Internal and Emergency Medicine最新文献

Syncope is a frequent presentation in the emergency department (ED) and carries a heterogeneous risk of adverse outcomes, making early stratification challenging. The Canadian Syncope Risk Score (CSRS) is among the most validated prognostic tools; however, its inclusion of the "ED diagnosis" variable may hinder real-time applicability. We aimed to evaluate a modified version of the CSRS, excluding this variable (CSRS-ED), in predicting 30-day serious outcomes. We conducted a retrospective, single-center study including 935 consecutive patients presenting with syncope to the ED of Santa Croce e Carle Hospital (Cuneo, Italy) between January 2021 and December 2024. The primary endpoint was a composite of arrhythmic and non-arrhythmic serious conditions and all-cause mortality within 30 days, in accordance with prior CSRS derivation and validation studies. CSRS-ED performance was assessed through discrimination, calibration, and diagnostic accuracy at predefined score thresholds to determine sensitivity, specificity, and predictive values. Comparisons were made with SFSR, EGSYS and OESIL scores. Overall, 127 patients (13.6%) experienced adverse outcomes, with 1.3% 30-day mortality. The CSRS-ED showed excellent discrimination (AUROC 0.87, 95% CI 0.84-0.90). At a threshold of ≥ 0, sensitivity was 0.97 with a negative predictive value of 0.99 and a negative likelihood ratio of 0.06. Calibration analysis revealed no significant miscalibration. In conclusion, the CSRS-ED maintains strong prognostic accuracy without requiring an adjudicated ED diagnosis, supporting its potential as a practical tool for early risk stratification and safe discharge decisions in ED patients presenting with syncope.

In patients with exacerbation of chronic obstructive pulmonary disease (ECOPD), the presence of respiratory acidosis is considered "a marker of severity", identifying the need for ventilation treatment. The evaluation of ECOPD patients with hypercapnia, even without acidosis, may provide information on patients not commonly defined as "at risk". We retrospectively assessed 407 hospitalised patients with ECOPD, divided into three groups at admission: patients with normocapnia (N = 176), hypercapnia (PaCO₂ > 45 mmHg and pH ≥ 7.35, N = 126), and acidosis (PaCO₂ > 45 mmHg and pH < 7.35, N = 105). Data on general, clinical, laboratory and microbiological characteristics, and on outcomes (mortality up to 3 years), were collected. Patients with hypercapnia and acidosis had similar functional and clinical characteristics to their normocapnic peers, but of greater severity. The mortality rate at 1 year was similar between hypercapnic and acidotic patients (24% and 25%), and higher than that recorded in the normocapnic group (14%). Similar trends were observed in mortality from 6 months to 3 years. The presence of hypercapnia and acidosis was significantly associated with an increased and independent risk of death at 1 year. A threshold value of PaCO₂ ≥ 55 mmHg was associated with 1-year mortality. In a multivariate analysis considering the new threshold and compared to normocapnia, the presence of hypercapnia (PaCO₂ ≥ 55), regardless of acidosis, was independently associated with a higher mortality risk at 1 year. In hospitalised ECOPD patients, hypercapnia itself, even when compensated, is associated with a worse prognosis up to an intermediate-term follow-up. The need to ventilate these patients should be evaluated, regardless of the presence or absence of acidosis.

Heart failure (HF) is a major endpoint of cardiovascular disease (CVD) and a growing global public health challenge. This study assessed the global burden of CVD-related HF from 1990 to 2021 and projected trends to 2050. Utilizing data from the Global Burden of Disease (GBD) 2021 study, we analyzed years lived with disability (YLD) and prevalence for CVD-related HF, stratified by sex, age, socio-demographic index (SDI), region, and specific CVD etiology. In 2021, CVD-related HF affected approximately 45.56 million individuals globally, causing 4.32 million YLD. The global age-standardized prevalence and YLD rates were 548.81 and 52.00 per 100,000 population, respectively, with higher rates in males. Hypertensive and ischemic heart disease were predominant causes, except in the under-20 age group where cardiomyopathy/myocarditis and rheumatic heart disease prevailed. From 1990 to 2021, global age-standardized prevalence and YLD rates increased, with the sharpest rise in the 20-54 age group, males and middle to high-middle SDI countries. Age-standardized prevalence and YLD rates declined for rheumatic heart disease, stroke, and non-rheumatic valvular heart disease-related HF, whereas most other etiologies exhibited upward trends, most notably atrial fibrillation/flutter and endocarditis. There were significant disparities in various CVD-related HF across sex, age, SDI country, and region in 2021 and from 1990 to 2021. By 2050, projections indicate that CVD-related HF will increase to varying degrees across sex, age, and specific CVD types. The global burden of CVD-related HF is substantial, escalating, and characterized by significant disparities across sex, age, SDI country, region, and CVD type. Urgent and targeted public health strategies are essential to mitigate this rising burden.

