Tele-medicine versus face-to-face consultation in Endocrine Outpatients Clinic during COVID-19 outbreak: a single-center experience during the lockdown period.

CONTEXT: The COVID-19 outbreak in Italy is the major concern of Public Health in 2020: measures of containment were progressively expanded, limiting Outpatients' visit. OBJECTIVE: We have developed and applied an emergency plan, tailored for Outpatients with endocrine diseases. DESIGN: Cross-sectional study from March to May 2020. SETTING: Referral University-Hospital center. PATIENTS: 1262 patients in 8 weeks. INTERVENTIONS: The emergency plan is based upon the endocrine triage, the stay-safe procedures and the tele-Endo. During endocrine triage every patient was contacted by phone to assess health status and define if the visit will be performed face-to-face (F2F) or by tele-Medicine (tele-Endo). In case of F2F, targeted stay-safe procedures have been adopted. Tele-Endo, performed by phone and email, is dedicated to COVID-19-infected patients, to elderly or frail people, or to those with a stable disease. MAIN OUTCOME MEASURE: To assess efficacy of the emergency plan to continue the follow-up of Outpatients. RESULTS: The number of visits cancelled after endocrine triage (9%) is lower than that cancelled independently by the patients (37%, p < 0.001); the latter reduced from 47 to 19% during the weeks of lockdown (p = 0.032). 86% of patients contacted by endocrine-triage received a clinical response (F2F and tele-Endo visits). F2F visit was offered especially to young patients; tele-Endo was applied to 63% of geriatric patients (p < 0.001), visits' outcome was similar between young and aged patients. CONCLUSIONS: The emergency plan respects the WHO recommendations to limit viral spread and is useful to continue follow-up for outpatients with endocrine diseases.

Antimicrobial use and microbiological testing in district general hospital ICUs of the Veneto region of north-east Italy.

International - predominantly American - studies undertaken in the ICUs of teaching centres show that inadequate antibiotic therapy increases mortality and length of stay. We sought to ascertain whether this also pertains to smaller ICUs in the Veneto region of north-east Italy. To the best of our knowledge, this is the first such survey in the Veneto area or in Italy as a whole. A retrospective, observational study was performed across five general-hospital ICUs to examine appropriateness of microbiological sampling, empirical antibiotic adequacy, and outcomes. Among 911 patients (mean age, 65.8 years ± 16.2 SD; median ICU stay, 17.0 days [IQR, 8.0-29.0]), 757 (83.1 %) were given empirical antibiotics. Treatment adequacy could be fully assessed in only 212 patients (28.0 %), who received empirical treatment and who had a relevant clinical sample collected at the initiation of this antibiotic (T0). Many other patients only had delayed microbiological investigation of their infections between day 1 and day 10 of therapy. Mortality was significantly higher among the 34.9 % of patients receiving inadequate treatment (48.6 % vs 18.80 %; p < 0.001). Only 32.5 % of combination regimens comprised a broad-spectrum Gram-negative ß-lactam plus an anti-MRSA agent, and many combinations were irrational. Inadequate treatment was frequent and was strongly associated with mortality; moreover, there was delayed microbiological investigation of many infections, precluding appropriate treatment modification and de-escalation. Improvements in these aspects and in antibiotic stewardship are being sought.

Hospital-associated funguria: analysis of risk factors, clinical presentation and outcome.

Fungal urinary tract infections are an increasing problem in hospitalized patients. Funguria may be a result of contamination of the urine specimen, colonization of hte urinary tract, or may be indicative of true invasive infection. In this study, we report the risk factors, clinical features, treatments and outcome in a group of 68 hospitalized patients (adults and children) with fungal isolates recovered from 103 urinary samples. Underlying medical conditions were present in most patients. In the pediatric group, urinary tract abnormalities (86%) and prematurity (19%)accounted for the majority of the cases. Diabetes mellitus (28%), nephrolithiasis, and benign prostatic hyperplasia were the most common diseases in adults. Indwelling urethral catheters were noted in 38% of the pediatric patients and in 43% of adults during hospitalization. Candida albicans strains were responsible for 97% and 75% of positive cultures in children and adults, respectively. Symptoms such as fever, dysuria, frequency and flank pain were generally absent in both groups. Fluconazole was the most frequent antifungal utilized (61%) in children and ketoconazole in the adult group (42%). Removing the urinary catheter was attempted in 6 pediatric patients (29%) and in only 8 adults (17%). One patient (4%) in the pediatric group died compared to 10 in the adult group (21%, p=0.04). Successful diagnosis and treatment of funguria depends on a clear understanding of the risk factors and awareness of fungal epidemiology.

[Fungal keratitis in the State of Paraná-Brazil: clinical, epidemiological and diagnostic findings]. / Ceratite fúngica no estado do Paraná-Brasil: aspectos epidemiológicos, etiológicos e diagnósticos.

Fungal keratites is more prevalent in tropical and subtropical regions, such as Brazil, and causes high morbidity. Usually, it is preceded by underlying conditions like ocular trauma or immunosuppression. The diagnosis is confirmed by the demonstration of the etiologic agent in the clinical specimen. Data were analysed from 49 patients with fungal keratitis observed in Ophthalmologic Division of Hospital de Clinicas, Federal University of Parana, from 1983 to 1997. The diagnosis was confirmed by culture and/ or direct examination. Of the cases studied, 22% were diagnosed only by direct examination; 50% by isolation in culture and 26% by the association of the both methods. The most prevalent etiologic agents were: Fusarium sp. (32%), Aspergillus sp. (16,5%) and Penicillium sp. (10%).

Pathogenesis I: interactions of host cells and fungi.

