Management outcomes of mucormycosis in COVID-19 patients: A preliminary report from a tertiary care hospital

Background

Coronavirus disease 2019 (COVID-19) continues to be a significant health problem worldwide. The unprecedented surge of mucormycosis in patients with COVID-19 is a new emerging challenge. Although a few studies documenting high incidence of mucormycosis in COVID -19 patients have recently emerged in literature, data pertaining to treatment outcomes in such cohorts is lacking. Here, we report our experience in management of mucormycosis in COVID-19 patients at our tertiary care centre.

Method

The clinical, imaging, histopathological and treatment data of 20 patients with mucormycosis (in setting of COVID-19) was analysed.

Results

35% and 65 % of cases developed mucormycosis in setting of active and recovered COVID-19 infections respectively. Diabetes mellitus was documented in 80% cases, with 55% demonstrating HbA1c >10%. Steroid was administered in 80% during COVID-19 illness. Imaging demonstrated paranasal sinus (PNS), orbital and intracranial extension in 100%, 55% and 20% patients respectively. All received amphotericin and underwent endoscopic debridement, 20% underwent orbital decompression and 5% maxillectomy with orbital exenteration. 6/20(30%) patients died (4 with rhino-orbito-cerebral disease, 1 with extensive orbito-maxillary involvement and 1 sino-nasal disease). All 6 patients received steroids and documented poor glycaemic control.

Conclusion

The strong association of hyperglycemia and steroid intake with mucormycosis in COVID-19 cases warrants judicious use of corticosteroids and optimal glycaemic control. Our study highlights that good clinical outcome can be achieved in invasive mucormycosis provided prompt treatment is instituted with aggressive surgical debridement and antifungal medication.

Road traffic accident clinical pattern and management outcomes at JUMC Emergency Department; Ethiopia

Background

Road Traffic Accident is an incident on a way or street open to public traffic. It becomes one of the most significant public health problems in the world especially in developing countries. In Ethiopia, it represents a significant risk for morbidity and mortality. It is also the major public health problem even though studies done on this topic in the study area is limited.

Objective

To assess clinical pattern, associated factors and management outcomes among road traffic accident Victims attending emergency department of Jimma University Medical Center.

Methods

Hospital based cross sectional study design was employed to review patients' chart visited the hospital from March to April 2021. A systematic random sampling technique was applied. The data were collected using pretested checklist and analyzed using SPSS version 26. Descriptive statistics and multivariate logistic regression were computed. Variables with P<0.05 were considered statistically significant.

Results

About 49.6%) were pedestrians injured of which motorcycle accounted 42.9%. More than half of victims never got any type of prehospital care. On arrival, 38.7% were classified as Red of which 71.4% of them were managed surgically. About 84.9% of victims were discharged with improvement whereas12.6% were died. Victims with head injury (AOR= 16.61: 95% CI; 3.85, 71.71), time elapsed to reach nearby health facility (AOR= 3.30; 95 CI (1.13, 9.60), condition of patient at Emergency Department (AOR= 7.78; 95% CI: 2.33, 26.06), GCS at admission (AOR= 20.12; 95% CI: 7.23, 55.96) and days spent in hospital (AOR= 6.85; 95% CI 5.81, 8.06) were independent predictors of unfavorable outcome.

Conclusion

Road Traffic Accident represents a significant risk for morbidity and mortality in Ethiopia, of which head injury and multiple sites injury increase injury severity. Targeted approaches to improving care of the injured victims may improve outcomes. Thus, the clinician should take into consideration the clinical presentation and give due attention to the identified contributing factors in its management.

