The Management of Recurrent Urinary Tract Infection: Non-Antibiotic Bundle Treatment

Recurrent urinary tract infections (rUTIs) are a common condition with high morbidity and negatively impact the quality of life. They account for approximately 25% of all antibiotic prescriptions and are a public health concern in an era of increasing multidrug-resistant organisms (MDROs). Several non-antibiotic treatment strategies have been tried to curb antimicrobial use, and many are effective to some degree, but no experience testing multimodal interventions. We created a "care bundle" consisting of behavioral interventions, vaginal and oral probiotics, D-mannose, and cranberry to be followed for six months. We enrolled women with rUTIs over three years. Changes in urinary tract infections, antibiotic use, chronic symptoms, and quality of life were compared in the six months before and after participation in the study. Forty-seven women were enrolled in the study, six of whom were excluded from the final analysis. We observed a 76% reduction in urinary tract infections (p < 0.001) and a reduction in total antibiotic exposure of more than 90% (p < 0.001); all chronic symptoms showed a trend toward reduction. Adherence to the bundle was high (87.2%). Overall, 80.5% of women experienced an improvement in their quality of life. In our experience, a bundle protocol is effective in reducing recurrences and antimicrobial use in a cohort of women with rUTIs and results in a subjective improvement in chronic symptoms and quality of life. Further research with larger sample size is needed to confirm these findings.

Lung ultrasound presentation of COVID-19 patients: phenotypes and correlations

Bedside lung ultrasound (LUS) can play a role in the setting of the SarsCoV2 pneumonia pandemic. To evaluate the clinical and LUS features of COVID-19 in the ED and their potential prognostic role, a cohort of laboratory-confirmed COVID-19 patients underwent LUS upon admission in the ED. LUS score was derived from 12 fields. A prevalent LUS pattern was assigned depending on the presence of interstitial syndrome only (Interstitial Pattern), or evidence of subpleural consolidations in at least two fields (Consolidation Pattern). The endpoint was 30-day mortality. The relationship between hemogasanalysis parameters and LUS score was also evaluated. Out of 312 patients, only 36 (11.5%) did not present lung involvment, as defined by LUS score < 1. The majority of patients were admitted either in a general ward (53.8%) or in intensive care unit (9.6%), whereas 106 patients (33.9%) were discharged from the ED. In-hospital mortality was 25.3%, and 30-day survival was 67.6%. A LUS score > 13 had a 77.2% sensitivity and a 71.5% specificity (AUC 0.814; p < 0.001) in predicting mortality. LUS alterations were more frequent (64%) in the posterior lower fields. LUS score was related with P/F (R2 0.68; p < 0.0001) and P/F at FiO2 = 21% (R2 0.59; p < 0.0001). The correlation between LUS score and P/F was not influenced by the prevalent ultrasound pattern. LUS represents an effective tool in both defining diagnosis and stratifying prognosis of COVID-19 pneumonia. The correlation between LUS and hemogasanalysis parameters underscores its role in evaluating lung structure and function.

Lopinavir/Ritonavir and Darunavir/Cobicistat in Hospitalized COVID-19 Patients: Findings From the Multicenter Italian CORIST Study

Background: Protease inhibitors have been considered as possible therapeutic agents for COVID-19 patients. Objectives: To describe the association between lopinavir/ritonavir (LPV/r) or darunavir/cobicistat (DRV/c) use and in-hospital mortality in COVID-19 patients. Study Design: Multicenter observational study of COVID-19 patients admitted in 33 Italian hospitals. Medications, preexisting conditions, clinical measures, and outcomes were extracted from medical records. Patients were retrospectively divided in three groups, according to use of LPV/r, DRV/c or none of them. Primary outcome in a time-to event analysis was death. We used Cox proportional-hazards models with inverse probability of treatment weighting by multinomial propensity scores. Results: Out of 3,451 patients, 33.3% LPV/r and 13.9% received DRV/c. Patients receiving LPV/r or DRV/c were more likely younger, men, had higher C-reactive protein levels while less likely had hypertension, cardiovascular, pulmonary or kidney disease. After adjustment for propensity scores, LPV/r use was not associated with mortality (HR = 0.94, 95% CI 0.78 to 1.13), whereas treatment with DRV/c was associated with a higher death risk (HR = 1.89, 1.53 to 2.34, E-value = 2.43). This increased risk was more marked in women, in elderly, in patients with higher severity of COVID-19 and in patients receiving other COVID-19 drugs. Conclusions: In a large cohort of Italian patients hospitalized for COVID-19 in a real-life setting, the use of LPV/r treatment did not change death rate, while DRV/c was associated with increased mortality. Within the limits of an observational study, these data do not support the use of LPV/r or DRV/c in COVID-19 patients.

