Internal and Emergency Medicine最新文献

The primary objective of this article is to provide an overview of studies in humans that evaluate and compare the effects of heated tobacco products (HTPs) with those of conventional cigarette smoking on cardiovascular and respiratory diseases. To address this research question, a scoping review methodology was employed.A comprehensive literature search was conducted in the PubMed, Scopus, Web of Science, and Cochrane Library databases to identify relevant articles published between January 2014 and March 2025. Two reviewers independently screened all articles. This process resulted in the identification of 34 articles deemed appropriate to the aims of this scoping review.Despite the heterogeneity of the available data, the current evidence suggests that HTPs are associated with a lower harmful impact on the cardiovascular and respiratory systems as compared to conventional cigarettes. However, considering the relatively recent introduction of HTPs, in contrast to the long latency periods typically required for the development of smoking-related chronic diseases, as well as the evolving design and composition of these products, it is not surprising that definitive conclusions regarding their clinical, and public health impact bring up the need to be integrated by long-term evidence derived from independently conducted studies.

Delirium in elderly inpatients needs to be prevented being associated with worse clinical outcome and higher cost burden. Effects of a structured intervention aimed at cognitive stimulation and reorientation to prevent delirium occurrence were tested. A nonrandomized stepped-wedge study was conducted. Patients were consecutively enrolled from 07/05/2024 to 03/10/2024 at an Internal Medicine Unit. Eligibility was verified based on inclusion criteria: age ≥ 65 years; hospitalization at the Unit; and exclusion criteria: personal history of dementia or cognitive impairment; delirium at admission. Demographic and clinical data were collected at enrollment. Delirium was assessed daily via the 4AT. Inpatients received a protocol-driven intervention aimed at cognitive stimulation and reorientation (cases) or usual care (controls). The intervention was administered daily from day 1 of hospitalization to discharge. A total of 222 subjects were evaluated (104 received the intervention, 118 had usual care). Males and females were equally distributed (54 males under the intervention, 62 males under usual care). Mean age was 81·54 ± 8·28 yrs among those who received the intervention and 81·24 ± 8·84 yrs among those under usual care. The two groups differed for delirium incidence: 7·69% (n = 8) among those who received the intervention and 22·03% (n = 26) among those who received usual care. The findings of the pilot study should be interpreted as preliminary feasibility results rather than evidence of efficacy. They need replication in larger samples, being promising in terms of implementation of the intervention in real life of Internal Medicine Units.

Chronic pain may elevate the risk of frailty in older adults, but its characteristics in age and sex remains unclear, and the mediators of this relationship are largely unknown. We analyzed cross-sectional data from the Comprehensive Geriatric Assessment Database of Tongji Hospital and explored the relationship between chronic pain and frailty in adults aged ≥ 60 years through multiple linear regression, binary logistic regression, restricted cubic spline regression and mediation analysis. Covariates comprised age, sex, education, marital status, smoking, drinking, body mass index, hypertension, diabetes, cardiovascular disease, and stroke, while sleep quality, activities of daily living, anxiety, and depression were regarded as potential mediators. Among 1951 adults aged ≥ 60 years (mean age 77.86 ± 9.74 years, 45.7% female), the prevalence of frailty increased with chronic pain severity, with the odds of frailty being 1.28 (95% CI 1.06-1.54), 1.35 (95% CI 1.18-1.55), 1.39 (95% CI 1.19-1.61), and 1.71 (95% CI 1.39-2.11) times higher among participants aged 60-69, 70-79, 80-89, and ≥ 90 years, respectively, compared to those without pain. Additionally, the increase in frailty prevalence with rising pain severity was more pronounced in females than in males. Mediation analysis suggested that poor sleep quality (28.63%), depression (27.64%), and anxiety (43.73%) partially explained the association between chronic pain and frailty. These findings underscore the importance of addressing chronic pain and its associated factors (such as poor sleep quality, depression, and anxiety) in interventions aimed at managing frailty, particularly among females.

Global smoking prevalence remains high, underscoring the need for strategies that complement conventional cessation. Tobacco harm reduction (THR) offers a pragmatic strategy by promoting substitution of combustible cigarettes with substantially less harmful alternatives. Oral nicotine pouches (ONPs) have emerged as a promising option. Modeled on the Scandinavian success of snus, ONPs deliver pharmaceutical-grade nicotine without tobacco leaf or combustion, eliminating thousands of toxicants and lowering exposure to carcinogens such as tobacco-specific nitrosamines to near-undetectable levels. Epidemiological evidence from snus users provides a strong precedent for ONPs' potential impact on population health. Preclinical, toxicological, and biomarker studies consistently demonstrate a favorable safety profile for ONPs, with minimal cytotoxic or inflammatory effects. Their discreet, odorless, and spit-free design may further promote adherence compared with traditional nicotine replacement therapies. Despite this promise, skepticism persists within public health, particularly concerning youth uptake and the potential renormalization of nicotine use. Yet current evidence indicates that ONPs are primarily adopted by adult smokers and smokeless users seeking lower-risk options. Regulatory responses are uneven: while the U.S. Food and Drug Administration has authorized their marketing, other jurisdictions have enacted prohibitions that risk perpetuating cigarette consumption. Incorporating ONPs into tobacco control frameworks, especially in low- and middle-income countries where cessation support is scarce, represents both an urgent and ethical opportunity to accelerate progress toward ending combustible tobacco use.

