Low eGFR Is a Strong Predictor of Worse Outcome in Hospitalized COVID-19 Patients.

BACKGROUND: The clinical course of COVID-19 is more severe in elderly patients with cardio-metabolic co-morbidities. Chronic kidney disease is considered an independent cardiovascular risk factor. We aimed to evaluate the impact of reduced eGFR on the composite outcome of admission to ICU and death in a sample of consecutive COVID-19 hospitalized patients. METHODS: We retrospectively evaluated clinical records of a consecutive sample of hospitalized COVID-19 patients. A total of 231 patients were considered for statistical analysis. The whole sample was divided in two groups on the basis of eGFR value, e.g., ≥ or <60 mL/min/1.73 m2. Patients with low eGFR were further divided among those with a history of chronic kidney disease (CKD) and those without (AKI, acute kidney injury). The primary outcome was a composite of admission to ICU or death, whichever occurred first. The single components were secondary outcomes. RESULTS: Seventy-nine (34.2%) patients reached the composite outcome. A total of 64 patients (27.7%) died during hospitalization, and 41 (17.7%) were admitted to the ICU. A significantly higher number of events was present among patients with low eGFR (p < 0.0001). Age (p < 0.001), SpO2 (p < 0.001), previous anti-platelet treatment (p = 0.006), Charlson's Comorbidities Index (p < 0.001), serum creatinine (p < 0.001), eGFR (p = 0.003), low eGFR (p < 0.001), blood glucose levels (p < 0.001), and LDH (p = 0.003) were significantly associated with the main outcome in univariate analysis. Low eGFR (HR 1.64, 95% CI 1.02-2.63, p = 0.040) and age (HR per 5 years 1.22, 95% CI 1.10-1.36, p < 0.001) were significantly and independently associated with the main outcome in the multivariate model. Patients with AKI showed an increased hazard ratio to reach the combined outcome (p = 0.059), while those patients with both CKD had a significantly higher probability of developing the combined outcome (p < 0.001). CONCLUSIONS: Patients with reduced eGFR at admission should be considered at high risk for clinical deterioration and death, requiring the best supportive treatment in order to prevent the worst outcome.

Venous Needle Dislodgement and Access-Bloodline Separation.

Serious hemodialysis therapy complications are venous needle dislodgement and access-bloodline separation. In 2020, the American Nephrology Nurses Association (ANNA) brought together a task force to update the information and resources developed by the 2012 ANNA Venous Needle Dislodgement Task Force along with the development of additional resources, if needed. The 2020-2021 ANNA Venous Needle Dislodgement Task Force conducted a literature review, requested information from ANNA members, and tested taping techniques. This article discusses the results of the literature review, information requests, and taping technique testing, and provides resources on venous needle dislodgement and access-bloodline dislodgement, along with practice recommendations.

Diagnosis of COVID-19 in Patients with Negative Nasopharyngeal Swabs: Reliability of Radiological and Clinical Diagnosis and Accuracy Versus Serology.

BACKGROUND: The diagnosis of Coronavirus disease 2019 (COVID-19) relies on the positivity of nasopharyngeal swab. However, a significant percentage of symptomatic patients may test negative. We evaluated the reliability of COVID-19 diagnosis made by radiologists and clinicians and its accuracy versus serology in a sample of patients hospitalized for suspected COVID-19 with multiple negative swabs. METHODS: Admission chest CT-scans and clinical records of swab-negative patients, treated according to the COVID-19 protocol or deceased during hospitalization, were retrospectively evaluated by two radiologists and two clinicians, respectively. RESULTS: Of 254 patients, 169 swab-confirmed cases and one patient without chest CT-scan were excluded. A total of 84 patients were eligible for the reliability study. Of these, 21 patients died during hospitalization; the remaining 63 underwent serological testing and were eligible for the accuracy evaluation. Of the 63, 26 patients showed anti-Sars-Cov-2 antibodies, while 37 did not. The inter-rater agreement was "substantial" (kappa 0.683) between radiologists, "moderate" (kappa 0.454) between clinicians, and only "fair" (kappa 0.341) between radiologists and clinicians. Both radiologic and clinical evaluations showed good accuracy compared to serology. CONCLUSIONS: The radiologic and clinical diagnosis of COVID-19 for swab-negative patients proved to be sufficiently reliable and accurate to allow a diagnosis of COVID-19, which needs to be confirmed by serology and follow-up.

