Widespread Use Of Steroids Research Articles

Risk factors affecting outcome of rhino-orbital-cerebral mucormycosis in COVID-19 patients

BackgroundMucormycosis is a serious life-threatening fungal infection that recently made severe sudden and devastating surge during the second wave of the COVID-19 epidemic with a mortality rate of up to 50%.Although the causality link between COVID-19 and rhino-orbito-cerebral mucormycosis (ROCM) remains unclear, many factors including poor diabetes control, high doses of steroids, viral-induced lymphopenia, and cytokine storm have been attributed to ROCM in patients with COVID-19.Orienting to risk factors and early recognition of this potentially fatal opportunistic infection is the key to optimal management and improved outcomes. In these contexts, we conducted a prospective study for 33 patients admitted to our tertiary hospital to determine the risk factors for ROCM in patients with COVID-19 and the cumulative mortality rates.ResultsThis study found a statistically significant relation between the fate of death in COVID-MUCOR patients who had presented fever, ophthalmoplegia, facial skin necrosis, and visual loss with those who received dose of steroid to control their respiratory symptoms P < 0.001.Death from COVID-MUCOR was statistically significant related to the prolonged interval from the onset of the symptoms to start of treatment and intervention. Also, it was found that there was a significant decrease in duration between COVID-19 infection and the start of mucormycosis (days) with incidence of DKA on admission. Nineteen (57.6%) of the patients had uncontrolled diabetes mellitus (hemoglobin A1C (HbA1c) of > 7.0%).ConclusionMucormycosis epidemic was precipitated by a unique confluence of risk factors: diabetes mellitus, widespread use of steroids, and perhaps SARS-CoV-2 infection itself. Restricting steroid use in patients with severe COVID-19 requiring oxygen therapy, and screening for and optimally controlling hyperglycemia, can prevent COVID-MUCOR in a large majority.

Analysis of ophthalmic manifestations of invasive rhino-orbito-cerebral mucormycosis in COVID-19 patients in a medical college

To analyze different ophthalmic manifestations of rhino-orbital mucormycosis (ROM) infection in COVID-19 patients. Prospective interventional clinical study.20 microbiologically confirmed ROCM cases with ophthalmic involvement hospitalized between May 2021 and July 2021 in our center were included in this study. Among 20 cases there were 9 female and 11 male with a mean age of 57.5 years. All 20 patients had uncontrolled type 2 diabetes with a mean diagnosis duration of 3.67 years. All patients had COVID-19-associated acute respiratory distress syndrome and received corticosteroids. The mean time interval between COVID-19 diagnosis and ROM diagnosis was 3.46 days. 4 patients (20%) had orbital apex syndrome, and 16 patients (80%) presented with orbital cellulitis. CT scan/MRI revealed sino-orbital involvement in all patients, and 3 of these had cerebral involvement at initial presentation. All 20 patients received intravenous amphotericin B and 7 patients received TRAMB and all 20 patients had undergone radical debridement of involved sinuses. Despite all measures, 3 (7.5%) of 20 patients with cerebral dissemination expired. Severe COVID-19 is associated with a significant incidence of ROM with higher mortality rates due to immune dysregulation and the widespread use of steroids. An aggressive multidisciplinary approach can help to reduce mortality.

Focus on Ophthalmopathology - Orbital Infections from Hordeolum to Necrotizing Fasciitis.

(Peri)orbital infections comprise a multitude of diagnoses, ranging from common hordeolum to rare but life-threatening necrotizing fasciitis. However, these disease entities are rarely diagnosed by an ophthalmic pathologist because (peri)orbital infections are usually diagnosed clinically, with the help of imaging and microbiological techniques when indicated. In this review article, the role of ophthalmopathology in the diagnosis of (peri)orbital infections is illustrated on the basis of several exemple diagnoses. An infectious hordeolum must be distinguished from a noninfectious chalazion. A nodular thickening of the eyelid, which is diagnosed and treated as a chalazion, can hide a malignant neoplasia. The correct diagnosis and treatment of canaliculitis is often delayed. In this context the most common causative organism, Actinomyces, can be depicted histologically, as can lacrimal stones/dacryoliths. Necrotizing fasciitis is a rapidly worsening infection of the fascia, which can lead to necrosis, sepsis, and death. During the Sars-CoV2 pandemic, an increased incidence of mucormycosis cases was observed, especially in India. This superinfection was facilitated by the widespread use of steroids and immunosuppression. Histologically, it is possible to visualize infiltration of vessel walls by the fungus. Ophthalmopathology contributes to the diagnosis and to understanding the pathophysiology of these diseases.