A Review of Surgical Outcomes of Management of Sinonasal Malignancies: A 8-Year of Clinical Experience (2013-2021) at the Tertiary Centre, Sarawak

Sinonasal carcinoma, a rare and challenging malignancy, originating in the nasal cavity and paranasal sinuses, poses diagnostic and management complexities. This 8-year retrospective analysis at Sarawak General Hospital aims to elucidate demographic trends, histopathological entities, and management outcomes, shedding light on this multifaceted malignancy. Emphasizing the significance of accurate histopathological classification, the study explores the impact on prognostication and treatment strategies. Spanning 2013 to 2021, the study involved 54 patients with sinonasal malignancies. Demographic, clinical, and histopathological details were examined, adhered to the AJCC staging criteria. Analysis involved demographic distributions, tumour characteristics, treatment modalities, and instances of treatment failure. Statistical analysis was done using SPSS version 29.02. The cohort, predominantly male (57.4%) and of Iban ethnicity (44.4%), with a mean age of 52.8 years, exhibited diverse histopathologies, with squamous cell carcinoma as the most common (38.9%). Epistaxis and nasal blockage were common clinical presentations. Advanced stages (III and IV) were prevalent, with the nasal cavity as the primary site. Surgical interventions, mainly endoscopic endonasal excision, were complemented by adjuvant therapies. Complications occurred in 24% of cases. The study highlights a male predilection, occupational risk factors, and a significant association between tobacco smoking and sinonasal cancers. Surgical interventions predominantly utilized the endoscopic approach. Despite a mean survival of 46.6 months, treatment failure occurred in 29.6% of cases, with recurrence and metastasis. Histopathological analysis revealed comparable 5-year disease survival rates between squamous and non-squamous histologies. Treatment failure was significantly associated with the mode of surgery, with open surgery showing a lower incidence. However, nodal status, histopathology types, T staging, and overall staging did display positive associations with treatment failure. This 8-year review provides comprehensive insights into sinonasal carcinoma, addressing demographic, clinical, and histopathological dimensions. The study underlines the complexity of managing this challenging malignancy, emphasizing the need for a holistic approach to patient care. The findings contribute to the understanding of sinonasal carcinoma, guiding clinical decision-making and fostering further research.

Evaluating outcomes of management targeting the recovery of a migratory songbird of conservation concern

Background

Assessing outcomes of habitat management is critical for informing and adapting conservation plans. From 2013–2019, a multi-stage management initiative aims to create >26,000 ha of shrubland and early-successional vegetation to benefit Golden-winged Warblers (Vermivora chrysoptera) in managed forested landscapes of the western Great Lakes region. We studied a dense breeding population of Golden-winged Warblers at Rice Lake National Wildlife Refuge (NWR) in Minnesota, USA, where shrubs and young trees were sheared during the winter of 2014–2015 in a single treatment supported in part by the American Bird Conservancy (ABC) and in part by other funding source(s) to benefit Golden-winged Warblers and other species associated with young forest [e.g., American Woodcock (Scalopax minor)] and as part of maintenance of early successional forest cover on the refuge.

Methods

We monitored abundance of Golden-winged Warblers before (2013–2014) and after (2015–2016) management at the treatment site and a control site, and we estimated full-season productivity (i.e., young recruited into the fall population) on the treatment site from predictive, spatially explicit models, informed by nest and fledgling survival data collected at sites in the western Great Lakes region, including Rice Lake NWR, during 2011 and 2012. Then, using biologically informed models of Golden-winged Warbler response to observed and predicted vegetation succession, we estimated the cumulative change in population recruitment over various scenarios of vegetation succession and demographic response.

Results

We observed a 32% decline in abundance of Golden-winged Warbler breeding pairs on the treatment site and estimated a 27% decline in per-pair full-season productivity following management, compared to no change in a nearby control site. In models that ranged from highly optimistic to progressively more realistic scenarios, we estimated a net loss of 72–460 juvenile Golden-winged Warblers produced from the treatment site in the 10–20 years following management. Even if our well-informed and locally validated productivity models produced erroneous estimates and the management resulted in only a temporary reduction in abundance (i.e., no change in productivity), our forecast models still predicted a net loss of 61–260 juvenile Golden-winged Warblers from the treatment site over the same time frame.

