Effect of high versus low dose of dexamethasone on clinical worsening in patients hospitalised with moderate or severe COVID-19 pneumonia: an open-label, randomised clinical trial.

BACKGROUND: Low-dose dexamethasone demonstrated clinical improvement in patients with coronavirus disease 2019 (COVID-19) needing oxygen therapy; however, evidence on the efficacy of high-dose dexamethasone is limited. METHODS: We performed a randomised, open-label, controlled trial involving hospitalised patients with confirmed COVID-19 pneumonia needing oxygen therapy. Patients were randomly assigned in a 1:1 ratio to receive low-dose dexamethasone (6 mg once daily for 10 days) or high-dose dexamethasone (20 mg once daily for 5 days, followed by 10 mg once daily for an additional 5 days). The primary outcome was clinical worsening within 11 days since randomisation. Secondary outcomes included 28-day mortality, time to recovery and clinical status at day 5, 11, 14 and 28 on an ordinal scale ranging from 1 (discharged) to 7 (death). RESULTS: A total of 200 patients (mean±sd age 64±14 years; 62% male) were enrolled. 32 (31.4%) out of 102 patients enrolled in the low-dose group and 16 (16.3%) out of 98 in the high-dose group showed clinical worsening within 11 days since randomisation (rate ratio 0.427, 95% CI 0.216-0.842; p=0.014). The 28-day mortality was 5.9% in the low-dose group and 6.1% in the high-dose group (p=0.844). There was no significant difference in time to recovery, and in the seven-point ordinal scale at days 5, 11, 14 and 28. CONCLUSIONS: Among hospitalised COVID-19 patients needing oxygen therapy, high dose of dexamethasone reduced clinical worsening within 11 days after randomisation, compared with low dose.

Development of prognostic models to estimate the probability of lung injury one year after COVID-19-related hospitalization-a prospective study.

Background: Long-term effects of severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) infection still under study. The objectives of this study were to identify persistent pulmonary lesions 1 year after coronavirus disease 2019 (COVID-19) hospitalization and assess whether it is possible to estimate the probability that a patient develops these complications in the future. Methods: A prospective study of ≥18 years old patients hospitalized for SARS-COV-2 infection who develop persistent respiratory symptoms, lung function abnormalities or have radiological findings 6-8 weeks after hospital discharge. Logistic regression models were used to identify prognostic factors associated with a higher risk of developing respiratory problems. Models performance was assessed in terms of calibration and discrimination. Results: A total of 233 patients [median age 66 years [interquartile range (IQR): 56, 74]; 138 (59.2%) male] were categorized into two groups based on whether they stayed in the critical care unit (79 cases) or not (154). At the end of follow-up, 179 patients (76.8%) developed persistent respiratory symptoms, and 22 patients (9.4%) showed radiological fibrotic lesions with pulmonary function abnormalities (post-COVID-19 fibrotic pulmonary lesions). Our prognostic models created to predict persistent respiratory symptoms [post-COVID-19 functional status at initial visit (the higher the score, the higher the risk), and history of bronchial asthma] and post-COVID-19 fibrotic pulmonary lesions [female; FVC% (the higher the FVC%, the lower the probability); and critical care unit stay] one year after infection showed good (AUC 0.857; 95% CI: 0.799-0.915) and excellent performance (AUC 0.901; 95% CI: 0.837-0.964), respectively. Conclusions: Constructed models show good performance in identifying patients at risk of developing lung injury one year after COVID-19-related hospitalization.

Inappropriate sinus tachycardia in post-COVID-19 syndrome.

