Characteristics, hospital referrals and 60-day mortality of older patients living in nursing homes with COVID-19 assessed by a liaison geriatric team during the first wave: a research article.

BACKGROUND: The infection by SARS-CoV-2 (COVID-19) has been especially serious in older patients. The aim of this study is to describe baseline and clinical characteristics, hospital referrals, 60-day mortality, factors associated with hospital referrals and mortality in older patients living in nursing homes (NH) with suspected COVID-19. METHODS: A retrospective observational study was performed during March and April 2020 of institutionalized patients assessed by a liaison geriatric hospital-based team. Were collected all older patients living in 31 nursing homes of a public hospital catchment area assessed by a liaison geriatric team due to the suspicion of COVID-19 during the first wave, when the hospital system was collapsed. Sociodemographic variables, comprehensive geriatric assessment, clinical characteristics, treatment received including care setting, and 60-days mortality were recorded from electronic medical records. A logistic regression analysis was performed to analyze the factors associated with mortality. RESULTS: 419 patients were included in the study (median age 89 years old, 71.6 % women, 63.7 % with moderate-severe dependence, and 43.8 % with advanced dementia). 31.1 % were referred to the emergency department in the first assessment, with a higher rate of hospital referral in those with better functional and mental status. COVID-19 atypical symptoms like functional decline, delirium, or eating disorders were frequent. 36.9% had died in the 60 days following the first call. According to multivariate logistic regression age (p 0.010), Barthel index <60 (p 0.002), presence of tachypnea (p 0.021), fever (p 0.006) and the use of ceftriaxone (p 0.004) were associated with mortality. No mortality differences were found between those referred to the hospital or cared at the nursing home. CONCLUSIONS AND IMPLICATIONS: 31% of the nursing home patients assessed by a liaison geriatric hospital-based team for COVID-19 were referred to the hospital, being more frequently referred those with a better functional and cognitive situation. The 60-days mortality rate due to COVID-19 was 36.8% and was associated with older age, functional dependence, the presence of tachypnea and fever, and the use of ceftriaxone. Geriatric comprehensive assessment and coordination between NH and the hospital geriatric department teams were crucial.

Occurrence and genetic diversity of Enterocytozoon bieneusi (Microsporidia) in owned and sheltered dogs and cats in Northern Spain.

Enterocytozoon bieneusi is an obligate intracellular protist-like fungi parasite that infects numerous mammal hosts including humans, raising concerns of zoonotic transmission. There is little information available on the presence and diversity of E. bieneusi genotypes in companion animals. Here, we determined the occurrence and genetic diversity of E. bieneusi in domestic dogs and cats from Northern Spain. A total of 336 genomic DNA samples extracted from canine (n = 237) and feline (n = 99) faecal specimens were retrospectively investigated. The presence of E. bieneusi was assessed by PCR of the rRNA internal transcribed spacer (ITS) gene. The parasite was detected in 3.0% (3/99) and 0.8% (2/237) of the cats and dogs examined, respectively. All three feline positive samples were from stray cats living in an urban setting, whereas the two canine samples were from owned dogs living in rural areas. Sequence analysis revealed the presence of two genotypes in dogs, BEB6 and PtEb IX, and two genotypes in cats, D and Peru11. The identification of Peru11 in a cat and BEB6 in a dog constitutes the first report of those genotypes in such hosts as well as first report in Spain. This is also the first evidence of genotype D in cats and PtEb IX in dogs in Spain. Three out of the four genotypes, BEB6, D and Peru11, have been previously reported as human pathogens and are potentially zoonotic indicating that dogs and cats need to be considered potential sources of human infection and environmental contamination.

Detection and molecular characterisation of Giardia duodenalis, Cryptosporidium spp. and Entamoeba spp. among patients with gastrointestinal symptoms in Gambo Hospital, Oromia Region, southern Ethiopia.