Regional cardiac uptake of 99-Tc-DPD is a novel powerful and independent prognostic marker in cardiac ATTR wild type amyloidosis

Background

Skeletal scintigraphy with bone tracers is a key tool for cardiac ATTR diagnosis. However its prognostic value has not been systematically assessed.

Purpose

We evaluated the prognostic relevance of a quantitative method to assess regional 99mTc-DPD uptake by SPECT in the heart of ATTRwt patients.

Methods

All ATTRwt patients (n=229) undergoing clinical assessment and bone scintigraphy at our center (from 2012 to 2019) were enrolled. Theyreceived approximately 700 MBq of 99mTc-DPD. Planar whole body acquisition 10' after the injection followed by cardiac SPECT after 3 hours were performed. SPECT data were reconstructed into 64x64 matrices with an ordered-subset expectation maximization algorithm. For each wall region and for the apex, a circular region of interest (ROI, 20 pixels) was manually drawn and a value equating to the number of counts contained in the ROI was obtained. Partial correlation of ln-transformed ROI and biomarkers was retrieved from a multivariable regression model, while controlling for each cardiac wall region. Multivariable Cox regression was used to assess the prognostic role of lnROI while adjusting for wall region, NT-proBNP, cTnI and eGFR. Hazard ratios and 95% confidence intervals (HR, 95% CI) were computed. The Harrell's c statistic was reported for model discrimination. The interaction of biomarker and regional wall on survival was assessed; also, to account for intra-subject correlation of measures, within subject robust standard errors were computed.

Results

Median follow-up was 21 months (IQR 11, 40) and 39 (17%) patients died. Median age was 76 years (IQR, 72–80), NT-proBNP 2944 ng/L (IQR, 1815–5319), cTnI 0.095 ng/L (IQR, 0.062–0.144) and eGFR 62 mL/min (IQR, 51–77). ROI did not correlate with any of NT-proBNP, eGFR, age, cTnI or mLVWT (R&lt;1% in all cases). All analyses were adjusted for cardiac wall. At the multivariable Cox regression (Harrell's c=0.75), there was a linear increase in the risk of death associated with lnROI (HR 2.14, P=0.014), which was independent of cardiac wall region, NTproBNP, cTnI and eGFR. Only cTnI maintained a significant prognostic value. The association of lnROI and mortality was not modified by the site of measurement test for interaction with cardiac wall p=0.818). At the predefined subgroup analysis, the risk of death was similar for all walls; we computed the optimal cut-off for 12 months survival at the apex (a region usually lately involved) to 4193 (AUC: 0.68, sensitivity 80%, specificity 68%). At the multivariable Cox regression (Harrell's c 0.76), apex ROI&gt;4193 was an independent predictor of death (HR 3.60, 95% CI 1.45–8.93, p=0.006) and outperformed all the biomarkers tested.

Conclusions

Quantitative assessment of ROI uptake at cardiac SPECT is a powerful predictor of survival in ATTRwt patients, independent of and outperforming the other known prognostic factors. This observation warrants validation with prolonged follow-up and in independent patient series.

Funding Acknowledgement

Type of funding source: None

Cardiac transthyretin wild-type amyloidosis (ATTRwt): a prospective study of 400 patients followed at the Italian referral center

Background

Cardiac wild type transthyretin (ATTRwt) amyloidosis, formerly known as senile systemic amyloidosis, is an increasingly recognized, progressive, and fatal cardiomyopathy. Two biomarkers staging systems were proposed based on NT-proBNP (in both cases) and troponin or estimated glomerular filtration rate, that are able to predict survival in this population. The availability of novel effective treatments requires large studies to describe the natural history of the disease in different populations.

Objective

To describe the natural history of the disease in a large, prospective, national series.

Methods

Starting in 2007, we protocolized data collection in all the patients diagnosed at our center (n=400 up to 7/2019).

