The Impact of Climate Change and Extreme Weather Conditions on Cardiovascular Health and Acute Cardiovascular Diseases

Climate change is widely recognized as one of the most significant challenges facing our planet and human civilization. Human activities such as the burning of fossil fuels, deforestation, and industrial processes release greenhouse gases into the atmosphere, leading to a warming of the Earth's climate. The relationship between climate change and cardiovascular (CV) health, mediated by air pollution and increased ambient temperatures, is complex and very heterogeneous. The main mechanisms underlying the pathogenesis of CV disease at extreme temperatures involve several regulatory pathways, including temperature-sympathetic reactivity, the cold-activated renin-angiotensin system, dehydration, extreme temperature-induced electrolyte imbalances, and heat stroke-induced systemic inflammatory responses. The interplay of these mechanisms may vary based on individual factors, environmental conditions, and an overall health background. The net outcome is a significant increase in CV mortality and a higher incidence of hypertension, type II diabetes mellitus, acute myocardial infarction (AMI), heart failure, and cardiac arrhythmias. Patients with pre-existing CV disorders may be more vulnerable to the effects of global warming and extreme temperatures. There is an urgent need for a comprehensive intervention that spans from the individual level to a systemic or global approach to effectively address this existential problem. Future programs aimed at reducing CV and environmental burdens should require cross-disciplinary collaboration involving physicians, researchers, public health workers, political scientists, legislators, and national leaders to mitigate the effects of climate change.

Hematological Complications in a COVID-19 Patient: A Case Report

Hemophilia A is a hemorrhagic disorder caused by insufficient or inadequate coagulation factor VIII activity. Two different forms are described: congenital, hereditary X-linked, and acquired. Acquired hemophilia A (AHA) is a rare condition and it is defined by the production of autoantibodies neutralizing factor VIII, known as inhibitors. We report the case of a 72-year-old man with a clinical diagnosis of AHA after SARS-CoV-2 infection, which has been described in association with several hematological complications. SARS-CoV-2 infection could represent the immunological trigger for the development of autoantibodies. In our patient, SARS-CoV-2 infection preceded the hemorrhagic complications by 15 days. This lag time is in line with the other cases reported and compatible with the development of an intense immune response with autoantibody production. It is possible that since our patient was affected by type 1 diabetes mellitus, he was more prone to an immune system pathological response against self-antigens. A prompt, appropriate therapeutic intervention with activated recombinant factor VII administration and cyclophosphamide has led to rapid remission of clinical and laboratory findings.

Differences in HCV Seroprevalence, Clinical Features, and Treatment Outcomes between Female and Male Incarcerated Population: Results from a Matched Cohort Study

BACKGROUND

Women represent less than 5% of the incarcerated population in Italy, with very limited data on HCV infection. Higher HCV seroprevalence and active infection rates have been described among incarcerated females in available studies. Our aim is to compare the prevalence and cascade of care of HCV between male and female populations in Italian penitentiaries.

METHODS

We conducted a multicentre, retrospective study comparing HCV seroprevalence, active infections, treatment, and SVR rates between female (Group A) and male (Group B) populations in Italian prison settings.

RESULTS

No significant differences were found between the two groups regarding PWIDs (p = 0.16), nor in people living with HIV (p = 0.35) or HBV co-infection (p = 0.36). HCV seroprevalence was higher in Group A (p = 0.002). There was no statistically significant difference between the two groups regarding active infections (p = 0.41). Both groups showed a low level of fibrosis, and the dominant genotype was 3a. Almost all patients underwent antiviral treatment. All treated patients achieved SVR12.

CONCLUSIONS

Our findings illuminate the importance of recognizing and addressing gender differences in HCV seroprevalence within penitentiary settings. Moving forward, addressing the unique needs of incarcerated females and optimizing HCV care for all incarcerated individuals are essential steps in the pursuit of achieving HCV micro-elimination goals.

Predicting ICU admission and death in the Emergency Department: A comparison of six early warning scores

AIM

To compare the ability of the most used Early Warning Scores (EWS) to identify adult patients at risk of poor outcomes in the emergency department (ED).

METHODS

Single-center, retrospective observational study. We evaluated the digital records of consecutive ED admissions in patients ≥ 18 years from 2010 to 2019 and calculated NEWS, NEWS2, MEWS, RAPS, REMS, and SEWS based on parameters measured on ED arrival. We assessed the discrimination and calibration performance of each EWS in predicting death/ICU admission within 24 hours using ROC analysis and visual calibration. We also measured the relative weight of clinical and physiological derangements that identified patients missed by EWS risk stratification using neural network analysis.

RESULTS

Among 225,369 patients assessed in the ED during the study period, 1941 (0.9%) were admitted to ICU or died within 24 hours. NEWS was the most accurate predictor (area under the receiver operating characteristic [AUROC] curve 0.904 [95% CI 0.805-0.913]), followed by NEWS2 (AUROC 0.901). NEWS was also well calibrated. In patients judged at low risk (NEWS < 2), 359 events occurred (18.5% of the total). Neural network analysis revealed that age, systolic BP, and temperature had the highest relative weight for these NEWS-unpredicted events.

CONCLUSIONS

NEWS is the most accurate EWS for predicting the risk of death/ICU admission within 24 h from ED arrival. The score also had a fair calibration with few events occurring in patients classified at low risk. Neural network analysis suggests the need for further improvements by focusing on the prompt diagnosis of sepsis and the development of practical tools for the measurement of the respiratory rate.