Eculizumab in refractory catastrophic antiphospholipid syndrome: a case report and systematic review of the literature.

Catastrophic antiphospholipid syndrome (CAPS) is a rare disorder, characterized by the development of multiple vascular thrombosis over a short period of time, in patients with persistently detectable antiphospholipid antibodies (aPLs). The vascular occlusions predominantly affect small vessels. The overall mortality is 36.9%, despite the recent progress in the therapeutic approach. It has been shown that aPLs are able to induce a hypercoagulability state through different mechanisms of action, including complement activation, which in turn plays a key role in the pathogenesis of some thrombotic microangiopathies. Consequently, complement inhibition may be proposed as a targeted intervention to effectively prevent the progression of the microthrombotic storm. The employment of the complement inhibitor eculizumab has been proposed in CAPS on the basis of occasional reports and expert opinion. We report the case of a 54-year-old woman with a CAPS refractory to conventional therapies, who was successfully treated with eculizumab. The administration of this anti-C5 monoclonal antibody aborted the acute progressive thrombotic events and prevented further clinical episodes of thrombosis in the following year. We also faced our case to a systematic literature review, by analyzing all reported cases of CAPS in which eculizumab was added to conventional therapy. Even if further investigation is needed, our results suggest that the inhibition of one mechanism of aPL-induced organ damage may be an add-on treatment for this condition.

Behçet syndrome: from pathogenesis to novel therapies.

Behçet syndrome is a chronic disease hallmarked by inflammation of the blood vessels that is related to an autoimmune reaction caused by inherited susceptibility due to specific genes and environmental factors, probably components of infectious microorganisms, which turn on or get going the disease in genetically susceptible subjects. The more common clinical expression of the disease is represented by a triple-symptom complex of recurrent oral aphthous ulcers, genital ulcers, and uveitis, sometimes associated with inflammatory arthritis, phlebitis, iritis, as well as inflammation of the digestive tract, brain, and spinal cord. The treatment strategies used to manage the manifestations of Behçet syndrome have gradually progressed, and a number of new therapeutic resources have been implemented in recent years, allowing better control of pathogenic mechanisms, reducing symptoms and suffering, and ameliorating patient's outcome.

The synovio-entheseal complex in enthesoarthritis.

The group of diseases classified as seronegative spondyloarthritis or enthesoarthritis is characterized by typical osteoarticular and extra-articular manifestations. Diverse patterns of disease can affect different members of the same family and may show different features in the same patient, with clinical overlaps thwarting the differential diagnosis. An anatomo-pathological hallmark in enthesoarthritis is the inflammatory process in the synovio-entheseal sites. The inflammatory microenvironment of synovio-entheseal complex, named enthesitis, is characterized, after an initial inflammatory/erosive phase, by a subsequent phase of neobone apposition, which seems to progress independently from the previous erosive phase, suggesting that the physiopathogenetic mechanisms that underlay the two phases are driven by different pivots. The structural damage is characterized by excessive neobone formation, with the syndesmophyte as a typical lesion. The process underlying their formation is not fully understood, although there are many useful information to clarify the physiopathogenetic puzzle. The primum movens of the enthesitic process is the micro-trauma to which entheses are subject, especially in the lower limbs, for biomechanical reasons. The inflammatory process is facilitated by the sequential structure of the organ enthesis, constitutionally devoid of sub-enthesitic cortical bone and closely related to the underlying trabecular bone and the medullary vascular system. The reparative attempt from the vascular system, thanks to the activating action of certain loco-regional cytokines, such as TNF α, conditions the possible deposit in the enthesis of molecules derived from other organic sites and able, especially in HLA-B27+ subjects, to activate and self-renew an immune-mediated inflammatory process following the initial mechanical process.

Stem cell autograft and allograft in autoimmune diseases.

Autoimmune diseases are characterized by an insufficiency of immune tolerance and, although treated with a number of useful drugs, may need more unconventional therapeutic strategies for their more severe presentations. Among such unconventional therapeutic approaches, stem cell autograft and allograft have been used, with the aim of stimulating disease remission by modifying the pathogenic mechanisms that induce anomalous responses against self-antigens. Autologous transplantation is performed with the purpose of retuning autoimmune cells, whereas allogeneic transplantation is performed with the purpose of replacing anomalous immune effectors and mediators. In this article, we comprehensively review up-to-date information on the autoimmune diseases for which the transplantation of stem cells is indicated.

