Comparison of different frailty instruments for prediction of functional decline in older hypertensive outpatients (HYPER-FRAIL pilot study 2).

BACKGROUND AND AIMS: Few studies have evaluated frailty in older hypertensive individuals and the most appropriate tools to identify frailty in this population have yet to be identified. This study compared the performance of six frailty instruments in the prediction of 1-year functional decline in older hypertensive outpatients. METHODS: The HYPERtension and FRAILty in Older Adults (HYPER-FRAIL) longitudinal pilot study involved hypertensive participants ≥75 years from two geriatric outpatient clinics at Careggi Hospital, Florence, Italy, undergoing identification of frailty with four frailty scales (Fried Frailty Phenotype, Frailty Index [FI], Clinical Frailty Scale [CFS], Frailty Postal Score) and two physical performance tests (Short Physical Performance Battery [SPPB] and gait speed). Prediction of 1-year functional decline (i.e. a ≥ 10-point Barthel Index decrease between baseline and follow-up) was examined based on ROC curve analysis and multivariable logistic regression. RESULTS: Among 116 participants, 24 % reported functional decline. In the ROC curve analyses, FI (AUC=0.76), CFS (AUC=0.77), gait speed (AUC=0.73) and the SPPB (AUC=0.77) achieved the best predictive performance, with FI ≥0.21 and CFS ≥4 showing the highest sensitivity (82 %) and negative predictive value (91 %). Frailty identified with FI, CFS or physical performance tests was associated with an increased risk of 1-year functional decline, independently of baseline functional status and comorbidity burden. CONCLUSIONS: FI, CFS and physical performance tests showed similar predictive ability for functional decline in hypertensive outpatients. The CFS and gait speed might be more suitable for clinical use and may be useful to identify non-frail individuals at lower risk of functional decline.

Cardiac cystic echinococcosis-A systematic review and analysis of the literature.

Human cystic echinococcosis (CE) is a parasitic infection caused by the larval stage of the tapeworm Echinococcus granulosus sensu lato, primarily affecting the liver and lungs. Although the heart is affected in only 0.02-2% of all CE cases, a considerable number of cases have been, and continue to be, published. However, due to the rare occurrence of cardiac CE and the resulting lack of clinical trials, knowledge about various aspects of the disease remains limited. To obtain a clearer picture of anatomical, clinical, diagnostic as well as therapeutic aspects of cardiac CE, we systematically reviewed the literature published between 1965 and 2022. The anatomical pattern of the affected cardiac structures follows the extension of the supplying capillary bed. The majority of patients (82.7%) are symptomatic and present with prolonged non-specific symptoms such as dyspnoea, chest pain and palpitations. Acute complications generally derive from cyst rupture, occur in 18.3% of cases and manifest as embolism, pericardial tamponade, or anaphylactic reaction in 83.2%, 17.8% and 10.9% of these cases, respectively. As for CE cysts localized in other organs, the diagnosis of cardiac CE is made by imaging. Serology plays a minor role due to its limited sensitivity. Unlike abdominal CE cysts, cardiac CE cysts are usually resected independent of their stage (active/inactive), because their presence impairs cardiac performance and carries the risk of long-term sequelae. More than 80% of patients are treated with a single surgical intervention. We found a disease-related case fatality rate of 11.1%. Since local recurrence was reported up to 108 months and secondary CE up to 72 months after surgery, patients should be followed up for a minimum of 10 years.

Delayed Surgical Treatment of a CE1 Lung Cyst Resulting in Pericystectomy of CE4 Cyst.

Lung is the second most common locationof cystic echinococcosis (CE), after the liver. Diagnosis of lung CE is often incidental, and clinical manifestations depend on the location and size of the cyst, the most common being chest pain, shortness of breath, expectoration of fragments of endocyst, and haemoptysis. Surgery is the primary treatment, with a minor role for medical therapy. Delayed diagnosis and treatment may have important consequences. We present a case of lung CE in whichsurgical treatment was delayed due to the first wave of COVID-19. Since surgery could not be performed immediately, the patient was kept on albendazole and the cyst stage moved from CE1 to CE3a, to CE4, eventually requiring a more aggressive pericystectomy instead of the commonly performed endocystectomy. The clinical and imaging characteristics of a rare CE4 cyst of the lung are reported.