Sex-Based Differences in Clinical Characteristics and Outcomes among Patients with Peripheral Artery Disease: A Retrospective Analysis

Peripheral arterial disease (PAD) is a prevalent medical condition associated with high mortality and morbidity rates. Despite the high clinical burden, sex-based differences among PAD patients are not well defined yet, in contrast to other atherosclerotic diseases. This study aimed to describe sex-based differences in clinical characteristics and outcomes among hospitalized patients affected by PAD. This was a retrospective study evaluating all patients with a diagnosis of PAD admitted to the Emergency Department from 1 December 2013 to 31 December 2021. The primary endpoint of the study was the difference between male and female PAD patients in cumulative occurrence of Major Adverse Cardiovascular Events (MACEs) and Major Adverse Limb Events. A total of 1640 patients were enrolled. Among them, 1103 (67.3%) were males while females were significantly older (median age of 75 years vs. 71 years; p =< 0.001). Females underwent more angioplasty treatments for revascularization than men (29.8% vs. 25.6%; p = 0.04); males were treated with more amputations (19.9% vs. 15.3%; p = 0.012). A trend toward more MALEs and MACEs reported in the male group did not reach statistical significance (OR 1.27 [0.99-1.64]; p = 0.059) (OR 0.75 [0.50-1.11]; p = 0.153). However, despite lower extremity PAD severity seeming similar between the two sexes, among these patients males had a higher probability of undergoing lower limb amputations, of cardiovascular death and of myocardial infarction. Among hospitalized patients affected by PAD, even if there was not a sex-based significant difference in the incidence of MALEs and MACEs, adverse clinical outcomes were more common in males.

Reduced Prognostic Role of Serum PCT Measurement in Very Frail Older Adults Admitted to the Emergency Department

BACKGROUND

This study aims to evaluate the prognostic role of serum PCT in older patients with suspect sepsis or infective diagnosis in the Emergency Department (ED) with a particular focus on the clinical consequences and characteristics due to frailty status.

METHODS

This is a observational retrospective study conducted in the ED of a teaching hospital. We identified all consecutive patients aged ≥ 80 years admitted to the ED and subsequently hospitalized for clinical suspicion of infection. Inclusion criteria were: age ≥ 80 years and clinical suspicion of infection; availability of a PCT determination obtained < 24 h since ED access; and Clinical Frailty Scale (CFS) determination. Study endpoints were the diagnostic accuracy of PCT for all-cause in-hospital death, infective diagnosis at discharge, and bloodstream infection. Diagnostic accuracy was calculated via ROC analysis and compared in the patients with severe frailty, measured by CFS > 6, and patients with low or moderate frailty (CFS 1-6). A multivariate analysis was performed to calculate the adjusted odds of raised PCT values for the study endpoints.

RESULTS

In total, 1459 adults ≥ 80 years with a clinical suspicion of infection were included in the study cohort. The median age of the sample was 85 years (82-89), with 718 (49.2%) males. The multivariate models revealed that, after adjusting for significant covariates, the PCT values at ED admission were significantly associated with higher odds of infective diagnosis only in the fit/moderately frail group (Odds Ratio [95% CI] 1.04 [1.01-1.08], p 0.009) and not in very frail patients (Odds Ratio [95% CI] 1.02 [0.99-1.06], p 0.130). Similarly, PCT values were significantly associated with higher odds of in-hospital death in the fit/moderately frail group (Odds Ratio [95% CI] 1.01 [1.00-1.02], p 0.047), but not in the very frail ones (Odds Ratio [95% CI] 1.00 [0.98-1.02], p 0.948). Conversely, the PCT values were confirmed to be a good independent predictor of bloodstream infection in both the fit/moderately frail group (Odds Ratio [95% CI] 1.06 [1.04-1.08], p < 0.001) and the very frail group (Odds Ratio [95% CI] 1.05 [1.03-1.07], p < 0.001).

CONCLUSIONS

The PCT values at ED admission do not predict infective diagnosis, nor are associated with higher odds of in-hospital death. Still, in frail older adults, the PCT values in ED could be a useful predictor of bloodstream infection.

A New Clinical Prediction Rule for Infective Endocarditis in Emergency Department Patients With Fever: Definition and First Validation of the CREED Score

Background Infective endocarditis (IE) could be suspected in any febrile patients admitted to the emergency department (ED). This study was aimed at assessing clinical criteria predictive of IE and identifying and prospectively validating a sensible and easy-to-use clinical prediction score for the diagnosis of IE in the ED. Methods and Results We conducted a retrospective observational study, enrolling consecutive patients with fever admitted to the ED between January 2015 and December 2019 and subsequently hospitalized. Several clinical and anamnestic standardized variables were collected and evaluated for the association with IE diagnosis. We derived a multivariate prediction model by logistic regression analysis. The identified predictors were assigned a score point value to obtain the Clinical Rule for Infective Endocarditis in the Emergency Department (CREED) score. To validate the CREED score we conducted a prospective observational study between January 2020 and December 2021, enrolling consecutive febrile patients hospitalized after the ED visit, and evaluating the association between the CREED score values and the IE diagnosis. A total of 15 689 patients (median age, 71 [56-81] years; 54.1% men) were enrolled in the retrospective cohort, and IE was diagnosed in 267 (1.7%). The CREED score included 12 variables: male sex, anemia, dialysis, pacemaker, recent hospitalization, recent stroke, chest pain, specific infective diagnosis, valvular heart disease, valvular prosthesis, previous endocarditis, and clinical signs of suspect endocarditis. The CREED score identified 4 risk groups for IE diagnosis, with an area under the receiver operating characteristic curve of 0.874 (0.849-0.899). The prospective cohort included 13 163 patients, with 130 (1.0%) IE diagnoses. The CREED score had an area under the receiver operating characteristic curve of 0.881 (0.848-0.913) in the validation cohort, not significantly different from the one calculated in the retrospective cohort (P=0.578). Conclusions In this study, we propose and prospectively validate the CREED score, a clinical prediction rule for the diagnosis of IE in patients with fever admitted to the ED. Our data reflect the difficulty of creating a meaningful tool able to identify patients with IE among this general and heterogeneous population because of the complexity of the disease and its low prevalence in the ED setting.