Results

The referrals to our center increased over time: 5 cases (1%) between 2007–2009, 33 (9%) in 2010–2012, 90 (22%) in 2013–2015 and 272 (68%) in 2016–2019. Median age was 76 years [interquartile range (IQR): 71–80 years] and 372 patients (93%) were males. One hundred and seventy-three (43%) had atrial fibrillation, 63 (15%) had a history of ischemic cardiomyopathy and 64 (15%) underwent pacemaker or ICD implantation. NYHA class was I in 58 subjects (16%), II in 225 (63%) and III in 74 (21%). Median NT-proBNP was 3064 ng/L (IQR: 1817–5579 ng/L), troponin I 0.096 ng/mL (IQR: 0.063–0.158 ng/mL), eGFR 62 mL/min (IQR: 50–78 mL/min). Median IVS was 17 mm (IQR: 15–19 mm), PW 16 mm (IQR: 14–18 mm) and EF 53% (IQR: 45–57%). One-hundred and forty-eight subjects (37%) had a concomitant monoclonal component in serum and/or urine and/or an abnormal free light chain ratio. In these patients, the diagnosis was confirmed by immunoelectron microscopy or mass spectrometry. In 252 (63%) the diagnosis was based on bone scintigraphy. DNA analysis for amyloidogenic mutations in transthyretin and apolipoprotein A-I genes was negative in all subjects. The median survival of the whole cohort was 59 months. The Mayo Clinic staging based on NT-proBNP (cutoff: 3000 ng/L) and troponin I (cutoff: 0.1 ng/mL) discriminated 3 different groups [stage I: 131 (35%), stage II: 123 (32%) and stage III: 127 (33%)] with different survival between stage I and II (median 86 vs. 81 months, P=0.04) and between stage II and III (median 81 vs. 62 months, P&lt;0.001). The UK staging system (NT-proBNP 3000 ng/L and eGFR 45 mL/min), discriminated three groups [stage I: 170 (45%), stage II: 165 (43%) and stage III: 45 (12%)] with a significant difference in survival: between stage I and stage II (86 vs. 52 months, P&lt;0.001) and between stage II and stage III (median survival 52 vs. 33 months, P=0.045).

Conclusions

This is one of the largest series of patients with cardiac ATTRwt reported so far. Referrals and diagnoses increased exponentially in recent years, One-third of patients has a concomitant monoclonal gammopathy and needed tissue typing. Both the current staging systems offered good discrimination of staging and were validated in our independent cohort.

Funding Acknowledgement

Type of funding source: None

Cardiac involvement at presentation in patients hospitalized with COVID-19 and their outcome in a tertiary referral hospital in Northern Italy

The correlation between myocardial injury and clinical outcome in COVID-19 patients is gaining attention in the literature. The aim of the present study was to evaluate the role of cardiac involvement and of respiratory failure in a cohort of COVID-19 patients hospitalized in an academic hospital in Lombardy, one of the most affected Italian (and worldwide) regions by the epidemic. The study included 405 consecutive patients with confirmed COVID-19 admitted to a medical ward from February 25th to March 31st, 2020. Follow-up of surviving patients ended either at hospital discharge or by July 30th, 2020. Myocardial injury was defined on the basis of the presence of blood levels of hs-TnI above the 99th percentile upper reference limit. Respiratory function was assessed as PaO₂/FiO₂ (P/F) ratio. The primary end-point was death for any cause. During hospitalization, 124 patients died. Death rate increased from 7.9% in patients with normal hs-TnI plasma levels and no cardiac comorbidity to 61.5% in patients with elevated hs-TnI and cardiac involvement (p < 0.001). At multivariable analysis, older age, P/F ratio < 200 (both p < 0.001) and hs-TnI plasma levels were independent predictors of death. However, it must be emphasized that the median values of hs-TnI were within normal range in non-survivors. Cardiac involvement at presentation was associated with poor prognosis in COVID-19 patients, but, even in a population of COVID-19 patients who did not require invasive ventilation at hospital admission, mortality was mainly driven by older age and respiratory failure.

Common cardiovascular risk factors and in-hospital mortality in 3,894 patients with COVID-19: survival analysis and machine learning-based findings from the multicentre Italian CORIST Study

BACKGROUND AND AIMS

There is poor knowledge on characteristics, comorbidities and laboratory measures associated with risk for adverse outcomes and in-hospital mortality in European Countries. We aimed at identifying baseline characteristics predisposing COVID-19 patients to in-hospital death.

METHODS AND RESULTS

Retrospective observational study on 3894 patients with SARS-CoV-2 infection hospitalized from February 19th to May 23rd, 2020 and recruited in 30 clinical centres distributed throughout Italy. Machine learning (random forest)-based and Cox survival analysis. 61.7% of participants were men (median age 67 years), followed up for a median of 13 days. In-hospital mortality exhibited a geographical gradient, Northern Italian regions featuring more than twofold higher death rates as compared to Central/Southern areas (15.6% vs 6.4%, respectively). Machine learning analysis revealed that the most important features in death classification were impaired renal function, elevated C reactive protein and advanced age. These findings were confirmed by multivariable Cox survival analysis (hazard ratio (HR): 8.2; 95% confidence interval (CI) 4.6-14.7 for age ≥85 vs 18-44 y); HR = 4.7; 2.9-7.7 for estimated glomerular filtration rate levels <15 vs ≥ 90 mL/min/1.73 m2; HR = 2.3; 1.5-3.6 for C-reactive protein levels ≥10 vs ≤ 3 mg/L). No relation was found with obesity, tobacco use, cardiovascular disease and related-comorbidities. The associations between these variables and mortality were substantially homogenous across all sub-groups analyses.

