Internal and Emergency Medicine最新文献

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.

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.