•Older patients are facing a more severe COVID-19 due to age-related vulnerability•Reduced PaO2/FiO2 and consolidations at chest x-ray were predictors of mortality•Age≥85 yo, dementia and impairment ...in ADL were predictors of in-hospital death•Severity scores had good ability in death risk stratification in older people
: To date, mainly due to age-related vulnerability and to coexisting comorbidities, older patients often face a more severe COVID-19. This study aimed to identify at Emergency Department (ED) admission the predictors of in-hospital mortality and suitable scores for death risk stratification among COVID-19 patients ≥ 80 years old.
: Single-centre prospective study conducted in the ED of an university hospital, referral center for COVID-19 in central Italy. We included 239 consecutive patients ≥ 80 years old with laboratory-confirmed COVID-19.
The primary study endpoint was all-cause in-hospital mortality. Multivariable Cox regression analysis was performed on significant variables at univariate analysis to identify independent risk factor for death. Overall performance in predicting mortality of WHO severity scale, APACHE II score, NEWS score, and CURB-65 was calculated.
: Median age was 85 82-89 and 112 were males (46.9%). Globally, 77 patients (32.2%) deceased. The presence of consolidations at chest x-ray and the hypoxemic respiratory failure were significant predictors of poor prognosis. Moreover, age ≥ 85 years, dependency in activities of daily living (ADL), and dementia were risk factors for death, even after adjusting for clinical covariates and disease severity. All the evaluated scores showed a fairly good predictive value in identifying patients who could experience a worse outcome.
: Among patients ≥ 80 years old hospitalized with COVID-19, not only a worse clinical and radiological presentation of the disease, but also the increasing age, dementia, and impairment in ADL were strong risk factors for in-hospital death, regardless of disease severity.
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.
Introduction
Antibody response plays a fundamental role in the natural history of infectious disease. A better understanding of the immune response in patients with SARS-CoV-2 infection could be ...important for identifying patients at greater risk of developing a more severe form of disease and with a worse prognosis.
Methods
We performed a cross-sectional analysis to determine the presence and the levels of both anti-SARS-CoV-2 IgG and IgA in a cohort of hospitalized patients with confirmed infection at different times in the natural history of the disease. Patients enrolled when admitted at the emergency department were prospectively followed up during hospital stay.
Results
Overall, 131 patients were considered with a total of 237 samples processed. Cross-sectional analysis showed that seroconversion for IgA seems to occur between days 6 and 15, while IgG response seems to occur slightly later, peaking at day 20 after symptoms onset. Both IgA and IgG were maintained beyond 2 months. Severe patients showed a higher IgA response compared with mild patients when analyzing optical density (8.3 versus 5.6,
p
< 0.001). Prospective analysis conducted on 55 patients confirmed that IgA appear slightly earlier than IgG. After stratifying for the severity of disease, both the IgA and IgG responses were more vigorous in severe cases. Moreover, while IgG tended to stabilize, there was a relevant decline after the first month of IgA levels in mild cases.
Conclusion
IgA and IgG antibody response is closely related, although seroconversion for IgA occurs earlier. Both IgA and IgG are maintained beyond 2 months. Severe patients showed a more vigorous IgA and IgG response. IgA levels seem to decline after 1 month since the onset of symptoms in mild cases. Our results should be interpreted with cautions due to several limitations in our study, mainly the small number of cases, lack of data on viral load and clinical setting.
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;
=< 0.001). Females underwent more angioplasty treatments for revascularization than men (29.8% vs. 25.6%;
= 0.04); males were treated with more amputations (19.9% vs. 15.3%;
= 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;
= 0.059) (OR 0.75 0.50-1.11;
= 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.
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 (
= 0.014); HR 1.83, 95% CI 1.34-2.49 in patients 75-84 years (
= 0.001); HR 1.74, 95% CI 1.24-2.19 in patients ≥85 years (
= 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.
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.
This retrospective analysis at a major Italian university hospital (January 2018–September 2022) assessed the prognostic significance of fever in patients with bloodstream infections (BSIs). Of the ...1299 patients with positive blood cultures, a comparison between febrile and afebrile patients at emergency department admission was conducted. This study particularly focused on the mortality rates associated with these two groups. Notably, afebrile patients exhibited a higher mortality rate. The odds ratio for mortality in afebrile patients was significantly higher compared to febrile patients. This suggests that the absence of fever might be an indicator of increased mortality risk, highlighting the complexity of diagnosing bloodstream infections based on fever presence. This study contributes to the understanding of fever as a diagnostic marker in emergency settings.
We report the case of a 74‐year‐old male, with a medical history of cor triatriatum, admitted with a 10‐day history of intermittent fever. Three sets of blood cultures were positive for Providencia ...rettgeri. Transthoracic and transesophageal echocardiogram excluded infective endocarditis, but revealed a congenital accessory tissue adhering to the mitral valve, causing supravalvular mitral stenosis. Cor triatriatum sinistrum is a rare congenital cardiac anomaly, even more uncommon in adults, and quite exceptional when associated with mitral valve disease. Because the patient had no symptoms related to the heart valve disease, no surgical indication was given and he was managed conservatively.
Background
SBO is a potentially life-threatening condition that often affects older patients. Frailty, more than age, is expected to play a crucial role in predicting SBO prognosis in this ...population. This study aims to define the influence of Clinical Frailty Scale (CFS) on mortality and major complications in patients ≥80 years with diagnosis of SBO at the emergency department (ED).
Methods
All patients aged ≥80 years admitted to our ED for SBO from January 2015 to September 2020 were enrolled. Frailty was assessed through the CFS, and then analyzed both as a continuous and a dichotomous variable. The endpoints were in-hospital mortality and major complications.
Results
A total of 424 patients were enrolled. Higher mortality (20.8% vs 8.6%,
p
<0.001), longer hospital stay (9 range 5–14 days vs 7 range 4–12 days,
p
=0.014), and higher rate of major complications (29.9% vs 17.9%,
p
=0.004) were associated with CFS ≥7. CFS score and bloodstream infection were the only independent prognostic factors for mortality (OR 1.72 CI: 1.29–2.29,
p
<0.001; OR 4.69 CI: 1.74–12.6,
p
=0.002, respectively). Furthermore, CFS score, male sex and surgery were predictive factors for major complications (OR 1.41 CI: 1.13–1.75,
p
=0.002; OR 1.67 CI: 1.03–2.71,
p
=0.038); OR 1.91 CI: 1.17–3.12,
p
=0.01; respectively). At multivariate analysis, for every 1-point increase in CFS score, the odds of mortality and the odds of major complications increased 1.72-fold and 1.41-fold, respectively.
Conclusion
The increase in CFS is directly associated with an increased risk of mortality and major complications. The presence of severe frailty could effectively predict an increased risk of in-hospital death regardless of the treatment administered. The employment of CFS in elderly patients could help the identification of the need for closer monitoring and proper goals of care.
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