BACKGROUND: Little is known about the association between acute mental changes and adverse outcomes in hospitalized adults with COVID‐19. OBJECTIVES: To investigate the occurrence of delirium in hospitalized patients with COVID‐19 and explore its association with adverse outcomes. DESIGN: Longitudinal observational study. SETTING: Tertiary university hospital dedicated to the care of severe cases of COVID‐19 in São Paulo, Brazil. PARTICIPANTS: A total of 707 patients, aged 50 years or older, consecutively admitted to the hospital between March and May 2020. MEASUREMENTS: We completed detailed reviews of electronic medical records to collect our data. We identified delirium occurrence using the Chart‐Based Delirium Identification Instrument (CHART‐DEL). Trained physicians with a background in geriatric medicine completed all CHART‐DEL assessments. We complemented our baseline clinical information using telephone interviews with participants or their proxy. Our outcomes of interest were in‐hospital death, length of stay, admission to intensive care, and ventilator utilization. We adjusted all multivariable analyses for age, sex, clinical history, vital signs, and relevant laboratory biomarkers (lymphocyte count, C‐reactive protein, glomerular filtration rate, D‐dimer, and albumin). RESULTS: Overall, we identified delirium in 234 participants (33%). On admission, 86 (12%) were delirious. We observed 273 deaths (39%) in our sample, and in‐hospital mortality reached 55% in patients who experienced delirium. Delirium was associated with in‐hospital death, with an adjusted odds ratio of 1.75 (95% confidence interval = 1.15–2.66); the association held both in middle‐aged and older adults. Delirium was also associated with increased length of stay, admission to intensive care, and ventilator utilization. CONCLUSION: Delirium was independently associated with in‐hospital death in adults aged 50 years and older with COVID‐19. Despite the difficulties for patient care during the pandemic, clinicians should routinely monitor delirium when assessing severity and prognosis of COVID‐19 patients.

Objectives: The coronavirus disease (COVID‐19) pandemic has been associated with severe disruptions in health care services, and nonpharmacological measures such as social distancing also have an impact on access to screening tests and on the long‐term care of patients with chronic conditions globally. We aimed to describe the impact of the COVID‐19 pandemic on HIV testing and treatment and to describe strategies employed to mitigate the impact of COVID‐19 on HIV care.Methods: In this retrospective cohort study, we used secondary data from the AIDS Healthcare Foundation (AHF) Global Quality Program from 44 countries in four continents (Asia, Latin America and the Caribbean, Europe and Africa), and compared information on HIV testing, percentage of positive results, number of in‐person appointments, and number of new enrolments in HIV care from 1 January 2020 to 31 August 2020 with the equivalent period in 2019.Results: Despite marked inter‐country heterogeneities, we found that COVID‐19 was associated with a significant reduction in HIV testing, an increase in the percentage of positive tests, a reduction in the number of in‐person consultations and a reduction in the number of new enrolments in care, despite the implementation of several mitigation strategies. The impact of COVID‐19 differed across continents and key populations.Conclusions: Our findings suggest that, in the years to come, health care services must be prepared to respond to the impact of COVID‐19 on HIV testing and care. Providers and facilities should build on the lessons learned so far to further improve mitigation strategies and establish care priorities for both the pandemic and the post‐pandemic periods.

Comprehensive Geriatric Assessment (CGA) provides detailed information on clinical, functional and cognitive aspects of older patients and is especially useful for assessing frail individuals. Although a large proportion of hospitalized older adults demonstrate a high level of complexity, CGA was not developed specifically for this setting. Our aim was to evaluate the application of a CGA model for the clinical characterization and prognostic prediction of hospitalized older adults. This was a prospective observational study including 746 patients aged 60 years and over who were admitted to a geriatric ward of a university hospital between January 2009 and December 2011, in Sao Paulo, Brazil. The proposed CGA was applied to evaluate all patients at admission. The primary outcome was in-hospital death, and the secondary outcomes were delirium, nosocomial infections, functional decline and length of stay. Multivariate binary logistic regression was performed to assess independent factors associated with these outcomes, including socio-demographic, clinical, functional, cognitive, and laboratory variables. Impairment in ten CGA components was particularly investigated: polypharmacy, activities of daily living (ADL) dependency, instrumental activities of daily living (IADL) dependency, depression, dementia, delirium, urinary incontinence, falls, malnutrition, and poor social support. The studied patients were mostly women (67.4%), and the mean age was 80.5±7.9 years. Multivariate logistic regression analysis revealed the following independent factors associated with in-hospital death: IADL dependency (OR=4.02; CI=1.52-10.58; p=.005); ADL dependency (OR=2.39; CI=1.25-4.56; p=.008); malnutrition (OR=2.80; CI=1.63-4.83; p<.001); poor social support (OR=5.42; CI=2.93-11.36; p<.001); acute kidney injury (OR=3.05; CI=1.78-5.27; p<.001); and the presence of pressure ulcers (OR=2.29; CI=1.04-5.07; p=.041). ADL dependency was independently associated with both delirium incidence and nosocomial infections (respectively: OR=3.78; CI=2.30-6.20; p<.001 and OR=2.30; CI=1.49-3.49; p<.001). The number of impaired CGA components was also found to be associated with in-hospital death (p<.001), delirium incidence (p<.001) and nosocomial infections (p=.005). Additionally, IADL dependency, malnutrition and history of falls predicted longer hospitalizations. There were no significant changes in overall functional status during the hospital stay. CGA identified patients at higher risk of in-hospital death and adverse outcomes, of which those with functional dependence, malnutrition and poor social support were foremost.