OBJECTIVES: To assess the prevalence and genetic diversity of the enteric protozoa species G. duodenalis, Cryptosporidium spp. and Entamoeba histolytica in individuals with gastrointestinal symptoms compatible with infections by these pathogens seeking medical attention in a rural area in southern Ethiopia. METHODS: A total of 92 stool samples were initially screened by direct microscopy and immunochromatography and further confirmed by molecular methods. G. duodenalis-positive samples were molecularly characterised by multilocus genotyping of the glutamate dehydrogenase and ß-giardin genes of the parasite. PCR and DNA sequence analysis of the gene encoding the 60-kDa glycoprotein was used for the subtyping of Cryptosporidium isolates. Detection and differential diagnosis of E. histolytica/dispar were conducted by real-time PCR. RESULTS: PCR-based prevalences were 10.9% for G. duodenalis, 1.1% for Cryptosporidium spp. and 3.3% for Entamoeba spp. Seven (four novel and three known) subtypes of G. duodenalis assemblage B were identified at the GDH locus and 5 (one novel and four known) at the BG locus. A novel variant of C. hominis subtype IbA9G3 was also identified. Two Entamoeba isolates were assigned to E. dispar and an additional one to E. histolytica. CONCLUSION: Although preliminary, our results strongly suggest that giardiasis, cryptosporidiosis and amoebiasis represent a significant burden in Ethiopian rural population.

Deprescribing in older patients with advanced cancer referred to palliative care.

OBJECTIVES: This study aimed to explore the prevalence of potentially inappropriate medications (PIMs) in a cohort of older adults with advanced cancer referred to palliative care. Secondary objectives were to describe the categories of identified PIMs and assess risk factors associated with their presence in this population. METHODS: This retrospective, observational study evaluated patients with advanced cancer admitted to a tertiary university hospital in Madrid, Spain and referred to palliative care between 1 January 2020 and 30 June 2020. Demographic, clinical, and pharmacotherapeutic data were obtained from the electronic medical records and regional databases. PIMs were assessed using the Screening Tool of Older Persons Prescriptions in Frail adults (STOPPFrail) criteria, V1. RESULTS: Among 123 patients (median age 80 years (IQR 73.5-87), 64.2% male), 74% presented at least one PIM according to the STOPPFrail criteria. The most common categories of inappropriate medications were lipid-lowering therapies, proton pump inhibitors, calcium supplements, and oral antidiabetics. The number of chronic comedications was significantly associated with PIM presence. CONCLUSIONS: Our study found a high prevalence of PIM among a cohort of older adults with advanced cancer and short life expectancy. This underlines the need for a comprehensive medication review to optimise pharmacotherapy in this population.

[Inappropriate drug use in palliative care: SPANISH version of the STOPP-Frail criteria (STOPP-Pal)]. / Uso potencialmente inapropiado de fármacos en cuidados paliativos: versión en castellano de los criterios STOPP-Frail (STOPP-Pal).

Multiple medication and inappropriate drug prescription are prevalent and challenging problems in older patients in end-of-life situations, and increases both preventable adverse events and health care costs. Recent literature recommends de-prescribing some drugs in patients with short life expectancy, when the aim of drug treatments is not prevention or cure, but symptom control. Recently, a list of explicit criteria (STOPP-Frail) intended to guide prescribing physicians in decision making on the use of drugs in older patients with terminal conditions. This article presents a Spanish version of such criteria, which have been named STOPP-Pal to avoid confusion with the current concept of frailty.

[Regional protocol for adjusting the therapeutic intensity. Southern Metropolitan Area of Barcelona]. / Protocolo territorial de adecuación de la intensidad terapéutica. Área Metropolitana Sur de Barcelona.

The identification of patients with advanced and complex chronic diseases, and the fragmentation of care towards the end of life, requires the drawing up a long-term therapeutic plan. This should take into account the values and preferences of the patients, as well as the vital and functional prognosis. Having an adjustment tool for determining the diagnostic and therapeutic effort is helpful in the continuity of care, as well as in decision-making in the transitions and dynamic changes of patients as they approach the end of life process.

