Internal and Emergency Medicine最新文献

Fibromyalgia (FM) is more prevalent in patients with Sjögren's disease (SjD) than in the general population and a bidirectional association between the two conditions has been proposed. However, the clinical profile of patients with concomitant FM and SjD remains poorly characterized. This study aimed to assess the prevalence and clinical correlates of FM in a multicenter Italian cohort of patients with SjD. Patients fulfilling the 2016 ACR-EULAR classification criteria for SjD were retrospectively evaluated. FM was defined according to the 2016 diagnostic criteria. Clinical, serological, and therapeutic data were compared between patients with and without FM. Logistic regression models identified factors associated with FM. Among 267 patients with SjD (95% female, median age 60), FM was diagnosed in 30%. Patients with FM reported significantly higher symptom burden, as measured by the EULAR Sjögren's Syndrome Patient-Reported Index (median 7.7 vs. 6.0; p < 0.001), with all individual domains, namely pain, fatigue, and dryness, being significantly increased (p < 0.01, for all). In contrast, EULAR Sjögren's Syndrome Disease Activity Index scores were comparable between groups (p = 0.808). In the logistic regression model, three variables were independently associated with FM: higher symptom burden (adjusted odds ratio (aOR 1.36, 95% CI 1.13-1.62; p = 0.001), mixed anxiety-depressive disorder (aOR 3.24, 95% CI 1.13-9.30; p = 0.029), and corticosteroid use (aOR 2.76, 95% CI 1.02-7.48; p = 0.046). In patients with SjD, FM is associated with a higher symptom burden despite similar disease activity level. These findings highlight the need to distinguish symptom amplification from true inflammatory activity, limiting unnecessary corticosteroid use.

Hypercalcemia is a potentially life-threatening metabolic disorder with diverse etiologies. In oncology patients, it is often attributed to malignancy-related mechanisms, such as parathyroid hormone-related peptide (PTHrP) secretion. However, non-malignant causes, like calcium-alkali syndrome (CAS) and adrenal insufficiency, should not be overlooked. We report a 60-year-old man with nasopharyngeal carcinoma (NPC) treated with cranial radiotherapy, stage 3 chronic kidney disease (CKD), and multiple comorbidities, who presented with recurrent severe hypercalcemia (11.0-14.9 mg/dL) and hyperphosphatemia. Initial suspicion focused on paraneoplastic hypercalcemia; however, parathyroid hormone (PTH) and PTHrP levels were suppressed, alkaline phosphatase and bone turnover markers [N-terminal propeptide of type I procollagen (PINP) and beta-C-terminal telopeptide of type I collagen (β-CTx)] were consistently low, along with paradoxically elevated urinary calcium and phosphate excretions. This profile suggested a low-turnover, non-parathyroid, non-malignant etiology. A detailed history revealed chronic ingestion of calcium-fortified supplements via gastrostomy, implicating CAS as the primary cause. Persistent hypotension and biochemical abnormalities prompted an endocrine evaluation, revealing secondary adrenal insufficiency confirmed through consistently low cortisol and adrenocorticotropic hormone (ACTH) levels and ACTH stimulation testing. Positron emission tomography (PET) imaging demonstrated increased uptake at the skull base, suggestive of radiation-induced damage to the hypothalamic-pituitary axis. Discontinuation of calcium/vitamin D supplementation and initiation of low-dose prednisolone and fludrocortisone led to resolution of hypercalcemia and renal impairment. This case highlights the importance of recognizing dual non-malignant etiologies in cancer survivors with suppressed PTH/PTHrP and persistent hypercalcemia, particularly when urinary calcium excretion remains high despite renal impairment.

Diabetic ketoacidosis (DKA) is a life-threatening endocrine emergency characterized by metabolic acidosis, hyperglycemia, and ketonemia. Although pH and bicarbonate (HCO₃⁻) levels are commonly used to classify the severity of diabetic ketoacidosis (DKA), base excess (BE) is not included in the current classification. BE is defined as the amount of acid or base required to restore blood pH to normal under standardized conditions. This study evaluated the relationship between BE and DKA severity in patients presenting to the emergency department (ED).This retrospective observational study included adult patients (≥ 18 years) diagnosed with DKA in a tertiary ED between January 2022 and December 2024. Data on venous blood gas parameters-pH, HCO₃⁻, lactate, BE, and anion gap-were collected at 0, 4, 12, and 24 h. Patients were stratified into mild, moderate, or severe DKA based on American Diabetes Association criteria, which consider factors such as arterial pH, serum HCO₃⁻ level, and mental status, to determine the severity of the condition. 44 patients (mean age 49.72 ± 19.11 years; 59.1% male) were analyzed. At admission, BE values were significantly more negative in the severe DKA group (p < 0.001), correlating with lower pH and HCO₃⁻ levels. Across all time points, BE demonstrated significant differences by severity and showed progressive normalization, with delayed recovery in cases of severe disease. A BE cutoff of -14.2 identified moderate/severe DKA with 73.1% sensitivity and 94.4% specificity (AUC: 0.858; 95% CI: 0.720-0.945). BE, a sensitive marker for metabolic acidosis, correlates strongly with DKA severity. The routine use of BE, similar to HCO₃⁻, may support improved clinical management of DKA in emergency settings.

