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.

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.

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.

Scurvy as cause of purpura in the XXI century: a review on this "ancient" disease

OBJECTIVE

Scurvy is defined as a deficiency of ascorbic acid, which is an essential exogenous vitamin in humans. Vitamin C is involved in collagen synthesis and its deficit can cause disorders of connective tissue. The most frequent symptoms are weakness, arthralgias, anorexia and depression, commonly associated with follicular hyperkeratosis and perifollicular hemorrhage, with purpura.

PATIENTS AND METHODS

A young woman, with a history of malnutrition, manifested purpura and hematoma of the left lower limb. The laboratory tests didn't detect alterations either in coagulation, the platelet count or in the autoimmunity. The total body TC scan didn't show neoplasia or other suspected lesions. Excluding the most important causes of purpura, in consideration of malnutrition, scurvy was suspected.

RESULTS

A skin biopsy confirmed the diagnosis. Accordingly to this finding, a treatment with a daily intravenous infusion of vitamin C was started with consequent improvement of hematoma and purpura.

CONCLUSIONS

Scurvy is a re-emerging disease, also in western countries. When purpura appears in young adults, scurvy has to be investigated, especially when a history of malnutrition is present. The treatment with vitamin C infusions should be started as soon as possible in order to prevent any complications.

Fever of unknown origin and splenomegaly: A case report of blood culture negative endocarditis

RATIONALE

Fever of unknown origin (FUO) can be determined by different conditions among which infectious diseases represent the main cause.

PATIENT CONCERNS

A young woman, with a history of aortic stenosis, was admitted to our unit for a month of intermittent fever associated with a new diastolic heart murmur and splenomegaly. Laboratory tests were negative for infectious screening. The total body computed tomography (CT) scan excluded abscesses, occulted neoplasia, or lymphadenopathy.

DIAGNOSES

The transthoracic and transesophageal echocardiogram showed an aortic valve vegetation. Three sets of blood cultures were negative for all microorganisms tested. According to these findings, Bartonella endocarditis was suspected and the serology tests performed were positive. Finally, real-time polymerase chain reaction (RT-PCR) detected Bartonella henselae DNA on tissue valve.

INTERVENTIONS

The patient underwent heart valve surgery and a treatment of Ampicillin, Gentamicin, and oral Doxycycline was prescribed for 16 days and, successively, with Doxycycline and Ceftriaxone for 6 weeks.

OUTCOMES

After surgery and antibiotic therapy, patient continued to do well.

LESSONS

Bartonella species are frequently the cause of negative blood culture endocarditis. Molecular biology techniques are the only useful tool for diagnosis. Valvular replacement is often necessary and antibiotic regimen with Gentamicin and either Ceftriaxone or Doxycycline is suggested as treatment.Echocardiogram and blood cultures must be performed in all cases of FUO. When blood cultures are negative and echocardiographic tools are indicative, early use of Bartonella serology is recommended.