Detection and molecular diversity of Giardia duodenalis and Cryptosporidium spp. in sheltered dogs and cats in Northern Spain.

Domestic dogs and cats may act as natural reservoirs of a large number of zoonotic pathogens, including the enteric parasites Giardia duodenalis and Cryptosporidium spp., the most relevant protozoan species causing gastrointestinal disease worldwide. A cross-sectional epidemiological study aiming to assess the prevalence and molecular diversity of G. duodenalis and Cryptosporidium spp. was conducted in an animal rescue centre in the province of Álava (Northern Spain). A total of 194 and 65 faecal dropping samples from individual dogs and cats, respectively, were collected between November 2013 and June 2016. G. duodenalis cysts and Cryptosporidium spp. oocysts were detected by direct fluorescence microscopy and PCR-based methods targeting the small subunit ribosomal RNA gene of these parasites. Overall, G. duodenalis and Cryptosporidium spp. were detected in 33% (63/194) and 4.1% (8/194) of dogs, and 9.2% (6/65) and 4.6% (3/65) of cats, respectively. G. duodenalis and Cryptosporidium co-infections were observed in 1.5% (3/194) of dogs, but not in cats. No significant differences in infection rates could be demonstrated among dogs or cats according to their sex, age group, status, or geographical origin. Multi-locus sequence-based genotyping of the glutamate dehydrogenase and ß-giardin genes of G. duodenalis allowed the characterization of 19 canine isolates that were unambiguously assigned to sub-assemblages AII (n=7), BIII (n=1), and BIV (n=7), and assemblages C (n=3) and D (n=1). Two feline isolates were genotyped as assemblages A and F, respectively. No mixed assemblage or sub-assemblage infections were identified. C. canis (n=5) and C. hominis (n=1) were the Cryptosporidium species found in dogs, whereas C. felis (n=1) was identified in cats. The finding of G. duodenalis sub-assemblages AII, BIII, and BIV circulating in dogs (but not cats) may have zoonotic potential, although most of the AII and BIV isolates sub-genotyped corresponded to genetic variants not previously found in Spanish human populations. Dogs may also act as novel suitable hosts for C. hominis. We recommend to considerer companion animals as sentinel surveillance system for zoonotic giardiasis and cryptosporidiosis in order to minimize the risk of spreading of these parasitic diseases among the human population.

[Analysis of palliative sedation in hospitalised elderly patients: Effectiveness of a protocol]. / Análisis de la sedación paliativa en pacientes mayores hospitalizados: efectividad de un protocolo.

OBJECTIVE: To measure changes in the practice of palliative sedation during agony in hospitalised elderly patients before and after the implementation of a palliative sedation protocol. MATERIAL AND METHODS: A retrospective before-after study was performed in hospitalised patients over 65 years old who received midazolam during hospital admission and died in the hospital in two 3-month periods, before and after the implementation of the protocol. Non-sedative uses of midazolam and patients in intensive care were excluded. Patient and admission characteristics, the consent process, withdrawal of life-sustaining treatments, and the sedation process (refractory symptom treated, drug doses, assessment and use of other drugs) were recorded. Association was analysed using the Chi(2) and Student t tests. RESULTS: A total of 143 patients were included, with no significant differences between groups in demographic characteristics or symptoms. Do not resuscitate (DNR) orders were recorded in approximately 70% of the subjects of each group, and informed consent for sedation was recorded in 91% before vs. 84% after the protocol. Induction and maintenance doses of midazolam followed protocol recommendations in 1.3% before vs 10.4% after the protocol was implemented (P=.02) and adequate rescue doses were used in 1.3% vs 11.9% respectively (P=.01). Midazolam doses were significantly lower (9.86mg vs 18.67mg, P<.001) when the protocol was used than when it was not used. Ramsay sedation score was used in 8% vs. 12% and the Palliative Care Team was involved in 35.5% and 16.4% of the cases (P=.008) before and after the protocol, respectively. CONCLUSIONS: Use of midazolam slightly improved after the implementation of a hospital protocol on palliative sedation. The percentage of adequate sedations and the general process of sedation were mostly unchanged by the protocol. More education and further assessment is needed to gauge the effect of these measures in the future.

