Nephrogenic diabetes insipidus in a geriatric patient affected by SARS-CoV-2: complexity of a diagnosis, complexity of a virus.

Background: Coronavirus disease 2019 (COVID-19) has an important impact on the kidney through direct and indirect damage mechanisms. Most previous studies have highlighted lesions caused by this virus in the early segments of the nephron. However, due to the antigenic characteristics of the virus, with almost ubiquitous receptors, and the molecular release it triggers, the distal segments of the nephron could also be affected. Methods: A 71 year-old-man with respiratory failure while suffering from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia presented with typical symptoms of diabetes insipidus after ~20 days of hospitalization. The water deprivation test led to the diagnosis of nephrogenic diabetes insipidus. The aetiological study was complex, in particular because of the patient's previous lithium therapy. Results: The sequence of pathognomonic events typical of diabetes insipidus associated with anamnestic, clinical and laboratory evidence strongly supported the diagnosis of nephrogenic diabetes insipidus due to SARS-CoV-2 rather than other aetiologies. Conclusions: The collecting duct could represent a target for SARS-CoV-2 infection, directly or indirectly, as a result of lesions of upstream portions of the nephron, which would cascade into the distal segment. Other molecules, besides angiotensin 2 converting enzyme, might be involved in facilitating the viral aggression. The complexity of the geriatric patient shows the importance of a comprehensive approach that integrates careful monitoring of clinical signs and symptoms and laboratory and instrumental tests. This is especially important in the context of SARS-CoV-2 infection and in the management of its unexpected complications.

Oral health status as predictor of 1-year mortality after discharge from an acute geriatric unit.

PURPOSE: Predicting mortality of older patients is a difficult, yet crucial task, which has lead to development of several prognostic tools. We hypothesized that the evaluation of oral health, which is often neglected, might be helpful to improve 1-year mortality prediction in a cohort of patients > 65 years admitted to an acute geriatric unit. METHODS: We assessed 200 patients using the Decayed, Missing or Filled Teeth tool, the Periodontal Screening and Recording tool and the Plaque Index. A comprehensive geriatric assessment was performed to measure functional, cognitive, nutritional and comorbidity status and to calculate the Multidimensional Prognostic Index (MPI). An age- and sex-adjusted regression model was used to identify independent predictors of 1-year mortality. Area under ROC curve (AUROC) was calculated to assess predictive accuracy of MPI risk groups before and after correction for dental examination results. RESULTS: Plaque Index and Periodontal Screening and Recording tool were associated with 1-year mortality. Participants with periodontal disease had a fivefold higher risk of death (p < 0.001). Conversely, absence of periodontal disease identified with high specificity (96.6%) participants who were still alive 1 year after discharge. Periodontal disease was an independent predictor of 1-year mortality in a regression model adjusted for age, sex and other variables of the comprehensive geriatric assessment. The correction of MPI according to results of Periodontal Screening and Recording tool significantly improved AUROC from 0.62 to 0.68 (p < 0.003). CONCLUSION: Oral health evaluation, if integrated in the comprehensive geriatric assessment, improves estimation of 1-year mortality in hospitalized patients.

Constructional apraxia screening and oral health among hospitalized older adults: A cross-sectional study.

AIMS: Apraxia may hinder oral self-care and is associated with poor oral hygiene. Intersecting Pentagons Test (IPT) is a simple screening tool for constructional apraxia (CA) that tests the ability to copy a bidimensional figure. In this study we investigated whether IPT is useful to identify subjects that need interventions to support oral health in a cohort of geriatric inpatients. METHODS AND RESULTS: We assessed oral health through the decayed, missing or filled teeth index, plaque index, and periodontal screening and recording tool. We inquired about autonomy in oral hygiene activities through a standardized questionnaire. Among subjects with CA (273 out of 478 hospitalized subjects aged > 65 years) we found a higher prevalence of edentulism (P = 0.04), periodontal disease (PD) (P = 0.03), and dependence in oral hygiene activities (P < 0.001). Only 34.8% of nonautonomous apraxic patients had a caregiver that supplied oral care. In an age and sex-adjusted generalized linear model, IPT proved to be an independent predictor of dependence in oral care, reaching 61.5% sensitivity in identifying dependent patients. CONCLUSION: Among elderly inpatients, there is a significant association between IPT results, poor oral health status, and dependence in oral hygiene activities. Positivity to IPT should prompt proper device counseling and caregiver education.

Poor nutritional status but not cognitive or functional impairment per se independently predict 1 year mortality in elderly patients with hip-fracture.

BACKGROUND & AIMS: Hip fractures are strongly associated with mortality in the elderly. Studies investigating predisposing factors have suggested a negative impact of poor nutritional, cognitive and functional status on patient survival, however their independent prognostic impact as well as their interactions remain undefined. This study aimed to determine whether poor nutritional status independently predicts 1 year post-fracture mortality after adjusting for cognitive and functional status and for other clinically relevant covariates. METHODS: 1211 surgically treated hip fracture elderly (age ≥ 65) patients consecutively admitted to the Orthopaedic Surgery Unit of the "Azienda Sanitaria Universitaria Integrata Trieste" (ASUITs), Cattinara Hospital, Trieste, Italy and managed by a dedicated orthogeriatric team. Pre-admission nutritional status was evaluated by Mini Nutritional Assessment (MNA) questionnaire, cognitive status by Short Portable Mental Status Questionnaire (SPMSQ) and functional status by Activity of Daily Living (ADL) questionnaire. All other clinical data, including comorbidities, type of surgery, post-operative complications (delirium, deep vein thrombosis, cardiovascular complications, infections, need for blood transfusions) were obtained by hospital clinical records and by mortality registry. RESULTS: Poor nutritional status (defined as MNA ≤23.5), increased cognitive and functional impairment were all associated with 3-, 6- and 12 month mortality (p < 0.001). Both cognitive and functional impairment were associated with poor nutritional status (p < 0.001). Logistic regression analysis demonstrated that the association between nutritional status and 3-, 6- and 12- month mortality was independent of age, gender, comorbidities, type of surgery and post-operative complications as well as of cognitive and functional impairment (p < 0.001). In contrast, the associations between mortality and cognitive and functional impairment were independent (p < 0.001) of demographic (age, gender) and clinical covariates but not of malnutrition. Kaplan-Meier analysis showed a lower mean survival time (p < 0.001) in patients with poor nutritional status compared with those well-nourished. CONCLUSIONS: In hip fracture elderly patients, poor nutritional status strongly predicts 1 year mortality, independently of demographic, functional, cognitive and clinical risk factors. The negative prognostic impact of functional and cognitive impairment on mortality is mediated by their association with poor nutritional status.