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The link between type 2 diabetes (T2D) and the severe outcomes of COVID-19 has raised concerns about the optimal management of patients with T2D. This study aimed to investigate the clinical characteristics and outcomes of T2D patients hospitalized with COVID-19 and explore the potential associations between chronic T2D treatments and adverse outcomes. This was a multicenter prospective cohort study of T2D patients hospitalized with COVID-19 in Greece during the third wave of the pandemic (February-June 2021). Among the 354 T2D patients included in this study, 63 (18.6%) died during hospitalization, and 16.4% required ICU admission. The use of DPP4 inhibitors for the chronic management of T2D was associated with an increased risk of in-hospital death (adjusted odds ratio (adj. OR) 2.639, 95% confidence interval (CI) 1.148-6.068, p = 0.022), ICU admission (adj. OR = 2.524, 95% CI: 1.217-5.232, p = 0.013), and progression to ARDS (adj. OR = 2.507, 95% CI: 1.278-4.916, p = 0.007). Furthermore, the use of DPP4 inhibitors was significantly associated with an increased risk of thromboembolic events (adjusted OR of 2.249, 95% CI: 1.073-4.713, p = 0.032) during hospitalization. These findings highlight the importance of considering the potential impact of chronic T2D treatment regiments on COVID-19 and the need for further studies to elucidate the underlying mechanisms.

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Amyloid light-chain (AL) amyloidosis is a multisystemic disease. Among its clinical manifestations, vein and arterial thromboembolic events are included. We report the unusual case of a 57-year-old female patient with AL amyloidosis presenting with an ST segment elevation myocardial infarction due to coronary artery embolization (CE). The patient reported a history of exertional dyspnoea along with episodes of haemoptysis for the last few months. Her coronary angiography demonstrated embolization of the distal segment of the left anterior descending artery. The main findings of her cardiac ultrasound included concentric left ventricular hypertrophy, mildly impaired left ventricular systolic function, left atrium enlargement and a restrictive-like filling pattern, while her chest computed tomography (CT) demonstrated bilateral pleural effusions. Cardiac magnetic resonance imaging that was performed afterwards, indicated areas of microvascular infarction, a small apex infarct and findings compatible with possible amyloidosis, a diagnosis that was confirmed later by fat tissue biopsy. Patient was referred for an oncology consultation, started therapy with direct oral anticoagulants, angiotensin converting enzyme inhibitor, statins and anti-plasma cell therapy. She has been improving since then and has been free of cardiovascular events for a follow-up period of 12 months. Cardiologists ought to be aware of amyloidosis as a rare but possible cause of coronary embolization, while close collaboration with oncologists is required for the establishment of the correct diagnosis.

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BACKGROUND/AIM: To investigate the efficacy (prognosis, coagulation/inflammation biomarkers) and safety (bleeding events) of different anticoagulation dosages in COVID-19 inpatients. PATIENTS AND METHODS: COVID-19 inpatients (Athens, Greece) were included. The "Enhanced dose THRomboprophylaxis in Admissions (ETHRA)" protocol was applied in certain Departments, suggesting the use of intermediate anticoagulation dosage. The primary endpoint was a composite of intubation/venous thromboembolism/death. Inflammation/coagulation parameters were assessed. RESULTS: Among 127 admissions, 95 fulfilled the inclusion criteria. Twenty-one events (4 deaths, 17 intubations) were observed. Regression analysis demonstrated significant reduction of events with intermediate or therapeutic dosage [HR=0.16 (95%CI=0.05-0.52) p=0.002; HR=0.17 (0.04-0.71) p=0.015, respectively]. D-Dimer values were higher in those who met the composite endpoint. Intermediate dosage treatment was associated with decreased values of ferritin. Three patients (3%) had minor hemorrhagic complications. CONCLUSION: Anticoagulation treatment (particularly intermediate dosage) appears to have positive impact on COVID-19 inpatients' prognosis by inhibiting both coagulation and inflammatory cascades.