Predictors and Outcomes of Oral Anticoagulant Deprescribing in Geriatric Inpatients With Atrial Fibrillation: A Retrospective Multicenter Cohort Study.

OBJECTIVE: To investigate prevalence and predictors of oral anticoagulant therapy (OAT) deprescribing in older inpatients with atrial fibrillation (AF), and its association with 1-year incidence of major clinical outcomes. DESIGN: Multicenter retrospective cohort study. SETTING AND PARTICIPANTS: Inpatients aged ≥75 years with known AF on OAT at admission discharged from 3 Italian acute geriatric wards between January 2014 and July 2018. METHODS: Data from a routine Comprehensive Geriatric Assessment (CGA), along with OAT status at discharge were recorded. One-year incidence of all-cause death, stroke or systemic embolism (SSE), and major and clinically relevant nonmajor bleeding (MB/CRNMB) were retrieved from administrative databases. Associations were explored through multilevel analysis. RESULTS: Among 1578 patients (median age 86 years, 56.3% female), OAT deprescription (341 patients, 21.6%) was associated with bleeding risk, functional dependence and cognitive impairment, and inversely, with previous SSE and chronic AF. Incidences of death, SSE, and MB/CRNMB were 56.6%, 1.5%, and 4.1%, respectively, in OAT-deprescribed patients, and 37.6%, 2.9%, and 4.9%, respectively, in OAT-continued patients, without significant differences between groups. OAT deprescription was associated with all-cause mortality [adjusted odds ratio (aOR) 1.41, 95% CI 1.68-1.85], along with older age, comorbidity burden, cognitive impairment, and functional dependence, but with neither SSE nor MB/CRNMB incidence, as opposed to being alive and free from SSE and MB/CNRMB, respectively (aOR 0.68, 95% CI 0.25-1.82, and aOR 0.95 95% CI 0.49-1.85, respectively). Conversely, OAT deprescription was associated with higher odds of being dead than alive both in patients free from SSE and in those free from MB/CRNMB. CONCLUSIONS AND IMPLICATIONS: CGA-based OAT deprescribing is common in acute geriatric wards and is not associated with increased SSE. The net clinical benefit of OAT in geriatric patients is strongly related with the competing risk of death, suggesting that functional and cognitive status, as well as residual life expectancy, should be considered in clinical decision making in this population.

Prevalence and correlates of frailty in older hypertensive outpatients according to different tools: the HYPER-FRAIL pilot study.

OBJECTIVES: To date, few studies have investigated frailty in hypertensive individuals. This study aimed at identifying the prevalence of frailty in a sample of hypertensive older outpatients using six different identification tools. Clinical correlates of frailty and agreement between different frailty definitions were also investigated. METHODS: The HYPER-FRAIL pilot study recruited hypertensive patients aged at least 75 years from two geriatric outpatient clinics of Careggi Hospital, Florence, Italy. Four frailty scales [Fried Frailty Phenotype, Frailty Index, Clinical Frailty Scale (CFS), Frailty Postal Score] and two physical performance tests [Short Physical Performance Battery (SPPB) and usual gait speed] were applied. The Cohen's kappa coefficient was calculated to assess agreement between measures. Multiple logistic regression was used to identify clinical features independently associated with frailty. RESULTS: Among 121 participants (mean age 81, 60% women), frailty prevalence varied between 33 and 50% according to the tool used. Moderate agreement was observed between Fried Frailty Phenotype, Frailty Index and SPPB, and between Frailty Index and CFS. Agreement was minimal or weak between the remaining measures (K < 0.60). Use of walking aids and depressive symptoms were independently associated with frailty, regardless of the definition used. Frailty correlates also included dementia, disability and comorbidity burden, but not office and 24-h blood pressure values. CONCLUSION: Frailty is highly prevalent among older hypertensive outpatients, but agreement between different frailty tools was moderate-to-weak. Longitudinal studies are needed to assess the prognostic role of different frailty tools and their clinical utility in the choice of antihypertensive treatment.

Simultaneous Echinococcal superinfection in a patient with polycystic liver disease.

