Peculiar clinical presentation of COVID-19 and predictors of mortality in the elderly: A multicentre retrospective cohort study.

BACKGROUND: The spectrum of COVID-19 clinical manifestations is not yet known. In the elderly, mortality and extrapulmonary involvement appears more frequent than expected. METHODS: A multicentre-retrospective-case-series study of COVID-19 patients, aged ≥65 years, hospitalised between March 1 and June 15, 2020. Patients were classified at admission into 3 groups based on their Clinical Frailty Scale (CFS) score: 1-3 (group A), 4-6 (group B) and 7-9 (group C). RESULTS: Of the 206 patients in the study, 60 (29%) were assigned to group A, 60 (29%) to B and 86 (42%) to C. Significantly more frequent in group C than in B or A were: mental confusion (respectively 65%, 33%, 7%; P < 0.001), kidney failure (39%, 22%, 20%; P = 0.019), dehydration syndrome (55%, 27%, 13%; P < 0.001), electrolyte imbalance (54%, 32%, 25%; P = 0.001), and diabetic decompensation (22%, 12%, 7%; P = 0.026). Crude mortality was 27%. By multivariate logistic regression model independent predictors of death were male sex (adjusted odds ratio (aOR) = 2.87,95%CI = 1.15-7.18), CFS 7-9 (aOR = 9.97,95%CI = 1.82-52.99), dehydration at admission (aOR = 4.27,95%CI = 1.72-10.57) and non-invasive/invasive ventilation (aOR = 4.88,95%CI = 1.94-12.26). CONCLUSIONS: Elderly patients with a high CFS showed frequent extrapulmonary signs at admission, even in the absence of lung involvement. These findings, along with a high CFS, predicted a significant risk of mortality.

Reduced community viral load does not coincide with a reduction in the rate of new HIV diagnoses and recent infections: data from a region of southern Italy.

OBJECTIVES: We assessed whether changes in community viral load (CVL) over time were associated with the rate of new HIV diagnoses (NDs). METHODS: HIV-1-positive individuals referred to our institute and permanently residing in our province were considered for inclusion in the study. A total of 861 HIV-infected adults with at least one HIV RNA measurement (12 530 measurements in total) between 2008 and 2014 were included. Viraemia copy-years were calculated from all HIV RNA values for each patient using the trapezoidal rule; multiple CVL indicators were considered. Total NDs and recent infections (< 1 year) were analysed separately. The association between NDs and CVL was tested by means of mixed Poisson models, with CVL as a fixed effect and year as a random effect. RESULTS: The incidence of NDs was 2.28 per 100 000 residents in 2008 and 2.52 per 100 000 residents in 2014. Total numbers of NDs and recent infections did not vary significantly over time (P for trend 0.879 and 0.39, respectively). Mean HIV RNA decreased from 31 095.8 HIV-1 RNA copies/mL in 2008 to 21 231.5 copies/mL in 2014 (P < 0.001); a downward trend was always observed regardless of the CVL indicator considered. Depending on the indicator, there were some differences in CVL by patient characteristics. The most substantial contributors to CVL appeared to be male individuals, men who have sex with men (MSM), non-Italians, and untreated subjects (all P < 0.05). The relative risk of ND increased among Italians and MSM with an increasing proportion of subjects having an undetectable HIV RNA, and decreased in the same population with increasing levels of CVL. CONCLUSIONS: In our setting, CVL represented a good marker of access to care and treatment; however, reduced CVL did not coincide with a reduction in the rate of NDs.

Access to health services for undocumented immigrants in Apulia.

This paper, part of a larger epidemiological study carried out between 2004 and 2010, analyzed immigrants frequenting the largest Apulian regional hospital (Bari Policlinico). Our aim was to evaluate the perception on the part of undocumented immigrants of their rights of access to the National Health Care services and whether this privilege is actually utilized. An anonymous multi-language questionnaire was distributed to all patients with STP (code number for temporary presence of foreigners) at the immigrant outpatient Infectious Diseases Clinic of Bari from June 2009 to June 2010. Questions were related to nationality, date of arrival in Italy, use of health facilities in the 2 years prior to the compilation of the questionnaire, and their understanding of STP. The patients were also screened for infectious diseases (HIV-Ab, HBsAg, HCV-Ab, VDRL, TPHA and Mantoux). A total of 256/272 patients completed the questionnaire; the meaning of STP was unknown to 156/256 (60.9%) patients, only 54/256 (21%) knew the exact meaning of STP and only 42/54 (76.6%) of the latter knew how long STP was valid. Moreover, 128/256 (50.7%) were aware that doctors from the emergency unit were not allowed to notify police regarding presence of illegal immigrants. Regarding clinical data 3% were HIV+ (8/256), 5% (13 patients) positive for TPHA, 5% for HBsAg, 2% were HCV (five patients). A >10 mm diameter infiltrate of Mantoux test was noted for 44% of patients. A lower prevalence than expected for infections such as HIV, HBV or HCV was noted for immigrants compared to data from their countries of origin. At present, large-scale political solutions to the challenges of facilitating access to health facilities for undocumented immigrants are lacking in Italy. The development of communication systems is fundamental to improving access to health services and to creating links between immigrants and the healthcare system.