CONCLUSIONS

Impaired renal function, elevated C-reactive protein and advanced age were major predictors of in-hospital death in a large cohort of unselected patients with COVID-19, admitted to 30 different clinical centres all over Italy.

Emergency accesses in Dermatology Department during the Covid-19 pandemic in a referral third level center in the north of Italy

During the lockdown period, most planned visits have been postponed and the number of accesses to emergency department (ED) has dramatically reduced. The aim of our study is to analyze the impact of the lockdown on the number, type, and severity of Dermatological ED diagnosis. We performed a retrospective review of all dermatological consultations in the ED of IRCSS San Matteo during the lockdown period in Italy (February 22‐May 3 2020) and compared them with those from the same period in 2019. We noticed a sharply reduction in the number of dermatological consultations requested in the ED: from 164 patients in 2019 to 33 in 2020. Some diagnostic categories showed a significant difference with a higher incidence of vasculopathic lesions (0.6% vs 12.1%, P < .0001), urticarial rashes (8.5% vs 21.2%, P = .03), and scabies (3% vs 12.1%, P = .023). We observed an increase in the proportion of patients starting medications, before coming to the ED 26.2% in 2019 vs 66.7% in 2020 (P < .001). Furthermore, we noticed a significant increase in the average complexity of cases presenting to the ED in 2020, as proven by the increased need for biopsies and systemic therapy.

P2732Prevalence of electrocardiographic abnormalities in patients with cardiac amyloidosis

Background

Electrocardiographic (ECG) abnormalities are common in patients presenting with Light-Chain (AL) or Transthyretin (ATTR) related Cardiac Amyloidosis (CA). Type of amyloid may differently affect electrical properties of the heart being responsible for variable patterns of ECG anomalies at presentation.

Purpose

In this retrospective, observational study we sought to compare prevalence of ECG abnormalities between AL and ATTR patients with CA.

Methods

Clinical files from two Referral Centres were reviewed; ECG recordings were analysed by trained cardiologists and relevant findings were reported about rhythm (sinus vs atrial fibrillation [AF]), grade I or grade II atrio-ventricular (AV) delays, intra-ventricular (IV) conduction abnormalities, low-voltage QRS and pseudo-necrosis pattern. Presence of pace-maker (PM) and stimulated QRS were regarded to as clinical equivalents for AV block, after review of indications to implantation.

Results

Two hundred and fifty-one patients were identified (127 ATTR vs 124 AL; among ATTR, 27 patients had mutation in TTR gene: 10 Val142Ile, 11 Ile88Leu, 6 other). As expected, most ATTR patients were male (89% vs 56% in AL, p: <0.001), and AL patients were younger (mean age 64 [53–70] vs 79 [73–83]; p: <0.001).

Pathological ECG findings were common in both subgroups, involving more than three-quarters of the overall population (82% in ATTR, vs 72% in AL, p: 0.06). Atrial fibrillation was more common in ATTR, prevailing in 39% vs 5.6% (p: <0.001). ATTR had a higher burden of AV block (53% vs 13%, p: <0.001) and IV conduction delays (43% vs 21%, p: <0.001), and consistently presented a higher prevalence of PMs (24 patients vs 1). Low-voltage QRS was more prevalent in AL patients (52% vs 28%, p: <0.001), while no significant difference was found in prevalence of pseudo-necrosis patterns (ATTR: 29%, AL: 40%; p: ns).

Due to imbalance in age and gender and relative possible confounding effect on rhythm disturbances, adjusted odds ratios (OR) were calculated. It resulted that ATTR was independently associated with a higher prevalence of AF and AV conduction delays when compared to AL (adjusted OR: 4 [95% CI: 1.4–11.2], p: 0.008, and 6.2 [95% CI: 2.6–14.9], p: <0.001; respectively), while being inversely associated with low-voltage QRS (adjusted OR: 0.4 [95% CI: 0.2–0.9], p: 0.026).

Conclusions

ECG abnormalities are common in CA. Rhythm disturbances are more prevalent in ATTR, while AL more often results in low-voltage QRS. Such differences remain relevant after adjustment for age and gender imbalance, thus suggesting an aetiology-specific link.