Key Clinical Message: Concurrent polycystic liver disease and echinococcus infection can hinder diagnosis. Surgery may be needed for accurate diagnosis and treatment. Multidisciplinary collaboration is crucial. Abstract: Cystic echinococcosis, caused by Echinococcus granulosus eggs, is a parasitic zoonosis that typically affects humans through accidental ingestion. Polycystic liver disease is a condition characterized by the presence of multiple liver cysts and is often associated with polycystic kidney disease. Here, we present a case of a man in his 70s with a pre-existing diagnosis of polycystic liver disease. Radiological findings of a suspicious cyst in the S4 segment initially lacked serological evidence of echinococcosis; however, intraoperative confirmation revealed the presence of an echinococcal cyst. This article aims to explore both clinical conditions and highlight the therapeutic considerations for their management. Moreover, we discuss the significance of this unique case, emphasizing the possibility of the coexistence of these two pathologies.

Visceral larva Migrans in a Young Italian Patient: A Diagnostic Dilemma.

BACKGROUND: The association of fever, focal hepatic lesions and peripheral hyper-eosinophilia (FHLH) can be observed in both infectious and non-infectious conditions. Fascioliasis, capillariasis, toxocariasis, all causes of visceral larva migrans (VLM), represent most of the former, whilst lymphomas, eosinophilic leukemias and mastocytosis belong in the non-infectious conditions. METHODS: We prospectively followed a young patient presenting with FHLH in the Tuscany region of Italy. RESULTS: The patient was subject to serological and parasitological examination in an attempt to clarify the origin of the lesions. Serologies for both Fasciola hepatica and Toxocara spp. were positive, with the latter presenting a higher index. We opted for treatment with a prolonged course of albendazole due to the serological results and being toxocariasis more frequent in our setting. The patient was then subject to radiological follow-up. The patient responded to treatment with albendazole as shown by a decrease in eosinophils, seronegativization for Toxocara spp., clinical and radiological improvement. Toxocariasis was hence considered the most likely diagnosis. CONCLUSIONS: Parasitic infections cannot be disregarded in the presence of FHLH. Differential diagnosis between these parasitic infections can be challenging due to the presence of similar clinical presentations and serological cross-reactions, and follow-up of the patient is needed to ensure optimal treatment outcomes.

The high burden of pediatric cystic echinococcosis in Kazakhstan: epidemiological and clinical consequences.

BACKGROUND: Cystic echinococcosis (CE) is attributable to Echinococcus granulosus metacestodes. Ultrasound examinations enable a stage-specific approach to CE management. However, this approach is not often applied in endemic areas, which include Kazakhstan. METHODS: We collected clinical and ultrasound data on CE pediatric patients seen at a national referral surgical center in Almaty, Kazakhstan, during 2015-2020. RESULTS: We included 49 patients, and 79 cysts that were all surgically treated. All but one patient carried active cysts (CE1-CE3 stages). Twenty-six (53.2%) did not receive albendazole postsurgery. Children with CE1 and CE3a cysts underwent surgery, while the use of albendazole and percutaneous drainage were advised upon by experts. CONCLUSIONS: A stage-specific approach to CE management in Kazakhstan is urgent, especially in the pediatric population. The rate of active cysts suggests continuing transmission of CE.

Atypical Course of SarsCov-2 Infection in a Patient with Multiple Myeloma Treated with Autologous Stem Cell Transplantation.

Covid-19 infection has more relevant consequences in frail and comorbid patients, but little is known about its course in patients with hematologic malignancies. In this report, we would like to present the case of a patient with multiple myeloma treated with recent autologous bone marrow stem cell transplantation and affected by Covid-19 pneumonia, presenting with a possible reinfection or an extremely long viral shedding.

Watch-and-wait approach for inactive echinococcal cysts: scoping review update since the issue of the WHO-IWGE Expert Consensus and current perspectives.

