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.

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.

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.

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.

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.

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.

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.

Not Only COVID-19: Prevalence and Management of Latent Mycobacterium Tuberculosis Infection in Three Penitentiary Facilities in Southern Italy.

Latent Mycobacterium tuberculosis infection (LTBI) and active tuberculosis in prisoners are higher than the general population and are two public health concerns, especially in low- and middle-income countries. We conducted a cross-sectional study to determine the prevalence and the factors associated with LTBI among the inmate population detained in three Southern Italian penitentiaries. Tuberculin intradermal reaction skin test was performed on the inmates who agreed to participate in the study. In case of positivity, the QuantiFERON-TB test was performed. In those positive to QuantiFERON, chest X-ray films were performed, and treatment initiated. A total of 381 inmates accepted to participate. The prevalence of LTBI was 4.2%. In the analysis, LTBI was associated with no self-reported contact with active tuberculosis patients within the prisons, and 10% of subjects admitted the use of inhaled drugs. No HIV coinfections were found. No cases of active symptomatic tuberculosis were identified during the study period. Our results confirm that incarceration increases the risk of tuberculous infection. Non-EU nationality and a history of drug addiction appear to be major risk factors for tuberculosis infection in the penitentiary setting. Reinforcing tuberculosis control is essential to prevent its transmission in prisons.

Frailty Assessment in the Emergency Department for Patients ≥80 Years Undergoing Urgent Major Surgical Procedures.

OBJECTIVES: To evaluate, in a cohort of adults ≥80 years old, the frailty status at the emergency department (ED) admission, for the in-hospital death risk stratification of patients needing major surgical procedures. DESIGN: Single-center prospective observational cohort study. SETTING AND PARTICIPANTS: The study was conducted in the ED of a teaching hospital. We enrolled all patients ≥80 years old consecutively admitted to the ED for conditions requiring urgent surgical procedures, between 2018 and 2021. METHODS: Clinical variables and frailty status assessed in the ED were evaluated for the association with all-cause in-hospital death. The parameters evaluated were frailty [assessed by the Clinical Frailty Scale (CFS)], comorbidities, physiological parameters, type of surgery needed, laboratory values at admission. Cox regression analysis was used to identify independent risk factors for poor outcomes. RESULTS: The study enrolled 1039 patients aged ≥80 years [median age 85 years (interquartile range 82-89); 445 males (42.8%)]. Overall, 127 patients (12.2%) were classified as nonfrail (CFS score 1-3), 722 (69.5%) as mild frail (CFS score 4-6), and 190 (18.3%) as frail (CFS score 7-9). The covariate-adjusted analysis revealed that severe frailty [hazard ratio (HR) 12.55, 95% CI 2.96-53.21, P = .016], ≥3 comorbidities (HR 2.08, 95% CI 1.31-3.31, P = .002), shock at ED presentation (HR 3.58, 95% CI 2.16-5.92, P < .001), anemia (HR 1.88, 95% CI 1.17-3.04, P = .009), and neurosurgery procedures (HR 3.97, 95% CI 1.98-7.96, P < .001) were independent risk factors for in-hospital death. CONCLUSIONS AND IMPLICATIONS: In patients aged ≥80 years undergoing urgent surgical procedures, the evaluation of functional status in the ED could predict the risk of in-hospital death. Frail patients have an increased risk of death and major complications, whereas those with mild frailty have a similar prognosis compared with the more fit ones. Nonsurgical management should be considered in the case of severely frail and comorbid patients aged ≥80 years needing neurosurgery or abdominal surgery.

Clinical Characteristics and Predictors of In-Hospital Mortality among Older Patients with Acute Heart Failure.

Acute Heart Failure (AHF)-related hospitalizations and mortality are still high in western countries, especially among older patients. This study aimed to describe the clinical characteristics and predictors of in-hospital mortality of older patients hospitalized with AHF. We conducted a retrospective study including all consecutive patients ≥65 years who were admitted for AHF at a single academic medical center between 1 January 2008 and 31 December 2018. The primary outcome was all-cause, in-hospital mortality. We also analyzed deaths due to cardiovascular (CV) and non-CV causes and compared early in-hospital events. The study included 6930 patients, mean age 81 years, 51% females. The overall mortality rate was 13%. Patients ≥85 years had higher mortality and early death rate than younger patients. Infections were the most common condition precipitating AHF in our cohort, and pneumonia was the most frequent of these. About half of all hospital deaths were due to non-CV causes. After adjusting for confounding factors other than NYHA class at admission, infections were associated with an almost two-fold increased risk of mortality, HR 1.74, 95% CI 1.10-2.71 in patients 65-74 years (p = 0.014); HR 1.83, 95% CI 1.34-2.49 in patients 75-84 years (p = 0.001); HR 1.74, 95% CI 1.24-2.19 in patients ≥85 years (p = 0.001). In conclusion, among older patients with AHF, in-hospital mortality rates increased with increasing age, and infections were associated with an increased risk of in-hospital mortality. In contemporary patients with AHF, along with the treatment of the CV conditions, management should be focused on timely diagnosis and appropriate treatment of non-CV factors, especially pulmonary infections.

