Notable progress has been made in the past years in the classification, diagnosis and treatment of pulmonary aspergillosis. New criteria were proposed by the Working Group of the International Society for Human and Animal Mycology (ISHAM) for the diagnosis of allergic bronchopulmonary aspergillosis (ABPA). The latest classification of chronic pulmonary aspergillosis (CPA) suggested by the European Society for Clinical Microbiology and Infectious Diseases (ESCMID) has become widely accepted among clinicians. Subacute invasive pulmonary aspergillosis is now considered a type of CPA, yet it is still diagnosed and treated similarly to invasive pulmonary aspergillosis (IPA). Isavuconazole, an extended-spectrum triazole, has recently been approved by the Food and Drug Administration (FDA) and the European Medicines Agency (EMA) for the treatment of IPA. The most recent Infectious Diseases Society of America (IDSA) guidelines strongly recommend reducing mold exposure to patients at high risk for pulmonary aspergillosis. The excessive relapse rate following discontinuation of therapy remains a common reality to all forms of this semi-continuous spectrum of diseases. This highlights the need to continuously reassess patients and individualize therapy accordingly. Thus far, the duration of therapy and the frequency of follow-up have to be well characterized.
Water pipe smoking (WPS), an old method of tobacco smoking, is re-gaining widespread popularity all over the world and among various populations. Smoking machine studies have shown that the water pipe (WP) mainstream smoke (MSS) contains a wide array of chemical substances, many of which are highly toxic and carcinogenic for humans. The concentrations of some substances exceed those present in MSS of cigarettes. Despite being of low grade, current evidence indicates that WPS is associated with different adverse health effects, not only on the respiratory system but also on the cardiovascular, hematological, and reproductive systems, including pregnancy outcomes. In addition, association between WPS and malignancies, such as lung, oral and nasopharyngeal cancer, has been suggested in different studies and systematic reviews. Despite its long standing history, WPS research still harbors a lot of deficiencies. The magnitude of toxicants and carcinogen exposures, effects on human health, as well as the addiction and dependence potentials associated with WPS need to be studied in well-designed prospective trials. Unfortunately, many of the tobacco control and clean indoor policies have exempted water pipes. World wide awareness among the public, smokers, and policymakers about the potential health effects of WPS is urgently required. Furthermore, stringent policies and laws that control and ban WPS in public places, similar to those applied on cigarettes smoking need to be implemented.
Background
Hospitalization of patients infected with the severe acute respiratory syndrome virus 2 (SARS-CoV-2) have remained considerable worldwide. Patients often develop severe complications and have high mortality rates. The cycle threshold (Ct) value derived from nasopharyngeal swab samples using real time polymerase chain reaction (RT-PCR) may be a useful prognostic marker in hospitalized patients with SARS-CoV-2 infection, however, its role in predicting the course of the pandemic has not been evaluated thus far.
Methods
We conducted a retrospective cohort study which included all patients who had a nasopharyngeal sample positive for SARS-CoV-2 between April 4 –June 5, 2020. The Ct value was used to estimate the number of viral particles in a patient sample. The trend in initial viral load on admission on a population level was evaluated. Moreover, patient characteristics and outcomes stratified by viral load categories were compared and initial viral load was assessed as an independent predictor of intubation and in-hospital mortality.
Results
A total of 461 hospitalized patients met the inclusion criteria. This study consisted predominantly of acutely infected patients with a median of 4 days since symptom onset to PCR. As the severity of the pandemic eased, there was an increase in the percentage of samples in the low initial viral load category, coinciding with a decrease in deaths. Compared to an initial low viral load, a high initial viral load was an independent predictor of in-hospital mortality (OR 5.5, CI 3.1–9.7, p < 0.001) and intubation (OR 1.82 CI 1.07–3.11, p = 0.03), while an initial intermediate viral load was associated with increased risk of inpatient mortality (OR 1.9, CI 1.14–3.21, p = 0.015) but not with increased risk for intubation.
Conclusion
The Ct value obtained from nasopharyngeal samples of hospitalized patients on admission may serve as a prognostic marker at an individual level and may help predict the course of the pandemic when evaluated at a population level.
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