Conclusions

Our study sites represent only a small portion of a large young-forest management initiative directed at Golden-winged Warblers in the western Great Lakes region; however, the brush management, or shearing of shrubs and small trees, that was applied at our study site is a common treatment applied by contractors funded by ABC and its partners on public lands across Minnesota with the expressed intent of benefiting Golden-winged Warblers and related species. Furthermore, the resulting vegetation structure at our treatment site is consistent with that of other areas managed under the initiative, and ABC documents include our study site as successful Golden-winged Warbler management based on observations of ≥1 Golden-winged Warbler at the treatment site since the management. Our assessment demonstrates that, at least for the only site for which pre- and post-management data on Golden-winged Warblers exist, the shearing of shrubs and small trees has had a substantial and likely enduring negative impact on Golden-winged Warblers. We suggest that incorporating region-specific, empirical information about Golden-winged Warbler—habitat relations into habitat management efforts would increase the likelihood of a positive response by Golden-winged Warblers and also suggest that management directed generically at young forest may not benefit Golden-winged Warblers.

Clinical Features and Initial Management Outcomes of Uveal Melanomas in a Single Tertiary Center in Egypt

Introduction

We aimed to report the demographic data, clinical features, and management outcomes of patients with uveal melanoma (UM) in a single tertiary center in Egypt.

Methods

This is a single-center retrospective case series. Patients with UM who were managed at Cairo University Ocular Oncology Service between January 2019 and December 2023 were included. Records were analyzed for patients' demographics, clinical features and different management options. Outcomes included changes in best corrected visual acuity and tumor dimensions (thickness and largest base diameter), perioperative complications, globe salvage, and recurrence rates.

Results

A total of 93 eyes of 93 patients with UM were treated in our service over a period of 5 years. The mean age of patients was 52.18 ± 13.30 years, and 91.4% of tumors were choroidal or ciliochoroidal. 52 eyes (55.91%) were managed with ruthenium-106 episcleral brachytherapy, of which two eyes required additional brachytherapy, 8 eyes ended with secondary enucleation, and the globe was salvaged in 84.62% of eyes. 8 eyes (8.60%) were managed by gamma knife radiosurgery with or without endoresection. One eye with an iridociliary tumor was managed with partial lamellar sclerouvectomy, and the remaining 32 eyes (34.41%) were primarily enucleated.

Conclusion

Timely referral channels and accurate assessment of cases with UM are invaluable for achievement of higher success rates in tumor regression, as well as globe and/or vision salvage in eyes managed with brachytherapy. Patients with more advanced tumors should be counseled on the importance of more invasive options such as enucleation in achieving lower metastasis and mortality rates.

Prediction of vitreomacular traction syndrome outcomes with deep learning: A pilot study

PURPOSE

To investigate the potential of an Optical Coherence Tomography (OCT) based Deep-Learning (DL) model in the prediction of Vitreomacular Traction (VMT) syndrome outcomes.

DESIGN

A single-centre retrospective review.

METHODS

Records of consecutive adult patients attending the Royal Adelaide Hospital vitreoretinal clinic with evidence of spontaneous VMT were reviewed from January 2019 until May 2022. All patients with evidence of causes of cystoid macular oedema or secondary causes of VMT were excluded. OCT scans and outcome data obtained from patient records was used to train, test and then validate the models.

RESULTS

For the deep learning model, ninety-five patient files were identified from the OCT (SPECTRALIS system; Heidelberg Engineering, Heidelberg, Germany) records. 25% of the patients spontaneously improved, 48% remained stable and 27% had progression of their disease, approximately. The final longitudinal model was able to predict 'improved' or 'stable' disease with a positive predictive value of 0.72 and 0.79, respectively. The accuracy of the model was greater than 50%.

CONCLUSIONS

Deep-learning models may be utilised in real-world settings to predict outcomes of VMT. This approach requires further investigation as it may improve patient outcomes by aiding ophthalmologists in cross-checking management decisions and reduce the need for unnecessary interventions or delays.

Management and Outcomes of Hospitalized Patients With Primary Neuroendocrine Tumor and Non-Neuroendocrine Tumor Appendiceal Cancers in the United States

Background

The incidence of appendiceal cancers continues to rise at a very rapid pace. Although surgery has a central role in the management of appendiceal tumors, literature is lacking regarding the pattern and predictors of surgical treatment for patients with appendiceal cancers. We aimed to describe the surgical treatment for patients with appendiceal cancers, with emphasis on utilization based on histology.

