Background: Few studies evaluated the clinical outcomes of Community Acquired Pneumonia (CAP), Hospital-Acquired Pneumonia (HAP) and Health Care-Associated Pneumonia (HCAP) in relation to the adherence of antibiotic treatment to the guidelines of the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS) in hospitalized elderly people (65 years or older). Methods: Data were obtained from REPOSI, a prospective registry held in 87 Italian internal medicine and geriatric wards. Patients with a diagnosis of pneumonia (ICD-9 480-487) or prescribed with an antibiotic for pneumonia as indication were selected. The empirical antibiotic regimen was defined to be adherent to guidelines if concordant with the treatment regimens recommended by IDSA/ATS for CAP, HAP, and HCAP. Outcomes were assessed by logistic regression models. Results: A diagnosis of pneumonia was made in 317 patients. Only 38.8% of them received an empirical antibiotic regimen that was adherent to guidelines. However, no significant association was found between adherence to guidelines and outcomes. Having HAP, older age, and higher CIRS severity index were the main factors associated with in-hospital mortality. Conclusions: The adherence to antibiotic treatment guidelines was poor, particularly for HAP and HCAP, suggesting the need for more adherence to the optimal management of antibiotics in the elderly with pneumonia

IntroductionThe use of anti-retroviral therapy (ART) has dramatically reduced HIV-1 associated morbidity and mortality. However, HIV-1 infected individuals have increased rates of morbidity and mortality compared to the non-HIV-1 infected population and this appears to be related to end-organ diseases collectively referred to as Serious Non-AIDS Events (SNAEs). Circulating miRNAs are reported as promising biomarkers for a number of human disease conditions including those that constitute SNAEs. Our study sought to investigate the potential of selected miRNAs in predicting mortality in HIV-1 infected ART treated individuals.Materials and MethodsA set of miRNAs was chosen based on published associations with human disease conditions that constitute SNAEs. This case: control study compared 126 cases (individuals who died whilst on therapy), and 247 matched controls (individuals who remained alive). Cases and controls were ART treated participants of two pivotal HIV-1 trials. The relative abundance of each miRNA in serum was measured, by RTqPCR. Associations with mortality (all-cause, cardiovascular and malignancy) were assessed by logistic regression analysis. Correlations between miRNAs and CD4+ T cell count, hs-CRP, IL-6 and D-dimer were also assessed.ResultsNone of the selected miRNAs was associated with all-cause, cardiovascular or malignancy mortality. The levels of three miRNAs (miRs -21, -122 and -200a) correlated with IL-6 while miR-21 also correlated with D-dimer. Additionally, the abundance of miRs -31, -150 and -223, correlated with baseline CD4+ T cell count while the same three miRNAs plus miR-145 correlated with nadir CD4+ T cell count.DiscussionNo associations with mortality were found with any circulating miRNA studied. These results cast doubt onto the effectiveness of circulating miRNA as early predictors of mortality or the major underlying diseases that contribute to mortality in participants treated for HIV-1 infection.

A 71-year-old man with a history of diabetes and coronary artery disease, was admitted to the emergency department (ED) with a 4-h history of left-sided abdominal, leg and scrotal pain. He was taking insulin and antiplatelet therapy. Upon arrival at the ED, the patient was responsive, hemodynamically stable, and complaining of abdominal pain. The vital signs were: heart rate 130 beats/min, right arm blood pressure 120/75 mmHg, temperature 37°C and respiratory rate 26 breaths/min. Percutaneous oxygen saturation was 98 % on room air. The lung sounds were clear and symmetrical with no wheezes or crackles; the heart beats were regular without murmurs: the femoral pulses were reduced on the left side, and the extremities were moist and cold with hypoperfusion.A bedside ultrasound study performed by the emergency physician showed an infrarenal abdominal aortic aneurysm (AAA 6.9 9 6.2 cm) with an aortocaval fistula (ACF), as evidenced by a jet effect of aortic blood flow into the inferior vena cava (IVC). An urgent surgery intervention was mandatory. Promptly, an abdominal preoperative computed tomography (CT scan) with contrast-enhanced arterial phase was performed as requested by the surgeon, and it confirmed the presence of the infrarenal abdominal aortic aneurysm (7 cm 9 9 cm of length). During the arterial phase, there was a rapid contrast filling of the inferior vena cava and iliac veins, indicating the presence of a large ACF confirming our hypothesis (Fig. 1). A subsequent three-dimensional CT scan reconstruction in coronary projection has identified a fistula between the aorta and the inferior vena cava just a few centimeters above the iliac vein (Fig. 2).Due to the considerable size of the ACF and the potentially unstable clinical situation, the patient was taken Fig. 1 CT scan: three of the four typical CT findings of ACF on CT are present in this slice. Early contrast enhancement of the inferior vena cava, which has the same density of the adjacent aorta, an associated aortic aneurysm, and loss of normal anatomic space between aorta and inferior vena cava (arrow). Contrast computed tomography simultaneously showed an abdominal infrarenal aortic aneurysm (7 9 9 cm) with communication between the aorta (AO) and the inferior vena cava (IVC). On the right you can see the true and the false lumen of the aortic aneurism, and on the left the aortocaval fistula (arrow)

There is no univocal standardized strategy to predict outcomes and stratify risk of SARS-CoV-2 infected patients, notably in emergency departments. Our aim is to develop an accurate indicator of adverse outcomes based on a retrospective analysis of a COVID-19 database established at the Emergency Department (ED) of a North-Italian hospital during the first wave of SARS-CoV-2 infection. Laboratory, clinical, psychosocial and functional characteristics including those obtained from the Braden Scale—a standardized scale to quantify the risk of pressure sores which takes into account aspects of sensory perception, activity, mobility and nutrition—from the records of 117 consecutive patients with swab-positive COVID-19 disease admitted to the Emergency Medicine ward between March 1, 2020 and April 15, 2020 were included in the analysis. Adverse outcomes included admission to the Intensive Care Unit (ICU) and in-hospital death. Among the parameters collected, the highest cutoff sensitivity and specificity scores to best predict adverse outcomes were displayed by lactate dehydrogenase (LDH) blood value at admission > 439 U/L, Horowitz Index (P/F Ratio) < 257 and Braden score < 18. The estimation power reached 93.6%. We named the assessment BLITZ (Braden-LDH-HorowITZ). Despite the retrospective and preliminary nature of the data, a multidimensional tool to assess overall functions, not chronological age, produced the highest prediction power for poor outcomes in relation to SARS-CoV-2 infection. Further analyses are now needed to establish meaningful correlations between ventilation therapies and multidimensional frailty as assessed by ad-hoc validated and standardized tools.

Gout/allopurinol intake has a high prevalence in elderly patients acutely admitted to hospital and are associated with renal and cardiovascular diseases, an increased rate of adverse events and a high degree of drug consumption. In contrast, this finding did not affect the length of hospitalization nor hospital mortality.