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

Does chronic oral anticoagulation reduce in-hospital mortality among COVID-19 older patients?

Background: Patients hospitalized with COVID-19 experienced an increased risk of venous thromboembolism. Aims: To evaluate the effect of chronic oral anticoagulation (OAC) therapy, both with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs), on prognosis of COVID-19 older patients. Methods: Single-center prospective study conducted in the Emergency Department (ED) of a teaching hospital, referral center for COVID-19 in central Italy. We evaluated all the patients ≥ 65 years, consecutively admitted to our ED for confirmed COVID-19. We compared the clinical outcome of those who were on chronic OAC at ED admission with those who did not, using a propensity score matched paired cohort of controls. The primary study endpoint was all-cause in-hospital death. Patients were matched for age, sex, clinical comorbidities, and clinical severity at presentation (based on NEWS ≥ 6). Study parameters were assessed for association to all-cause in-hospital death by a multivariate Cox regression analysis to identify independent risk factor for survival. Results: Although overall mortality was slightly higher for anticoagulated patients compared to controls (63.3% vs 43.5%, p = 0.012), the multivariate adjusted hazard ratio (HR) for death was not significant (HR = 1.56 [0.78–3.12]; p = 0.208). Both DOACs (HR 1.46 [0.73–2.92]; p = 0.283) and VKAs (HR 1.14 [0.48–2.73]; p = 0.761) alone did not affect overall survival in our cohort. Conclusions: Among older patients hospitalized for COVID-19, chronic OAC therapy was not associated with a reduced risk of in-hospital death. Moreover, our data suggest similar outcome both for patients on VKAs or in patients on DOACs

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

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

The T.O.S.C.A. Project: Research, Education and Care

Despite recent and exponential improvements in diagnostic- therapeutic pathways, an existing “GAP” has been revealed between the “real world care” and the “optimal care” of patients with chronic heart failure (CHF). We present the T.O.S.CA. Project (Trattamento Ormonale dello Scompenso CArdiaco), an Italian multicenter initiative involving different health care professionals and services aiming to explore the CHF “metabolic pathophysiological model” and to improve the quality of care of HF patients through research and continuing medical education

A Repertoire of Virtual-Reality, Occupational Therapy Exercises for Motor Rehabilitation Based on Action Observation

There is a growing interest in action observation treatment (AOT), i.e., a rehabilitative procedure combining action observation, motor imagery, and action execution to promote the recovery, maintenance, and acquisition of motor abilities. AOT studies employed basic upper limb gestures as stimuli, but—in principle—the AOT approach can be effectively extended to more complex actions like occupational gestures. Here, we present a repertoire of virtual-reality (VR) stimuli depicting occupational therapy exercises intended for AOT, potentially suitable for occupational safety and injury prevention. We animated a humanoid avatar by fitting the kinematics recorded by a healthy subject performing the exercises. All the stimuli are available via a custom-made graphical user interface, which allows the user to adjust several visualization parameters like the viewpoint, the number of repetitions, and the observed movement’s speed. Beyond providing clinicians with a set of VR stimuli promoting via AOT the recovery of goal-oriented, occupational gestures, such a repertoire could extend the use of AOT to the field of occupational safety and injury prevention. Dataset: https://doi.org/10.5281/zenodo.5592131. Dataset License: CC-BY 4.0

Characteristic of IgA and IgG antibody response to SARS-CoV-2 infection in an Italian referral COVID-19 Hospital

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

Multiple hormonal and metabolic deficiency syndrome predicts outcome in heart failure: The T.O.S.CA. Registry