PURPOSE OF REVIEW: This work aims to provide an update of knowledge on the evolution of inactive cystic echinococcosis (CE) cysts (CE4-CE5) managed by 'watch-and-wait', by means of a scoping review of the literature published after the publication of the WHO-IWGE (Informal Working Group on Echinococcosis) Expert Consensus document in 2010. RECENT FINDINGS: A total of 31 articles were included. Population ultrasound-based studies showed that spontaneously inactivated CE cysts represent 50.2% (95% confidence interval 38.7-61.8) of all detected untreated CE cysts, and that the prevalence of CE4-CE5 cysts tends to increase with age. Four longitudinal population-based studies showed that CE cysts naturally tend to evolve towards inactivation and that spontaneously inactivated cysts reactivate in a minority of cases. This was confirmed by four hospital-based studies, showing that spontaneously inactivated cysts reactivate rarely, while rate of reactivation is higher if inactivity was obtained posttreatment. It was not possible to drive conclusions on any difference in the clinical course of infection in immunocompromised or pregnant patients. SUMMARY: CE cysts tend to evolve spontaneously to inactivation over time. The published literature supports the safety of the watch-and-wait approach for inactive cysts, sparing treatment to a substantial proportion of asymptomatic patients. A regular follow-up with ultrasound of all inactive cysts is required to detect reactivations.

Fungal Osteomyelitis: A Systematic Review of Reported Cases.

Fungal osteomyelitis is considered a rare disease, and the published literature mainly comprises case reports, case series and narrative reviews. A systematic review was undertaken to provide a practice-based global perspective on this disease, focusing on epidemiology and treatment strategies. We searched MEDLINE, EMBASE and Cochrane Library between the 3rd and 8th of March 2023 using a predefined search string. We included studies with at least one patient with a diagnosis of fungal osteomyelitis published before the 1st of January 2023. We included all study designs except for reviews, and we excluded non-English languages and grey literature. After exclusion, 678 studies, mostly case reports, were included. Descriptive analysis was performed on 1072 patients. The most common aetiological agent was Aspergillus (26.5%), followed by Candida (20.7%) and Mucor (16.8%), and the bones most frequently involved were the vertebrae. We described the characteristics of patients divided by site of infection, and we found that diabetes mellitus, disseminated fungal infection, surgery and local lesion were major risk factors. We also successfully associated duration of treatment with outcome. We provided a general overview of this rare disease, and we highlighted the need for high-quality investigations on the subject.

Predictors of In-Hospital Mortality in Older Inpatients with Suspected Infection.

OBJECTIVES: To determine the rate and predictors of death in older individuals with suspected infection at any time during hospital stay in a geriatric acute ward and the prognostic ability of different tools [quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA), Modified and National Early Warning Scores (MEWS) and (NEWS)] in such population. DESIGN: Prospective observational single-center cohort study. SETTING AND PARTICIPANTS: Among patients admitted to an acute geriatric unit of an Italian University Hospital with at least 1 sepsis risk factor, all subjects with suspected infection at admission or during hospital stay (defined as antibiotic prescription and associated culture test) were considered. METHODS: A geriatric assessment including comorbidity and social, functional, and cognitive status was performed for each patient. Clinical parameters were evaluated at least twice daily throughout hospital stay; qSOFA, MEWS, and NEWS were derived, with positive cutoffs set at ≥2, ≥5, and ≥7, respectively. RESULTS: Among 305 older inpatients (median age 86.0 years, 49.2% female), 21% died during hospital stay. Sepsis was diagnosed in 31.8% of the overall sample and in 64.1% of deceased patients. Deceased patients showed a significantly higher prevalence of prior institutionalization, functional dependence, cognitive impairment, and multimorbidity. The prognostic accuracy of the qSOFA score at infection onset was only fair (area under the receiver operating characteristic curve 0.72; 95% CI, 0.65-0.79, P < .001) and comparable with that of MEWS and NEWS. After multivariable analysis, in-hospital death was positively associated with male sex [odds ratio (OR), 2.11; 95% CI, 1.01-4.44; P = .048] and abnormal white blood cells count (OR, 4.93; 95% CI, 2.36-10.29; P < .001), platelet count (OR, 2.61; 95% CI, 1.10-6.16; P = .029) and serum creatinine (OR, 2.70; 95% CI, 1.30-5.61; P = .008), along with any of the score considered, and negatively associated with autonomy in instrumental activities (OR, 0.78; 95% CI, 0.68-0.90; P < .001). CONCLUSIONS: Prognosis in older inpatients with infection or sepsis appears to be determined both by the geriatric characteristics and by the severity of the acute event, expressed by recommended tools and blood test results.