Late presentation and loss to follow-up of immigrants newly diagnosed with HIV in the HAART era.

To compare clinical characteristics and therapeutic management of newly HIV-diagnosed immigrants to natives. Patients with a first HIV diagnosis from 1996 to 2010 were included. Of 716 new diagnoses, 85 (12 %) were immigrants. Migrants were younger, more frequently females and sexually infected, less likely to voluntarily request testing, and less HCV-coinfected. Late presenters (CD4 <350 or AIDS) were 76 % among migrants versus 56 % in natives (p = 0.006) with an increasing trend over time. HAART was initiated in 76.5 % of natives and 72.4 % of immigrants; the number/type of adverse events and treatment discontinuation were similar. Immigrants received more NNRTIs-based regimens. A similar proportion of patients reached virological suppression at month 1-3-6 after HAART initiation, but 43 % of immigrants versus 27 % of natives resulted lost to follow-up (p < 0.001). Diagnosis of HIV was often delayed among migrants, who also presented a higher rate of lost to follow-up.

Heterogeneity and penetration of HIV-1 non-subtype B viruses in an Italian province: public health implications.

This study assessed changes in prevalence and distribution of HIV-1 non-subtype B viruses in Italian and immigrant patients over two decades in a province in Italy. All HIV-positive patients who underwent genotypic resistance testing were selected. Prevalence of non-subtype B viruses in 3-year periods was calculated. All sequences of non-subtype B and those provided by REGA as unassigned were analysed for phylogenetic relationships. In total, 250/1563 (16%) individuals were infected with a non-subtype B virus. Prevalence increased over time, reaching a peak (31.5%) in 2004-2006. In Italian patients, the most frequent subtypes were B (92.5%) and F1 (4%). F1 subtype was also prevalent in patients from South America (13.6%); in patients of African origin, CRF02_AG (54.9%) and G (12.3%) were the most frequent. HIV-1 non-subtype B infections in Italians were mostly found in patients who acquired HIV sexually. A phylogenetic relationship between F subtypes in Italian and representative HIV-1 sequences from Brazil was found. C subtypes in Italians were phylogenetically related to subtypes circulating in Brazil. Inter-subtype recombinants were also found in the latest years. The HIV-1 epidemic in Brescia province evolved to the point where about 1/3 patients recently diagnosed harboured non-B HIV subtypes. The distribution of HIV-1 non-B subtypes in Italian patients resembled that in South American patients and phylogenetic relatedness between some Italian and South American HIV-1 strains was found. The possible epidemiological link between these two populations would have been missed by looking only at risk factors for HIV acquisition declared by patients. The evidence of inter-subtype recombinants points to significant genetic assortment. Overall our results support phylogenetic analysis as a tool for epidemiological investigation in order to guide targeted prevention strategies.

HIV-1 biological phenotype and predicted coreceptor usage based on V3 loop sequence in paired PBMC and plasma samples.

Paired PBMCs and plasma samples from 34 HIV-infected patients were studied to verify the relationship between coreceptor use based on genotyping of V3 region of HIV-1 envelope gp120 and biological phenotype with virus isolation and subsequent correlation to clinical characteristics. The "11/25" rule, geno2pheno and PSSM were compared. All SI patients were HIV-1 subtype B (p=0.04) and had a lower CD4 count than NSI patients (p=0.01), while no differences were observed in mean HIV-RNA (log) (p=0.6). SI phenotype was not associated with AIDS-defining events (p=0.1) or with concurrent antiretroviral therapy (p=0.4). With geno2pheno, which shows the highest sensibility (83%), an X4 or X4/R5 genotype in PBMC DNA was also associated to B-subtype and lower CD4 count (p=0.01) compared to R5 isolates. Based on plasma RNA sequences, the predicted coreceptor usage agreed with PBMC DNA in 79% of cases with the "11/25" rule, 82% with geno2pheno, and 82% with PSSM. A X4 virus in plasma (but not in PBMCs) was significantly associated with HAART in all three methods (p=0.01 for "11/25" rule, p=0.01 for geno2pheno and p=0.03 for PSSM). Due to viral mixtures and/or difficulties in genotype interpretation, current V3 sequence-based methods cannot accurately predict HIV-1 coreceptor use.