Long-Term Effects of Hospitalization for COVID-19 on Frailty and Quality of Life in Older Adults ≥80 Years

Objectives: This study aimed to assess the effects of frailty and the perceived quality of life (QOL) on the long-term survival (at least 1 year) of patients ≥ 80 years hospitalized for COVID-19 and the predictors of frailty and QOL deterioration in survivors. Design: This is a single-center, prospective observational cohort study. Setting and Participants: The study was conducted in a teaching hospital and enrolled all COVID-19 patients ≥80 years old consecutively hospitalized between April 2020 and March 2021. Methods: Clinical variables assessed in the Emergency Department (ED), and during hospitalization, were evaluated for association with all-cause death at a follow-up. Frailty was assessed by the clinical frailty scale (CFS), and the QOL was assessed by the five-level EuroQol EQ-5d tool. Multivariate Cox regression analyses and logistic regression analyses were used to identify independent factors for poor outcomes. Results: A total of 368 patients aged ≥80 years survived the index hospitalization (age 85 years [interquartile range 82–89]; males 163 (44.3%)). Compared to non-frail patients (CFS 1–3), patients with CFS 4–6 and patients with CFS 7–9 had an increased risk of death (hazard ratio 6.75 [1.51, 30.2] and HR 3.55 [2.20, 5.78], respectively). In patients alive at the 1-year follow-up, the baseline QOL was an independent predictor of an increase in frailty (OR 1.12 [1.01, 1.24]). Male sex was associated with lower odds of QOL worsening (OR 0.61 [0.35, 1.07]). Conclusions and Implications: In older adults ≥80 years hospitalized for COVID-19, the frailty assessment by the CFS could effectively stratify the risk of long-term death after discharge. In survivors, the hospitalization could produce a long-term worsening in frailty, particularly in patients with a pre-existing reduced baseline QOL. A long-term reduction in the perceived QOL is frequent in ≥80 survivors, and the effect appears more pronounced in female patients.

HCV spread among female incarcerated population and treatment pathways to viral elimination in Italian prison settings: clinical perspectives and medico legal aspects

Background

Hepatitis C virus (HCV) infection is more frequent among incarcerated people than in general population. In the DAAs era, the short schedules and the low risk of adverse reactions, increased the number of HCV treatments. However, the most part of literature reports lack of incarcerated women inclusion in studies on field. Our aim is to assess the screening execution, HCV prevalence, and DAAs treatment among incarcerated women. A focused insight on quick vs standard diagnosis and staging approach will be also provided.

Methods

Incarcerated women from 4 Italian regions’ penitentiary institutes were included. HCV screening was executed with HCV saliva test (QuickOral Test^®) or phlebotomy. Stage of liver fibrosis was evaluated with FIB-4 value or fibroscan^®, based on physicians’ decision. Treatment prescription followed national protocols.

Results

We included 156 women, 89 (57%) were Italian, mean age was 41 ± 10 years, and 28 (17.9%) were people who inject drugs (PWIDs). Overall, the HCV seroprevalence was 20.5%. Being PWID and on opioid substitution therapy (OST) were significantly associated with serological status (p-value < 0.001). Of them, the 75.5% of patients had active infection, the most frequent genotype was 3a (50%). Among them, 4 (16.6%) and 6 (25%) had psychosis or alcohol abuse history. The 62.5%, 25% and 12.5% had low, intermediate, and advanced fibrosis, respectively. Out of the 24 HCV-RNA positive patients, the 75% underwent to DAAs treatment. The sustained virological response (SVR12) was achieved in 88.8% of cases. When evaluating the influence of quick diagnosis and staging methods vs standard phlebotomy and fibroscan^® on SVR12, FIB-4 use showed higher performance for retainment in treatment during prison staying (p = 0.015), while the use of quick saliva test had no influence on the outcome (p = 0.22).

Conclusion

HCV seroprevalence and active infections are very high among incarcerated women. More tailored interventions should be focused on HCV diagnosis and treatment in female prison population. The use of quick staging methods (FIB-4) is useful to increase SVR12 achievement without delays caused by the fibroscan^® awaiting.

Frailty in Elderly Patients with Covid-19: A Narrative Review

Introduction

The SARS CoV-2 pandemic still generates a very high number of affected patients and a significant mortality rate. It is essential to establish objective criteria to stratify COVID-19 death risk. Frailty has been identified as a potential determinant of increased vulnerability in older adults affected by COVID-19, because it may suggest alterations of physical performance and functional autonomy.

Methods

We have conducted a narrative review of the literature on the evidences regarding COVID-19 and the frailty condition. Thirteen observational studies were included.

Conclusion

Data emerging from the studies indicate that older COVID-19 patients with a frailty condition have an increased risk of mortality compared with non-frail patients, and this association is independent of other clinical and demographic factors. A frailty evaluation is required to help clinicians to better stratify the overall risk of death for older patients with COVID-19.

Effect of hepatitis C antiviral therapy on oral lichen planus and hyposalivation in inmates

Background

Oral lichen planus (OLP) and hyposalivation have been reported as extrahepatic manifestations of hepatitis C virus (HCV) infection. Our study evaluated the effect of direct antiviral agents (DAAs) on OLP and hyposalivation in convicts with chronic hepatitis C, examining patients before, during and after the antiviral treatment period with direct acting antiviral agents (DAAs).

Methods

We screened 198 inmates for the presence of the HCV antibody. Patients found to be positive underwent a quantitative HCV-RNA test and HCV genotype typing, as well as an oral cavity examination using a scoring system for OLP (REU score) and the clinical oral dryness score (CODS). Subsequently, all patients underwent DAA therapy and a systematic physical examination of the oral cavity at 1, 3 and 6 months from the beginning of treatment.