This study aimed to analyze patient outcomes in the emergency departments (EDs) during the peak of the pandemic in 2020, focusing on mortality and disposition, utilizing National Emergency Department Sample (NEDS) data. For this study, we included patients aged 18 and older who presented to the ED and were diagnosed with COVID-19, in 2020. Patient records were analyzed using SAS and Python softwares. Chi-squared tests and logistic regression models were utilized, with statistical significance set at p < 0.05. The study examined 2,863,207 COVID-19 patients out of 111,683,248 patient visits to the ED. There was a slight preponderance of females (52.6%) compared with males (47.4%), with the majority of patients being 50-69 years old (34%). Females exhibited significantly lower odds of mortality compared with males, with an OR of 0.7 (p < 0.001). Those aged 70 and above (p < 0.001), and Black individuals exhibited significantly higher odds of mortality in the ED (p < 0.001). Our study aims to guide equitable interventions and resource allocation to optimize patient care and mitigate healthcare disparities, particularly by improving access through the ED and better preparing for the future, including other waves of COVID-19 infection with newer variants.

Biologic agents and small molecules have transformed the management of rheumatoid arthritis (RA), psoriatic arthritis (PsA), and spondyloarthritis (SpA). Nevertheless, some patients experience persistent, uncontrolled inflammation despite multiple targeted therapies. Evidence for dual targeted therapy (DTT) remains scarce. This study aims to describe the clinical characteristics, therapeutic rationale, and outcomes of patients with severe, multi-drug-refractory inflammatory arthritis and autoinflammatory disease treated with DTT. This clinical case series included patients with RA, PsA, FMF-associated SpA and Crohn's disease, SpA-associated atopic dermatitis, and one patient with TRAPS and PsA treated with DTT. Disease activity was evaluated using validated indices, physician assessment, patient-reported outcomes, and inflammatory markers. Safety was evaluated through clinical and laboratory monitoring. Eight patients received nine DTT courses. Mean follow-up was 11.7 ± 4.3 months. Median ESR decreased from 42 mm/h (IQR 34) to 16.1 mm/h (IQR 9), and mean CRP declined from 1.52 ± 0.55 mg/dL to 0.35 ± 0.24 mg/dL. Disease activity improved across all assessed indices. One patient with FMF-associated SpA and Crohn's disease required modification of DTT due to persistent intestinal activity and subsequently achieved remission. The prednisone dose decreased from 25 mg/day (IQR 12.5) to 2.5 mg/day (IQR 5). No adverse events were observed. DTT was associated with clinically meaningful improvements in refractory inflammatory arthritis and autoinflammatory disease, demonstrating a favourable safety profile and a clear steroid-sparing effect. These preliminary findings support its potential role in highly refractory settings, although larger studies are needed to define long-term safety and optimal therapeutic combinations.

Reducing the rate of re-hospitalization is an important goal to improve the quality of care and reduce healthcare costs. The aims of this study were to assess the prevalence of hospital readmissions, to investigate the causes of index admissions, readmissions and related determinants in an older population. Data from the REgistro dei pazienti per le POlipatologie e politerapie in reparti della rete SIMI (REPOSI) register were used. Older patients (65 + years old) acutely hospitalized and discharged from internal medicine and geriatric wards were followed-up by phone interview after 3 months. Prevalence of hospital readmission was calculated from 2010 to 2022, as well as the patterns of causes of index admission and readmission. Multivariate logistic regression models were used to evaluate the association with 3-month readmissions of patients' variables. Out of 4216 patients evaluated, 828 (19.6%) were re-hospitalized within 3 months. The most frequent causes of index hospitalization were ill-defined conditions (28.6%) and heart failure (12.1%), and those of re-hospitalization heart failure (14.0%) and rehabilitation procedures (11.7%). Multimorbidity, functional dependence and previous hospital admissions were the most important risk factors for re-hospitalization. Among the patients readmitted, 24.3% (201/828) were re-hospitalized with the same condition of their index admission. These results demonstrate that the prevalence of hospital readmission remains high, thus underlying the need for increased medical and social attention towards elderly patients at the time of hospital discharge.

This study analyses the incidence and death trends of gastric cancer in individuals aged 70 and older, and assesses the burden attributable to key risk factors, to inform targeted public health strategies. The Global Burden of Disease (GBD) 2021 study covers 371 conditions and 88 risk factors across 204 nations and territories. We evaluated gastric cancer burden in individuals aged 70 and older using incidence and death rates and their estimated annual percentage change (EAPC), stratified by sex, age, region, nation, socio-demographic index (SDI) levels, and risk factors. Correlations with the SDI were assessed using Pearson's correlation tests. Globally, the incident cases of gastric cancer in individuals aged 70 and older increased by 25.42% from 1990 to 2021. However, the incidence rate decreased with an overall EAPC of - 1.23. Similarly, the death cases increased by 11.73% from 1990 to 2021, but the death rate decreased with an EAPC of - 1.64. The highest incidence and death rates were observed in the 90 and older age groups, while the highest absolute numbers were in the 70-79 age group. Compared with females, males presented greater numbers and rates of incidence and death. The burden of gastric cancer in individuals aged 70 and older in 2021 and its trend changes from 1990 to 2021 vary greatly by region or nation. The correlation between gastric cancer in individuals aged 70 and older and the SDI was weakly positive, with high-middle SDI regions or nations having the highest incidence and death rates in 2021.The risk factors identified included diet high in sodium and smoking, which contributed significantly to the disease burden, accounting for 7.9% and 11.7% of disability-adjusted life years in 2021, respectively. Despite declines in the incidence and death rates of gastric cancer in individuals aged 70 and older from 1990 to 2021, the incident cases and death cases have increased. These results emphasize the need for continued efforts in public health strategies, particularly in males, high-middle SDI regions, and key risk factors, to address the challenges posed by gastric cancer in individuals aged 70 and older.