Inappropriate sinus tachycardia (IST) is a common observation in patients with post-COVID-19 syndrome (PCS) but has not yet been fully described to date. To investigate the prevalence and the mechanisms underlying IST in a prospective population of PCS patients. Consecutive patients admitted to the PCS Unit between June and December 2020 with a resting sinus rhythm rate ≥ 100 bpm were prospectively enrolled in this study and further examined by an orthostatic test, 2D echocardiography, 24-h ECG monitoring (heart rate variability was a surrogate for cardiac autonomic activity), quality-of-life and exercise capacity testing, and blood sampling. To assess cardiac autonomic function, a 2:1:1 comparative sub-analysis was conducted against both fully recovered patients with previous SARS-CoV-2 infection and individuals without prior SARS-CoV-2 infection. Among 200 PCS patients, 40 (20%) fulfilled the diagnostic criteria for IST (average age of 40.1 ± 10 years, 85% women, 83% mild COVID-19). No underlying structural heart disease, pro-inflammatory state, myocyte injury, or hypoxia were identified. IST was accompanied by a decrease in most heart rate variability parameters, especially those related to cardiovagal tone: pNN50 (cases 3.2 ± 3 vs. recovered 10.5 ± 8 vs. non-infected 17.3 ± 10; p < 0.001) and HF band (246 ± 179 vs. 463 ± 295 vs. 1048 ± 570, respectively; p < 0.001). IST is prevalent condition among PCS patients. Cardiac autonomic nervous system imbalance with decreased parasympathetic activity may explain this phenomenon.

A case-control analysis of stroke in COVID-19 patients: Results of unusual manifestations of COVID-19-study 11.

OBJECTIVE: We investigated the incidence, predictor variables, clinical characteristics, and stroke outcomes in patients with COVID-19 seen in emergency departments (EDs) before hospitalization. METHODS: We retrospectively reviewed all COVID-19 patients diagnosed with stroke during the COVID-19 outbreak in 62 Spanish EDs. We formed two control groups: COVID-19 patients without stroke (control A) and non-COVID-19 patients with stroke (control B). We compared disease characteristics and four outcomes between cases and controls. RESULTS: We identified 147 strokes in 74,814 patients with COVID-19 seen in EDs (1.96‰, 95% confidence interval [CI] = 1.66‰ to 2.31‰), being lower than in non-COVID-19 patients (6,541/1,388,879, 4.71‰, 95% CI = 4.60‰ to 4.83‰; odds ratio [OR] = 0.42, 95% CI = 0.35 to 0.49). The estimated that standardized incidences of stroke per 100,000 individuals per year were 124 and 133 for COVID-19 and non-COVID-19 individuals, respectively (OR = 0.93 for COVID patients, 95% CI = 0.87 to 0.99). Baseline characteristics associated with a higher risk of stroke in COVID-19 patients were hypertension, diabetes mellitus, and previous cerebrovascular and coronary diseases. Clinically, these patients more frequently presented with confusion, decreased consciousness, and syncope and higher D-dimer concentrations and leukocyte count at ED arrival. After adjustment for age and sex, the case group had higher hospitalization and intensive care unit (ICU) admission rates (but not mortality) than COVID-19 controls without stroke (OR = 3.41, 95% CI = 1.27 to 9.16; and OR = 3.79, 95% CI = 1.69 to 8.50, respectively) and longer hospitalization and greater in-hospital mortality than stroke controls without COVID-19 (OR = 1.55, 95% CI = 1.24 to 1.94; and OR = 1.77, 95% CI = 1.37 to 2.30, respectively). CONCLUSIONS: The incidence of stroke in COVID-19 patients presenting to EDs was lower than that in the non-COVID-19 reference sample. COVID-19 patients with stroke had greater need for hospitalization and ICU admission than those without stroke and longer hospitalization and greater in-hospital mortality than non-COVID-19 patients with stroke.

Advantages and limitations of 18-fluoro-2-deoxy-d-glucose positron emission tomography/computed tomography in the diagnosis of infective endocarditis.