Methods

Hospitalized patients with appendiceal cancer in the US between 2006 and 2010 were included in the study. The Nationwide Inpatient Sample database maintained by the Agency for Health Care Research and Quality was employed for univariate and multivariate testing to identify factors significantly associated with patient outcome.

Results

A total of 3,799 patient discharges were identified over the 5-year period covered by the study. Neuroendocrine tumor (NET) was the diagnosis in 291 (7.66%) patients and non-NET in 3,508 (92.34%) patients. The mean age was 56.8 years (± SD 14.6), with female predominance (54.73% vs. 45.27%). NET patients were younger than those with non-NET (50.7 vs. 57.4 years; P < 0.001). NET patients were more commonly treated with appendectomy compared to non-NET (OR: 1.59; 95% CI: 1.23 - 2.07; P < 0.001). Hyperthermic intraperitoneal chemotherapy (HIPEC) was used in 8.5% of all the cases, mostly in non-NET histology (91% vs. 8%). Majority of the patients treated with HIPEC had no co-morbid medical illness (60%), and received care at high volume hospitals located in urban areas. There was a very low incidence of in-hospital mortality (2.5%).

Conclusions

The described surgical utilization pattern should prompt more research focusing on barriers to appropriate surgical debulking and HIPEC utilization in non-NET appendiceal cancers.

Quality of life during usual epilepsy care for anxiety or depression symptoms: Secondary patient-reported outcomes in a randomized trial of remote assessment methods

BACKGROUND AND OBJECTIVES

Anxiety and depression are highly prevalent and impactful in epilepsy. American Academy of Neurology quality measures emphasize anxiety and depression screening and quality of life (QOL) measurement, yet usual epilepsy care QOL and anxiety/depression outcomes are poorly characterized. The main objective was to assess 6-month QOL, anxiety and depression during routine care among adults with epilepsy and baseline anxiety or depression symptoms; these were prespecified secondary outcomes within a pragmatic randomized trial of remote assessment methods.

METHODS

Adults with anxiety or depression symptoms and no suicidal ideation were recruited from a tertiary epilepsy clinic via an electronic health record (EHR)-embedded process. Participants were randomized 1:1 to 6 month outcome collection via patient portal EHR questionnaires vs. telephone interview. This report focuses on an a priori secondary outcomes of the overall trial, focused on patient-reported health outcomes in the full sample. Quality of life, (primary health outcome), anxiety, and depression measures were collected at 3 and 6 months (Quality of Life in Epilepsy-10, QOLIE-10, Generalized Anxiety Disorder-7, Neurological Disorders Depression Inventory-Epilepsy). Change values and 95 % confidence intervals were calculated. In post-hoc exploratory analyses, patient-reported anxiety/depression management plans at baseline clinic visit and healthcare utilization were compared with EHR-documentation, and agreement was calculated using the kappa statistic.

RESULTS

Overall, 30 participants (15 per group) were recruited and analyzed, of mean age 42.5 years, with 60 % women. Mean 6-month change in QOLIE-10 overall was 2.0(95 % CI -6.8, 10.9), and there were no significant differences in outcomes between the EHR and telephone groups. Mean anxiety and depression scores were stable across follow-up (all 95 % CI included zero). Outcomes were similar regardless of whether an anxiety or depression action plan was documented. During the baseline interview, most participants with clinic visit EHR documentation indicating action to address anxiety and/or depression reported not being offered a treatment(7 of 12 with action plan, 58 %), and there was poor agreement between patient report and EHR documentation (kappa=0.22). Healthcare utilization was high: 40 % had at least one hospitalization or emergency/urgent care visit reported and/or identified via EHR, but a third (4/12) failed to self-report an EHR-identified hospitalization/urgent visit.

DISCUSSION

Over 6 months of usual care among adults with epilepsy and anxiety or depression symptoms, there was no significant average improvement in quality of life or anxiety/depression, suggesting a need for interventions to enhance routine neurology care and achieve quality of life improvement for this group.