Vitamin D in the news: A call for clear public health messaging during Covid-19.

Background: The public are increasingly reliant on the internet and media to access healthcare related information during the Covid-19 pandemic. Vitamin D is essential for musculoskeletal and immune health, with daily supplementation advised by public health bodies. Several studies assessing a possible link between vitamin D and Covid-19 severity have arrived at conflicting results and news articles have been rapidly disseminating such research to the public. There has been little focus on studying the quality of information available. Aim: To identify if online search interest in vitamin D increased with pandemic burden and analyse the accuracy of public health messaging relating to vitamin D in online news articles. Methods: Online search interest data for vitamin D was correlated with pandemic burden, defined as the number of Covid-19 deaths. Online news articles discussing vitamin D and Covid-19 were analysed using qualitative coding. Results: Online search interest for vitamin D increased as pandemic burden increased (p < 0.0001, Spearman's rank). Of the 72 articles identified, most (50%) offered a mixed opinion on the benefit of vitamin D in Covid-19. From articles making a recommendation for vitamin D supplementation, 23% of articles gave mixed messaging or advised against supplementation. 16% of articles recommended a dose which exceeded the safe limit of 4000 IU/day, risking toxicity. Conclusion: A significant number of articles provided mixed messaging or incorrectly advised supratherapeutic doses. This study highlights an opportunity for public health bodies to utilise the increased interest in vitamin D during the pandemic to raise awareness with accurate information.

Dexamethasone treatment may mitigate adverse effects of vitamin D deficiency in hospitalized Covid-19 patients.

AIMS: We have previously demonstrated that vitamin D deficiency might be associated with worse outcomes in hospitalized Covid-19 patients. The aim of our study was to explore this relationship with dexamethasone therapy. METHODS: We prospectively studied two cohorts of hospitalized Covid-19 patients between March and April and between September and December 2020 (n = 192). Patients were tested for serum 25-hydroxyvitamin D (25-OH-D) levels during admission. The first cohort not treated with dexamethasone (n = 107) was divided into vitamin D deficient (25-OH-D ≤ 30 nmol/L) (n = 47) and replete subgroups (25-OH-D > 30 nmol/L) (n = 60). The second cohort treated with dexamethasone (n = 85) was similarly divided into deficient (25-OH-D ≤ 30 nmol/L) (n = 27) and replete subgroups (25-OH-D > 30 nmol/L) (n = 58). Primary outcome was in-hospital mortality and secondary outcomes were elevation in markers of cytokine storm and ventilatory requirement. RESULTS: No mortality difference was identified between cohorts and subgroups. The "no dexamethasone" cohort 25-OH-D deplete subgroup recorded significantly higher peak D-Dimer levels (1874 vs. 1233 µgFEU/L) (p = 0.0309), CRP (177 vs. 107.5) (p = 0.0055), and ventilatory support requirement (25.5% vs. 6.67%) (p = 0.007) compared to the replete subgroup. Among the 25-OH-D deplete subgroup higher peak neutrophil counts, peak CRP, peak LDH, peak ferritin, and lower trough lymphocyte counts were observed, without statistical significance. In the "dexamethasone" cohort, there was no apparent association between 25-OH-D deficiency and markers of cytokine storm or ventilatory requirement. CONCLUSION: Vitamin D deficiency is associated with elevated markers of cytokine storm and higher ventilatory requirements in hospitalized Covid-19 patients. Dexamethasone treatment appears to mitigate adverse effects of vitamin D deficiency.

Not a fungi to be with: Shiitake mushroom flagellate dermatitis.

Shiitake dermatitis is a rare adverse cutaneous reaction to the ingestion of raw or undercooked shiitake mushrooms (Lentinula edodes). We report the case of a patient who developed a striking linear flagellate dermatitis without urticaria three days after returning from a trip from Tokyo where he had eaten shiitake mushrooms. The rash resolved after two weeks with topical corticosteroids and antihistamines given for symptomatic relief. Shiitake dermatitis is thought to be either a toxic or hypersensitivity reaction to lentinan, a heat-inactivated polysaccharide found in the cell walls of shiitake mushrooms. Although this mushroom is widely consumed in Eastern Asia, with the increasing globalisation of cuisine and travel, cases are likely to become more common in the Western world.

Fragmentation of the QRS Complex Is Associated with Right Ventricular Dilatation and Mortality in Critically Unwell Coronavirus Disease 2019 Patients.