INTRODUCTION: The early diagnosis of infective endocarditis (IE) is a medical challenge and a multidisciplinary approach is essential to improve its frequently fatal prognosis. Our goal was to evaluate the usefulness of [18F]2-fluoro-2-deoxy-d-glucose positron emission tomography (18F-FDG PET) in the diagnosis of this disease. MATERIALS AND METHODS: We prospectively assessed 43 patients (five female and 38 male) with clinical suspicion of IE between 2014 and 2017. All patients underwent transesophageal echocardiography (TEE) and an 18F-FDG PET scan, and the results were compared. A positive PET finding was defined as increased FDG uptake on cardiac valves or intracardiac devices. RESULTS: Out of 43 patients with suspected IE, the diagnosis was confirmed in 30 cases (79.7%). 18F-FDG PET was positive in 24 patients, with 19 showing FDG uptake on cardiac valves (two native and 17 prosthetic) and five on cardiac devices, being concordant with echocardiographic findings in 11 cases. 18F-FDG PET sensitivity was 80%, specificity 92%, positive predictive value (PPV) 96% and negative predictive value (NPV) 66%. Echocardiography presented sensitivity, specificity, PPV and NPV of 36%, 84%, 84% and 36%, respectively. CONCLUSIONS: 18F-FDG PET proved to be a sensitive technique with a high diagnostic value in patients with prosthetic valves and intracardiac devices and suspected IE. Its utility decreased dramatically in patients with suspected IE on native valves, in which TEE presented higher sensitivity and thus better diagnostic value.

Epithelioid hemangioendothelioma in the posterior mediastinum.

Epithelioid hemangioendothelioma is a rare neoplasm usually presenting in soft tissues. A case of epithelioid hemangioendothelioma arising in the posterior mediastinum and presenting as a large pleural effusion in a young woman is presented.

Legionnaires disease and HIV infection.

STUDY OBJECTIVES: To compare the outcome of Legionnaires disease (LD) in patients with and without HIV infection. DESIGN: Retrospective review of clinical charts. SETTING: Six hundred-bed university hospital. PATIENTS: We studied the clinical findings of 64 patients without HIV and 15 patients with HIV. Patients with a serologic diagnosis only were not included. Patients with previous immunosuppressive therapy or transplant recipients were excluded from the former group. In the HIV group, the mean CD4 cell count was 347.5/ microL, plasma viral load was undetectable in 50% of the patients, and only one patient (7%) was receiving cotrimoxazole as prophylaxis against Pneumocystis carinii at the time of pneumonia. No differences were observed in the two groups with respect to community or nosocomial acquisition, delay in the initiation of appropriate treatment, the use of macrolides or fluoroquinolones, and Fine score in cases of community-acquired LD. RESULTS: Univariate analysis showed that time to apyrexia was longer, and respiratory symptoms, bilateral infiltrates in chest radiograph, hyponatremia, increase in aspartate aminotransferase and creatine phosphokinase (CK), and respiratory failure were more frequent in the HIV group. Mortality was greater in patients with HIV, achieving a statistically significant value of 20%; however, multivariate analysis only confirmed these differences with respect to the increase in CK. CONCLUSIONS: LD has a more severe clinical presentation and worse evolution in patients with HIV.

[Legionnaires' disease and HIV infection: an opportunistic infection?]. / Legionelosis e infección por el virus de la inmunodeficiencia humana: infección oportunista?

BACKGROUND AND OBJECTIVE: Legionella infections are not frequent in HIV-infected patients, although clinical manifestations and outcome are particularly severe in this subset. This manuscript analyzes the clinical features and immunological situation of HIV-infected patients with Legionnaires' disease (LD). PATIENTS AND METHOD: The clinical files of HIV-infected patients diagnosed with LD from 1983 to December 2003 were reviewed. The incidence of hospital-acquired Legionella pneumonia (HALP) from 1997-2000 in HIV-infected patients was compared with that of non infected patients. RESULTS: Eighteen patients were included. 72.2% were diagnosed by the Legionella urinary antigen assay. The incidence of HALP in HIV-infected and non infected patients was 0.3 and 0.25/1000 admissions/year, respectively (p = 0.42). 83.3% received appropriate antibiotic treatment at the Emergency department. The mean lymphocyte CD4 count was 348.1/microl, 53.8% had an undetectable viral load and 64.7% were on antiretroviral therapy. 72.2% were smokers, 38.8% had cancer and 16.7% were on chemotherapy. 93.8% had cough, 75% dyspnea, 62.5% extrarespiratory symptoms, 76.5% increased AST, 50% increased CK and 56.3% hyponatremia. Moreover, 50% developed bilateral pulmonary infiltrates, 83.3% respiratory failure and 22.2% died. CONCLUSIONS: Although LD is not more frequent in HIV-infected than in non infected patients, its clinical severity suggests that it is an opportunistic infection.

