Association of patient characteristics with clinical outcomes in a cohort of hospitalised patients with SARS-CoV-2 infection in a Greek referral centre for COVID-19.

Patient-important outcomes related to coronavirus disease 2019 (COVID-19) continue to drive the pandemic response across the globe. Various prognostic factors for COVID-19 severity have emerged and their replication across different clinical settings providing health services is ongoing. We aimed to describe the clinical characteristics and their association with outcomes in patients hospitalised with COVID-19 in the University Hospital of Ioannina. We assessed a cohort of 681 consecutively hospitalised patients with COVID-19 from January 2020 to December 2021. Demographic data, underlying comorbidities, clinical presentation, biochemical markers, radiologic findings, COVID-19 treatment and outcome data were collected at the first day of hospitalisation and up to 90 days. Multivariable Cox regression analyses were performed to investigate the associations between clinical characteristics (hazard ratios (HRs) per standard deviation (s.d.)) with intubation and/or mortality status. The participants' mean age was 62.8 (s.d., 16.9) years and 57% were males. The most common comorbidities were hypertension (45%), cardiovascular disease (19%) and diabetes mellitus (21%). Patients usually presented with fever (81%), cough (50%) and dyspnoea (27%), while lymphopenia and increased inflammatory markers were the most common laboratory abnormalities. Overall, 55 patients (8%) were intubated, and 86 patients (13%) died. There were statistically significant positive associations between intubation or death with age (HR: 2.59; 95% CI 1.52-4.40), lactate dehydrogenase (HR: 1.44; 95% CI 1.04-1.98), pO2/FiO2 ratio < 100 mmHg (HR: 3.52; 95% CI 1.14-10.84), and inverse association with absolute lymphocyte count (HR: 0.54; 95% CI 0.33-0.87). These data might help to identify points for improvement in the management of COVID-19 patients.

Injection of an alpha-melanocyte stimulating hormone expression plasmid is effective in suppressing experimental autoimmune uveitis.

PURPOSE: The neuropeptide, alpha-melanocyte stimulating hormone (alpha-MSH), is an endogenous antagonist of inflammation. Injections of alpha-MSH peptide into inflamed tissues have been found to be very effective in suppressing autoimmune and endotoxin mediated diseases. We evaluated the potential to suppress ocular autoimmune disease (uveitis) by augmenting the expression of alpha-MSH through subconjunctival injections of naked adrenocorticotropic hormone amino acids 1-17 (ACTH1-17) plasmid. METHODS: We clinically scored the uveitis over time in B10.RIII, C57BL/6, and melanocortin 5 receptor knock-out (MC5r((-/-))) mice with experimental autoimmune uveitis (EAU) that were conjunctively injected with a naked DNA plasmid encoding ACTH1-17 at the time of EAU onset and three days later. The post-EAU retina histology of plasmid injected eyes was examined, and post-EAU concentrations of alpha-MSH in aqueous humor was assayed by ELISA. RESULTS: The subconjunctival injection of ACTH1-17 plasmid augmented the concentration of alpha-MSH in the aqueous humor of all post-EAU mice. The injection of ACTH1-17 suppressed the severity of EAU in the B10.RIII and C57BL/6 mice but the MC5r((-/-)) mice. In all the models of EAU, the ACTH1-17 injection helped to preserve the structural integrity of the retina; however, post-EAU aqueous humor was not immunosuppressive. CONCLUSIONS: The subconjunctival injection of the alpha-MSH expression vector ACTH1-17 plasmid is effective in suppressing EAU. The suppressive activity is dependent on MC5r expression, and possibly works though alpha-MSH antagonism of inflammation than on alpha-MSH directly modulating immune cells. The results suggest that an effective therapy for uveitis could include a gene therapy approach based on delivering alpha-MSH.

Alpha-MSH regulates protein ubiquitination in T cells.