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We report our initial experience with the management of a mixed group of patients with COVID-19 infection, admitted and treated in a designated COVID-19 centre in the Athens Metropolitan area over a 4-week period. The SARS-CoV-2 pandemic presented a huge challenge to the Greek National Healthcare System and healthcare workers. Their response so far has been miraculously effective. Since there are essentially no therapeutic guidelines yet for this disease, we relied mainly on our medical intuition, our empathy for our patients and team work to do the best possible for 49 people with this infection. We present the therapeutic algorithm we gradually developed (on the job) and applied in our patients, based on continuous creative brainstorming and monitoring of the literature.

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The unfolding COVID-19 pandemic began in December 2019 in Wuhan, Hubei Province. COVID-19 is a systemic infection affecting several systems including the haematopoietic system. Surveys illustrating the laboratory findings of these patients conclude that lymphocytopenia, neutrophilia and thrombocytopenia are prominent amongst them. Moreover, it has been reported a significant decrease in T lymphocyte subsets and an increase of inflammatory cytokines of hospitalized patients with COVID-19. Generally, thrombocytopenia is commonplace in critically ill patients and usually suggests serious organ malfunction. In view of this, this review investigates the correlation between these abnormalities and the prognosis and disease course. Full blood count is an easy, economic and widely available tool which may help to discriminate between patients with or without severe disease. Last but not least, this review examines potential pathophysiological mechanisms by the novel coronavirus which contribute to these haematological alterations aiding the clinicians to better understand this disease and provide more clinical treatment options.

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The aim of this study was to identify risk factors for tracheobronchial acquisition with the most common resistant Gram-negative bacteria in the intensive care unit (ICU) during the first week after intubation and mechanical ventilation. Tracheobronchial and oropharyngeal cultures were obtained at admission, after 48 hours, and after 7 days of mechanical ventilation. Patient characteristics, interventions, and antibiotic usage were recorded. Among 71 eligible patients with two negative bronchial cultures for resistant Gram-negative bacteria (at admission and within 48 hours), 41 (58%) acquired bronchial resistant Gram-negative bacteria by day 7. Acquisition strongly correlated with presence of the same pathogens in the oropharynx: Acinetobacter baumannii [odds ratio (OR) = 20·2, 95% confidence interval (CI): 5·5-73·6], Klebsiella pneumoniae (OR = 8·0, 95% CI: 1·9-33·6), and Pseudomonas aeruginosa (OR = 27, 95%: CI 2·7-273). Bronchial acquisition with resistant K. pneumoniae also was associated with chronic liver disease (OR = 3·9, 95% CI: 1·0-15·3), treatment with aminoglycosides (OR = 4·9, 95% CI: 1·4-18·2), tigecycline (OR = 4·9, 95% CI: 1·4-18·2), and linezolid (OR = 3·9, 95% CI: 1·1-15·0). In multivariate analysis, treatment with tigecycline and chronic liver disease were independently associated with bronchial resistant K. pneumoniae acquisition. Our results show a high incidence of tracheobronchial acquisition with resistant Gram-negative microorganisms in the bronchial tree of newly intubated patients. Oropharynx colonization with the same pathogens and specific antibiotics use were independent risk factors.

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Late onset combined immunodeficiency (LOCID) is a recently described variant of common variable immunodeficiency (CVID), involving adult patients presenting with opportunistic infections and/or low CD4+ lymphocyte counts. A 36-year-old male with unremarkable past medical history presented with fever, respiratory failure, and lymphocytopenia. He was found to have Pneumocystis jiroveci pneumonia (PJP), subsequently complicated by recurrent hospital-acquired Pseudomonas aeruginosa pneumonia and immune reconstitution phenomena, attributed to restoration of immunoglobulin levels. Clinicians should be aware of LOCID, which could be confused with HIV infection/AIDS or idiopathic CD4 lymphocytopenia. In the English bibliography there is only one case report, where PJP was the initial presentation of CVID (that case would probably be classified as LOCID). Phenomena of immune reconstitution are described in various settings, including primary immunodeficiency, manifesting as temporary clinical and radiologic deterioration and leading to misperceptions of therapeutic failure and/or presence of alternative/additional diagnoses.