Results

Fifty patients (25.25%) had a positive HCV-RNA test. At baseline, OLP was detected in 4 patients (8%), with a mean REU score of 10.13±4, and different degrees of hyposalivation were seen in 17 patients (34%), with a mean CODS score of 4.71±1.72. Six months after the start of DAA therapy, we observed resolution of OLP in 3 patients (75%) and improvement in the remaining subject with a significantly lower mean REU score (2±4). Hyposalivation disappeared in 5 patients, improved in 10, and remained unchanged in 2 patients with a significantly lower mean CODS score (0.06±0.24).

Conclusion

This study demonstrated the effectiveness of DAAs in the treatment of OLP and hyposalivation.

Improved gut microbiota features after the resolution of SARS‑CoV‑2 infection

BACKGROUND

The severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) has a tropism for the gastrointestinal tract and several studies have shown an alteration of the gut microbiota in hospitalized infected patients. However, long-term data on microbiota changes after recovery are lacking.

METHODS

We enrolled 30 patients hospitalized for SARS‑CoV‑2-related pneumonia. Their gut microbiota was analyzed within 48 h from the admission and compared with (1) that of other patients admitted for suspected bacterial pneumonia (control group) (2) that obtained from the same subject 6 months after nasopharyngeal swab negativization.

RESULTS

Gut microbiota alpha-diversity increased 6 months after the resolution of SARS-CoV-2 infection. Bacteroidetes relative abundance was higher (≈ 36.8%) in patients with SARS-CoV-2, and declined to 18.7% when SARS-CoV-2 infection resolved (p  =  0.004). Conversely, Firmicutes were prevalent (≈ 75%) in controls and in samples collected after SARS-CoV-2 infection resolution (p  =  0.001). Ruminococcaceae, Lachnospiraceae and Blautia increased after SARS-CoV-2 infection resolution, rebalancing the gut microbiota composition.

CONCLUSION

SARS-CoV-2 infection is associated with changes in the gut microbiome, which tend to be reversed in long-term period.

Frailty Assessment in the Emergency Department for Risk Stratification of COVID-19 Patients Aged ≥80 Years

OBJECTIVES

To evaluate, in a cohort of adults aged ≥80 years, the overlapping effect of clinical severity, comorbidities, cognitive impairment, and frailty, for the in-hospital death risk stratification of COVID-19 older patients since emergency department (ED) admission.

DESIGN

Single-center prospective observational cohort study.

SETTING AND PARTICIPANTS

The study was conducted in the ED of a teaching hospital that is a referral center for COVID-19 in central Italy. We enrolled all patients with aged ≥80 years old consecutively admitted to the ED between April 2020 and March 2021.

METHODS

Clinical variables assessed in the ED were evaluated for the association with all-cause in-hospital death. Evaluated parameters were severity of disease, frailty, comorbidities, cognitive impairment, delirium, and dependency in daily life activities. Cox regression analysis was used to identify independent risk factors for poor outcomes.

RESULTS

A total of 729 patients aged ≥80 years were enrolled [median age 85 years (interquartile range 82-89); 346 were males (47.3%)]. According to the Clinical Frailty Scale, 61 (8.4%) were classified as fit, 417 (57.2%) as vulnerable, and 251 (34.4%) as frail. Severe disease [hazard ratio (HR) 1.87, 95% confidence interval (CI) 1.31-2.59], ≥3 comorbidities (HR 1.54, 95% CI 1.11-2.13), male sex (HR 1.46, 95% CI 1.14-1.87), and frailty (HR 6.93, 95% CI 1.69-28.27) for vulnerable and an overall HR of 12.55 (95% CI 2.96-53.21) for frail were independent risk factors for in-hospital death.

CONCLUSIONS AND IMPLICATIONS

The ED approach to older patients with COVID-19 should take into account the functional and clinical characteristics of patients being admitted. A sole evaluation based on the clinical severity and the presence of comorbidities does not reflect the complexity of this population. A comprehensive evaluation based on clinical severity, multimorbidity, and frailty could effectively predict the clinical risk of in-hospital death for patients with COVID-19 aged ≥80 years at the time of ED presentation.

Prognostic role of hypothyroidism and low free-triiodothyronine levels in patients hospitalized with acute heart failure

Low thyroid function has been widely recognized as a potential cause of heart failure (HF), but the evidence about a possible association with in-hospital, all-cause mortality in patients with acute HF (AHF) is not consistent. This study sought to investigate the prevalence and prognostic role of hypothyroidism, overt and subclinical, and of low free-triiodothyronine (fT3) levels in patients hospitalized with AHF. We retrospectively analyzed consecutive 1018 patients who were hospitalized for AHF in a single academic medical center [Fondazione Policlinico A.Gemelli IRCCS, Rome, Italy] between January 1st 2016, and December 31st 2018. Patients were divided into three groups: normal thyroid function (n = 798), subclinical hypothyroidism (n = 105), and overt hypothyroidism (n = 115). The outcome was in-hospital, all-cause mortality. Patients were 81 years of age, 55% were females and nearly two-thirds of the patients were on New York Heart Association functional class III. The three most common cardiovascular comorbidities were coronary artery disease, hypertension, and atrial fibrillation with no differences across the three groups. Overall, 138 patients (14%) died during the hospital stay. The mortality rate was 27% among patients with overt hypothyroid, 17% among those with subclinical hypothyroidism, and 11% among euthyroid patients (p < 0.001). At a multivariate Cox regression model, overt hypothyroidism (HR 2.1, 95% CI 1.4-3.2) and fT3 levels < 1.8 pg/mL (HR 3.4, 95% CI 2.3-5.1) were associated with an increased likelihood of in-hospital death. No association was found with subclinical hypothyroidism. Among patients hospitalized with AHF, overt hypothyroidism and low fT3 levels are independent predictors of all-cause mortality during the hospital stay.