Aims Recent evidence supports the occurrence of multiple hormonal and metabolic deficiency syndrome (MHDS) in chronic heart failure (CHF). However, no large observational study has unequivocally demonstrated its impact on CHF progression and outcome. The T.O.S.CA. (Trattamento Ormonale nello Scompenso CArdiaco; Hormone Treatment in Heart Failure) Registry has been specifically designed to test the hypothesis that MHDS affects morbidity and mortality in CHF patients. Methods The T.O.S.CA. Registry is a prospective, multicentre, observational study involving 19 Italian centres. Thyroid and Results hormones, insulin-like growth factor-1, total testosterone, dehydropianoandrosterone sulfate, insulin resistance, and the presence of diabetes were evaluated. A MHDS was defined as the presence of >_2 hormone deficiencies (HDs). Primary endpoint was a composite of all-cause mortality and cardiovascular hospitalizations. Four hundred and eighty heart failure patients with ejection fraction <_45% were enrolled. MHDS or diabetes was diagnosed in 372 patients (77.5%). A total of 271 events (97 deaths and 174 cardiovascular hospitalizations) were recorded, 41% in NO-MHDS and 62% in MHDS (P < 0.001). Median follow-up was of 36 months. MHDS was independently associated with the occurrence of the primary endpoint [hazard ratio 95% (confidence interval), 1.93 (1.37-2.73), P < 0.001] and identified a group of patients with a higher mortality [2.2 (1.28-3.83), P = 0.01], with a graded relation between HDs and cumulative events (P < 0.01). Conclusion MHDS is common in CHF and independently associated with increased all-cause mortality and cardiovascular hospitalization, representing a promising therapeutic target

Multiple hormonal and metabolic deficiency syndrome predicts outcome in heart failure: the T.O.S.CA. Registry.