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OBJECTIVES: Both total antimicrobial use and specific antimicrobials have been implicated as risk factors for healthcare-associated methicillin-resistant Staphylococcus aureus (HCA-MRSA) infection. The aims of this study were: (I) to explore predictors of a new HCA-MRSA infection in comparison with a new healthcare-associated methicillin-sensitive Staphylococcus aureus (HCA-MSSA); (II) to thoroughly assess the role of recent antibiotic use qualitatively and quantitatively. METHODS: The time-period for our study was from October 1997 through September 2001. Through applying strict criteria, we identified two groups of inpatients, one with a new HCA-MRSA infection and one with a new HCA-MSSA infection. We recorded demographic, clinical and antibiotic use-related data up to 30 days before the positive culture date. RESULTS: We identified 127 and 70 patients for each group, respectively. Two logistic regression models were carried out to assess the role of antimicrobial use (qualitatively and quantitatively). In model I, duration of hospital stay, presence of chronic wounds, aminoglycoside and fluoroquinolone use retained statistical significance. In model II, duration of hospital stay and history of intubation during the last month stood out as the only significant predictors of a subsequent HCA-MRSA infection. No significant differences in outcome were noted. CONCLUSIONS: The length of exposure to the hospital environment may be the best predictor of a new HCA-MRSA infection. Use of aminoglycosides and fluoroquinolones may also stand independently along with presence of chronic ulcers and surgical procedures. No independent association between quantitative antibiotic use and subsequent HCA-MRSA infection was documented.

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We report the case of a HIV and syphilis co-infected patient who presented with headache and rash and was found to have syphilitic periostitis. Our case illustrates a rare manifestation of early syphilis and presents the diagnostic dilemmas that can arise in HIV and syphilis co-infected patients.

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OBJECTIVES: Both total antimicrobial use and specific antimicrobials have been implicated as risk factors for healthcare-associated methicillin-resistant Staphylococcus aureus (HCA-MRSA) infection. The aims of this study were: (I) to explore predictors of a new HCA-MRSA infection in comparison with a new healthcare-associated methicillin-sensitive Staphylococcus aureus (HCA-MSSA); (II) to thoroughly assess the role of recent antibiotic use qualitatively and quantitatively. METHODS: The time-period for our study was from October 1997 through September 2001. Through applying strict criteria, we identified two groups of inpatients, one with a new HCA-MRSA infection and one with a new HCA-MSSA infection. We recorded demographic, clinical and antibiotic use-related data up to 30 days before the positive culture date. RESULTS: We identified 127 and 70 patients for each group, respectively. Two logistic regression models were carried out to assess the role of antimicrobial use (qualitatively and quantitatively). In model I, duration of hospital stay, presence of chronic wounds, aminoglycoside and fluoroquinolone use retained statistical significance. In model II, duration of hospital stay and history of intubation during the last month stood out as the only significant predictors of a subsequent HCA-MRSA infection. No significant differences in outcome were noted. CONCLUSIONS: The length of exposure to the hospital environment may be the best predictor of a new HCA-MRSA infection. Use of aminoglycosides and fluoroquinolones may also stand independently along with presence of chronic ulcers and surgical procedures. No independent association between quantitative antibiotic use and subsequent HCA-MRSA infection was documented.

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OBJECTIVES: This study was intended to present evidence for the reliability and validity of a Greek translation of the Medical Outcomes Study-HIV Health Survey (MOS-HIV). DESIGN: Sample consisted of 154 HIV-positive men and women, regardless of disease stage, who are being followed at the department of Infectious Diseases of a tertiary hospital of Athens, Greece. METHODS: The translated Greek version of the MOS-HIV instrument, a brief, comprehensive 35-item health-related quality of life questionnaire, was used to assess ten dimensions of health including overall quality of life, pain, physical functioning, role functioning, social functioning, mental health, energy/fatigue, cognitive function, health distress, and health transition. Additional socio-demographic data and clinical parameters were also collected. Standard guidelines were followed for questionnaire translation to the Greek language. Internal consistency reliability using Cronbach's alpha and the range of measurement of the MOS-HIV subscales were examined. Convergent validity was further examined with the intercorrelations of subscales. ROC analysis was used to estimate the ability of the subscales to discriminate patients according to the characteristics of the disease [i.e. asymptomatic, symptomatic and AIDS, CD4+ lymphocyte count (<200 cells/mm(3) and >200 cells/mm(3))] and assess concurrent validity. RESULTS: All the MOS-HIV scales exceeded the minimum reliability standard of 0.70. Physical functioning and health distress had the greatest reliability coefficient, equal to 0.87 and 0.88, respectively. Correlations among MOS-HIV scales were all significant. Physical functioning, pain, and physical health summary scales were significantly lower for AIDS patients compared to asymptomatic HIV+ individuals. All scales except for role functioning and health transition could discriminate well subjects with CD4+ lymphocyte count <200 cells/mm(3) and >200 cells/mm(3). CONCLUSIONS: The Greek version of the MOS-HIV had good reliability and validity among patients with AIDS. Convergent and concurrent validity were generally confirmed. The MOS-HIV may be useful in assessing health-related quality of life in AIDS patients in Greece. Further research is needed for the evaluation of the Greek version of the MOS-HIV responsiveness to changes over time.

