Clinical Severity on Hospital Admission for COVID-19: An Analysis of Social Determinants of Health From an Early Hot Spot in the Southeastern U.S.

INTRODUCTION: Disparities in COVID-19 infection, illness severity, hospitalization, and death are often attributed to age and comorbidities, which fails to recognize the contribution of social, environmental, and financial factors on health. The purpose of this study was to examine relationships between social determinants of health (SDOH) and COVID-19 severity. METHODS: This multicenter retrospective study included adult patients hospitalized with COVID-19 in Southwest Georgia, U.S. The primary outcome was the severity of illness among patients on hospital admission for COVID-19. To characterize the effect of biological and genetic factors combined with SDOH on COVID-19, we used a multilevel analysis to examine patient-level and ZIP code-level data to determine the risk of COVID-19 illness severity at admission. RESULTS: Of 392 patients included, 65% presented with moderate or severe COVID-19 compared to 35% with critical disease. Compared to moderate or severe COVID-19, increasing levels of Charlson Comorbidity Index (OR 1.15, 95% CI 1.07-1.24), tobacco use (OR 1.85, 95% CI 1.10-3.11), and unemployment or retired versus employed (OR 1.91, 95% CI 1.04-3.50 and OR 2.17, 95% CI 1.17-4.02, respectively) were associated with increased odds of critical COVID-19 in bivariate models. In the multi-level model, ZIP codes with a higher percentage of Black or African American residents (OR 0.94, 95% CI 0.91-0.97) were associated with decreased odds of critical COVID-19. CONCLUSION: Differences in SDOH did not lead to significantly higher odds of presenting with severe COVID-19 when accounting for patient-level and ZIP code-level variables.

Cerebral Cryptococcomas: A Systematic Scoping Review of Available Evidence to Facilitate Diagnosis and Treatment.

BACKGROUND: Recommendations for managing patients with cerebral cryptococcomas are scarce across multiple clinical guidelines. Due to the deficiency of high-quality data coupled with an increasing number of at-risk patients, the purpose of this review is to describe the demographic characteristics, causative pathogen, intracranial imaging, surgical and/or pharmacological interventions, as well as outcomes of patients with cerebral cryptococcomas to improve recognition and management. METHODS: We conducted a scoping review in accordance with the PRISMA guidelines using PubMed and Web of Science. Reports were included if the following details were presented: (1) site of infection; (2) treatment details which at least include the specific antifungal therapy administered, if applicable; and (3) patient outcome. RESULTS: A total of 40 records representing 47 individual patients were included, of which the median age was 48.5 years, 75% were male, and 60% reported a significant past medical, surgical, or social history. C. neoformans was isolated more often than C. gattii (74% vs. 26%, respectively). Patients most often presented with headache, altered mental status and/or confusion, and vomiting occurring over a median of 30 days; though few were noted to have significant findings on physical examination. More than 50% of patients had a single cerebral cryptococcoma lesion, whereas perilesional edema was present in 73% of cases. Surgical intervention occurred in 49% of patients. An amphotericin B-based formulation was administered as "induction" therapy to 91% of patients, but combined with flucytosine or fluconazole in only 58%, for an overall median of 42 days. Fifty two percent of patients received "maintenance" therapy for a median of 126 days, in which fluconazole was most often used. Corticosteroids were administered to approximately 30% of patients for a median of 31.5 days. Overall, mortality was 34%. CONCLUSION: Based on our findings, management should include antifungal therapy for a minimum of 6 months with considerations for concomitant corticosteroids in the setting of perilesional edema, as well as surgical intervention. Emphasis should be placed on providing well-documented treatment details in future case reports and series to allow for the development of more concise evidence-based recommendations.

Ischemic Stroke in a Child after a Probable Scorpion Sting.

Scorpion stings are common emergencies in the tropics. Species-specific antivenom therapies are available. However, fatalities resulting from scorpion stings remain a public health concern in many settings. Children residing in rural towns and peri-urban areas represent the most vulnerable populations. Delays in the diagnosis of scorpion stings often occur as a result of the non-specific clinical presentations, which then lead to life-threatening complications. We report a 2-year-old Venezuelan boy presenting with acute pancreatitis and pulmonary edema without an identifiable cause 48 hours after his initial symptoms. We administered antivenom therapy when an undetected scorpion sting was suspected. Despite some initial clinical improvement with respect to his acute pancreatitis, pulmonary edema, and coagulation abnormalities, our patient experienced an ischemic stroke. Fortunately, our patient did demonstrate some neurological improvement. Although acute pancreatitis and pulmonary edema are known end-organ damage manifestations of the sting of Tityus in the Americas, our particular case illustrates the risk of ischemic stroke.

Acute Toxoplasma Dissemination With Encephalitis in the Era of Biological Therapies.

We report the case of a 65-year-old patient with pseudolymphoma who developed acute toxoplasmosis following 6 cycles of rituximab and bendamustine therapy. Acute toxoplasmosis in the setting of biological response modifiers, rather than reactivation, is a unique unreported infection. The patient developed severe disease with multi-organ involvement, including retinitis, myocarditis, and myositis. We discuss the clinical findings, epidemiology, and laboratory diagnosis.

Radiotherapy Alone or With Chemotherapy in the Management of Carcinoma of the Supraglottic Larynx: A 25-Year Community Hospital Experience.

OBJECTIVES: The purpose of this study was to retrospectively review outcomes for patients treated with definitive radiotherapy for carcinoma of the supraglottic larynx at a community hospital and to compare our results with the literature. MATERIALS AND METHODS: Treatment records of 46 patients with localized carcinoma of the supraglottic larynx treated from January 1987 through January 2012 were reviewed. Overall, 18 (39%) presented with stage I or II disease, whereas 28 (61%) presented with stage III to IV. In total, 30 patients (65%) were treated using hyperfractionation, whereas 16 (35%) received once-daily fractionation. Twelve patients (26%) received concurrent chemotherapy with weekly cisplatin. The Kaplan-Meier method was used to assess outcomes. RESULTS: The median follow-up for the living patients was 6.7 years (range, 1.7 to 23.1 y). At 5 years, the local-regional control (LRC), ultimate LRC, laryngeal preservation, and overall survival (OS) rates were 70%, 82%, 65%, and 53%, respectively. At 5 years, disease-free survival and cause-specific survival rates were 75% and 76%, respectively. The 5-year OS rates by American Joint Committee on Cancer stage were as follows: I to II, 61%; III, 51%; and IV, 44%. For those receiving concurrent chemotherapy, there was no improvement in 5-year LRC (83% vs. 66%; P=0.4081) or OS (55% vs. 50%; P=0.7697). For those receiving hyperfractionation, there was no improvement in 5-year LRC (75% vs. 63%; P=0.3369) or OS (55% vs. 50%; P=0.4161). CONCLUSIONS: Our outcomes are similar to those reported in the literature. Neither hyperfractionation nor chemotherapy appeared to confer a benefit for disease control or OS possibly owing to small sample size and the inherent bias of a retrospective review.