Internal and Emergency Medicine最新文献

Vascular and neuronal networks are examples of body structures created by processes of branching morphogenesis, showing a similar architecture. Like vascular network morphogenesis, where morphology adapts to the amount of flow, neuronal branching dynamics also can be modulated by neural activity. Axon branching, indeed, often occurs as a dynamic process that involves branch addition and branch retraction. Self-similarity logic characterizes both the nervous and the vascular system. From a morphologic point of view, the self-similarity of the vascular system is straightforward, being the result of a hierarchical sequence of bifurcations, leading to a structure which can be considered strictly self-similar.

Postoperative atrial fibrillation (PoAF) complicates 10-15% of pulmonary lobectomy and 20-30% of pneumonectomy, contributing to increased morbidity, extended hospital stays, and healthcare costs. Identifying predictors of PoAF may aid in risk stratification and preventive care. We prospectively studied 100 consecutive patients who underwent lung surgery for a malignant tumour, including video-assisted thoracic surgery (VATS) and open thoracotomy. Patients with prior atrial fibrillation, cardiac surgery, or thyroid abnormalities were excluded. All patients received pre-operative echocardiography, including speckle-tracking for left atrial (LA) and ventricular function. PoAF incidence was monitored through continuous electrocardiographic follow-up. Univariable and multivariable analyses identified clinical and echocardiographic predictors of PoAF. At univariable analysis, PoAF patients (8%) were more likely to have hypertension (100% vs. 58%, p = 0.018), higher fibrinogen (432 ± 118 mg/dl vs. 346 ± 87 mg/dl, p = 0.03), and lower magnesium levels (1.8 ± 0.2 mEq/l vs. 2.1 ± 0.2 mEq/l, p = 0.003). Echocardiographic differences included larger LA diameter (42 ± 5 mm vs. 35 ± 5 mm, p = 0.002), area (23.8 ± 3.3 cm² vs. 17.7 ± 4.5 cm², p < 0.001), and volume (36.9 ± 7.2 ml vs. 28.6 ± 9.4 ml, p = 0.003). Multivariable analysis identified fibrinogen (HR 1.01, p = 0.036), interventricular septal thickness (HR 3.05, p = 0.029), LA area (HR 1.33, p = 0.016) and LA peak contraction strain (PACS, HR 2.3, p = 0.023) as independent PoAF predictors. Hypertension, inflammation, electrolyte imbalance, and LA remodelling were associated with PoAF. Pre-operative identification of these factors may help target high-risk patients for preventive interventions.

Proton pump inhibitors are widely prescribed at hospital discharge from internal medicine wards and inappropriate use is common. We retrospectively conducted a survival analysis on data collected from the Registro Politerapie SIMI (REPOSI) registry to evaluate the 1-year risk of hospitalization or mortality associated with the use of PPI, with a particular focus on the appropriateness of use and newly initiated prescriptions at discharge. 7280 patients were discharged from hospital and 4579 (62.9%) had a PPI prescription. The use of PPI was significantly associated with 1-year risk of mortality in the univariate model (hazard ratio (HR) 1.33, p = 0.0012) and also when adjusted for confounders (adjusted HR 1.47, p = 0.0009). In the sensitivity analysis, new PPI prescription use at discharge was associated with an increased risk of mortality (adjusted HR of 1.53, p = 0.006). Inappropriate use was also linked to a nearly 60% higher risk of 1-year mortality and 27% increased risk of 1-year re-hospitalization. Among new PPI users, inappropriate use was associated with nearly 70% increased risk of 1-year mortality (HR 1.69). PPI use was associated with an increased risk of 1-year mortality and re-hospitalization in older adults discharged from hospitals. A higher risk of mortality was observed among new inappropriate PPI users, underscoring the importance of carefully evaluating the unnecessary initiation of new medications at discharge to maintain a favorable benefit-risk ratio.Impact of findings on practice statements. Proton pump inhibitors are among the most commonly prescribed medications. Use of proton pump inhibitors at hospital discharge was associated with a risk of 1-year mortality. Unnecessary PPI use was associated with higher risk of mortality. Patients discharged from internal medicine wards had high rates of inappropriate PPI use. The unnecessary initiation of new drugs at discharge for a favorable benefit-risk ratio was evaluated.

Acute pancreatitis (AP) is an inflammatory disease that can represent a challenge for clinicians, in fact, the early determination of its severity in the first 72 h is crucial for prognosis, recognizing the etiology and carrying out risk stratification to determine a more specific therapy. No accurate early prognostic scores for disease severity have been published, so the severity of AP often cannot be properly defined in the first few hours of the disease. This initial phase represents a "no man's land", in which there is no certainty in the stratification of the damage, prognosis is difficult to establish, therapy must be started promptly, although there is still no effective medical therapy against pancreatic enzymatic activation. Therefore, it is very difficult at this stage to make the correct decisions to achieve the best outcome for the patient with AP. Literature search was carried out using the PubMed database by entering early management of acute pancreatitis [title] or therapy of acute pancreatitis [title] and selecting the most relevant articles for the diagnosis and therapy of acute pancreatitis in clinical practice. This document provides suggestions on managing the key clinical decisions for patients suffering from AP before disease severity is defined, to achieve the best outcomes for patients with AP.

