Internal and Emergency Medicine最新文献

Environmental health should be an ethical obligation for experts in internal medicine. Besides the harmful health effects of air pollution, endocrine-disrupting chemicals and climate change, growing evidence points to glyphosate, a widely used herbicide, which generates risks to public health in terms of noncommunicable diseases and cancer. Detection of glyphosate in humans has been associated with all-cause mortality, increased frailty, insulin resistance, impaired glucose homeostasis and diabetes, increased risk of atherosclerotic cardiovascular diseases, fatty liver, and chronic obstructive pulmonary disease. In addition, recent animal studies demonstrated that long-term intake of glyphosate with drinking water, even at very low levels, dose-dependently increases cancer incidence. Experts in internal medicine are called to increase awareness on the pathogenetic role of glyphosate, to amplify their function as privileged healthcare providers. The discussion about environmental hazards, as for glyphosate, could be efficiently driven by an ethical involvement of experts in internal medicine to generate significant beneficial effects. Although primary prevention is mainly a political issue, internists should act as health advocates for the community, sharing scientific evidence and expert knowledge in complexity, and encouraging them to take actions oriented at decreasing the health risk deriving from glyphosate through a one-health approach.

Dual use of electronic and combustible cigarettes among adolescents is an emerging public health concern, particularly in countries experiencing rapid shifts in tobacco and nicotine product availability. This study examined the prevalence and correlates of ever and current dual use among adolescents aged 13-15 in Saudi Arabia. We analysed data from the 2022 Saudi Arabia Global Youth Tobacco Survey (GYTS), a nationally representative, school-based cross-sectional survey. Ever dual use was defined as having ever tried both cigarettes and e-cigarettes, while current dual use was defined as past 30-day use of both products. We used survey-weighted logistic regression to examine predictors of dual use. In the 2022 GYTS, 12.6% of adolescents had ever smoked cigarettes and 14.4% had ever used e-cigarettes; 2.9% and 5.4% were current users, respectively. Among 5,436 adolescents aged 13-15, 5.3% (95% CI: 4.3-6.4) reported ever dual use and 1.4% (95% CI: 1.1-1.9) reported current dual use. Ever dual use was associated with being aged 15 compared to 13 years (AOR = 1.82, 95% CI: 1.14-2.91, p = 0.013), having ≥ 50 SAR weekly spending money compared to none (AOR = 1.60, 95% CI: 1.04-2.45, p = 0.032), having at least one parent who smoked vs none (AOR = 1.64, 95% CI: 1.18-2.28, p = 0.004), having close friends who smoked vs none (AOR = 5.01, 95% CI: 3.62-6.92, p < 0.001), being offered free nicotine products vs not offered (AOR = 2.96, 95% CI: 2.30-3.81, p < 0.001), and perceiving quitting nicotine as difficult vs not difficult (AOR = 1.85, 95% CI: 1.41-2.43, p < 0.001). Supporting both indoor and outdoor smoking bans vs not supporting bans (AOR = 0.40, 95% CI: 0.29-0.55, p < 0.001) and perceiving tobacco as less attractive vs more attractive (AOR = 0.63, 95% CI: 0.43-0.94, p = 0.023) were protective. Similar correlates were found for current dual use, notably having close friends who smoked vs none (AOR = 8.61, 95% CI: 4.21-17.61, p < 0.001) and being offered free nicotine products vs not offered (AOR = 2.82, 95% CI: 1.59-5.01, p = 0.001). Dual use among Saudi adolescents appears to be influenced by peer dynamics, product availability, and permissive social norms. Caution is warranted in interpreting associations due to potential reverse-causal explanations. These findings highlight the urgent need for tailored prevention and stronger policy enforcement.

Medical devices represent a vast category of products that fuel a growing turnover of thousands of small- and medium-sized companies in Europe. After many years of debate, a very analytical and complex new European medical device regulation (MDR) has been approved, but its application is still ongoing. The new European MDR classifies medical devices in four classes by potential risk of harms. The main purpose of this classification by risk is to address new medical devices to the assessment procedure for approval, which falls under the national remit of each member state. According to this decentralized model, manufacturers can choose the countries where to approve their devices. National competent authorities have historically devolved approval of high-risk medical devices to the Notified Bodies (NBs). NBs (mainly private organizations) charge fees to manufacturers in order to assess the safety and performance conformity of high-risk medical devices before their market approval. The new MDR also foresees that an independent advice on the clinical evaluations performed by NBs for certain high-risk medical devices may be required to the Expert Panels (EPs), which are funded by the European Commission. Despite the high expectations raised by the new MDR, the European regulation still suffers major weaknesses and needs a radical change. Instead of the present decentralized and fragmented system populated by too many organizations, a European regulatory agency should govern medical devices approval through a centralized process such as that for pharmaceuticals. Then, national competent authorities should purchase medical devices by combining competitive tendering and reference pricing in order to constrain health expenditures.