The interactions of host cells and fungi during infection represent a complex interplay. Although T helper 1 (Th1)-mediated immunity is primarily responsible for acquired resistance to Paracoccidioides brasiliensis, studies have demonstrated that polymorphonuclear neutrophils play a critical role in providing an early resistance to this organism. One study has shown that the invasiveness of Candida albicans requires adherence, particularly to endothelial cells, which in turn are stimulated to express various cell-markers and pro-inflammatory cytokines as part of a proactive resistance to invasion. Somewhat in contrast to infection with C. albicans, it has been shown that the capsular glucuronoxylomannan of Cryptococcus neoformans causes the shedding of host-cell adherence molecules (L-selectins) needed for the migration of host-inflammatory cells to sites of infection and likely explains, in part, the reduced host inflammatory response to this organism. Resistance to aspergillosis is often associated with the immune status of the host. In one set of studies, it has been demonstrated that lymphocytes have little direct effect on the organism, but that antigen-presenting dendritic cells stimulate the production of Th1 cytokines, suggesting a positive role for the dendritic cell in host-response. Similarly, another study has shown that among the regulatory cytokine networks that Th2-associated cytokines (e.g., interleukin-10) likely play a detrimental role in the resistance of the host to Aspergillus fumigatus.

Detection and characterization of Helicobacter pylori from patients with gastroduodenal diseases.

Polymerase chain reaction and cytotoxin assays were performed to identify as Helicobacter pylori type I (cagA+/tox+) or type II (cagA-/tox-) 56 (59.6%) strains from 94 patients. Of these patients 64 were affected by nonulcer dyspepsia (NUD), 10 by gastric ulcer (GU), 19 by duodenal ulcer (DU), and 1 by both GU and DU. H. pylori strains were tested for cagA using two sets of primers; target sequences were detected in 40-42/56 (71.4-75%) depending on the set of primers used, while cytotoxin-producing strains (tox +) were 26/56 (46.4%). Tox+ strains were isolated in 13/32 (40.6%), 2/7 (28.6%), and 11/17 (64.7%) in NUD, GU, and DU patients, respectively. However, the different percentage between cagA+ strains from NUD patients (13/32; 40.6%) and patients with ulcerative diseases (13/23; 54.2%) is not statistically significant (p = 0.462). Because the two sets of primers employed for amplification of cagA target sequences give different results, we concluded that cagA alone could not be taken as predictive factor for severity of gastroduodenal disease. It has been found that H. pylori type I is associated with duodenal ulcer disease.

Detection of Mycoplasma genitalium and Chlamydia trachomatis DNAs in male patients with urethritis using the polymerase chain reaction.

The use of PCR assays as a fast and reliable method is constantly improving and easing microbiological diagnosis. We used a polymerase chain reaction (PCR) assay designed to detect Mycoplasma genitalium and Chlamydia trachomatis in urethral swab samples of 56 males with urethritis and 44 asymptomatic patients as a control group. The PCR assay provides an amplification of target sequence within MgPa (M. genitalium protein attachment) gene. Results indicated that M. genitalium was present in 6 (10.7%) patients with urethritis and none in the control group. Eleven of 56 (17.8%) patients were positive for Chlamydia trachomatis when tested by an outer membrane protein primer-based PCR. The amplified DNA fragments were homogeneous as shown by restriction enzyme analysis and found to be consistent with the published sequences. The PCR assay employed was as reliable as the cultural method in detecting C. trachomatis in the urethral swabs of patients with urethritis (100% of sensitivity when compared with the cultural method) and it has been revealed as an essential method for detection of M. genitalium.

Itraconazole in the treatment of chromoblastomycosis due to Fonsecaea pedrosoi.

The efficacy and tolerability of itraconazole in chromoblastomycosis due to Fonsecaea pedrosoi were evaluated in a non-comparative open clinical trial in 19 Brazilian patients with histopathologically and mycologically proven active chromoblastomycosis. Patients were classified in terms of severity and received itraconazole at the dosage of 200 to 400 mg per day until previously described criteria of cure have been reached. Clinical, mycologic, histopathologic, and laboratory evaluations were performed before, during, and after therapy. The plasma levels of itraconazole and the in vitro susceptibility of the isolates were determined in 15 cases. Clinical and biologic cure were achieved by eight patients (42%) having mild to moderate disease, after a mean duration of therapy of 7.2 months (3.2-29.6 months). Sterile scarred lesions were observed in a post-therapy follow-up lasting on average 9.6 months that was carried out in this subgroup. Clinical cure alone occurred after a mean period of 25.1 months of treatment (16-30.5 months) in seven patients (36%) with moderate to severe disease. Finally, clinical improvement was obtained in four patients (21%) with severe lesions after a mean treatment time of 17.6 months (10.7-22.5 months). All patients responded favorably to itraconazole therapy. No significant side effects nor biochemical alteration during this trial were important enough to interrupt the treatment. Our results support those of previous trials, suggesting that itraconazole is an effective compound against chromoblastomycosis due to Fonsecaea pedrosoi.

201Tl for the differential diagnosis of cold thyroid nodules.

We used 201Tl-chloride for studying and differentiating thyroid areas shown to be 'cold' in previous 131I or 99mTc scanning. We investigated sixteen thyroid neoplasms that were removed surgically shortly afterwards. We found an intense intranodular accumulation of 301T1 in five scintigraphs shown to be of histologically malignant neoplasms, and an intense accumulation also in one of those shown to be histologically benign. We did not detect any 201Tl-chloride accumulation in two cases of thyroiditis; one of these had shown an intense accumulation in a previous 131Cs scintigram.