Hip Fracture Risk in Elderly With Non-End-Stage Chronic Kidney Disease: A Fall Related Analysis

BACKGROUND

The aim of this study was to evaluate the risk of fracture as a consequence of trauma and its association with kidney function status in a cohort of elderly patients.

METHODS

This is an observational, cross-sectional study. We evaluated all fall-related trauma of patients ≥ 65 years in the emergency department (ED) between 2016 and 2018. According to CDK-EPI formula, we stratified the study population in different stages of chronic kidney disease (CKD) for glomerular filtrate rate (GFR) ≥ 15 and < 60, not on hemodialysis. The hip fracture rate was adjusted at multivariate analysis for age, sex, comorbid conditions, and CKD status.

RESULTS

We enrolled 5620 patients: 3482 patients had GFR ≥60, 1045 had GFR ≥45 and <60, 722 had GFR ≥30 and <45, and 371 had GFR ≥15 and <30. We recorded 636 (11.3%) hip fractures. After adjusting for significant covariates (age, sex, known osteoporosis, osteoporosis therapy, anemia, and dementia), patients with GFR ≥ 45 and <60 and GFR ≥30 and <45 exhibited an increased risk of femur fracture (odds ratio 2.01 [1.36-2.97] and 1.64 [1.08-2.48], respectively). Patients with GFR ≥15 and <30 had a higher risk of fracture, although not reaching statistical significance.

CONCLUSIONS

Our study confirms that patients with non-end stage CKD have an increased risk of femur fracture after a fall. Our data supports the hypothesis that this risk could be associated with increased bone fragility in CKD patients. Active osteoporosis therapy was found to be an effective preventive factor in our cohort.

Solving the gap between HCV detection and treatment in prison. HCV-RNA testing and treatment in a cohort of new arriving convicts in Southern Italy

INTRODUCTION

HCV infection elimination is set to be carried out by 2030. To achieve this goal, the WHO has set minor achievable short-term "mini-goals." One of these is the treatment of "difficult to reach and treat populations," such as prisoners. One of the biggest obstacles to reaching this mini goal is the poor knowledge of the real HCV prevalence in such a population and the barriers to its detection, treatment, and follow-up. Even if HCV testing in Italian prisons is feasible and recommended, it is not always carried out. To worsen the picture, the peculiar status of conviction is correlated with the difficulty in carrying out the antiviral therapy due to challenges in follow-up and the refusals by inmates.

AIMS

A point-of-care test-and-treat program was set up in a penitentiary in Southern Italy to reduce the number of patients lost-to-follow-up (LTFU) between detection and treatment. A secondary aim was to evaluate the prevalence of HCV-infected patients in a cohort of new inmates.

METHODS

This prospective-observational study was carried out from January 2020 to February 2020. We performed a quick HCV-RNA blood capillary test on all new arriving inmates. As a routine, the new inmates underwent clinical and laboratory assessments. To those who were detected as HCV-RNA positive, the shortest possible antiviral treatment was offered, according to genotype and clinical features.

RESULTS

We observed 122 new inmates in the period between January and February of 2020. Overall, 62 (50.8%) subjects accepted HCV-RNA quick testing through blood sampling. Four (6.4%) subjects were found to be HCV-RNA positive; 1 refused antiviral therapy while 3 accepted, obtaining 100% SVR. None of the HCV-active inmates were lost-to-follow-up between detection and treatment proposal.

CONCLUSION

The use of a very fast test-and-treat protocol for HCV infection demonstrated to be effective to avoid LTFU in HCV-positive new inmates in the period between detection and treatment. We observed an apparent prevalence of HCV incident cases in newly arriving inmates of 6.4%. Antiviral therapy was quickly provided, secure, and successful.

Lung Ultrasound for COVID-19 Patchy Pneumonia: Extended or Limited Evaluations?

OBJECTIVES

The 2019 novel coronavirus (severe acute respiratory syndrome coronavirus 2) is causing cases of severe pneumonia. Lung ultrasound (LUS) could be a useful tool for physicians detecting a bilateral heterogeneous patchy distribution of pathologic findings in a symptomatic suggestive context. The aim of this study was to focus on the implications of limiting LUS examinations to specific regions of the chest.

METHODS

Patients were evaluated with a standard sequence of LUS scans in 14 anatomic areas. A scoring system of LUS findings was reported, ranging from 0 to 3 (worst score, 3). The scores reported on anterior, lateral, and posterior landmarks were analyzed separately and compared with each other and with the global findings.

RESULTS

Thirty-eight patients were enrolled. A higher prevalence of score 0 was observed in the anterior region (44.08%). On the contrary, 21.05% of posterior regions and 13.62% of lateral regions were evaluated as score 3, whereas only 5.92% of anterior regions were classified as score 3. Findings from chest computed tomography performed in 16 patients with coronavirus disease 2019 correlated with and matched the distribution of findings from LUS.

CONCLUSIONS

To assess the quantity and severity of lung disease, a comprehensive LUS examination is recommended. Omitting areas of the chest misses involved lung.

