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Background Data regarding the importance of multidimensional frailty to guide clinical decision making for remdesivir use in older patients with coronavirus disease 2019 (COVID-19) are largely unexplored. Objective The aim of this research was to evaluate if the Multidimensional Prognostic Index (MPI), a multidimensional frailty tool based on the Comprehensive Geriatric Assessment (CGA), may help physicians in identifying older hospitalized patients affected by COVID-19 who might benefit from the use of remdesivir. Methods This was a multicenter, prospective study of older adults hospitalized for COVID-19 in 10 European hospitals, followed-up for 90 days after hospital discharge. A standardized CGA was performed at hospital admission and the MPI was calculated, with a final score ranging between 0 (lowest mortality risk) and 1 (highest mortality risk). We assessed survival with Cox regression, and the impact of remdesivir on mortality (overall and in hospital) with propensity score analysis, stratified by MPI = 0.50. Results Among 496 older adults hospitalized for COVID-19 (mean age 80 years, female 59.9%), 140 (28.2% of patients) were treated with remdesivir. During the 90 days of follow-up, 175 deaths were reported, 115 in hospital. Remdesivir treatment significantly reduced the risk of overall mortality (hazard ratio [HR] 0.54, 95% confidence interval CI 0.35–0.83 in the propensity score analysis) in the sample as whole. Stratifying the population, based on MPI score, the effect was observed only in less frail participants (HR 0.47, 95% CI 0.22–0.96 in propensity score analysis), but not in frailer subjects. In-hospital mortality was not influenced by remdesivir use. Conclusions MPI could help to identify less frail older adults hospitalized for COVID-19 who could benefit more from remdesivir treatment in terms of long-term survival.

IgA nephropathy (IgAN) remains the most frequent glomerular disease worldwide, with a broad spectrum of clinical and histological presentations. It has been associated with many secondary causes. The remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome is an autoimmune disorder characterized by swelling in the extremities and negative autoimmune serological tests. The primary treatment for this condition involves the use of immunosuppressive therapy. Although several triggers have been identified, the exact cause of this condition is still unknown. We report a case of a 53-year-old man who presented with acute exacerbation of chronic kidney disease, whose etiological study revealed advanced IgAN, associated with pleural and pericardial effusions. Even with volume optimization and dialysis intensification, the pericardial effusion worsened, despite the resolving pleural effusion. Upper arm arthralgias were developed afterward. An extensive study ruled out other causes and the hypothesis of RS3PE syndrome was considered. Glucocorticoid (GC) therapy was instituted for 6 months with clinical improvement and no recurrence at 2 years follow-up. The complexity of this case shows the importance of considering a wider diagnosis for the complaints of arthralgias and volume overload, reinforcing the importance of clinical awareness for other concurrent conditions, whose treatment may be lifesaving.

Key summary points Aim Testing the role of the Multidimensional Prognostic Index (MPI), based on the Comprehensive Geriatric Assessment (CGA), in predicting the risk of incident delirium in hospitalized older patients with COVID-19. Findings The MPI showed a good accuracy in predicting incident delirium (AUC = 0.71). Its accuracy is higher than the ones of two validated predictive models (AWOL delirium risk-stratification score’s AUC = 0.63; Martinez Model’s AUC = 0.61; p < 0.0001 for both comparisons). Message The MPI is a sensitive tool for risk-stratification of the incident delirium in hospitalized older COVID-19 patients. Purpose Incident delirium is a frequent complication among hospitalized older people with COVID-19, associated with increased length of hospital stay, higher morbidity and mortality rates. Although delirium is preventable with early detection, systematic assessment methods and predictive models are not universally defined, thus delirium is often underrated. In this study, we tested the role of the Multidimensional Prognostic Index (MPI), a prognostic tool based on Comprehensive Geriatric Assessment, to predict the risk of incident delirium. Methods Hospitalized older patients (≥ 65 years) with COVID-19 infection were enrolled (n = 502) from ten centers across Europe. At hospital admission, the MPI was administered to all the patients and two already validated delirium prediction models were computed (AWOL delirium risk-stratification score and Martinez model). Delirium occurrence during hospitalization was ascertained using the 4A’s Test (4AT). Accuracy of the MPI and the other delirium predictive models was assessed through logistic regression models and the area under the curve (AUC). Results We analyzed 293 patients without delirium at hospital admission. Of them 33 (11.3%) developed delirium during hospitalization. Higher MPI score at admission (higher multidimensional frailty) was associated with higher risk of incident delirium also adjusting for the other delirium predictive models and COVID-19 severity (OR = 12.72, 95% CI = 2.11–76.86 for MPI-2 vs MPI-1, and OR = 33.44, 95% CI = 4.55–146.61 for MPI-3 vs MPI-1). The MPI showed good accuracy in predicting incident delirium (AUC = 0.71) also superior to AWOL tool, (AUC = 0.63) and Martinez model (AUC = 0.61) ( p  < 0.0001 for both comparisons). Conclusions The MPI is a sensitive tool for early identification of older patients with incident delirium.