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BACKGROUND: Rates of invasive group B Streptococcus (GBS; Streptococcus agalactiae) disease in adults are on the rise. Invasive GBS disease can be community- or healthcare-associated. We report an outbreak of GBS catheter-related bacteremia in a hemodialysis (HD) unit. MATERIALS AND METHODS: Two patients undergoing HD at the same outpatient HD unit were admitted on the same day (within a few hours of each other) with catheter-related GBS bacteremia. A retrospective study was undertaken at the HD unit to address risk factors for febrile illness on the last HD session day. A detailed questionnaire was completed by all HD patients treated on the same day as the two GBS patients and by all members of the nursing and medical staff. Medical and nursing records of the HD unit were reviewed, as well as infection control and catheter care practices. Patients and staff members submitted swabs for culture. RESULTS: No rectal or vaginal culture of any HD patient or staff member was positive for GBS. The development of recent febrile disease was significantly associated with the presence of a hemodialysis catheter (p=0.028) and care for more than 30min by a specific nurse during the last two HD sessions (p=0.007). CONCLUSIONS: We speculate that the GBS strain was transmitted from one patient to the other through the hands of medical personnel. No such outbreak has ever been reported in HD patients. The importance of strict infection control practices in HD units and the avoidance of catheters for long-term HD should be emphasized.

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The authors conducted a systematic review of the English literature for cases of Gastric Syphilis (GS) in the last 50 years. The 34 studies which met selection criteria included 52 patients with GS. Of the reviewed patients, only 13% had a history of syphilis diagnosis and 46% had prior or concurrent clinical manifestations of the disease. Epigastric pain/fullness was the most common presenting symptom (92%) and epigastric tenderness being the most common sign. Gastric bleeding of variable intensity was documented in 35% of the cases. In the radiologic examinations, fibrotic narrowing and rigidity of the gastric wall was the most common finding (43%), followed by hypertrophic and irregular folds, while in endoscopy the most common lesion types were multiple ulcerations (48%), nodular mucosa, and erosions. The antrum was the most commonly affected area (56%). The majority of the patients received penicillin (83%) with a rapid resolution of their symptoms. Seventeen percent of the patients were treated surgically either due to a complication or due to strong suspicion of infiltrating tumor or lymphoma. The nonspecific clinical, radiologic, and pathologic characteristics of GS can establish it as a great imitator of other gastric diseases. GS should be considered in the differential diagnosis in patients at risk for sexually transmitted diseases who present with abdominal complaints and unusual endoscopic lesions and no other diagnosis is made, irrespective of the presence of H. pylori. The absence of primary or secondary luetic lesions should not deter one from considering GS.