Starting at the Source: Donor Research, Done Right.

Transplant research needs to start at the source. Optimizing graft function to ameliorate ischemia-reperfusion needs to occur before the injury occurs to protect organs and prevent graft failure. The aim of donor management is to optimize perfusion and oxygen delivery to the grafts by maintaining favorable hemodynamics, intravascular volume, and metabolic states while averting the pathophysiological derangements that occur with death by neurological criteria. Defining specific donor management goals a priori and implementing standardized interventions to meet these goals improve organ yield1 and are widely put in practice by organ procurement organizations. Achieving the hemodynamic goals (usually mean arterial pressure between 60 and 110 mm Hg) to maintain organ perfusion is considered particularly important; however, it is controversial what interventions are best suited to reach that goal. The study by van Bakel et al2 studied almost 200 organ donors who were randomized to receive either high-dose methylprednisolone, levothyroxine, both, or neither before organ procurement. Although the study was not powered to detect a difference in organ yield or quality, the authors found that methylprednisolone either alone or in combination with levothyroxine (but not levothyroxine alone) reduced vasopressor requirements. Administration of methylprednisolone further reduced a number of inflammatory markers, specifically of interleukin-6, interleukin-12p40, and tumor necrosis factor-alpha, potentially an indication that the reduction of vasopressors may actually improve organ perfusion. Vasopressors are a double-edged sword that may—in the vasodilated state—restore vascular tone and organ perfusion and can also decrease graft perfusion and cause ischemia. Nevertheless, use of high-dose vasopressors in donors has consistently been associated with worse outcome, and reduction of vasopressor requirements should probably be considered beneficial. A number of studies have demonstrated that bundles of hormone replacement (steroids, thyroid hormone, vasopressin) improve organ yield and function,3 but which component of the bundle is beneficial has been unknown. Based on the results of the present study, administration of steroids should be considered part of donor management protocols. Unfortunately, this study was not powered to actually detect the difference in outcomes and therefore does not provide the conclusive, strong evidence needed to unequivocally support wide spread use of steroids in all donors. There is scant evidence for any donor interventions before procurement to a large degree because of the logistical difficulties of organ donor research. A landmark study by Niemann et al4 demonstrated the benefit of mild donor hypothermia to prevent delayed graft function in kidney recipients. More importantly, this study provided a blueprint on how to conduct large, randomized studies of transplant donors. Ethical considerations are real: studying donors who are dead by neurological criteria is not human subject research. But any (randomized) intervention applied to the donor can affect up to 8 solid organ recipients. True equipoise is essential for donor research to avoid biases and potential harm to recipients. Some interventions that may be favorable for 1 organ may harm others, and coordination of organ donor intervention research may be needed. The National Academies of Sciences, Engineering, and Medicine recognized the need for more donor research and provided a broad framework in their 2017 consensus study report “Opportunities for Organ Donor Intervention Research: Saving Lives by Improving the Quality and Quantity of Organs for Transplantation.”5 This report delineates a process to address the ethical concerns of donor research and recommends the institution of a single institutional review board, a Donor Research Oversight Committee, to coordinate different projects and data and the institution of safety monitoring boards to oversee the conduct of these studies. This is a great step in the right direction to create a scaffolding to support studies that further our knowledge about donor management and may help us improve organ yield, graft function, and outcomes after transplantation.