BACKGROUND: QRS fragmentation (fQRS) is a depolarization disorder that can be detected on routine electrocardiography (ECG). Current evidence suggests that fQRS is a prognosticator of adverse cardiovascular events. This study aimed to assess the relationship between fQRS and all-cause mortality in critically unwell coronavirus disease 2019 (COVID-19) patients and to investigate the significance of associated abnormalities on echocardiography. METHODS: A retrospective cohort study of COVID-19 patients in a critical care setting was performed. Electrocardiography was performed on presentation to hospital, admission to the critical care unit, and at subsequent points according to clinical need. Transthoracic echocardiography was performed at clinical discretion to assess for structural and functional cardiac abnormalities. Primary outcome was in-hospital mortality and secondary outcome was the need for mechanical invasive ventilation. RESULTS: Totally, 212 consecutive patients were included of which 120 (57%) exhibited fQRS and inferior leads were involved in 88% of the patients. Overall, fQRS was a significant predictor of mortality [65% vs. 44% P =.003; multivariate odds ratio = 2.96, 95% confidence interval (CI): 1.42-6.40, P =.005] and inferior fQRS itself was a significant predictor of mortality (P =.03). There was no significant association between fQRS and the need for invasive mechanical ventilation. A total of 112 patients underwent echocardiography. There was a greater incidence of right ventricular (RV) dilatation in the fQRS group (16% vs. 2% respectively, P =.02) and pulmonary hypertension (33% vs. 14% respectively, P =.03) based on echocardiographic criteria. CONCLUSION: Our study demonstrates that fQRS is significantly associated with RV dilation, pulmonary hypertension, and mortality in critically unwell COVID-19 patients.

Recurrent Nonbacterial Thrombotic Endocarditis and Primary Antiphospholipid Antibody Syndrome.

In 2015, a 37-year-old man was referred for evaluation of hypertension and was found to have a mobile structure on the posterior mitral valve leaflet on echocardiography. Laboratory investigations yielded a diagnosis of primary antiphospholipid antibody syndrome (APLS). He underwent excision of the lesion and mitral valve repair. Histology confirmed the diagnosis of nonbacterial thrombotic endocarditis (NBTE). The patient was anticoagulated with warfarin up until 2018, which was substituted for rivaroxaban because of an erratic international normalised ratio. Serial echocardiography up to 2020 was unremarkable. In 2021, he presented with breathlessness and peripheral oedema. Echocardiography demonstrated large vegetation on both mitral valve leaflets. At the operation, vegetations were also evident on the left and noncoronary cusps of the aortic valve and he underwent mechanical aortic and mitral valve replacement. Histology confirmed NBTE. The case is unusual and highlights recurrent NBTE requiring re-do valve surgery.

Elevated procalcitonin concentrations in severe Covid-19 may not reflect bacterial co-infection.

BACKGROUND: The variability of Covid-19 severity between patients has driven efforts to identify prognosticating laboratory markers that could aid clinical decision-making. Procalcitonin is classically used as a diagnostic marker in bacterial infections, but its role in predicting Covid-19 disease severity is emerging. We aimed to identify the association between procalcitonin and Covid-19 disease severity in a critical care setting and whether bacterial co-infection is implicated. METHODS: We retrospectively reviewed Covid-19 patients with procalcitonin concentrations measured in a critical care setting at our institution between February and September 2020. Laboratory markers including peak procalcitonin values and a range of bacterial culture results were analysed. Outcomes were the requirement and duration of invasive mechanical ventilation as well as inpatient mortality. RESULTS: In total, 60 patients were included; 68% required invasive mechanical ventilation and 45% died as inpatient. Univariate analysis identified higher peak procalcitonin concentrations significantly associated with both the requirement for invasive mechanical ventilation (OR: 3.2, 95% CI 1.3-9.0, P = 0.02) and inpatient mortality (OR: 2.6, 95% CI 1.1-6.6, P = 0.03). Higher peak procalcitonin concentrations was an independent predictor of mortality on multivariate analysis (OR 3.7, 95% CI 1.1-12.4, P = 0.03). There was a significant positive correlation between increased peak procalcitonin concentrations and duration on invasive mechanical ventilation. No significant difference was found between peak procalcitonin concentrations of patients with positive and negative bacterial cultures. CONCLUSIONS: Elevated procalcitonin concentrations in Covid-19 patients are associated with respiratory failure requiring prolonged invasive mechanical ventilation and inpatient mortality. This association may be independent of bacterial co-infection.