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BACKGROUND: Human immunodeficiency virus (HIV) infection depletes CD4+ lymphocytes, which may benefit patients with inflammatory bowel disease (IBD). The aim was to compare the course of IBD in HIV patients with a matched group of IBD seronegative patients. METHODS: A total of 20 IBD (14 Crohn's disease, 6 ulcerative colitis) HIV infected patients and 40 matched control seronegative IBD patients (2 controls per case) were compared regarding relapse of their disease. The CD4+ count was followed every 6 months and a value of < or =500 cells/microL was used to define patients with immunosuppression. Relapse rates per year of follow-up were compared among the 2 groups and survival curves for cumulative remission rates were compared with a log-rank test. Multivariate analysis was used to discriminate among the impact of different variables on the risk of IBD relapse. RESULTS: The median duration of follow-up was 8.4 years (range 0.6-18 years). The mean relapse rate for the HIV+IBD group was 0.016/year of follow-up as compared to 0.053/year of follow-up for the IBD-matched control group (P = 0.032). Regarding the HIV-positive/IBD group, 14 patients were immunosuppressed at any given time during the follow-up period. None of these patients experienced an IBD relapse, whereas 3 out of the 6 without immunosuppression relapsed (P = 0.017). According to the multivariate analysis, HIV status was the only risk factor independently associated with a lower probability of IBD relapse. CONCLUSIONS: HIV infection reduces the relapse rates in IBD patients and this may be attributed to the lower CD4+ counts seen in these patients.

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Post-sternotomy infectious complications, including superficial and deep wound infections, sternal osteomyelitis and mediastinitis, are rarely caused by fungi. Trichosporon asahii is the main Trichosporon species that causes systemic infection in humans. Most cases involved neutropenic patients with hematologic malignancies. We report a unique case of a non-cancer, non-neutropenic but severely ill patient who developed an ultimately lethal T. asahii infection after sternotomy. We speculate that our patient had been colonized with the fungus and his surgical site infection may have been related to his emergency revascularization surgery. Therapy with liposomal amphotericin failed to sterilize the bloodstream despite in vitro susceptibility results. The addition of voriconazole helped sterilizing the bloodstream without changing the outcome. Physicians must be aware of the continuously expanding spectrum of infections with this emerging difficult-to-treat fungal pathogen.

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Since the introduction of combination antiretroviral therapy (cART), there has been a decrease in the incidence of non-Hodgkin lymphoma among the HIV-infected population and also significantly improved survival rates. We describe a remarkable case of a HIV-infected patient whose large B-cell lymphoma, most likely arising by transformation of a nodal marginal zone lymphoma, completely regressed with the use of cART alone. He remained disease-free for almost 3 years and he finally died from presumed flare up of his lymphoma. There are very few cases of spontaneous regression of lymphomas with cART alone in the HIV population. This is an extreme example of the significance of cART in improving survival in HIV-non-Hodgkin lymphoma and changing the face of the HIV epidemic in general.

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In this article, we describe the first, to our knowledge, reported case of severe bacteremic upper urinary tract infection with pyonephrosis-in the context of prior chronic urinary tract disease-caused by community-acquired methicillin-resistant Staphylococcus aureus (MRSA). The patient presented with fever and constitutional symptoms, and computed tomography revealed extensive renal parenchymal infection along with a staghorn calculus and dilatation of the pyelocalyceal system. His clinical condition rapidly deteriorated, and he developed uncontrollable sepsis, necessitating an emergent nephrectomy. Significant pyonephrosis was noted during surgery. Blood cultures yielded MRSA, and molecular analysis (by polymerase chain reaction) of the MRSA strains from blood and wound fluid showed that they were Panton-Valentine leukocidin positive and they also possessed SCCmecA type IV. Postoperatively, the patient was treated with intravenous vancomycin for 3 weeks and had a favorable outcome.

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This article will provide insight into the evolving perspectives on HIV-related lipodystrophy syndrome: recent changes in epidemiology, a shifting focus from individual component assessment towards a more comprehensive risk evaluation for organ dysfunction and disease, the impact of patient-related outcomes in heath-related quality of life and the integration of this syndrome into a wider scenario of a premature ageing process in HIV-infected people will be discussed. The time has come to proceed beyond lipodystrophy studies based on blood concentrations of lipids and glucose and body fat evaluation. Surrogate markers of organ disease associated with lipodystrophy better identify patients vulnerable to non-infectious co-morbidities (NICMs) rather than statistical risk algorithms. In this evolving perspective NICMs take the place of lipodystrophy in the description of the clinical spectrum of HIV disease and allow integration of this syndrome into the wider scenario of a premature ageing process in HIV-infected people. Management of NICMs needs to be considered as part of a multi-disciplinary holistic approach that accommodates the increasing number of factors influencing non-infectious HIV-related outcomes.

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