Risk Factors Associated with the Mucormycosis Epidemic During the COVID-19 Pandemic

PurposeThe second wave of the COVID-19 pandemic in India is associated with an unprecedented surge of patients with mucormycosis. This study assessed the risk factors driving the epidemic of COVID-19 associated mucormycosis (CAM) and addressing these risk factors could reduce morbidity and mortality among vulnerable populations.Methods & MaterialsThis is a case-control analysis of risk factors in 164 adults from a prospective cohort database, the POISE Mucor Study, approved by the institutional review board and ethics committee with proven invasive mucormycosis of paranasal sinuses admitted in a tertiary care hospital in South India from 01.07.2020 to 10.06.2021 included after informed consent. Cases were patients with COVID-19 confirmed by RT-PCR for SARS-CoV-2 on a nasopharyngeal sample within three months of mucormycosis. Patients with ROCM (Rhino-orbito-cerebral mucormycosis) negative RT-PCR for SARS-CoV-2 were the controls.ResultsThe mean age of the 164 patients (132 cases and 32 controls) was 51 years, and 78% were men (table 1). Most patients with CAM had mild COVID-19 (76.7%); 16.3% and 7% had moderate and severe/critical disease, respectively. Almost all patients presented with acute ROCM within 3 months of COVID-19 occurrence.Diabetes mellitus (present in 97%) remained a strong predisposing factor in both groups.Uncontrolled diabetes mellitus (HbA1c of >7.0%), 40% of which was newly detected, was associated with CAM (OR: 4.6; p=0.026). Diabetic ketoacidosis and mean HbA1c values were not.Steroid use was common, even in mild disease, and was strongly associated with CAM (OR:38.3; p<0.001). Oxygen use was uncommon among cases (14.4%). Serum ferritin was significantly higher among patients with CAM (p=0.041); whereas C-reactive protein was not. Acute presentation of ROCM was commoner in CAM. Involvement of brain and orbit were similar between groups. Multivariate analysis revealed that steroid use was independently associated with CAM (OR 28.4; p=0.001).ConclusionThe current Indian mucormycosis epidemic (mostly acute ROCM) was precipitated by a unique confluence of risk factors – diabetes mellitus, widespread use of steroids, and the COVID-19 infection itself.Restricting steroid use to patients with severe COVID-19 requiring oxygen therapy, screening for and optimally controlling hyperglycaemia can prevent CAM in a large majority.

Practice Variation in Perioperative Steroid Dosing for Brain Tumor Patients: An International Survey

Steroids are commonly used to treat peritumoral edema and increased intracranial pressure in patients with brain tumors. Despite widespread use of steroids, relatively little evidence is available about their optimal perioperative dosing scheme. This study aimed to increase insight into practice variation of perioperative steroid dosing and tapering schedules used in the neurosurgical community. An electronic survey comprising 27 questions regarding steroid dosing, tapering schedules, and adverse events was administered to neurosurgeons between December 6, 2019, and June 1, 2020. The survey was distributed through the European Association of Neurosurgical Societies and social media platforms. Collected data were assessed for quantitative and qualitative analysis. The survey obtained 175 responses from 55 countries across 6 continents, including 30 from low- or middle-income countries; 152 (87%) respondents completed all questions. Of respondents, 130 (80%) indicated prescribing perioperative steroids. Reported doses ranged from 2 to 64 mg/day in schedules ranging from 1 to 4 times daily. The most prescribed steroid was dexamethasone in doses of 16 mg/day (n= 49; 31%), 12 mg/day (n= 31; 20%), and 8 mg/day (n= 18; 12%). No significant association was found between prescribed dose and physician and institutional characteristics. Steroids are commonly prescribed perioperatively in patients with brain tumors. However, there is great practice variation in dosing and schedules among neurosurgeons. Future investigation in a prospective and preferably randomized manner is needed to identify an optimal dosing scheme and implement international/national guidelines for steroid use.