none131siAims Recent evidence supports the occurrence of multiple hormonal and metabolic deficiency syndrome (MHDS) in chronic heart failure (CHF). However, no large observational study has unequivocally demonstrated its impact on CHF progression and outcome. The T.O.S.CA. (Trattamento Ormonale nello Scompenso CArdiaco; Hormone Treatment in Heart Failure) Registry has been specifically designed to test the hypothesis that MHDS affects morbidity and mortality in CHF patients. Methods and Results The T.O.S.CA. Registry is a prospective, multicentre, observational study involving 19 Italian centres. Thyroid hormones, insulin-like growth factor-1, total testosterone, dehydropianoandrosterone sulfate, insulin resistance, and the presence of diabetes were evaluated. A MHDS was defined as the presence of ≥2 hormone deficiencies (HDs). Primary endpoint was a composite of all-cause mortality and cardiovascular hospitalizations. Four hundred and eighty heart failure patients with ejection fraction ≤45% were enrolled. MHDS or diabetes was diagnosed in 372 patients (77.5%). A total of 271 events (97 deaths and 174 cardiovascular hospitalizations) were recorded, 41% in NO-MHDS and 62% in MHDS (P < 0.001). Median follow-up was of 36 months. MHDS was independently associated with the occurrence of the primary endpoint [hazard ratio 95% (confidence interval), 1.93 (1.37–2.73), P < 0.001] and identified a group of patients with a higher mortality [2.2 (1.28–3.83), P = 0.01], with a graded relation between HDs and cumulative events (P < 0.01). Conclusion MHDS is common in CHF and independently associated with increased all-cause mortality and cardiovascular hospitalization, representing a promising therapeutic target.openCittadini A, Salzano A, Iacoviello M, Triggiani V, Rengo G, Cacciatore F, Maiello C, Limongelli G, Masarone D, Perticone F, Cimellaro A, Perrone Filardi P, Paolillo S, Mancini A, Volterrani M, Vriz O, Castello R, Passantino A, Campo M, Modesti PA, De Giorgi A, Monte IP, Puzzo A, Ballotta A, D'Assante R, Arcopinto M, Gargiulo P, Sciacqua A, Bruzzese D, Colao A, Napoli R, Suzuki T, Eagle KA, Ventura HO, Marra AM, Bossone E. Saccà L, Monti MG, Matarazzo M, Stagnaro FM, Piccioli L, Lombardi A, Panicara V, Flora M, Golia L, Faga V, Ruocco A, Della Polla D, Franco R, Schiavo A, Gigante A, Spina E, Sicuranza M, Monaco F, Apicella M, Miele C, Campanino AG, Mazza L, Abete R, Farro A, Luciano F, Polizzi R, Ferrillo G, De Luca M, Crisci G, Giardino F, Barbato M, Ranieri B, Ferrara F, Russo V, Malinconico M, Citro R, Guastalamacchia E, Iacoviello M, Leone M, Triggiani V, Giagulli VA, Maiello C, Amarelli C, Mattucci I, Limongelli G, Calabrò P, Calabrò R, D’Andrea A, Maddaloni V, Pacileo G, Scarafile R, Perticone F, Belfiore A, Sciacqua A, Casaretti L, Paolillo S, Gargiulo P, Mancini A, Favuzzi AMR, Di Segni C, Bruno C, Vergani E, Volterrani M, Massaro R, Vriz O, F. Grimaldi F, Castello R, Frigo A, Campo MR, Sorrentino MR, Modesti PA, Malandrino D, Manfredini R, De Giorgi A, Fabbian F, Ragusa L, Caliendo L, Carbone L, Frigiola A, Generali T, Giacomazzi F, De Vincentiis C, Garofalo P, Malizia G, Milano S, Misiano G, Suzuki T, Israr MZ, Bernieh D, Cassambai S, Yazaki Y, Heaney LM, Eagle KA, Ventura HO, Colao A, Bruzzese D.Cittadini, A; Salzano, A; Iacoviello, M; Triggiani, V; Rengo, G; Cacciatore, F; Maiello, C; Limongelli, G; Masarone, D; Perticone, F; Cimellaro, A; Perrone Filardi, P; Paolillo, S; Mancini, A; Volterrani, M; Vriz, O; Castello, R; Passantino, A; Campo, M; Modesti, Pa; De Giorgi, A; Monte, Ip; Puzzo, A; Ballotta, A; D'Assante, R; Arcopinto, M; Gargiulo, P; Sciacqua, A; Bruzzese, D; Colao, A; Napoli, R; Suzuki, T; Eagle, Ka; Ventura, Ho; Marra, Am; Bossone E., Saccà L; Monti, Mg; Matarazzo, M; Stagnaro, Fm; Piccioli, L; Lombardi, A; Panicara, V; Flora, M; Golia, L; Faga, V; Ruocco, A; Della Polla, D; Franco, R; Schiavo, A; Gigante, A; Spina, E; Sicuranza, M; Monaco, F; Apicella, M; Miele, C; Campanino, Ag; Mazza, L; Abete, R; Farro, A; Luciano, F; Polizzi, R; Ferrillo, G; De Luca, M; Crisci, G; Giardino, F; Barbato, M; Ranieri, B; Ferrara, F; Russo, V; Malinconico, M; Citro, R; Guastalamacchia, E; Iacoviello, M; Leone, M; Triggiani, V; Giagulli, Va; Maiello, C; Amarelli, C; Mattucci, I; Limongelli, G; Calabrò, P; Calabrò, R; D’Andrea, A; Maddaloni, V; Pacileo, G; Scarafile, R; Perticone, F; Belfiore, A; Sciacqua, A; Casaretti, L; Paolillo, S; Gargiulo, P; Mancini, A; Favuzzi, Amr; Di Segni, C; Bruno, C; Vergani, E; Volterrani, M; Massaro, R; Vriz, O; F., Grimaldi F; Castello, R; Frigo, A; Campo, Mr; Sorrentino, Mr; Modesti, Pa; Malandrino, D; Manfredini, R; De Giorgi, A; Fabbian, F; Ragusa, L; Caliendo, L; Carbone, L; Frigiola, A; Generali, T; Giacomazzi, F; De Vincentiis, C; Garofalo, P; Malizia, G; Milano, S; Misiano, G; Suzuki, T; Israr, Mz; Bernieh, D; Cassambai, S; Yazaki, Y; Heaney, Lm; Eagle, Ka; Ventura, Ho; Colao, A; Bruzzese, D