The Italian Servizio Sanitario Nazionale (SSN) and other universal healthcare systems face increasing pressure from aging, multimorbidity, malnutrition, obesity and the widespread consumption of ultra-processed foods (UPFS). Hospitals struggle not only with resources but with managing complexity. Medicine (IM) wards absorb most acute admissions and represent the hidden backbone of hospital functioning. Delayed discharges, hospital malnutrition, and obesity-related meta-inflammation illustrate systemic inefficiency and escalating costs. Evidence shows that internist-led interventions, including systematic nutritional screening, integrated obesity care, and the use of point-of-care ultrasound (POCUS), improve patient outcomes and hospital efficiency. The evolving role of IM requires combining holistic oversight with subspecialty competence (cardio-pulmonary, neuro-internal medicine, onco-internal medicine, gastro-metabolism, geriatrics, immunology, an infectious diseases). As guardians of health, internists must extend their role beyond acute care to prevention regulation of UPFs, and sustainable patient transitions. In conclusion, strengthening Internal Medicine is essential for preserving universal healthcare. Internists-generalist in vision, subspecialist in competence, ultrasonographer in practice-are both the economic and ethical backbone of hospitals and the guardians of public health.

The demand for medical services and its burden on the healthcare system is worldwide increasing. Factors influencing service requests are still partially unknown. Extended shifts may impair decision-making, potentially affecting the request for ancillary diagnostic procedures. This study aimed to investigate the association between the time-of-shift and the rate of diagnostic service requests in pediatric emergency settings. This single-center observational study was conducted at the pediatric emergency department of the Ca' Granda Ospedale Maggiore Policlinico in Milan, Italy. The study included patient visits on weekends and public holidays. Data on blood tests, specialist consultations, and imaging requests were extracted. The shift was divided into the first 8 h and the last 4 h, and diagnostic service requests were analyzed using mixed-effects logistic regression models, adjusting for patient urgency and number of patients per shift. A total of 5370 visits were analyzed. At least one ancillary diagnostic procedure was requested in 31% of the visits. There was a 14% higher probability (p = 0.04) of requiring ancillary diagnostic procedures during the last 4 h of shifts compared to the first 8 h. This probability increased to 20% (p = 0.02) considering exclusively the dayshift. These findings suggest a potential role of shift duration on diagnostic service requests, warranting further multicenter studies to explore this association across various healthcare settings.

The growing number of patients with multimorbidity and increasing disease complexity presenting to the Emergency Department (ED) poses a global challenge, with overcrowding as a major consequence. To address these pressures, various interdisciplinary short-term monitoring and treatment units, such as Acute Medical Units, Frailty Units, Observation Units, and Chest Pain Units, have been implemented to improve patient flow from presentation to discharge. This systematic review, conducted according to PRISMA guidelines, aimed to evaluate the reported effects of these units on patient outcomes and ED crowding. We searched multiple databases and included studies reporting at least one primary outcome measure (length of stay, mortality, costs, readmissions, or staff satisfaction) following implementation of such a unit. The search yielded 2972 results, of which 50 studies met the inclusion criteria. Reported outcomes included reductions in hospital length of stay (0.24 to 6.16 days), cost savings (ranging from €162 to nearly €2 million across eight studies), and stable or decreased mortality in some settings. However, the evidence base is heterogeneous, with units differing substantially in patient populations, aims, and models of care, and cost analyses often relying on limited methods. Consequently, strong general conclusions across all unit types are not possible. Nonetheless, these findings suggest that when well-matched to local system bottlenecks and patient populations, specialized acute care units can improve patient flow and contribute to the accessibility of emergency care without compromising quality.Trial Registration: https://doi.org/10.17605/OSF.IO/A9EF7.

The primary objective is to know how the time from symptom onset to antiviral administration (total time, TT) affects hospitalisation and death from any cause at 30 days (composite endpoint) in patients with mild-to-moderate COVID-19 discharged from the emergency department (ED). Secondary objectives are to know how the time from ED admission to antiviral administration (hospital time, HT) modifies outcomes and whether the specialty of the prescribing physician influences these times. We conducted a nationwide, multicentre, retrospective cohort study in 16 Spanish EDs. We collected data from patients with mild-to-moderate COVID-19 who presented to an ED, received antiviral treatment, and were at risk of disease progression due to advanced age, comorbidities, or immunosuppression. We developed pooled logistic regression explanatory models to assess the association between TT, HT, and composite outcome, whilst we used quantile regression explanatory models to analyse the association between prescriber specialty and these times. All models were adjusted for confounding using inverse probability weighting. We analysed data on 534 treated patients. Longer TT was associated with worse outcomes, adjusted hazard ratio (aHR) 1,179 per day of delay, 95% confidence interval, 95% CI, 1,005 - 1,384; but no association was observed between HT and these events, aHR 1,312, 95% CI 0,900 - 1,913. Prescription by an emergency physician was associated with a reduction both in TT and in HT (adjusted median of reduction in hours, 6,78, 95% CI 0,21 - 20,65; 8,45, 95% CI 3,92 - 12,03, respectively). Earlier ED administration of antivirals for mild-to-moderate COVID-19 in vulnerable patients is associated with better clinical outcomes. Prescription by an emergency physician in the ED is also associated with shorter HT and TT.