Mucormycosis in Post COVID-19 Patients: A Case Study

Introduction: Acute respiratory distress syndrome (ARDS) is a common complication of severe pneumonia virus, such as the flu and COVID-19, which requires critical treatment, including asthma support, corticosteroids, and other treatments to prevent acute respiratory tract inflammation. Although steroid treatment is limited to the treatment of viral pneumonia, it is usually a double-edged sword, leading to increased morbidity and mortality. Mucormycosis is a fungal emergency with a high tendency for contaguous spread and a poor prognosis if not detected and treated promptly. Mucormycosis is believed to be caused by uncontrolled diabetes mellitus (DM) and other immunosuppressive disorders, such as corticosteroid therapy.&#x0D; Aim: To discuss causality factor of mucormycosis in COVID-19 infection.&#x0D; Conclusion: COVID-19 is correlated with a high rate of secondary infections, both bacterial and fungal, most likely as a result of immune dysregulation. Furthermore, the widespread use of steroids and broad-spectrum antibiotics as part of the COVID-19 remedy can result in the production or exacerbation of pre-existing fungal diseases. Physicians should be mindful of the likelihood of invasive secondary fungal infections in patients with COVID-19 infection, especially in those that have pre-existing risk factors, and should be able to detect and treat these infections early in order to reducing mortality and morbidity.

Post Covid-19 rhino-orbital fungal infections: A histopathological study of 20 cases

COVID-19 is associated with a significant incidence of secondary infections, both bacterial and fungal immune dysregulation. Additionally, the widespread use of steroids, monoclonal antibodies, broad spectrum antibiotics as part of the armamentarium against COVID-19 may lead to the development or exacerbation of pre-existing fungal diseases. As the infection spreads, it can manifest as headaches, proptosis, ophthalmoplegia, acute vision loss, and multiple cranial nerve palsies. Mucormycosis is a rare life threatening opportunistic fungal infection caused by fungi of Mucorales order belonging to the phycomycetes class. Rhino-orbital mucormycosis usually develops in the patients with diabetes, prolonged corticosteroid use, hematological malignancies, chronic renal failure, and other immunocompromised states. Rhino-orbital infection begins when fungal spores are inhaled and invade the nasal mucosa and sinusitis develops as the fungus spreads to the paranasal sinuses. Orbital involvement occurs when the infection invades the orbital wall from the paranasal sinuses. Symptoms may include pain, chemosis, vision loss, ophthalmoplegia and proptosis. Ophthalmoplegia arises from infection of the muscles and orbital space or when the third, fourth and sixth cranial nerves are affected. Peripheral seventh cranial nerve paresis or paralysis and hypoesthesia of the face are often observed. Here we are presenting histopathological study of 20 cases of post COVID-19 rhino-orbital fungal infection.

Epidemiology, Clinical Features and Management of Rhino Orbital Mucormycosis in Post COVID 19 Patients

COVID 19 infections may be associated with a wide range of bacterial and fungal co-infections. Mucormycosis is a fungal infection primarily affecting immunocompromised individuals. We have observed sudden rise of mucormycosis cases in post COVID 19 patients. Here we have reported 100 cases of mucormycosis associated with COVID 19. To study epidemiology and clinical features of rhino orbital mucormycosis in post COVID 19 patients. To evaluate efficacy of medical as well as surgical treatment in such patients. This was an observational mixed (retrospective + prospective) study with a duration of 2 months. After noting demographic data, necessary radiological investigation was advised and representative tissue was sent for KOH and histopathological examination. Medical and surgical treatment was planned accordingly. Most patients (55%) presented with complaint of headache and facial pain. Hard palate involvement was observed in 45% patients. Unilateral presentation (68%) was more common. Only 25% patients who presented early had normal vision. We reported 22 patients with complete loss of vision. Eye movements were restricted in 58% patients. Diabetes mellitus is most common predisposing factor (65%). 9 patients required orbital exentration. Only 18% patients required Amphotericin for more than 14 days. Immune dysregulation caused by COVID 19 infection in addition to widespread use of steroids and broad-spectrum antibiotics may lead to the development mucormycosis. Diabetes Mellitus type II is another important risk factor and the presence of both have additional effect in causing mucormycosis. Headache and facial pain should be considered highly suspicious of mucormycosis. Early diagnosis with efficient treatment can improve prognosis.

Susceptibility of severe COVID-19 patients to rhino-orbital mucormycosis fungal infection in different clinical manifestations.