[Holt-Oram syndrome: cardiological, radiological and genetic evaluation]. / Sindrome di Holt-Oram: valutazione cardiologica, radiologica e genetica.

A case of a 63-year-old woman with Holt-Oram syndrome is presented. The patient, operated at 38 years for correction of an interatrial defect of the ostium secundum type presented with upper extremity skeletal abnormalities, in particular on the left, and a severe mitral insufficiency with ruptured chordae tendinae of the posterior leaflet. Mitral valve reconstruction was followed by an unusual severe hemolytic anemia and acute secondary renal insufficiency. Valve replacement was therefore necessary. At present, the patient, whose karyotype is normal, is in NYHA functional class I.

Chronic juvenile AV nodal dysfunction associated with mitral valve prolapse.

The prevalence of atrioventricular (AV) conduction disturbances amongst patients with mitral valve prolapse is higher than may be expected by chance, thus implying the existence of a true association. The main clinical and electrophysiologic findings in 4 patients with mitral valve prolapse showing chronic AV conduction disturbances are presented. Supra-His localization, mild and variable degree of impairment, regression upon Atropine administration, apparent absence of progression, are common features of these disturbances. The most likely mechanisms considered are an AV node developmental abnormality or an AV nodal artery running in contact with the border of the mitral annulus and thus impaired by the abnormal dynamics of the mitral valve.

Electrophysiologic evaluation of intravenous verapamil in man.

The acute electrophysiological effects of intravenous verapamil (0.15 mg/kg body weight) were studied in 21 subjects with estimated normal impulse formation and conduction. Significant effects were sinus cycle shortening, depression of intranodal conduction and prolongation of AV node refractory periods. Sinus node recovery time, sinoatrial conduction time, atrial refractory periods, infranodal conduction, His--Purkinje system, and bundle branch refractory periods were unchanged. The clinical implications of these properties are discussed.

Effects of prindolol on impulse formation and conduction in man.

Electrophysiologic changes produced by intravenous administration of 0.6 mg Prindolol were studied in 16 subjects with normal impulse formation and conduction. The most important changes were: sinus bradycardia, prolongation of atrial refractory periods, depression of intranodal conduction and prolongation of A-V node refractory periods. Sinus node recovery time was unchanged, and sinoatrial conduction time was only slightly increased. Intraventricular conduction time and the refractory period of the His-Purkinje system and of the bundle branches were unchanged.

[Prinzmental's angina and disturbances of the stimulus conduction (author's transl)]. / Angina di Prinzmetal e disturbi della conduzione dello stimolo

Our series (30 cases) of variant angina as well as the reports from literature, were reviewed, to investigate the consequences of an acute regional ischemia on seno-atrial, atrio-ventricular and intraventricular conduction. Sinoatrial conduction was never affected independently from the anterior or posterior localization of the ischemia. A junctional impairment of atrio-ventricular conduction was rather frequent in cases of variant angina affecting the inferior wall, ranging in different series from 8% to 25%. Only one case of bundle branch block was observed. Hemiblocks were found to be extremely rare, while a deviation of the main axis of the QRS on the frontal plane, especially to the left in cases with anterior localization of the ischemia, was observed quite frequently. This axis deviation, in the absence of changes of the initial vector of the QRS compatible with the diagnosis of hemiblocks, were considered to be depending on a parietal block.

[Mitral valve prolapse and the ventricular pre-excitation syndrome (author's transl)]. / Prolasso della mitrale e sindrome di pre-eccitazione ventricolare

One of the most important clinical aspects of the mitral valve prolapse syndrome is the high incidence of arrhythmias. Some recent reports on the association of mitral valve prolapse with ventricular pre-excitation may be relevant to the understanding of such arrhythmias. In order to evaluate the clinical relevance of this association, all patients with proven idiopathic mitral valve prolapse who came under our observation during the last twelve months, were submitted to careful electrocardiographic examination with the aim of detecting even subtle degrees of pre-excitation. His bundle recording and programmed atrial stimulation were performed if there was any suspicion of a delta wave. The association with ventricular pre-excitation was proved in 6 out of 41 examined cases. The main clinical, phonocardiographic, echocardiographic, angiographic and electrophysiologic data, as well as the familial study of these cases, are presented. The need for electrophysiologic study in some cases with doubtful electrocardiographic pattern is pointed out. While previous reports only described cases with left-sided accessory pathways, examples of right-sided pathways are presented in our series. The high incidence of mitral valve prolapse, and especially of pre-excitation syndrome and arrhythmias in the familial study, suggests that the association is not an occasional one. The detection of ventricular pre-excitation in cases of mitral valve prolapse complicated by recurrent tachy-arrhythmias may be of practical importance for an appropriate therapeutic approach.