[Clinical observations on propranolol use for paediatric airway hemangiomas]. / Observaciones clínicas sobre el uso de propranolol en hemangiomas de vía aérea infantil.

Treatment of subglottic hemangiomas in children has traditionally been characterized as a challenging situation with multiple therapeutic options without consensus as to which one is the best and with risks of severe side effects. Recent reports on the experience of propranolol use in the treatment of paediatric airway hemangiomas suggest favourable reasons for this use due to the rapid improvement and its lack of severe side effects. In this paper we report the experience with 6 children having symptomatic airway hemangiomas treated with propranolol. All children improved their respiratory symptoms dramatically and did not need additional interventions.

[Enlarged vestibular aqueduct syndrome. A review of 55 paediatric patients]. / Hipoacusia en niños con acueducto vestibular dilatado. Estudio de 55 casos.

INTRODUCTION: Enlarged vestibular aqueduct (EVA) is the commonest congenital anomaly found with imaging techniques in paediatric sensorineural hearing loss (SNHL). Our aim was to describe clinical and audiological findings in paediatric hearing loss associated to EVA. METHODS: Retrospective review of 55 children with imaging-technique EVA findings from 2000 to 2009. Subjective and/or objective audiological tests were analysed and audiological findings related to clinical features were described. RESULTS: Thirty-seven patients (67.27%) showed bilateral EVA and 18 (32.72%) were unilateral. Hearing loss was bilateral in 46 (83.63%) patients and unilateral in 9 (16.36%). Mean age at diagnosis was 3.78 years. Fifty-three (96.36%) children showed SNHL (28 bilateral and profound), while 2 (3.63%) patients had mixed hearing loss. There were 3 cases of hearing loss progression, 2 fluctuations, 2 of them were asymmetric and 2 patients suffered from vestibular symptoms. Concomitant image findings were 6 cochlear hypoplasia, 2 enlarged internal auditory canals, 1 enlarged vestibule and 1 hypoplastic lateral semicircular canal. Six clinical syndromes were found (2 cases of Down's, and 1 each of Jacobsen, Pendred, Waardenburg and branchio-oto-renal). One child was positive for GJB2 mutation. Familial hearing loss was demonstrated on 12 (21.8%) cases. CONCLUSION: The clinical picture of hearing loss associated to EVA is characterised by great variability. It should be included in the differential diagnosis of unexplained mixed hearing loss. Familial and syndromic findings have to be taken into consideration in the diagnostic evaluations of such patients. Knowledge about the natural history of this illness is needed so as to give parents prognostic information.

Risk factors of invasive aspergillosis after heart transplantation: protective role of oral itraconazole prophylaxis.

The study was designed to identify a subset of heart transplant (HT) recipients who could benefit from the administration of targeted antifungal prophylaxis and to evaluate the efficacy of oral itraconazole as the preventive drug. We have analyzed the risk factors for invasive aspergillosis (IA) in our entire population of HT recipients (1988-2002) and also the role of oral itraconazole prophylaxis that was provided to all patients since 1995 [400 mg q.d. of itraconazole oral (PO) for 3-6 months]. There were 24 cases of IA. Our main results indicate that the independent risk factors for IA after heart transplantation are: re-operation (RR 5.8; 95% CI 1.8-18, p=0.002), cytomegalovirus (CMV) disease (RR 5.2; 95% CI 2-13.9, p=0.001), post-transplant hemodialysis (RR 4.9; 95% CI 1.2-18, p=0.02), and the existence of an episode of IA in the HT program 2 months before or after the transplantation date (RR 4.6; 95% CI 1.5-14.4, p=0.007). Itraconazole prophylaxis showed an independent protective value against developing IA (RR 0.2; 95% CI 0.07-0.9, p=0.03) and also determined a significantly prolonged 1-year survival (RR 0.5; 95% CI 0.3-0.8, p=0.01). We believe that antifungal prophylaxis in heart transplant patients should be offered at least to patients with one or more of these predisposing conditions.