Point-of-Care Ultrasound (POCUS), when used by experienced physicians, is a valuable diagnostic tool for the initial minutes of shock management and subsequent monitoring. It enables early diagnosis with high sensitivity (Sn) and specificity (Sp). Published protocols have advanced towards true multi-organ ultrasonographic exploration, with the RUSH (Rapid Ultrasound in Shock) protocol likely being the most well-known nowadays. Although there is no established order, cardiac evaluation, as well as vascular system assessments including intra- and extravascular volume, should be explored. Additionally, there are ultrasonographic evaluations particularly useful for diagnosing and monitoring response/tolerance to volume. Both the identification of B lines and the increase in left ventricular pressures bring us closer to a diagnosis of fluid overload in these patients. Velocity-time integral (VTI) of the left ventricle (LV) outflow tract (LVOT, LVOT_VTI) or right ventricular outflow tract (RVOT, RVOT_VTI) can be indicative of distributive shock if elevated, and help identifying volume responders through leg-raising manoeuvres or crystalloid bolus administration. Several index of the inferior vena cava (IVC) can also be helpful. In addition, different parameters to establish fluid responsiveness are being investigated at the carotid level. Venous congestion parameters have not yet been proven to identify volume responders but can identify patients with poor tolerance. Currently, it is essential that physicians treating critical patients use POCUS to enhance clinical outcomes.

Optimal duration of anticoagulant therapy for left ventricular thrombous (LVT) is unclear. The aim of this study is to evaluate effectiveness and safety of vitamin K antagonists (VKAs) up to 12 months in patients with LVT. Patients diagnosed with LVT between 2011 and 2023 and treated with VKAs until LVT resolution or up to 12 months were enrolled in a retrospective cohort study. Primary outcome included on-treatment LVT resolution, secondary outcomes acute ischemic stroke, myocardial infarction, peripheral embolism, and major and clinically relevant non-major bleedings during the 12-month follow-up. Ninety patients were included. Median age was 66 years and 78.9% were male. Mean time in therapeutic range was 61% and 32.9% of patients received VKA monotherapy, with the remaining concomitant antiplatelet treatment. The 3, 6, 12 months cumulative incidences of LVT resolution were 27% (95% confidence intervals -95%CI-, 18%-36%), 47% (95%CI 36%-57%), and 70% (95% CI 60%-79%), respectively. At Cox regression model, reduced left ventricular ejection fraction (Hazard Ratio 0.48; 95%CI 0.24-0.95) and left-ventricular aneurysms (Hazard Ratio 0.44; 95%CI 0.22-0.88) were associated with reduced LVT resolution. One patient developed an acute ischemic stroke and one an acute myocardial infarction. Two patients developed a major and four a clinically relevant non-major bleeding. Incidence of LVT resolution appeared to be higher at 12 than at 3 and 6 months of follow-up, and the rates of on-treatment acute arterial and bleeding events were low. Reduced left ventricular ejection fraction and left-ventricular aneurysm appeared to be associated with a lower rates of LVT resolution.

Twelve-lead electrocardiogram (ECG) may provide prognostic information for in-hospital cardiac arrest (IHCA). This study aimed to identify post-arrest ECG features and their temporal changes associated with IHCA outcomes. This single-center retrospective study included patients experiencing IHCA between 2005 and 2022. Post-arrest ECGs were obtained within 48 h after an IHCA, admission ECGs upon hospital admission, and pre-arrest ECGs within 72 h before an IHCA. Multivariable logistic regression analyses were conducted to identify ECG features associated with neurologically intact survival. A total of 708 patients were included, with 131 (18.5%) achieving neurologically intact survival. The median age was 70.4 years (interquartile range: 59.2-82.6), and 362 (62.7%) patients were male. Four post-arrest ECG features were associated with survival: sinus rhythm (odds ratio [OR]: 1.81, 95% confidence interval [CI]: 1.11-2.93), QRS duration between 80 and 120 ms (OR: 1.91, 95% CI 1.19-3.08), low QRS voltage (OR: 0.50, 95% CI 0.25-0.99), and prolonged QTc (OR: 1.89, 95% CI 1.08-3.28). Comparing with admission ECGs, new-onset right bundle branch block (OR: 0.39, 95% CI 0.16-0.95) and increases in the number of leads with ST depression (OR: 0.85, 95% CI 0.77-0.94) on post-arrest ECGs were inversely associated with survival. Compared with pre-arrest ECGs, increases in the number of leads with ST depression (OR: 0.91, 95% CI 0.88-0.96) on post-arrest ECGs were also inversely associated with survival. Post-arrest ECGs may serve as a valuable prognostic tool for IHCA. Further exploration is warranted to determine whether incorporating these ECG features can enhance the performance of prediction models for IHCA outcomes.

Despite efforts to mitigate high opioid prescription frequencies, previous research showed minimal change within emergency departments (ED) in the United States, and a few studies investigate prescription provider types. Thus, our primary objective was to assess opioid prescribing rates by differing healthcare team members using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS). Using the 2019-2021 NHAMCS, we calculated the overall opioid prescription rate during ED visits by provider type. Next, we estimated opioid prescription rates by provider type annually and determined differences by year using design-based X² tests and regression models. From 2019 through 2021, 7428 of 50,548 visits involved opioids, representing 15.62% of all ED visits. During this timeframe, 16.59% of total encounters with opioid prescriptions were among attending/consulting physicians. This was followed by physician assistants (13.91%), nurse practitioners (10.67%), and residents (7.28%). Compared to 2019, opioid prescribing rates showed no significant changes; however, resident physicians showed a significant decrease, and RNs showed a significant increase. From our analysis, opioid prescribing rates in the ED were highest among attending/consulting physicians, and rates among physician assistants and nurse practitioners were higher than 10%. Resident physicians had a significant decrease in opioid prescriptions, while RNs had an increase-likely due to new laws enacted during this timeframe. Removing barriers to alternative pain management for acute and long-term care may lessen rates of opioid prescriptions-including patient and provider training, physical therapists inclusion, and osteopathic manipulative therapy incorporation.