The Role of Early Procalcitonin Determination in the Emergency Departiment in Adults Hospitalized with Fever

Background and Objectives: Fever is one of the most common presenting complaints in the Emergency Department (ED). The role of serum procalcitonin (PCT) determination in the ED evaluation of adults presenting with fever is still debated. The aim of this study was to evaluate if, in adults presenting to the ED with fever and then hospitalized, the early PCT determination could improve prognosis. Materials and Methods. This is a retrospective, mono-centric study, conducted over a 10-year period (2009-2018). We analyzed consecutive patients ≥18 years admitted to ED with fever and then hospitalized. According to quick sequential organ failure assessment (qSOFA) at admission, we compared patients that had a PCT determination vs. controls. Primary endpoint was overall in-hospital mortality; secondary endpoints were in-hospital length of stay, and mortality in patients with bloodstream infection and acute respiratory infections. Results. The sample included 12,062 patients, median age was 71 years and 55.1% were men. In patients with qSOFA ≥ 2 overall mortality was significantly lower if they had a PCT-guided management in ED, (20.5% vs. 26.5%; p = 0.046). In the qSOFA < 2 group the mortality was not significantly different in PCT patients, except for those with a final diagnosis of bloodstream infection. Conclusions. Among adults hospitalized with fever, the PCT evaluation at ED admission was not associated with better outcomes, with the possible exception of patients affected by bloodstream infections. However, in febrile patients presenting to the ED with qSOFA ≥ 2, the early PCT evaluation could improve the overall in-hospital survival.

Reply to: Comment on Predicting In-Hospital Mortality in COVID-19 Older Patients with Specifically Developed Scores

This letter comments on the letter by Alain Putot

Angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers and prognosis of hypertensive patients hospitalised with COVID-19

BACKGROUND

Among hypertensive patients, the association between treatment with angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor blockers (ARB) and the clinical severity of COVID-19, remains uncertain.

AIMS

To determine whether hypertensive patients hospitalised with COVID-19 are at risk of worse outcomes if on treatment with ACEI or ARB compared to other anti-hypertensive medications.

METHODS

This is a retrospective study conducted at a single academic medical centre (Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy) from 1 to 31 March 2020. We compared patients on treatment with an ACEI/ARB (ACEI/ARB group) to patients receiving other anti-hypertensive medications (No-ACEI/ARB group). The end-points of the study were the all-cause in-hospital death and the combination of in-hospital death or need for intensive care unit (ICU) admission.

RESULTS

The sample included 166 COVID-19 patients; median age was 74 years and 109 (66%) were men. Overall, 111 (67%) patients were taking an ACEI or ARB. Twenty-nine (17%) patients died during the hospital stay, and 51 (31%) met the combined end-point. After adjustment for comorbidities, age and degree of severity at the presentation, ACEI or ARB treatment was an independent predictor neither of in-hospital death nor of the combination of in-hospital death/need for ICU. No differences were documented between treatment with ACEI compared to ARB.

CONCLUSIONS

Among hypertensive patients hospitalised for COVID-19, treatment with ACEI or ARB is not associated with an increased risk of in-hospital death.

Predicting In-Hospital Mortality in COVID-19 Older Patients with Specifically Developed Scores

BACKGROUND/OBJECTIVES

Several scoring systems have been specifically developed for risk stratification in COVID-19 patients.

DESIGN

We compared, in a cohort of confirmed COVID-19 older patients, three specifically developed scores with a previously established early warning score. Main endpoint was all causes in-hospital death.

SETTING

This is a single-center, retrospective observational study, conducted in the Emergency Department (ED) of an urban teaching hospital, referral center for COVID-19.

PARTICIPANTS

We reviewed the clinical records of the confirmed COVID-19 patients aged 60 years or more consecutively admitted to our ED over a 6-week period (March 1st to April 15th, 2020). A total of 210 patients, aged between 60 and 98 years were included in the study cohort.

MEASUREMENTS

International Severe Acute Respiratory Infection Consortium Clinical Characterization Protocol-Coronavirus Clinical Characterization Consortium (ISARIC-4C) score, COVID-GRAM Critical Illness Risk Score (COVID-GRAM), quick COVID-19 Severity Index (qCSI), National Early Warning Score (NEWS).

RESULTS

Median age was 74 (67-82) and 133 (63.3%) were males. Globally, 42 patients (20.0%) deceased. All the score evaluated showed a fairly good predictive value with respect to in-hospital death. The ISARIC-4C score had the highest area under ROC curve (AUROC) 0.799 (0.738-0.851), followed by the COVID-GRAM 0.785 (0.723-0.838), NEWS 0.764 (0.700-0.819), and qCSI 0.749 (0.685-0.806). However, these differences were not statistical significant.

CONCLUSION

Among the evaluated scores, the ISARIC-4C and the COVID-GRAM, calculated at ED admission, had the best performance, although the qCSI had similar efficacy by evaluating only three items. However, the NEWS, already widely validated in clinical practice, had a similar performance and could be appropriate for older patients with COVID-19.

HCV testing and treatment initiation in an Italian prison setting: A step-by-step model to micro-eliminate hepatitis C

BACKGROUND

HCV infection among vulnerable populations is currently a major issue for HCV elimination program. Incarcerated people and people who inject drugs (PWIDs) are key population groups potentially at high risk for HCV infection. Our aim was to evaluate an extended program of screening, staging and treatment in Italian prison settings.

METHODS

Patients from eight prisons in five different Italian Regions were enrolled. HCV saliva test (QuickOral Test®) was offered. Data on infection awareness and illicit drug use were also collected. Positive patients underwent early HCV RNA evaluation, staging and prescription on DAAs treatment. The definition of PWID was based on self-reported injecting drug use extracted from medical records (injecting drug use during the previous six months).

RESULTS

A total of 2,376 out of 2,687 individuals (88%) was tested. The median (IQR) age was 42 (32-50) years. PWIDs were 537out of 2,376 (23%). Prevalence of HCV antibodies was 10.4% (248/2,376). PWIDs had a lower awareness of their HCV-Ab positivity than non-PWIDs (p-value <0.001). Furthermore, PWIDs were less likely to be previously treated than non-PWIDs (78% vs 96%, p-value= 0.017). Active infection was found in 41% of patients (101/248). Overall, 61% HCV-positive were PWIDs, with 44% HCV RNA positive. HCV therapy was prescribed to 83% (84/101) of patients with active HCV infection and 67% of these (56/84) were PWIDs. Prescription for HCV treatment in PWIDs accounted for 84% (56/67) (while for non-PWIDs was 82% (28/34) p-value: 0.88. Seventeen patients were referred to a Specialist in other prisons because they were going to be transferred soon to another prison. EOT, as well as SVR12 were achieved in 98% (82/84) treated patients.