The neuropeptide alpha-melanocyte stimulating hormone (alpha-MSH) suppresses IFN-gamma + T cells from mice. We discovered, however, that despite this significant production by DTH-mediating effector CD4 supression of IFN-gamma production, alpha-MSH-treated effector T cells had the same level of IFN-gamma mRNA expression and intracellular IFN-gamma protein as untreated activated T cells. In order to explain why IFN-gamma production was suppressed in the face of unchanged mRNA and intracellular IFN-gamma levels, we looked for mechanisms that could increase the degradation of IFN-gamma within the alpha-MSH-treated T cells. Among the known pathways of post-translational intracellular protein modification, the ubiquitin-proteosome system was examined in alpha-MSH-treated T cells to see if a post-translational protein modification occurred to prevent IFN-gamma secretion from the cell. Immunoblots from alpha-MSH-treated T cells showed higher levels of protein ubiquitination when compared to untreated T cells. Resting T cells treated with alpha-MSH also demonstrated enhanced protein ubiquitination. We found that IFN-gamma is one of the ubiquitinated proteins in the alpha-MSH-treated activated T cells. Our results demonstrate that one of the mechanisms by which alpha-MSH regulates T cell activity is through mediating a change in the pattern of protein ubiquitination in T cells.

Melanocortin 5 receptor and ocular immunity.

The nervous system contributes to the mechanisms of ocular immune privilege by the constitutive presence of the immunosuppressive neuropeptide alpha-melanocyte stimulating hormone (alpha-MSH) in the eye. Alpha-MSH through the melanocortin 5 receptor (MC5r) mediates induction of CD4+ regulatory T cells that suppress in an antigen specific manner autoimmune disease. We investigated whether there was a role for MC5r expression in ocular immunity and the natural induction of regulatory T cells that emerged following resolution of experimental autoimmune uveoretinitis (EAU). Unlike wild type mice, EAU in MC5r-/- mice caused severe retinal damage, did mice expressed a not induce the emergence of ocular autoantigen regulatory immunity in the spleen, and the MC5r-/- classical memory immune response when reimmunized with ocular autoantigen. There was expression of MC5r in retinal pigment epithelial cells, in the ganglion cell and neural outer plexiform layers of healthy wild type mice retinas. The recovery of the ocular microenvironment from EAU was not dependent on the expression of MC5r, nor was the recovery dependent on the induction of CD4+ regulatory T cells (Treg cells) in the spleen. However, protection of the retina from the inflammatory damage of EAU and the induction of ocular autoantigen-responsive CD4+ Treg cells in the post EAU spleen requires expression of MC5r.

Enrofloxacin-associated retinal degeneration in cats.

OBJECTIVE: The objective of this study was to evaluate the possible relationship between the administration of parenteral and/or oral [corrected] enrofloxacin and the onset of acute retinal degeneration in cats. The animals studied included 17 cats that received systemic enrofloxacin and developed retinal degeneration soon thereafter. PROCEDURES: In this retrospective clinical study, cats that received parenteral and/or oral [corrected] enrofloxacin and developed acute blindness were identified. Parameters recorded included breed, age, sex, enrofloxacin dosage (daily dose and number of days administered), medical condition for which the antibiotic had been prescribed, ophthalmic signs, examination results, and the visual outcome. Fundus photographs were obtained in seven cats, and electroretinography was performed in five cats. Histopathology was performed on two eyes from one cat (case 1) that received enrofloxacin 5 months previously and developed retinal degeneration. RESULTS: All cats were the domestic shorthair breed; seven were females (one neutered) and ten were males (seven castrated). Ages ranged from 3 to 16 years old (mean +/- SD; 8.8 +/- 4.6 years). The medical disorders for which enrofloxacin was administered ranged from lymphoma and pancreatitis to otitis and dermatitis, and eight cats had urinary diseases. The daily and total dosage of enrofloxacin and number of days of administration were also highly variable. Presenting clinical signs were most often mydriasis and acute blindness. All cats had diffuse retinal degeneration as evidenced by increased tapetal reflectivity and retinal vascular attenuation. Absence of recordable electroretinographic responses suggested diffuse and extensive outer retinal disease. Vision returned in a few cats, but the retinal degeneration persisted or even progressed. Histopathology of two eyes revealed primarily outer retinal degeneration, with diffuse loss of the outer nuclear and photoreceptor layers, and hypertrophy and proliferation of the retinal pigment epithelium. CONCLUSION: Parenteral and/or oral [corrected] enrofloxacin is potentially retinotoxic in some cats, and may result in acute and diffuse retinal degeneration. Blindness often results, but some cats may regain vision. Practitioners should adhere closely to the manufacturer's current enrofloxacin dosage recommendation (5 mg/kg q 24 h), and continue clinical observations for this drug toxicity in cats.