Neuroendocrine-immune interactions in healthy aging.

AIM: The nervous, endocrine and immune systems are connected by shared neurotransmitters, hormones and cytokines. The function of these systems shows patterns of circadian rhythmicity and a number of age-related changes in the 24-h hormonal and non-hormonal rhythms have been found in older human beings. The aim of this study was to evaluate integration among the nervous, endocrine and immune systems in the elderly. METHODS: Cortisol and melatonin serum levels were measured and lymphocyte subpopulation analyses were performed on blood samples collected every 4 h for 24 h from 15 healthy young-middle-aged subjects (range 36-55 years, mean age±standard error [SE] 44.08±1.76) and 15 healthy old-aged subjects (range 67-79 years, mean age±SE 68.52±1.27). RESULTS: There was a statistically significant difference between the groups in the observed values of CD20 (total B cells higher in young-middle-aged subjects, P=0.02), CD25 (activated T cells with expression of the α-chain of interleukin-2 receptor, higher in elderly subjects, P=0.04) and DR+ T cells (activated T cells higher in elderly subjects, P=0.01). There were different correlations among lymphocyte subpopulations and hormone serum levels in young and middle-aged subjects in compared to old-aged subjects. In the group of young-middle-aged subjects, a clear circadian rhythm was validated for the time-qualified changes of all the factors studied. In the group of elderly subjects, a clear circadian rhythm was validated for the nyctohemeral changes of CD3 (with a phase delay of 3 h), CD8, CD4/CD8 ratio, CD16, CD25 (in opposite phase), cortisol (with a phase delay of 1 h) and melatonin. CONCLUSION: The results of the current study show that aging is associated with enhanced responsiveness of the T-cell compartment, impairment of B-cell compartment and alterations in temporal architecture and correlations of neuroendocrine-immune parameters.

A possible mechanism for altered immune response in the elderly.

BACKGROUND: Reciprocal influences and bidirectional connections among the nervous, endocrine and immune systems, mediated by shared neuroendocrine hormones, chemo/cytokines and binding sites contribute to the maintainment of body homeostasis. The hypothalamus-pituitary axis may play an immunomodulating role and influence cellular immune responses by releasing various hormones and neuropeptides into the blood with direct modulatory action on the immune effectors, or by regulating the hormonal secretion of peripheral endocrine glands. Aging is associated with changes in immune function. The aim of this study was to evaluate circadian variations of some endocrine and immune factors in the elderly. MATERIALS AND METHODS: Serum levels of cortisol, melatonin, thyrotropin-releasing hormone (TRH), thyroid stimulating hormone (TSH), free thyroxine (FT(4)), growth hormone (GH), insulin-like growth factor (IGF) 1 and interleukin (IL) 2 were measured and lymphocyte subpopulation analyses were performed on blood samples collected every four hours for 24 hours from ten healthy young and middle-aged individuals (age 35-54 years) and from ten healthy elderly individuals (age 65-76 years). RESULTS: There was a statistically significant difference between the groups in the observed values of CD20 and TSH serum levels (higher in the young and middle-aged) and CD25 and DR(+) T-cells (higher in the elderly). In the group of young and middle aged subjects, a clear circadian rhythm was validated for the time-qualified changes of all the factors studied, with the exception of FT(4), IGF1 and IL2. In the group of elderly individuals, a number of rhythms and correlations with neuroendocrine hormones were absent or altered. CONCLUSION: The results of the current study evidence aging-associated decrease of peripheral B-cell compartment, increase of activated T-cell compartment, decrease of hypophyseal thyrotropin secretion, altered circadian rhythmicity and altered hormone-immune cell correlations.

Von Hippel-Lindau disease: an overview.

Von Hippel-Lindau disease is a rare, familial disease consisting of multiple tumors, which can present in the eyes, brain, adrenal gland, pancreas, liver, spinal cord, kidneys, or other areas of the body. The renal tumors are primarily renal cell carcinoma. Renal involvement may be the primary manifestation, but most frequently it is a secondary manifestation. This article presents an overview of von Hippel-Lindau disease and the nursing care of the patient with renal involvement.