Ultrasound-Based Prevalence of Cystic Echinococcosis in the Samarkand Region of Uzbekistan: Results from a Field Survey.

Cystic echinococcosis (CE) is a zoonosis caused by Echinococcus granulosus. Uzbekistan is endemic for CE, but estimates of disease burden are lacking. We present findings from a cross-sectional, ultrasound-based survey evaluating the prevalence of human CE in the Samarkand region, Uzbekistan. The survey was conducted between September and October 2019 in the Payariq district, Samarkand. Study villages were selected based on sheep breeding and reported human CE. Residents aged 5-90 years were invited to receive a free abdominal ultrasound examination. The WHO Informal Working Group on Echinococcosis classification was used for cyst staging. Information regarding CE diagnosis and treatment was collected. Of 2,057 screened subjects, 498 (24.2%) were male. Twelve (0.58%) had detectable abdominal CE cysts. In total, five active/transitional (N = 1 CE1, N = 1 CE2, N = 3 CE3b) and 10 inactive cysts (N = 8 CE4, N = 2 CE5) were identified. Two participants had cystic lesions with no pathognomonic features of CE and were given a 1-month course of albendazole for diagnostic purposes. Twenty-three additional individuals reported previous surgery for CE in the liver (65.2%), lungs (21.6%), spleen (4.4%), liver and lungs (4.4%), and brain (4.4%). Our findings confirm the presence of CE in the Samarkand region, Uzbekistan. Additional studies are needed to assess the burden of human CE in the country. All patients with a history of CE reported surgery, even though most cysts found during the current study were inactive. Therefore, it appears there is a lack of awareness by the local medical community of the currently accepted stage-specific management of CE.

Circulating Small RNA Profiling of Patients with Alveolar and Cystic Echinococcosis.

Alveolar (AE) and cystic (CE) echinococcosis are two parasitic diseases caused by the tapeworms Echinococcus multilocularis and E. granulosus sensu lato (s. l.), respectively. Currently, AE and CE are mainly diagnosed by means of imaging techniques, serology, and clinical and epidemiological data. However, no viability markers that indicate parasite state during infection are available. Extracellular small RNAs (sRNAs) are short non-coding RNAs that can be secreted by cells through association with extracellular vesicles, proteins, or lipoproteins. Circulating sRNAs can show altered expression in pathological states; hence, they are intensively studied as biomarkers for several diseases. Here, we profiled the sRNA transcriptomes of AE and CE patients to identify novel biomarkers to aid in medical decisions when current diagnostic procedures are inconclusive. For this, endogenous and parasitic sRNAs were analyzed by sRNA sequencing in serum from disease negative, positive, and treated patients and patients harboring a non-parasitic lesion. Consequently, 20 differentially expressed sRNAs associated with AE, CE, and/or non-parasitic lesion were identified. Our results represent an in-depth characterization of the effect E. multilocularis and E. granulosus s. l. exert on the extracellular sRNA landscape in human infections and provide a set of novel candidate biomarkers for both AE and CE detection.

A beamline to control longitudinal phase space whilst transporting laser wakefield accelerated electrons to an undulator.

Laser wakefield accelerators (LWFAs) can produce high-energy electron bunches in short distances. Successfully coupling these sources with undulators has the potential to form an LWFA-driven free-electron laser (FEL), providing high-intensity short-wavelength radiation. Electron bunches produced from LWFAs have a correlated distribution in longitudinal phase space: a chirp. However, both LWFAs and FELs have strict parameter requirements. The bunch chirp created using ideal LWFA parameters may not suit the FEL; for example, a chirp can reduce the high peak current required for free-electron lasing. We, therefore, design a flexible beamline that can accept either positively or negatively chirped LWFA bunches and adjust the chirp during transport to an undulator. We have used the accelerator design program MAD8 to design a beamline in stages, and to track particle bunches. The final beamline design can produce ambidirectional values of longitudinal dispersion ([Formula: see text]): we demonstrate values of + 0.20 mm, 0.00  mm and - 0.22 mm. Positive or negative values of [Formula: see text] apply a shear forward or backward in the longitudinal phase space of the electron bunch, which provides control of the bunch chirp. This chirp control during the bunch transport gives an additional free parameter and marks a new approach to matching future LWFA-driven FELs.