Development of glaucoma after cataract surgery in dogs: 220 cases (1987-1998).

OBJECTIVE: To examine postoperative ocular hypertension (POH) and other variables as predictors of the risk of developing glaucoma after cataract surgery in dogs. DESIGN: Retrospective study. ANIMALS: 220 dogs that had cataract surgery. PROCEDURE: Medical records of 220 dogs (346 eyes) that had extracapsular cataract removal or phacoemulsification of cataracts were reviewed. With respect to glaucoma development, 8 variables were analyzed, which included development of POH, breed, sex, age at time of surgery, eye (right vs left), phacoemulsification time, intraocular lens (IOL) placement (yes or no), and stage of cataract development. Eyes developed glaucoma within 6 or 12 months of surgery or did not have signs of glaucoma at least 6 or 12 months after cataract surgery. RESULTS: Of 346 eyes, 58 (16.8%) developed glaucoma after surgery. At 6 months, 32 of 206 (15.5%) eyes examined had glaucoma; at 12 months, 44 of 153 (28.8%) eyes examined had glaucoma. Median follow-up time was 5.8 months (range, 0.1 to 48 months). Mixed-breed dogs were at a significantly lower risk for glaucoma, compared with other breeds. Eyes with IOL placement were at a significantly lower risk for glaucoma, compared with eyes without IOL placement. Eyes with hypermature cataracts were at a significantly higher risk for glaucoma, compared with eyes with mature or immature cataracts. CONCLUSIONS AND CLINICAL RELEVANCE: Multiple factors appear to contribute to the onset of glaucoma in dogs after cataract surgery. Complications prohibiting IOL placement during cataract surgery may lead to a high risk of glaucoma development.

Disease of the equine posterior segment.

The appearance of the equine fundus is reviewed from the perspective of differentiating normal variations from disease, and the descriptions have been updated to include recently published ocular fundic abnormalities. Most pathological lesions are identified near the optic nerve head, and typically involve depigmentation or hyperpigmentation. Depending upon configuration and appearance, linear pigmented bands may reflect the course of the vortex veins, the transition from tapetal to nontapetal fundus, or indicate chorioretinitis or equine motor neuron disease. Choroidal vasculature is readily apparent in color-dilute (subalbinotic) horses and must be differentiated from hemorrhage. Retinal hemorrhages in foals are common and may occur independently to hypoxic ischemic encephalopathy. Retinal cysts may signal more significant disease in the eye such as anterior segment dysgenesis. Prominence of gray or tan-colored material on or near the optic nerve head may represent traumatic optic neuropathy, benign optic neuropathy, proliferative optic neuropathy or actual neoplasia.

Rose bengal positive epithelial microerosions as a manifestation of equine keratomycosis.

Purpose To describe the clinical appearance of corneal epithelial cell microerosions associated with keratomycosis in the horse. METHODS: Retrospective clinical study. RESULTS: Multifocal, punctate, superficial corneal opacities with positive rose bengal retention were noted in six horses with presumed 'viral keratitis'. Faint fluorescein staining was also present in three cases. Equine herpesvirus tissue culture inoculation was negative for a cytopathic effect in three cases. Aspergillus (n = 3), Curvularia (n = 1), and an unidentified fungus (n = 1) were cultured in five horses, and hyphae found on corneal cytology from the sixth. Mixed bacterial infections were present in three eyes. The eyes of two horses with Aspergillus progressed to deep melting corneal ulcers that required surgical therapy. The microerosions remained superficial, but persistent in the other four eyes. Natamycin was utilized topically in all six horses. Transmission electron microscopy from case 6 revealed mucin layer disruption, an intact corneal epithelial cell layer, and fungal attachment to degenerating epithelial cells. The visual outcome was positive in all six horses, although healing was prolonged (48.5 +/- 14.5 days on average in the horses with no surgery; 62 days on average in the two horses that required surgery). CONCLUSIONS: Complete removal or full-thickness penetration of the corneal epithelial cell barrier may not be necessary to allow fungal adherence and initiation of keratomycosis in the horse. Prior to colonization and invasion of the horse cornea, fungi may induce changes in the mucin layer of the tear film that result in or are associated with rose bengal positive microerosions of the superficial corneal epithelium. Horses with painful eyes, and eyes with superficial, multifocal corneal opacities should have their corneas stained with both fluorescein and rose bengal as fungal microerosions may stain weakly, or not at all, with fluorescein, and may thus be mistaken for presumed 'viral keratitis' of the horse.