Emergency department (ED) overcrowding is a critical issue that compromises patient safety, prolongs waiting times, and increases staff workload. Contributing factors include insufficient primary-community care integration, staffing shortages, operational inefficiencies, and an ageing population with complex chronic conditions. These pressures are further exacerbated during disasters and are expected to worsen with the rising frequency of climate-related crises. Task shifting and the expansion of advanced nursing roles have been proposed as strategies to mitigate overcrowding; however, their adoption remains limited. This scoping review aims to map the existing evidence on advanced nursing practice in EDs, describing roles, outcomes, facilitators, and barriers. Following Joanna Briggs Institute methodology and PRISMA-ScR guidelines, we searched PubMed, Embase, and Scopus, without date restrictions, for original studies from high-income countries in which nurses autonomously performed functions beyond standard care. Of 3,029 records, 105 met the inclusion criteria, with most studies originating from Canada, Australia, and the USA. Three role categories were identified: (1) autonomous management of specific presentations ("See and treat"); (2) nurse-led patient flow management; and (3) triage nurse ordering, which allows nurses to order investigations or initiate treatment for predefined conditions at triage. Across settings, these models demonstrated comparable quality of care, clinical effectiveness, and patient and staff satisfaction to physician-led management, while often reducing waiting times and healthcare costs. Despite evidence being heterogeneous and largely single center, the findings support the safety and effectiveness of advanced nursing roles in EDs. This review highlights current research gaps and provides a foundation for designing multicenter trials and pilot programs to optimize the integration of advanced nursing competencies into ED systems.

A novel acquired coagulopathy characterized by severe procoagulant imbalance is common and associated with the clinical severity in COVID-19 patients. To elucidate the underlying mechanisms of coagulation activation in COVID-19 patients. Symptomatic COVID-19 patients were consecutively enrolled and stratified into 3 groups based on the intensity of care. Markers of intrinsic (FXIa, FXIIa) and extrinsic (FVIIa) pathway activation and of fibrinolysis (plasminogen and relative activator and inhibitors), D-dimer, fibrin monomer (FM), fibrin degradation products (FDP), and C1 inhibitor were tested. A total of 111 patients were enrolled, 26 in the low, 42 in the intermediate, and 43 in the high intensity of care group. Median D-dimer, FDP, and FM plasma levels were higher in COVID-19 patients than normal ranges, with a gradient of increase across the three intensity care units; the fibrinolytic pathway parameters were in the normal range. The median plasma levels of FVIIa were lower in COVID-19 patients (27.5 mU/mL) than the reference range while the median plasma levels of FXIIa and FXIa were higher (11.2 and 11.3 mU/mL), with a gradient of increase across the three intensity care units for FXIIa. C1 inhibitor plasma levels were above the normal range in all the 3 COVID-19 patient groups. 32 patients (29%) developed a venous thrombosis. Our study suggested a prevalent activation of the contact pathway over the extrinsic pathway of the coagulation cascade in COVID-19 patients, which is proportional to the clinical severity of the infection, opening the possibility for targeted anticoagulant therapies.