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.

Outcomes and Predictors of In-Hospital Mortality among Older Patients with Dementia.

Dementia is associated with high rates of admission to hospital, due to acute illness, and in-hospital mortality. The study aimed to investigate the impact of dementia on in-hospital mortality and identify the predictors of in-hospital mortality in these patients. This was a retrospective study evaluating all the patients ≥65 years consecutively admitted to our Emergency Department (ED). We compared the clinical outcomes of the patients with dementia at ED admission with those who did not have dementia, using a propensity score-matched (PSM) paired cohort of controls. The patients were matched for age, sex, Charlson Comorbidity Index value, and clinical severity at presentation (based on NEWS ≥ 5). The primary study endpoint was all-cause in-hospital death. After the PSM, a total of 7118 patients, 3559 with dementia and 3559 in the control group, were included in the study cohort. The mean age was 84 years, and 59.8% were females. The overall mortality rate was higher for the demented patients compared with the controls (18.7% vs. 16.0%, p = 0.002). The multivariate-adjusted hazard ratio (HR) showed that dementia was an independent risk factor for death (HR 1.13 [1.01−1.27]; p = 0.033). In the patients with dementia, respiratory failure (HR 3.08 [2.6−3.65]), acute renal failure (HR 1.64 [1.33−2.02]; p < 0.001), hemorrhagic stroke (HR 1.84 [1.38−2.44]; p < 0.001), and bloodstream infection (HR 1.41 [1.17−1.71]; p = 0.001) were significant predictors of worse outcomes. Finally, the comorbidities and severity of illness at ED admission negatively influenced survival among the patients with dementia (CCI HR 1.05 [1.01−1.1] p = 0.005; NEWS ≥ 5 HR 2.45 [1.88−3.2] p < 0.001). In conclusion, among the hospitalized older patients, dementia was associated with a higher risk of mortality. Furthermore, among the older patients with dementia, respiratory failure and bloodstream infections were independently associated with an increased risk of in-hospital mortality.

Incidence and Predictors of Thrombotic Complications in 4742 Patients with COVID-19 or Other Acute Infectious Respiratory Diseases: A Propensity Score-Matched Study.

BACKGROUND: A prothrombotic state, attributable to excessive inflammation, cytokine storm, hypoxia, and immobilization, is a feature of SARS-CoV-2 infection. Up to 30% of patients with severe COVID-19 remain at high risk of thromboembolic events despite anticoagulant administration, with adverse impact on in-hospital prognosis. METHODS: We retrospectively studied 4742 patients with acute infectious respiratory disease (AIRD); 2579 were diagnosed to have COVID-19 and treated with heparin, whereas 2163 had other causes of AIRD. We compared the incidence and predictors of total, arterial, and venous thrombosis, both in the whole population and in a propensity score-matched subpopulation of 3036 patients (1518 in each group). RESULTS: 271 thrombotic events occurred in the whole population: 121 (4.7%) in the COVID-19 group and 150 (6.9%) in the no-COVID-19 group (p < 0.001). No differences in the incidence of total (p = 0.11), arterial (p = 0.26), and venous (p = 0.38) thrombosis were found between the two groups after adjustment for confounding clinical variables and in the propensity score-matched subpopulation. Likewise, there were no significant differences in bleeding rates between the two groups. Clinical predictors of arterial thrombosis included age (p = 0.006), diabetes mellitus (p = 0.034), peripheral artery disease (p < 0.001), and previous stroke (p < 0.001), whereas history of solid cancer (p < 0.001) and previous deep vein thrombosis (p = 0.007) were associated with higher incidence of venous thrombosis. CONCLUSIONS: Hospitalized patients with COVID-19 treated with heparin do not seem to show significant differences in the cumulative incidence of thromboembolic events as well as in the incidence of arterial and venous thrombosis separately, compared with AIRD patients with different etiological diagnosis.

Improved gut microbiota features after the resolution of SARS­CoV­2 infection.

BACKGROUND: The severe acute respiratory syndrome coronavirus 2 (SARS­CoV­2) 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 SARS­CoV­2-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.