Posterior lamellar keratoplasty for treatment of deep stromal absesses in nine horses.

OBJECTIVE: To describe and evaluate the use of posterior lamellar keratoplasty as a surgical treatment for deep corneal stromal abscesses in horses. Animals studied Nine horses of various breeds and ages that presented with corneal stromal abscesses located in the posterior one-third of the cornea. Procedure Retrospective medical record study. RESULTS: Nine horses had deep corneal stromal abscesses that were treated with posterior lamellar keratoplasty. Median patient age was 3 years. Six patients were females and three were geldings. Medical therapy alone had been attempted prior to surgery in all nine animals. Corneal abscess culture and histopathology were performed in 8/9 horses. Cultures were positive for an infectious etiology in 4/8 (50%). Histopathology was positive for an infectious etiology in 5/8 (62.5%). Mean surgical time was 71.0 +/- 18.8 min and the average healing time was 23.7 +/- 5.2 days. Visual outcome was positive in 8/9 cases. Conclusion Posterior lamellar keratoplasty is a promising procedure for treatment of deep corneal stromal abscesses in horses. The procedure resulted in considerable shorter surgery time and healing time than had been observed with full-thickness penetrating keratoplasty. Scar formation with this procedure was not significantly different than with penetrating keratoplasty.

Ulcerative keratitis caused by beta-hemolytic Streptococcus equi in 11 horses.

Purpose To describe 11 clinical cases of ulcerative keratitis in horses associated with beta-hemolytic Streptococcus equi in Florida, USA. METHODS: Retrospective clinical study (1996-99). RESULTS: Beta-hemolytic Streptococcus equi was cultured from 11 horses with deep ulcers, descemetoceles or iris prolapse (n = 8), a suture abscess found with a penetrating keratoplasty for a stromal abscess (n = 1), and ulceration that developed following keratectomy/irradiation for corneal squamous cell carcinoma (n = 2). Beta-hemolytic Streptococcus equi subspecies zooepidemicus was found in 10 eyes and subspecies equi in one. Marked signs of uveitis including miosis and hypopyon were present in 8/11 (72.7%) eyes. Keratomalacia was severe in all eyes. The mean diameter of the ulcers associated with beta-hemolytic Streptococcus was 10.2 +/- 6.1 mm. Eight of the eyes required conjunctival flap surgery (four grafts dehisced) and one eye corneal transplantation. Two eyes were treated with medication only. Isolate sensitivity to antibiotics included ampicillin (6/11), bacitracin (11/11), cephalothin (11/11), chloramphenicol (11/11), gentamicin (5/11), polymyxin B (2/11), and tobramycin (1/11). All isolates were resistant to neomycin. The average healing time was 44.7 +/- 26.7 days. The visual outcome was positive in 8/11 eyes, and the globe retained in 9/11 eyes. CONCLUSIONS: Although Gram-positive bacteria predominate in the normal conjunctival microflora of horses throughout the world, Gram-negative bacteria and fungi are more often isolated from equine ulcers. Beta-hemolytic Streptococcus spp. are associated with a very aggressive ulcerative keratitis with the capability to digest conjunctival graft tissue. Clinical signs are pronounced. Aggressive surgical and intensive medical therapy with topical antibiotics and protease inhibitors is indicated.