (p = 0.000), were associated with unsuccessful reduction. Although lateral nasal X-ray is not considered a good instrument for diagnosis of a nasal fracture, this study has shown that the absence of a fracture line on a lateral nasal X-ray can be a predictor for unsuccessful reduction in patients older than 15 years.

Placenta accreta spectrum disorders - detection rate and maternal outcomes following implementation of an institutional protocol.

Placenta accreta spectrum (PAS) disorders have been on the rise in recent years with increasing caesarean rates. The purpose of this prospective observational study was to describe our detection rates and to review outcomes in PAS after the introduction of an institutional screening and management protocol. Twenty-one patients with suspected PAS over 5 years were identified. 20/21 patients had an accurate determination of placental invasion and positive correlation with surgical and histopathological examination. Early morbidity (massive haemorrhage) was found in 7/21 patients, whilst late morbidity (hospital readmission) was found in 5/21 patients. There were no maternal deaths and admissions to intensive therapy unit (ITU). In summary, our centre demonstrated a high antenatal detection rate for PAS using an evidence-based protocol. This has led to timely intervention by an experienced multidisciplinary team and excellent outcomes. Immediate and delayed postoperative counselling was effective for optimal patient understanding and experience.Impact StatementWhat is already known on this subject? With rising caesarean section rates, the incidence of placenta accreta spectrum (PAS) disorders is increasing. Despite this, most obstetricians have personally managed only a small number of patients with PAS. Moreover, there appears to be some debate over the optimal diagnostic and management strategy.What do the results of this study add? As the incidence increases, development of institutional screening and management protocol is a necessity for large units. Timely diagnosis, extensive pre and postoperative counselling and multidisciplinary teamwork ensure reduced early and late morbidity.What are the implications of these findings for clinical practice and/or further research? Evidence based screening protocols for PAS disorders reduce the likelihood of undiagnosed cases and should be developed in every unit. Consideration must also be given to standardisation of the diagnostic and management protocols, including contingency plan for emergencies.

Inflammatory Myofibroblastic Tumor: Two Cases in Head and Neck Region.

Previously described as inflammatory pseudotumor, inflammatory myofibroblastic tumors (IMT) are now considered as distinct tumors of specific histopathologic features. This rare mesenchymal tumor consists of spindle shaped fibroblasts associated with various amounts of inflammatory cells. Head and neck region, is an unusual site of involvement. In this article, we will introduce two separate cases with the diagnosis of IMT involving the nasopharynx and the temporal bone which are both rare locations of presentation. Inflammatory myofibroblastic tumor should be considered in the differential diagnosis list of every mass in head and neck region.

A unique intraluminal growth of juvenile nasopharyngeal angiofibroma: A case report.

Juvenile nasopharyngeal angiofibroma (JNA) is a rare, hypervascular, benign tumor which is mainly seen among male adolescents. The tumor typically originates from the sphenopalatine fossa, but could spread through natural foramens and fissures. There are some reports of atypical growth of this tumor in literature but the intraluminal growth, which could be seen in paraganglioma and glomus tumors, has not reported yet in angiofibroma. In this article we present a case of extensive angiofoibroma with intraluminal involvement of the ophthalmic vein. Our patient was a 19-year-old boy with a complaint of nasal obstruction and occasional epistaxis since a year ago, without any visual or neurologic complaints. The patient underwent an endoscopic resection of the tumor after embolization via the nasal cavity. The intraoperative findings revealed the tumor extension to the orbit, intracranial space and cavernous sinus via inferior orbital fissure. The intracranial extension of the tumor was extradural and was successfully excised without CSF leakage. An interesting finding in this patient, was an intraluminal extension of the tumor in to the ophthalmic vein, which was completely excised endoscopically. (pre and post operation pictures are available in the full text). The definitive treatment of angiofibroma is surgical excision. Different surgical approaches are used but nowadays endoscopic resection with or without pre-operative embolization is the first choice of treatment. The intraluminal growth of the tumor was also excised as a pedunculated mass separately.

Ulipristal acetate for uterine fibroids: 2 years of real world experience in a UK hospital.

Ulipristal acetate (UPA), is a selective progesterone-receptor modulator, it decreases fibroid size and reduces menstrual bleeding. We reviewed its use at the Heart of England Foundation Trust (HEFT), one of the largest prescribing trusts in the UK. The electronic records of patients treated with UPA from January 2013 to August 2015 were reviewed. One hundred and thirty four patients received UPA, 20 women (15%) received a second course. Eighty percent reported subjective global improvements in symptoms after the first course; 45.5% described amenorrhoea or light bleeding compared to 4.5% prior to treatment. Fewer patients were anaemic (Hb <11 g/dL) following treatment (8.2% versus 33.6%). The majority of fibroids (34%) reduced or remained the same size (25%). Two-thirds of women treated for symptom control avoided surgical intervention. UPA improves symptoms and modifies the use of surgery in treating fibroids. Correcting anaemia prior to major surgery reduces the risk of blood transfusion and optimises a patient's condition as part of an enhanced recovery pathway. Impact Statement What is already known on this subject: In women with heavy menstrual bleeding secondary to fibroids, UPA has been shown to reduce fibroid size and control uterine bleeding, inducing amenorrhoea in the majority. Initially, only licenced for pre-operative use, an expansion of the licence has included on-going intermittent use for symptomatic fibroids. What the results of this study add: Our review is the largest published cohort of women treated with UPA. It demonstrates symptomatic improvements and advantageous modifications in fibroid size in women of all ethnicities and ages. Our inclusion of women with a uterine size greater than 16 weeks and fibroid diameter larger than 10 cm demonstrates the benefits of UPA with increased fibroid dimensions. What the implications are of these findings for clinical practice and/or further research: These findings can allow clinicians to consider alternative surgical interventions or even avoid surgery completely in a proportion of patients with fibroids. Correcting anaemia and optimising a patient's pre-operative condition reduces post-operative complications and ongoing morbidity. However, 25% of fibroids failed to respond to UPA treatment, further research into the characteristics of women and fibroids that show favourable clinical outcomes will allow identification of those women who are likely to benefit from treatment and prevent futile use in others.