CONCLUSIONS

Among patients, PWIDs had a lower awareness of their HCV-Ab positivity and had previously received less treatments. Saliva test allowed to achieve a more rapid result, stage, and treatment approach. More than 80% of patients underwent treatment, without differences between PWIDs and non-PWIDs. Linkage to care during prison transfer allowed to avoid unplanned interruptions and offered more chances to reach the end of treatment.

Incidence of deep vein thrombosis among non-ICU patients hospitalized for COVID-19 despite pharmacological thromboprophylaxis

BACKGROUND

A remarkably high incidence of venous thromboembolism (VTE) has been reported among critically ill patients with COVID-19 assisted in the intensive care unit (ICU). However, VTE burden among non-ICU patients hospitalized for COVID-19 that receive guideline-recommended thromboprophylaxis is unknown.

OBJECTIVES

To determine the incidence of VTE among non-ICU patients hospitalized for COVID-19 that receive pharmacological thromboprophylaxis.

METHODS

We performed a systematic screening for the diagnosis of deep vein thrombosis (DVT) by lower limb vein compression ultrasonography (CUS) in consecutive non-ICU patients hospitalized for COVID-19, independent of the presence of signs or symptoms of DVT. All patients were receiving pharmacological thromboprophylaxis with either enoxaparin or fondaparinux.

RESULTS

The population that we screened consisted of 84 consecutive patients, with a mean age of 67.6 ± 13.5 years and a mean Padua Prediction Score of 5.1 ± 1.6. Seventy-two patients (85.7%) had respiratory insufficiency, required oxygen supplementation, and had reduced mobility or were bedridden. In this cohort, we found 10 cases of DVT, with an incidence of 11.9% (95% confidence interval [CI] 4.98-18.82). Of these, 2 were proximal DVT (incidence rate 2.4%, 95% CI -0.87-5.67) and 8 were distal DVT (incidence rate 9.5%, 95% CI 3.23-5.77). Significant differences between subjects with and without DVT were D-dimer > 3000 µg/L (P < .05), current or previous cancer (P < .05), and need of high flow nasal oxygen therapy and/or non-invasive ventilation (P < .01).

CONCLUSIONS

DVT may occur among non-ICU patients hospitalized for COVID-19, despite guideline-recommended thromboprophylaxis.

Clinical characteristics and prognostic factors in COVID-19 patients aged ≥80 years

AIM

The aim of the present study was to describe the clinical presentation of patients aged ≥80 years with coronavirus disease 2019 (COVID-19), and provide insights regarding the prognostic factors and the risk stratification in this population.

METHODS

This was a single-center, retrospective, observational study, carried out in a referral center for COVID-19 in central Italy. We reviewed the clinical records of patients consecutively admitted for confirmed COVID-19 over a 1-month period (1-31 March 2020). We excluded asymptomatic discharged patients. We identified risk factors for death, by a uni- and multivariate Cox regression analysis. To improve model fitting and hazard estimation, continuous parameters where dichotomized by using Youden's index.

RESULTS

Overall, 69 patients, aged 80-98 years, met the inclusion criteria and were included in the study cohort. The median age was 84 years (82-89 years is interquartile range); 37 patients (53.6%) were men. Globally, 14 patients (20.3%) presented a mild, 30 (43.5%) a severe and 25 (36.2%) a critical COVID-19 disease. A total of 23 (33.3%) patients had died at 30 days' follow up. Multivariate Cox regression analysis showed that severe dementia, pO₂ ≤90 at admission and lactate dehydrogenase >464 U/L were independent risk factors for death.

CONCLUSIONS

The present data suggest that risk of death could be not age dependent in patients aged ≥80 years, whereas severe dementia emerged is a relevant risk factor in this population. Severe COVID-19, as expressed by elevated lactate dehydrogenase and low oxygen saturation at emergency department admission, is associated with a rapid progression to death in these patients. Geriatr Gerontol Int 2020; ••: ••-••.

Hepatitis C virus infection in jail: Difficult-to-reach, not to-treat. Results of a point-of-care screening and treatment program

BACKGROUND

An unmet objective in the pursuit of HCV elimination is the creation of a simple and fast operating model to identify difficult-to-treat populations, like prisoners. Of many obstacles, the first is represented by the poor knowledge of inmates HCV-Ab prevalence. Moreover, due to the peculiar status of conviction, often their access to antiviral therapy is neglected.

AIMS

To evaluate the prevalence of HCV infection in a penitentiary Institution of Southern Italy through a point-of-care screening and treatment program.

METHODS

We conducted a prospective observational study in two phases: first, we reviewed all the prisoners' clinical records, to verify HCV-Ab execution. Subsequently, we performed a universal point-of-care screening and treatment program.

RESULTS

We enrolled 670 patients. Overall, 310(46.27%) were already HCV-Ab tested. At the screening initiation, 23.28% patients were discharged, whereas 8.35% refused. Of the remaining 458 subjects, 58(12.67%) were HCV-Ab positive and 46 HCVRNA positive. All these underwent DAA, obtaining 100% SVR. At the end of the program, a total of 491(73.28%) subjects had HCV-Ab available. Sixty-nine (14.05%) were positive. A total of 214(31.94%) subjects were lost to follow-up.

CONCLUSIONS

We revealed a prevalence of 14.05% of HCV-Ab in conviction. Antiviral treatment was safe and efficacious. More efforts are advisable to provide screening for HCV-Ab in conviction.

