Internal and Emergency Medicine最新文献

Chest pain (CP) is a common emergency department (ED) presenting symptom, requiring rapid assessment for acute coronary syndrome (ACS). The HEAR and HEART scores have been proposed to streamline patient evaluation. This study evaluated whether adding Focused Cardiac Ultrasound (FoCUS) could enhance risk stratification. Analysis of a prospective observational study involving adult patients at the ED of a University Hospital in Italy in 2022. Patients were stratified by the HEAR score into low (≤ 1) and mid-high risk (≥ 2) groups, and HEART score into low (≤ 3), mid (4-6), and high-risk (≥ 7) groups. All patients underwent FoCUS for regional wall motion abnormalities (RWMA). The primary outcome was non-ST-elevation (NSTE)-ACS within 30 days. We included 684 patients with median age of 58 years and 40% females. NSTE-ACS occurred in 106 (16%) patients, with 0/123 (0%) and 106/561 (19%) in low and mid-high-risk HEAR groups, respectively, and 6/337 (2%), 63/278 (23%) and 37/69 (54%) in low, mid and high-risk HEART groups, respectively. RWMA was found in 87 (13%) patients. In HEAR ≥ 2 (53% vs 13%, p < 0.001) and HEART 4-6 patients (50% vs 17%, p < 0.001), RWMA were associated with a higher frequency of NSTE-ACS. Multivariable analysis confirmed RWMA as an independent predictor of NSTE-ACS (OR 3.10, 95%CI 1.66-5.78). Including RWMA into the HEART score increased its sensitivity for high-risk patients (0.54 vs 0.35).Integrating RWMA identified by FoCUS into the HEAR and HEART scores might improve risk stratification for NSTE-ACS in patients presenting to the ED with chest pain.

Atrial fibrillation (AF) is the most common arrhythmia in the elderly and is associated with an increased risk of cardiovascular events (CVE); indeed, a percentage of patients develop CVE during oral anticoagulation. The 2MACE score is a clinical score used to predict the risk of MACE in patients with AF, but not in elderly patients with AF. Therefore, the purpose of this work is to evaluate the possible predictive value of the 2MACE score on MACE onset, in a cohort of elderly patients with non-valvular AF and several comorbidities for long-term follow-up. 1005 elderly with non-valvular AF were enrolled (76.4 ± 6.1 years; 291 on VKAs and 714 on DOACs) and stratified according to the median value of 2MACE score. MACE (non-fatal ischemic stroke, non-fatal myocardial infarction, and cardiovascular death) and all-cause mortality occurrence were evaluated during a mean follow-up of 6.2 years. In this multicenter retrospective observational study, a 2MACE score ≥ 4 pt (taken as a dichotomous value) (HR 4.38, 95% CI 3.46-5.55; p < 0.0001) was associated with a 4.3-fold increased risk of MACE, with modest discriminatory ability (AUC: 0.65; standard error: 0.018; 95% CI, 0.62-0.69). Furthermore, the presence of MMSE score < 24 pt (HR 1.27, 95% CI 1.03-1.56, p = 0.026) was associated with a 27% increased risk of MACE. In contrast, DOACs and SGLT2-inhibitor were associated with a 55% (HR 0.45, 95% CI 0.36-0.55, p < 0.0001) and 46% (HR 0.54, 95% CI 0.41-0.71, p < 0.0001) lower risk of MACE, respectively. Elderly patients with non-valvular AF whot exhibit a 2MACE score ≥ 4 pt show a higher risk of MACE and all-cause mortality.

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.

Emergency Medicine (EM) is facing a global crisis. System demands and utilization are increasing, while resources are constrained, putting society's healthcare safety net at risk. In order to approach this crisis, many areas of reform have been suggested (Heymann et al. in Intern Emerg Med, 2024). The first step is the recognition of EM as a specialty of its own. This will give Emergency Physicians (EPs) the potential to take control of their profession. Similar to other examples of bottom-up and horizontalization approaches ( Laloux, F., & Wilber, K. (2014). Reinventing organizations: A guide to creating organizations inspired by the next stage of human consciousness.), empowering EPs to provide solutions to wellbeing and resilience issues can only occur if EPs are allowed to organize and control their training, activity, research, and field of action. Traditional models have seen EM as a subspecialty or a secondary degree completed after initial training in an already established profession (e.g., internal medicine). These models ultimately result in longer training pathways and risk trainee and trainer fatigue. Furthermore, in these models, the profession is directed by specialties who do not face the daily challenges of modern EM. The following paper discusses the advantages of recognizing EM as a specialty and how this benefits wellbeing and resilience. The result is that EM recognition protects a cornerstone of the healthcare system.

Elderly patients (≥ 75 years) often require resuscitation room (RR) care in the emergency department (ED), yet decisions regarding intensive care unit (ICU) admission remain complex. Assessment of quality of life and frailty is necessary to determine the level of care required for elderly patients. The Clinical Frailty Scale (CFS) is a validated tool for assessing frailty and predicting mortality, but its role in ICU triage remains unclear. The aim of this study was to compare the CFS of patients admitted to the ICU with those admitted to the general inpatient unit (GIU) after receiving initial intensive care. This was a retrospective, single-center study including patients aged ≥ 75 years admitted to the ED RR from November 1, 2023, to March 31, 2024. The primary outcome was the comparison of CFS between ICU and GIU admissions after RR management. Secondary outcomes included predictive performance of CFS for ICU admission and in-hospital mortality. Of the 392 patients enrolled, 170 (43%) were admitted to the ICU and 222 (57%) to the GIU. The median CFS was 3 (2-4) in ICU-admitted patients and 4 (3-5) in GIU-admitted patients (p < 0.001). In-hospital mortality rate was 30/170 (18%) in the ICU-admitted group and 35/222 (16%) in the GIU-admitted group (p = 0.72). CFS predictive value for ICU admission had an area under the curve of 0.68 (95% confidence interval (95%CI): 0.63-0.73) and for in-hospital mortality of 0.62 (95%CI: 0.55-0.69). In elderly patients admitted to the RR, CFS values differed between those admitted to ICU and those admitted to GIU. However, the discriminative performance of CFS for hospital orientation and in-hospital mortality was limited. These findings suggest that frailty assessment may contribute to the overall evaluation of elderly patients in the ED RR but should be interpreted in conjunction with acute severity scores and clinical judgment.