Case Report: Role of Point-of-Care Ultrasound in the Diagnosis of Bacillary Angiomatosis.

Clinical skin manifestations are commonly seen in resource-limited settings, but they are frequently misdiagnosed due to the lack of microbiological tests with ensuing stigma and long-term disability. The adoption of portable ultrasound devices, which extend physical examination in the hands of trained clinicians, has partially improved the situation. Specific protocols, such as focused assessment with sonography for HIV-associated tuberculosis (FASH), have led to simplified diagnostic pathways. Here we describe a case of bacillary angiomatosis in a patient with advanced HIV disease presenting with subacute unusual cutaneous lesions. The patient also presented with significant weight loss, anemia, and prostration. Highly sensitive rapid tests for tuberculosis and cryptococcosis were negative, and CD4 count was very low. Ultrasound scanning (US) and biopsy of the cutaneous lesions finally led to diagnosis and treatment. This report illustrates the benefits of integrating ultrasound-based protocols with clinical skills, as the diagnosis was suspected based on clinical presentation and US and confirmed by pathology. The importance of adoption of US protocols by infectious diseases clinicians is discussed.

Antigen discovery by bioinformatics analysis and peptide microarray for the diagnosis of cystic echinococcosis.

BACKGROUND: Cystic echinococcosis (CE), caused by Echinococcus granulosus sensu lato, is a neglected zoonosis. Its diagnosis relies on imaging, supported by serology, while only imaging is useful for staging and follow-up. Since diagnostic tools and expertise are not widely available, new accurate and easily implementable assays for the diagnosis and follow-up of CE are highly needed. METHODOLOGY/PRINCIPAL FINDINGS: We aimed to identify new E. granulosus antigens through a bioinformatics selection applied to the parasite genome, followed by peptide microarray screening and validation in ELISA, using independent panels of sera from patients with hepatic CE and clinically relevant controls. From 950 proteins selected in silico, 2,379 peptides were evaluated by microarray for IgG reactivity and eight candidates selected for validation. Reactivity to one peptide was significantly higher in the CE group (p = 0.044), but had suboptimal diagnostic accuracy. CONCLUSIONS/SIGNIFICANCE: Here we performed bioinformatics analysis and peptide microarray for antigen discovery, useful for the diagnosis of CE. Eight candidates were selected and validated. Reactivity to one peptide associated to CE but had suboptimal diagnostic accuracy. Importantly, the database developed in this study may be used to identify other antigenic candidates for CE diagnosis and follow-up.

"Sponge pattern" of the spleen: a rarely described high-frequency ultrasound pattern in HIV-positive patients.

BACKGROUND: The spleen is frequently scanned in workup of infections. Hypoechoic splenic micro-abscesses are known signs of disseminated tuberculosis in HIV co-infected patients. The spleen of HIV patients is thus often scanned using high-frequency transducers. METHODS AND FINDINGS: We describe a reticulo-nodular "sponge pattern" in the spleen of an HIV-positive patient with Hodgkin's lymphoma. Disseminated throughout the spleen, very small (1.5-2.0 mm) hypoechoic lesions having a branching reticulo-nodular distribution were seen. The lesions partly, but not entirely, follow splenic vasculature. Review of stored images of other patients identified 15 more cases showing a similar pattern. All patients were HIV positive, almost all with CD4 counts below 200 cells/mm3. Seven (44%) were additionally diagnosed with HHV-8-associated diseases, but the pattern was seen with various underlying opportunistic infections. DISCUSSION AND CONCLUSION: After comparison with spleen microscopic anatomy, we hypothesize that the white pulp of spleens in our patients is hyperplastic or otherwise changed in consistency to be better visible by high-frequency ultrasound. Concomitant human herpesvirus-8 infection may be another cause of this visible white pulp. While we can only speculate about the etiology of the splenic "sponge pattern," it needs to be recognized as it may be misinterpreted as splenic micro-abscesses of disseminated infections, like tuberculosis in severely immune-compromised patients.