Association of Bright Liver With the PNPLA3 I148M Gene Variant in 1-Year-Old Toddlers

CONTEXT

Nonalcoholic fatty liver disease (NAFLD) is being increasingly diagnosed at younger ages, pointing toward an early-life origin.

OBJECTIVE

To evaluate the frequency and risk factors for bright liver (BL) in 1-year-old toddlers.

DESIGN

Secondary analysis of the 1-year follow-up of the Feeding Study. Exposures were child PNPLA3 and TM6SF2 gene variants; child anthropometry at birth and at 1 year of follow-up; child subcutaneous, visceral, and epicardial adipose tissue at 1 year of follow-up; maternal anthropometry at the start and at the end of pregnancy; and maternal red blood cell fatty-acid composition at the third trimester of pregnancy.

SETTING

General population.

PARTICIPANTS

Among 505 mother-toddler pairs, 391 children (77%) underwent liver and abdominal ultrasonography at the 1-year follow-up.

MAIN OUTCOME

BL as diagnosed by ultrasonography.

RESULTS

Seventeen (4%) of 391 toddlers had BL. Compared with the toddlers with the PNPLA 3 CC genotype, the odds (95% CI) of BL were 3.01 (1.05 to 8.64, P < 0.05) times higher in those with the PNAPLA3 CG genotype and 5.37 (1.12 to 25.77, P < 0.05) higher in those with the PNPLA3 CC genotype. We found no association between BL status and TM6SF2. Body weight, body mass index, and maternal weight gain during pregnancy were higher in BL+ than in BL- children. Visceral adipose tissue was higher but subcutaneous adipose tissue and epicardial adipose tissue were similar in BL+ and BL- children.

CONCLUSIONS

Four percent of the Feeding Study children had BL at 1 year of age. In line with expectations, PNAPLA3 was already a predictor of BL at this early age.

Tuberculous Arthritis of the Ankle

Tuberculosis (TB) is an infectious disease caused by the Mycobacterium tuberculosis complex (MTBC). Pulmonary TB is the most common form of presentation, but extrapulmonary tuberculosis (EPTB) contributes significantly to morbidity and mortality. Rarely, patients with EPTB develop a form of ankle or foot arthritis. The diagnosis of TB arthritis is often overlooked because of the insidious onset and the non-specific clinical symptoms. Prognosis is generally poor; early diagnosis and delivery of the most appropriate treatment is critical to avoid functional disability.

New semiquantitative ultrasonographic score for peripheral arterial disease assessment and its association with cardiovascular risk factors

The data concerning the distribution, extent and progression of peripheral arterial disease (PAD), as well as its association with traditional cardiovascular (CV) risk factors, have generally been obtained from studies of patients in advanced stages of the disease undergoing surgical or endovascular treatment. In this study, we have introduced a new semiquantitative ultrasonographic score (ultrasonographic lower limb atherosclerosis (ULLA) score) that is able to categorize lower limb atherosclerotic lesions at all stages of PAD. We then associated these ultrasonographic categories with a CV risk profile. We enrolled 320 consecutive subjects with symptoms suggestive of PAD or with known CV risk factors referring to our angiology unit between 1 July 2014 and 30 June 2015 for ultrasonographic evaluation of the lower limb arteries. Femoropopliteal and run-off segments were categorized together and separately based on their ultrasonographic characteristics. In univariate and multivariate analyses, the ULLA scores were significantly associated with the main CV risk factors, that is, age, male gender, cigarette smoking, arterial hypertension, diabetes, dyslipidemia, sedentary lifestyle, previous CV events and family history of CV disease, and also confirming the specific association of single risk factors with different segments of lower limb arteries. The proposed ULLA score enables a complete evaluation of the entire lower limb atherosclerotic burden, extending the results concerning the association of PAD with CV risk factors to all stages of the disease, including the early stages. It can be feasible that this new score will facilitate better evaluation of the progression of PAD and its prospective role in CV risk stratification.

Heart Failure Among Older Adults in Skilled Nursing Facilities: More of a Dilemma Than Many Now Realize

Post-acute care, encompassing long-term care hospitals, home health, inpatient rehabilitation, and skilled nursing facilities, is increasingly employed as an integral part of management for more complicated patients, particularly as hospitals seek to maintain costs and decrease length of stay. Skilled nursing facilities (SNFs) in particular are progressively utilized for patients with complex medical processes, including today's growing population of older hospitalized heart failure (HF) patients who pose a prominent challenge due to their high risks of mortality, 30-day readmissions, and substantial aggregate cost burden to the healthcare system. Publications to date have largely grouped post-hospitalized HF patients together when reporting demographic or outcome data, without differentiating those at SNFs from those at traditional nursing homes or other post-acute care settings. SNF patients suffer distinctive vulnerabilities and needs, and understanding these distinctions has implications for determining goals of care. In this review we evaluate HF patients referred to SNFs, and discuss the characteristics, outcomes, and management challenges associated with this particular population.

Skin cancer and other cutaneous disorders in liver transplant recipients

Patients who have received liver transplant are at increased risk of skin complications due to long-term immunosuppression regimen. The aim of this study was to analyze the incidence and risk factors of skin complications in liver transplant patients. We analyzed 161 liver transplant recipients. The mean age at transplantation was 47.4 years. Mean follow-up was 6 years. Seventy-one percent of patients presented with skin complications, including aestethic alterations, infections, precancerous lesions and malignancies, which represented 57%, 43%, 18% and 9%, respectively. Risk factors were: age at transplantation ≥ 45 years, immunosuppressive therapy with cyclosporine, and phototype II and III. Our study indicates that although liver transplant recipients are at greater risk of developing skin complications compared to the general population, the risk is lower than for other solid organ transplants, particularly for premalignant and malignant lesions.