PurposeTo present the different clinical manifestations of rhino-orbital mucormycosis (ROM) co-infection in severe COVID-19 patients.Study designProspective observational clinical studyMethodsAmong 32,814 patients hospitalized with the diagnosis of COVID-19 between March 2020 and December 2020 in our center, eleven microbiologically confirmed ROM co-infection cases in severe COVID-19 patients were evaluated.ResultsThere were nine men and two women with a mean age of 73.1 ± 7.7 years. Eight patients had uncontrolled type 2 diabetes with a mean diagnosis duration of 12.1 ± 4.4 years. All patients had COVID-19-associated acute respiratory distress syndrome and received corticosteroids. The mean time interval between COVID-19 diagnosis and ROM diagnosis was 14.4 ± 4.3 days. Seven patients (63.6%) had orbital apex syndrome, and four patients (36.4%) presented with orbital cellulitis. Endophthalmitis was detected in 54.5% of patients, and two of these patients developed retinoschisis. CT scan/MRI revealed sino-orbital involvement in all patients, and three of these had cerebral involvement at initial presentation. All patients received intravenous and retrobulbar liposomal amphotericin B and had undergone radical debridement of involved sinuses. Intravitreal liposomal amphotericin B injected in patients with endophthalmitis. Despite all measures, 63.6% of patients expired.ConclusionsSevere COVID-19 is associated with a significant incidence of ROM with higher mortality rates due to immune dysregulation and the widespread use of steroids. Physicians should be aware of the possibility of this infection in patients with COVID-19. An aggressive multidisciplinary approach can help to reduce mortality.Supplementary InformationThe online version contains supplementary material available at 10.1007/s10384-021-00845-5.

EPID-33. PRACTICE VARIATION OF STEROID DOSING AND TAPERING SCHEDULES AMONG THE NEURO-ONCOLOGY COMMUNITY

Abstract INTRODUCTION Steroids are commonly used for treatment of peritumoral edema and increased intracranial pressure in brain tumor patients. However, despite the widespread use of steroids, relatively little evidence is available about the optimal dosing scheme in brain tumor patients. PURPOSE The aim of this study is to increase insight in the practice variation of steroid dosing and tapering schedules among the neuro-oncology community. METHODS An electronic survey consisting of 27 questions regarding dosing and tapering schedules and adverse events of steroids was conducted among neurosurgeons internationally between 6 December 2019 and 1 June 2020. The survey was distributed by the electronic mailing lists of the Europeans Association of Neurosurgical Societies and via social media platforms. Collected data was assessed for quantitative and qualitative analysis using the Kruskal-Wallis test. RESULTS The survey obtained 175 responses. 87% of respondents answered all questions. Steroids are prescribed routinely perioperatively by 80% of respondents. Prescribed doses range from 2 to 64 mg/day in dosing schedule ranging from one to four times a day. The most prescribed steroid is dexamethasone in a dose of 16 mg/day. No significant association is seen between the prescribed dose and frequency of adverse events, years of experience, country, type of institution or having an institutional guideline. CONCLUSION Steroids are routinely prescribed perioperatively in brain tumor patients. However, there is a great practice variation in steroid dosing and tapering schedules among neurosurgeons. Future investigation is needed to identify an optimal dosing scheme and implement (inter)national guidelines for the dosing of steroids.

Steroids: a new look at performance-enhancing drugs

Sports fans or not, readers will be fascinated by this revealing examination of the pressures leading to the widespread use of steroids in sport and the negative, unintended consequences of their ban. * A comprehensive history of steroid use in Olympic sport and the policy decisions related to their proscription

A rapid, high content,in vivomodel of glucocorticoid‐induced osteoporosis

Glucocorticoid-induced osteoporosis (GIOP) is a major clinical problem given the widespread use of steroids and limited efficacy of biphosphonates. Existing animal models of GIOP are both slow and expensive. Hence, there is a need both for adjunctive modelling systems, as well as more efficacious therapies for the treatment of GIOP. We have addressed this issue through the creation of a zebrafish model of GIOP, which can be used for 96-well plate in vivo screening with an assay time of 5 days. The model demonstrates key similarities to human GIOP including a partial response to bisphosphonates. The ability to extract detailed pharmacological data, including concentration-response analyses, enables the screening and ranking of candidate therapeutic compounds. In addition, the zebrafish model is highly relevant for pathway dissection through genetic knockdown and overexpression studies.