Hospitalized older adults with preexisting dementia have increased risk of having delirium, but little is known regarding the effect of delirium superimposed on dementia (DSD) on the outcomes of these patients. Our aim was to investigate the association between DSD and hospital mortality and 12-mo mortality in hospitalized older adults. This was a prospective cohort study completed in the geriatric ward of a university hospital in São Paulo, Brazil. We included 1,409 hospitalizations of acutely ill patients aged 60 y and over from January 2009 to June 2015. Main variables and measures included dementia and dementia severity (Informant Questionnaire on Cognitive Decline in the Elderly, Clinical Dementia Rating) and delirium (Confusion Assessment Method). Primary outcomes were time to death in the hospital and time to death in 12 mo (for the discharged sample). Comprehensive geriatric assessment was performed at admission, and additional clinical data were documented upon death or discharge. Cases were categorized into four groups (no delirium or dementia, dementia alone, delirium alone, and DSD). The no delirium/dementia group was defined as the referent category for comparisons, and multivariate analyses were performed using Cox proportional hazards models adjusted for possible confounders (sociodemographic information, medical history and physical examination data, functional and nutritional status, polypharmacy, and laboratory covariates). Overall, 61% were women and 39% had dementia, with a mean age of 80 y. Dementia alone was observed in 13% of the cases, with delirium alone in 21% and DSD in 26% of the cases. In-hospital mortality was 8% for patients without delirium or dementia, 12% for patients with dementia alone, 29% for patients with delirium alone, and 32% for DSD patients (Pearson Chi-square = 112, p < 0.001). DSD and delirium alone were independently associated with in-hospital mortality, with respective hazard ratios (HRs) of 2.14 (95% CI = 1.33–3.45, p = 0.002) and 2.72 (95% CI = 1.77–4.18, p < 0.001). Dementia alone did not have a significant statistical association with in-hospital mortality (HR = 1.69, 95% CI = 0.72–2.30, p = 0.385). Finally, while 24% of the patients died after discharge, 12-mo mortality was not associated with dementia or delirium in any of the diagnostic groups (DSD: HR = 1.15, 95% CI = 0.79–1.68, p = 0.463; delirium alone: HR = 1.05, 95% CI = 0.71–1.54, p = 0.810; dementia alone: HR = 1.19, 95% CI = 0.79–1.78, p = 0.399). Limitations to this study include not exploring the effects of the duration and severity of delirium on the outcomes. DSD and delirium alone were independently associated with a worse prognosis in hospitalized older adults. Health care professionals should recognize the importance of delirium as a predictor of hospital mortality regardless of the coexistence with dementia.

Since 1963, when the first human liver transplantation (LT) was performed by Thomas Starzl, the world has witnessed 50 years of development in surgical techniques, immunosuppression, organ allocation, donor selection, and the indications and contraindications for LT. This has led to the mainstream, well-established procedure that has saved innumerable lives worldwide. Today, there are hundreds of liver transplant centres in over 80 countries. This review aims to describe the main aspects of LT regarding the progressive changes that have occurred over the years. We herein review historical aspects since the first experimental studies and the first attempts at human transplantation. We also provide an overview of immunosuppressive agents and their potential side effects, the evolution of the indications and contraindications of LT, the evolution of survival according to different time periods, and the evolution of methods of organ allocation.