This study aimed to assess the doctor-patient communication among hypertensive patients in the context of community health service and chronicity of the disease, and to highlight which demographic and clinical factors may make this task less effective for the doctor. The study was conducted at two community hospitals in Changsha, China, from January 1 to November 1, 2024. Set Elicit Give Understand End (SEGUE) framework and a self-developed questionnaire were used to assess doctor-patient communication and hypertension-related content. Multivariable logistic regression was employed to analyze associated factors. We collected 546 valid questionnaires, primarily from elderly individuals with over 10 years of hypertension history. The average SEGUE score was 68.80 ± 16.17, with 70.7% of patients having suboptimal communication (SEGUE score < 80). Hypertension-related communication content between doctors and patients was considered insufficient. Only 65.6% of patients reported that doctors discussed the importance of medication for blood pressure control, and 22.0% reported that they were explained the potential side effects of their medication. Factors associated with worse doctor-patient communication included obesity (BMI > 28 kg/m²; OR = 0.32, 95% CI 0.17-0.60) and a longer duration of hypertension (< 10 years; OR = 0.58, 95% CI 0.34-0.97). Conversely, better communication was also associated with a high school or higher education level (OR = 2.38, 95% CI 1.17-4.86), higher monthly income (2000-4000 yuan: OR = 2.11, 95% CI 1.18-3.77; > 4000 yuan: OR = 2.42, 95% CI 1.21-4.87), and better cognitive function (higher MMSE score; OR = 1.74, 95% CI 1.53-1.99). Most of the hypertensive patients perceived suboptimal doctor-patient communication. Factors associated with this included BMI, hypertension duration, education level, income, and cognitive function.

Heart failure (HF) management increasingly requires multimodal assessment beyond cardiac function. Although echocardiography remains central, skeletal muscle and diaphragmatic dysfunction-key drivers of exercise intolerance-are underdiagnosed. This review synthesizes two critical aspects: (1) the pathophysiological heterogeneity of muscle involvement across HF subtypes [HF with reduced ejection fraction (HFrEF), HF with mildly reduced ejection fraction (HFmrEF), and HF with preserved ejection fraction (HFpEF)] and (2) the clinical utility of muscle ultrasound as a dynamic, bedside-compatible tool for risk stratification and personalized interventions. Emerging evidence reveals distinct mechanisms: HFrEF predominantly associates with diaphragmatic atrophy and mitochondrial dysfunction, whereas HFpEF is characterized by reduced diaphragmatic motion and skeletal muscle fat infiltration. Ultrasound-derived parameters, such as echo intensity for quadriceps fat quantification and diaphragm thickness ratio for inspiratory weakness, strongly correlate with functional outcomes (e.g., 6-min walk distance and peak VO₂). Notably, a quadriceps echo intensity > 28 dB in HFrEF or a diaphragmatic excursion < 2.5 cm in HFpEF independently predicts adverse prognosis, guiding targeted interventions such as inspiratory muscle training or anti-inflammatory therapies. However, critical gaps persist, including the lack of standardized cutoff values for HF subtypes and insufficient data on ultrasound-guided therapeutic monitoring. Future research should prioritize subtype-specific protocols and validate cost-effective ultrasound algorithms against standard modalities. By bridging pathophysiology and clinical application, this review underscores muscle ultrasound's transformative potential in refining HF phenotyping, ultimately enhancing exercise capacity and reducing hospitalizations.

Purpose: The long-term prognostic impact of frailty in older adults recovering from COVID-19 remains underexplored. The Multidimensional Prognostic Index (MPI) has shown utility in predicting short-term outcomes, but its role over extended follow-up requires further investigation. The objective of this study is to evaluate the ability of an MPI-based model to predict 3.5-year mortality in older adults hospitalized for COVID-19.

Methods: This single-center cohort study with prospective follow-up included 183 patients aged ≥ 65 years hospitalized with confirmed SARS-CoV-2 infection. MPI was calculated at admission and dichotomized into low (classes 1-2) and high (class 3). Multivariable Cox regression was used to estimate the hazard of mortality over a 3.5-year follow-up. Discriminative performance was assessed using time-dependent ROC analysis, with AUC values compared between the multivariable model and MPI alone.

Results: During follow-up, 81/183 patients (44.3%) died. Kaplan-Meier curves showed lower survival in high-MPI patients (log-rank p = 0.0043). A Cox model with a time-varying effect for sex (sex × log(time)) confirmed that high MPI was associated with higher mortality (HR = 1.59, 95% CI 1.00-2.52), age was also associated (HR per year = 1.04, 95% CI 1.00-1.07), while vaccination was not. The female-to-male hazard ratio changed over time (HR at 180/365/730/1250 days: 0.90/1.31/1.87/2.48). AUCs for the full model at 180/365/730/1250 days were 0.704/0.654/0.680/0.659, derived from the sex-stratified Cox linear predictor, and exceeded the MPI-only model.

Conclusions: The MPI demonstrated moderate prognostic ability for long-term mortality among older adults after COVID-19. Adding demographic and clinical variables modestly improved prediction, supporting the role of multidimensional assessment in geriatric prognosis, while highlighting the need for cautious interpretation over extended follow-up.