138 The Nonimpact of Post-1994 Neonatal Technology on IUGR Preterm Newborns

Background: Widespread use of steroids and surfactant since the mid-1990s has improved survival for premature newborns (PN). Survival and neurodevelopmental outcomes are less favorable in the intrauterine growth restricted (IUGR) subset of premature newborns. Since 1983 our institution has cared for 398 IUGR PN with birth weights (BW) </= 900g including the worlds two smallest surviving newborns (280g female,1989; 260g female, 2004). We sought to compare survival among these IUGR PN before and after the advent of widespread use of steroids and surfactant.Methods: Our retrospective study included newborns with gestational age (GA) >/= 22 wks, BW </=900g and weight </=10th %ile for GA. Statistical analysis: survival to discharge:z-ratio; BW and GA: student t-test.Results: Newborns enrolled: 1983–94 (n=214) 1995–2004 (n=184) Survival to discharge: 1983–94 (61.2%) 1995–2004 (67.9%) p=0.16 Mean GA (wks): 1983–94 (27.5) 1995–2004 (27.1) p=0.17 BW (g): 1983–94 (662) 1995–2004 (639) p=0.14Conclusions: Despite widespread use of antenatal/postnatal steroids and surfactant after 1994, we failed to find a significant increase in survival among the IUGR PN. We hypothesize that the stresses associated with IUGR may preclude an additional benefit from antenatal steroid therapy. We will examine possible benefits of management strategies often employed in our NICU while caring for IUGR PN. These strategies include: Ventilator management: set physiologic rates of 40–60 breaths per minute, wean inspiratory pressures as tolerated, keep oxygen saturations 86%–89%, use HFOV as rescue only, no elective extubation <700g; Pulmonary: 3–5 day steroid burst if requiring FiO2>/= 0.50 at 7 days of life; Sedation/analgesia: scheduled around-the-clock sedation for first week of life; Hematology: maintain hematocrit >/= 40 if FiO2 >/= 0.50 for a duration >72 hours.

A review of the current management of infantile subglottic haemangioma, including a comparison of CO 2 laser therapy versus tracheostomy

Objectives: We reassessed the current practice and treatment options used in the management of subglottic haemangiomas (SGHs), including the place for open submucosal surgical excision, and have compared the results of different therapeutic modalities used for SGHs. Methods: The two studies were conducted as separate exercises; (1) a retrospective review of 36 patients collected over a recent 8-year period to assess the current practice and treatment options in use; (2) a retrospective comparative study of a previous cohort of 51 patients with SGHs treated in one of four groups: (a) tracheostomy alone, (b) tracheostomy and CO 2 laser, (c) systemic steroids and CO 2 laser (no tracheostomy) and (d) intralesional steroid injection, CO 2 laser therapy, or both, followed by intubation. Results: Systemic steroids were the most commonly used modality of treatment. Resolution of the SGH was achieved in 89% of cases at a mean follow up duration of 34 months. However, tracheostomy was required in 58% of cases, with a mean time from diagnosis to decannulation of 30 months. The time to resolution of SGHs does not appear to be reduced by laser therapy compared with treatment by tracheostomy alone. Intralesional steroid injection or laser therapy together with intubation was associated with avoidance of a tracheostomy in 66% of cases. Single-stage open surgical excision in two cases resulted in successful resolution of the SGH and discharge after a mean follow up period of 3 months. Conclusions: Despite the more widespread use of steroids and other treatment modalities, the requirement for tracheostomy has remained unchanged over the last 20 years. The use of laser therapy does not appear to confer any additional therapeutic benefit over and above tracheostomy alone in bringing about resolution of SGHs. Systemic steroids may reduce the size of the haemangioma but are associated with multiple adverse effects. The decision to use the above techniques must, therefore, be made in the light of these observations. Our early experience of single-stage excision suggests that this technique represents an exciting and promising surgical alternative, and its more widespread adoption may be the only way of further improving the outcome of patients with SGHs.