Identification and genotyping of Giardia spp. and Cryptosporidium spp. isolates in aquatic birds in the Salburua wetlands, Álava, Northern Spain.

Aquatic birds are known to be suitable hosts for a number of avian-specific species and genotypes of the enteric protozoan parasites Giardia and Cryptosporidium. Waterbirds have also been reported as sporadic carriers of species of both pathogens from human or domestic animal origin via environmental contamination. Because aquatic birds can shed substantial amounts of infective Giardia and Cryptosporidium (oo)cysts to the environment including surface waters intended for human consumption, this situation may pose a potential risk of waterborne zoonotic disease. A total of 265 waterbird faecal samples were collected from May 2014 to June 2015 at Salburua (Álava), one of the most valued continental wetlands in northern Spain. The detection of Giardia oocyst and Cryptosporidium oocysts was carried out by direct fluorescence microscopy and molecular (PCR and sequence analysis) methods targeting the small subunit ribosomal RNA gene of the parasites. Typing of Giardia duodenalis isolates at the sub-assemblage level was based on the specific amplification and sequencing of a partial fragment of the glutamate dehydrogenase gene. Overall, Giardia cysts and Cryptosporidium oocysts were detected in 22 (8.3%) and 6 (2.3%), respectively, of the 265 faecal samples analysed. The two only Giardia isolates characterized (one novel, one known) were assigned to the sub-assemblage BIV of G. duodenalis, none of them previously reported in Spanish human isolates. This finding raises doubts about the actual origin of the infection and whether waterbirds may serve as potential source of infective Giardia cysts to humans via waterborne transmission or through direct contact. The six Cryptosporidium isolates obtained were characterized as avian genotype III (n=4), duck genotype b (n=1), and goose genotype Id (n=1), all considered avian-specific and therefore of negligible risk of zoonotic infection.

Unexpected finding of feline-specific Giardia duodenalis assemblage F and Cryptosporidium felis in asymptomatic adult cattle in Northern Spain.

Giardia duodenalis and Cryptosporidium spp. are common enteric protozoan parasites in production animals, including cattle. Typically, both the clinical outcome of these infections and the distribution of G. duodenalis assemblages and Cryptosporidium species are age-dependent, with the occurrence of diarrhoeal disease being mainly associated with young animals and sub-clinical, low intensity infections being predominantly found in adult animals. To investigate the prevalence and genetic diversity of G. duodenalis and Cryptosporidium spp. in asymptomatic adult cattle, a total of 362 faecal samples were collected in four farms in the province of Álava, Northern Spain, between November 2011 and December 2012. The presence of G. duodenalis was estimated by real-time PCR, and the assemblages were determined by multilocus sequence-based genotyping of the glutamate dehydrogenase and ß-giardin genes of the parasite. Detection and identification of Cryptosporidium species was carried out by sequencing of a partial fragment of the small-subunit ribosomal RNA gene. Overall, G. duodenalis and Cryptosporidium spp. were detected in 68 (18.8%) and 45 (12.4%), respectively, of the 362 animals tested. Strikingly, four isolates representing two novel sub-types of G. duodenalis assemblage F were identified at the gdh, but not the bg, locus. This is the first report describing the presence of the feline-specific G. duodenalis assemblage F in bovine isolates. Additionally, five (three novel and two known) sub-types of G. duodenalis assemblage E were also identified at the gdh locus and a single one (assigned to sub-assemblage EII) at the bg locus. Of nine Cryptosporidium isolates, four (including a novel sub-type) were assigned to the cat-specific C. felis, two were typed as C. bovis, and the remaining three were only characterized at the genus level. Data presented here provide epidemiological and molecular evidence demonstrating that the host range specificity of G. duodenalis assemblages and Cryptosporidium species may be wider than previously anticipated.