COVID-19-Associated Invasive Pulmonary Aspergillosis in the Intensive Care Unit: A Case Series in a Portuguese Hospital.

Invasive pulmonary aspergillosis (IPA) has become a recognizable complication in coronavirus disease 2019 (COVID-19) patients admitted to intensive care units (ICUs). Alveolar damage in the context of acute respiratory distress syndrome (ARDS) appears to be the culprit in facilitating fungal invasion in COVID-19 patients, leading to a COVID-19-associated pulmonary aspergillosis (CAPA) phenomenon. From November 2020 to 15 February 2021, 248 COVID-19 patients were admitted to our ICUs, of whom ten patients (4% incidence) were classified as either probable (six) or possible (four) CAPA cases. Seven patients had positive cultural results: Aspergillus fumigatus sensu stricto (five), A. terreus sensu stricto (one), and A. welwitschiae (one). Five patients had positive bronchoalveolar lavage (BAL) and galactomannan (GM), and two patients had both positive cultural and GM criteria. All but two patients received voriconazole. Mortality rate was 30%. Strict interpretation of classic IPA definition would have resulted in eight overlooked CAPA cases. Broader diagnostic criteria are essential in this context, even though differentiation between Aspergillus colonization and invasive disease might be more challenging. Herein, we aim to raise awareness of CAPA in view of its potential detrimental outcome, emphasizing the relevance of a low threshold for screening and early antifungal treatment in ARDS patients.

Cytotoxic and genotoxic effects of environmental relevant concentrations of bisphenol A and interactions with doxorubicin.

Bisphenol A (BPA) is one of the most widely utilized endocrine disruptors to which humans are exposed, particularity through ingestion. BPA is an aneugenic compound with a putative association to tumorigenesis. Although extensively studied in estrogen responsive cells, information regarding its effects on cells from the upper gastrointestinal tract exposed to free/active forms of BPA is still scarce. Similarly, BPA interactions with other drugs have been neglected, although it has been suggested to have a potential role in doxorubicin (DOX) chemoresistance. This study is intended to assess potential cytotoxic and genotoxic effects of BPA, as well as its interactions with DOX, in Human epithelial type 2 cells (Hep-2) originated from a human laryngeal carcinoma and in a DNA damage responsive cell line, the human lung fibroblasts (MRC-5). Cell viability was analyzed through the resazurin assay. The G protein-coupled estrogen receptor 1 (GPER) expression was visualized by immunodetection. Genotoxicity, namely DNA damage and oxidative DNA damage, were assessed by comet assay and micronuclei induction, and mitotic disruption was evaluated cytologically by fluorescent microscopy with DAPI staining. Cytotoxicity analysis showed that exposure to BPA per se does not affect cellular viability. Nevertheless, the genotoxic analysis showed that BPA induced an increase of DNA damage in the Hep-2 cell line and in oxidative damage in the MRC-5 cell line. An increase of micronuclei was also observed in both cell lines following BPA exposure. BPA and DOX co-exposures suggested that BPA acts as an antagonist of DOX effects in both cell lines. The interaction with DOX appears to be cell type dependent, exhibiting a non-monotonic response curve in MRC-5 cells, a GPER expressing cell line. Our study emphasizes the need for a deeper knowledge of BPA interactions, particularly with chemotherapeutic agents, in the context of risk assessment and public health.

Accuracy of diagnostic tests for Legionnaires' disease: a systematic review.

PURPOSE: Rapid and effective diagnosis of Legionnaires' disease (LD) cases is extremely important so that timely and appropriate therapy can be provided, thereby lowering the morbidity and mortality rates and reducing the health and economic costs associated with this disease. METHODOLOGY: Diagnosis is established solely by microbiological tests. There are several methods available, each with different performance, sensitivity and specificity characteristics, and further understanding is required. Our objective was to assess the accuracy of urinary antigen detection, direct fluorescent antibody (DFA) staining, serological testing and the polymerase chain reaction (PCR) method versus culture analysis (the reference standard) in patients suspected of being infected with Legionella or patients with laboratory-confirmed LD. We performed a MEDLINE search in November 2014. Two authors independently assessed the trials and extracted data. Pooled analysis was performed through Meta-DiSc version 1.4. RESULT: The inclusion criteria were met by 11 studies. All the studies evaluated PCR and DFA tests to detect Legionella in clinical specimens, comparing them to culture techniques, and were included in the meta-analysis. The pooled sensitivity and specificity for PCR were 83 % [95 % confidence interval (CI): 79-87 %] and 90 % (95 % CI: 88-92 %), respectively. DFA was evaluated in one study and the sensitivity and specificity of this test were 67 % (95 % CI: 30-93 %) and 100 % (95 % CI: 91-100 %), respectively. PCR had high sensitivity and specificity for early diagnosis of LD. CONCLUSION: Culture analysis is deemed necessary for epidemiological studies, molecular strain typing and antibiotic sensibility evaluations; however, the performance of PCR in recent studies calls for additional, well-designed studies in order to achieve the best standard test, which will enable optimization of the Legionella infection diagnostic.

Are there effective interventions to prevent hospital-acquired Legionnaires' disease or to reduce environmental reservoirs of Legionella in hospitals? A systematic review.

BACKGROUND: Legionnaires' disease (LD) is recognized as an important hospital-acquired disease. Despite the several methods available, the optimal method to control hospital-acquired LD is not well established and their overall efficacy requires further evaluation. OBJECTIVE: To systematically review all controlled trials evaluating the efficacy of interventions to prevent hospital-acquired LD in patients at high risk of developing the disease and its effects on environmental colonization. METHODS: A database search was performed through PubMed and the Cochrane Central Register of Controlled Trials (inception-November 2014). Eligible studies included all controlled studies evaluating interventions to prevent hospital-acquired LD in patients at high risk or evaluating the effect on environmental colonization. Both individual and pooled risk estimates were reported using risk ratio (RR) and 95% confidence intervals (95% CIs). RESULTS: There were no studies evaluating the risk reduction in hospital-acquired LD, but 4 studies evaluated the influence of copper-silver ionization and ultraviolet light in the reduction of environmental reservoirs of Legionella. The meta-analysis showed a significant 95% risk reduction of Legionella positivity in environmental samples using copper-silver ionization (RR, 0.05; 95% CI, 0.01-0.17) and 97% risk reduction with ultraviolet light (RR, 0.03; 95% CI, 0.002-0.41). CONCLUSIONS: The best available evidence suggests that copper-silver ionization and ultraviolet light are effective in reducing Legionella positivity in environmental samples. Nevertheless, the low quality of evidence weakens the robustness of conclusions.