Histopathology update: Otomycosis

Although the systemic mycosis; aspergillosis, mucormycosis, candidiasis, coccidioidomycosis, cryptococcosis and histoplasmosis, were at one time largely medical curiosities, there has been an increase in mycotic infections of the head and neck over the past two decades.’ Most potentially pathogenic fungi are ubiquitous soil saprophytes or even normal human commensals. They are capable of causing isolated limited disease if local defense mechanisms are compromised. Recent advances in medicine, such as the widespread use of steroids, broad-spectrum antibiotic, and chemotherapeutic agents, have decreased the frequency and severity of bacterial infections of the ear; however, fungal labyrinthitis has become a devastating and real otologic threat.‘s3 We present a case of otomycosis with severe systemic infection following treatment with several chemotherapeutic agents.

Study shows little effect of steroids in spinal injury

Despite widespread use of steroids to treat spinal cord injuries, high doses of the agents may have negligible effects, at least in the first six weeks. This preliminary report comes from a randomized, collaborative study, supported by the National Institute of Neurological and Communicative Disorders and Stroke (NINCDS), Bethesda, Md, concerning the possible benefits of two different dosage levels of corticosteroids in treating such injuries. However, principal investigator Michael B. Bracken, PhD, points out that the patients involved will be evaluated further at six months and one year after their injuries. Bracken, a senior research associate and lecturer in epidemiology at Yale University School of Medicine, New Haven, Conn, explained the investigation this way at the annual Honolulu meeting of the American Association of Neurological Surgeons: The study involves 330 patients, in all of whom 11 days of intravenous steroid therapy was started in the emergency department. Half received a

Aspergillus endocarditis. Therapeutic failure of amphotericin B.

Fungal endocarditis is rare, although its reported incidence has been rising coincident with the widespread use of steroids, antibiotics, cytotoxic agents, the advent of cardiac surgery, and increased intravenous heroin addiction.1-3The genusAspergillusrarely causes endocarditis.4-9In two recent reviews, one of 98 patients5and another of 93 patients6with aspergillosis, none had endocarditis. Only four cases ofAspergillusendocarditis have been reported in patients who did not have previous cardiac surgery.10-13Only one case was diagnosed antemortem and the patient treated with a short course of amphotericin B before death.12 We wish to discuss the clinical course of a patient withAspergillus fumigatusendocarditis who received full therapeutic exposure to amphotericin B. Despite treatment, he succumbed to the embolic complications of the disease. The discussion will concern the management of this rare entity and of fungal endocarditis in general. Patient Summary A

Aspergillus Endocarditis

Fungal endocarditis is rare, although its reported incidence has been rising coincident with the widespread use of steroids, antibiotics, cytotoxic agents, the advent of cardiac surgery, and increased intravenous heroin addiction.^1-3The genus<i>Aspergillus</i>rarely causes endocarditis.^4-9In two recent reviews, one of 98 patients⁵and another of 93 patients⁶with aspergillosis, none had endocarditis. Only four cases of<i>Aspergillus</i>endocarditis have been reported in patients who did not have previous cardiac surgery.^10-13Only one case was diagnosed antemortem and the patient treated with a short course of amphotericin B before death.¹² We wish to discuss the clinical course of a patient with<i>Aspergillus fumigatus</i>endocarditis who received full therapeutic exposure to amphotericin B. Despite treatment, he succumbed to the embolic complications of the disease. The discussion will concern the management of this rare entity and of fungal endocarditis in general. <h3>Patient Summary</h3> A

Rheumatic Nodules Wanted

In the course of tissue culture studies on the pathogenesis of rheumatic fever, we are in need of rheumatic nodules which have recently formed in the course of rheumatic carditis. These structures have become rare due to the recent decrease in the prevalence and severity of acute rheumatic fever and the widespread use of steroids. The nodule should be situated on the extremities, be readily accessible to biopsy, and, preferably, be just in the process of forming, although nodules of any age would be welcome.