Sjögren’s syndrome (SS) is a complex autoimmune rheumatic disease that specifically targets salivary and lachrymal glands. As such, patients typically had ocular and oral dryness and salivary gland swelling. Moreover, skin, nasal and vaginal dryness are frequently present. In addition to dryness, musculoskeletal pain and fatigue are the hallmarks of this disease and constitute the classic symptom triad presented by the vast majority of patients. Up to 30% to 50 % of patients with SS may present systemic disease; moreover, there is an increased risk for the development of non-Hodgkin’s lymphoma that occurs in a minority of patients. The present work was developed in the framework of the European Reference Network (ERN) dedicated to Rare and Complex Connective Tissue and Musculoskeletal Diseases (ReCONNET). In line with its goals of aiming to improve early diagnosis, treatment and care of rare connective and musculoskeletal diseases, ERN-ReCONNET set to review the current state of clinical practice guidelines (CPGs) in the rare and complex connective tissue diseases of interest of the network. Therefore, the present work was aimed at providing a state of the art of CPGs for SS.

In the wake of the Portuguese vaccination program 50th anniversary it seems appropriate to review vaccination in patients with systemic lupus erythematosus. Controversial issues as regards the association between autoimmune diseases, infections, and vaccines are discussed as well as vaccine safety and efficacy issues as regards chronic immunosuppressant (IS) drug therapy. After a brief overview of national policies, specific recommendations are made as regards vaccination for adult patients with SLE with a particular focus on current IS therapy and unmet needs.

Background Cognitive decline is common in older people. Numerous studies point to the detrimental impact of polypharmacy and inappropriate medication on older people’s cognitive function. Here we aim to systematically review evidence on the impact of medication optimisation and drug interventions on cognitive function in older adults. Methods A systematic review was performed using MEDLINE and Web of Science on May 2021. Only randomised controlled trials (RCTs) addressing the impact of medication optimisation or pharmacological interventions on quantitative measures of cognitive function in older adults (aged > 65 years) were included. Single-drug interventions (e.g., on drugs for dementia) were excluded. The quality of the studies was assessed by using the Jadad score. Results Thirteen studies met the inclusion criteria. In five studies a positive impact of the intervention on metric measures of cognitive function was observed. Only one study showed a significant improvement of cognitive function by medication optimisation. The remaining four positive studies tested methylphenidate, selective oestrogen receptor modulators, folic acid and antipsychotics. The mean Jadad score was low (2.7). Conclusion This systematic review identified a small number of heterogenous RCTs investigating the impact of medication optimisation or pharmacological interventions on cognitive function. Five trials showed a positive impact on at least one aspect of cognitive function, with comprehensive medication optimisation not being more successful than focused drug interventions. More prospective trials are needed to specifically assess ways of limiting the negative impact of certain medication in particular and polypharmacy in general on cognitive function in older patients.

Key summary points Aim To describe the prevalence, indications, and complications of indwelling urinary catheters use in Portuguese older inpatients. Findings UriCath is the first Portuguese multicentric study including a high number of public hospitals, addressing the use of indwelling urinary catheter in older inpatients. Indwelling urinary catheter use among older inpatients is prevalent and often inappropriate. Message The results of UriCath will highlight the importance of rethinking the use of indwelling urinary catheter and the need to improve geriatric skills. Purpose Approximately 25% of older inpatients have an indwelling urinary catheter (IUC), 45–54% unnecessarily. This study aims to describe the prevalence, indications, and complications of IUC use in Portuguese older inpatients. Methods Multicentric, cross-sectional, observational study conducted in Portuguese internal medicine wards (UriCath). Results Of a total of 3135 inpatients from 39 hospitals, we included 628 patients with 65 years old or more using an IUC, mean age 82.0 ± 7.5. Prevalence of IUC use was 20.0%. The average Barthel Index was 44.0 ± 37.3 and Charlson comorbidity Index was 7.0 ± 2.8. The main reasons for IUC use were: urinary output monitoring (47.5%), urinary retention (22.5%), and pressure ulcers (11.0%). The IUC removal was attempted in 9.1% and 24.7% developed a complication. Conclusion IUC use among older inpatients is prevalent and often inappropriate. Clinical awareness and development guidelines for restricted use of IUC are essential to reduce morbimortality and healthcare costs.

With the increased presence of the elderly in the emergency department, sepsis represents a major cause of death. The Sepsis Taskforce developed the quick SOFA (qSOFA) score which consists of only 3 items, is quick and easy to apply, and establishes a mortality risk for patients. A retrospective review of electronic records of elderly patients, admitted during a year, with an infectious disease was made. Outcomes were in-hospital mortality, admission to intensive care unit, need for invasive mechanical ventilation, non-invasive mechanical ventilation, antibiotic escalation, and length of stay. In the 310 patients, 24% had a positive qSOFA score at admission. It correlated with increased mortality (2.7 times), also increased ICU admission (3.5 times), greater need for invasive ventilation (risk ratio 4.4), non-invasive ventilation (3 times higher), and a longer length of stay (2.3 days). qSOFA was a good predictor of IMV and NIMV need, ICU admission, and death.