Immunology-Rheumatology Approach to Sudden Sensorineural Hearing Loss.

BACKGROUND: Sensorineural hearing loss (SNHL) and vestibular dysfunction have been described in various autoimmune disorders and systemic vasculitides. A high prevalence of SNHL is reported to occur in established rheumatologic diseases; however, immunologic and rheumatologic disorders make up a small proportion of patients with sudden sensorineural hearing loss (SSNHL). OBJECTIVES: This prospective study was carried out in order to determine the prevalence of rheumatologic and immunologic disorders in patients with SSNHL in Northeast Iran. METHODS: Patients with a diagnosis of SSNHL referred to our University Hospital were enrolled in this prospective study conducted over a period of 3 years. Immunology-rheumatology evaluations were performed in all patients, including detailed history, physical exams and laboratory tests such as erythrocyte sedimentation rate (ESR), antinuclear antibody (ANA), rheumatoid factor (RF), anti neutrophil cytoplasmic antibody (PR3, c-ANCA), perinuclear anti neutrophil cytoplasmic antibody (p-ANCA), antiphospholipid antibody, anti-cyclic citrullinated peptide (ACCP), and complement proteins C3 and C4. RESULTS: Eighty-three patients with a mean age of 42.04±16.94 years were admitted into the study. The female-to-male ratio was 47% to 53%. ANA was positive in one patient, RF in six, p-ANCA in two, ACCP in one, and antiphospholipid antibody was positive in three patients with low titers. No diagnosis of rheumatologic diseases was detected, except for one patient who was diagnosed with primary Sjögren's syndrome. Fewer than 5% all cases had specific positive immunologic tests. CONCLUSION: The low frequency of immunology-rheumatology positive tests and disorders in our patients with SSNHL indicates that it is not reasonable to routinely perform all related tests for every patient. Instead, clinical evaluations should be used to decide whether or not to conduct these tests.

An unusual cause of dysphonia with hemoptysis: a laryngeal live leech.

INTRODUCTION: Foreign bodies in the upper airway are one of the most challenging otolaryngology emergencies and have various presentations depending on their physical properties and location. Leeches are blood-sucking hermaphroditic worms that vary in color, length, and shape. They usually reside in fresh-water streams and lakes. When rural untreated water is drunk, leeches may localize in the nose, pharynx, and esophagus, or rarely in the larynx. CASE REPORT: This case is a man who was referred to our otolaryngology clinic with a complaint of hemoptysis and mild respiratory distress. The patient's symptoms were all relieved post operatively and he was discharged on the second day following the procedure. CONCLUSION: Leeches should be suspected as an airway foreign body in patients with a recent history of drinking stream water.

Accuracy of high-resolution computed tomography in locating facial nerve injury sites in temporal bone trauma.

In this study, high-resolution, multislice computed tomography findings are compared with surgical findings in terms of the fracture location in patients with traumatic facial paralysis. Patients with traumatic facial paralysis with grade VI House-Brackmann scale who met the criteria for surgical decompression between 2008 and 2012 were included in this study. All the patients underwent a multislice high-resolution, multislice computed tomography (HRCT) using 1-mm-thick slices with a bone window algorithm. The anatomical areas of the temporal bone (including the Fallopian canal) were assessed by CT and during the surgery (separately by the radiologist and the surgeon), and fracture line involvement was recorded. Forty-one patients entered this study. The perigeniculate area was the most commonly involved region (46.34 %) of the facial nerve. The sensitivity and specificity of HRCT to detect a fracture line seems to be different in various sites, but the overall sensitivity and specificity were 77.5 and 77.7 %, respectively. Although HRCT is the modality of choice in traumatic facial paralysis, the diagnostic value may differ according to the fracture location. The results of HRCT should be considered with caution in certain areas.

Nodular fasciitis of the auricle: a case report.

INTRODUCTION: Nodular fasciitis is described as a benign reactive proliferation of myofibroblasts. Due to its rapid-growing nature, a precise clinical diagnosis is difficult and the condition is frequently misdiagnosed as malignant lesions. CASE REPORT: In this study, we present the case of a young woman with an auricular nodular fasciitis as an example of one of the rarest sites of this tumor. The patient underwent an excision of the lesion under general anesthesia. The literature choices for treatment include complete excision, partial excision, or intralesional injection of steroids. Due to its associated local discomfort, and in order to exclude other differential diagnosis, we recommend a complete surgical excision. CONCLUSION: Auricular nodular fasciitis is a rare lesion. Due to its associated local discomfort, and in order to exclude other differential diagnosis, we recommend a complete surgical excision.