Rapid differentiation between variceal and non-variceal upper gastrointestinal hemorrhage (UGIH) in the emergency department (ED) is critical for guiding vasoactive therapy, antibiotic use, and timely endoscopy. However, endoscopy is often delayed, deferring these key management decisions and potentially impacting patient outcomes. We aimed to study the utility of portal vein ultrasound by the emergency physician for the prediction of variceal etiology in UGIH. We also studied the diagnostic accuracy of laboratory markers and fibrosis scores for differentiating between variceal and non-variceal hemorrhage. In our prospective observational study, we enrolled patients with UGIH presenting to the ED. Portal vein indices were studied using bedside point-of-care ultrasound (POCUS) by the emergency physician. Laboratory results were noted, and fibrosis scores were calculated. The upper gastrointestinal endoscopy findings were noted for the presence and grade of varices. Out of 181 patients included in the study, 106 patients (58.56%) had varices. Multivariable logistic regression analysis identified spleen diameter, platelet count, PT, ascites, and portal vein flow velocity (PVFV) were significant predictors of variceal etiology. SCoPE score (Splenomegaly, Coagulopathy, PVFV Evaluation) which is a composite that includes spleen diameter, PT, and PVFV is a useful ED-based tool for early identification of variceal bleed (AUC = 0.843, OR = 1.633). Fibrosis scores (AAR, APRI, Fib-4, King, Lok) were also useful in identifying variceal hemorrhage (p < 0.001). Integrating POCUS parameters and laboratory markers into clinical decision algorithms may enhance the ability of emergency physicians to predict variceal etiology of UGIH. Novel ED-based composite SCoPE score can help the physicians predict varices and enable them to tailor the management plan and optimize resuscitation strategies.

Vitamin K antagonists (VKAs) for 3-6 months are the recommended treatment for left-ventricular thrombosis (LVT) to achieve thrombus resolution and reduce the risk of cardioembolic events. The aim of this study was to evaluate the association between quality of VKAs and early-6 months-thrombus resolution in patients with LVT. In this retrospective study, patients with LVT referred to three Italian Anticoagulation Clinics between January 2011 and December 2023 were enrolled if they received VKAs and data on LVT resolution up to 6 months of treatment were available. Primary outcome was the effect of time-in-therapeutic range and of INR variability defined according to validated formulas on early thrombus resolution. Fifty-four patients were included. Median age was 68 years and 87% were male. Overall, 41.7% and 35.4% patients had a reduced or moderately reduced left-ventricle ejection fraction and apical aneurysm. Twenty-three patients (42.6%) had early thrombus resolution. For the prediction of early LVT resolution, the best value of TTR was 56% (sensitivity, 57%; specificity, 71%; AUC, 0.657), that of INR variability, formula A was 1.65 (sensitivity, 0%; specificity, 96%; AUC, 0.478) and that of formula B 0.40 (sensitivity, 4%; specificity, 100%; AUC, 0.599). The cumulative incidence of early LVT resolution was higher in patients with TTR values ≥ 56% (57.1%; 95% confidence interval-CI 32.8-75.5%) than < 56% (30.3%; 95% CI 15.6-46.4%).The quality of VKAs anticoagulation may be a relevant driver for early LVT resolution. TTR evaluation appears to have a slightly greater accuracy compared to INR variability.

Direct oral anticoagulants (DOAC) have similar efficacy for stroke prevention in patients with non-valvular atrial fibrillation (AF) with improved safety. Recently, a higher bleeding risk was reported when elderly AF patients were switched from VKAs to DOACs. AF patients aged ≥ 75 years who were maintained on VKA treatment or who were switched from VKAs to DOACs at the time of enrollment in the START-AF Register were followed. Bleedings, thrombotic events, and deaths that occurred during follow-up were collected. We included 4230 AF patients, 2930 (69.3%) on VKAs and 1300 patients (30.7%) shifted to DOACs. Low-dose DOACs were prescribed to 732 (56.3%) patients, 257 (35.1%) of whom received off-label low-dose. Thrombotic events were more frequent among patients switched to DOACs compared to patients continuing VKAs (1.0 and 0.6 × 100pt-yrs p = 0.05). The rate of bleeding events was similar between the two groups (3.0 and 2.5 × 100pt-yrs; p = 0.2), and was higher in the subgroup treated with on-label low-dose DOACs (3.4 × 100pt/yrs) compared to patients on VKAs (2.5 × 100pt-yrs)(RR1.4, 95%CI 0.9-2.0; p = 0.1). Conversely, patients on off-label low-dose DOACs showed higher rates of thrombotic events compared to patients on VKAs (1.4 vs 0.6 × 100pt/yrs, p = 0.05). Mortality was significantly higher in VKA patients than in DOACs patients independently from the dosage (6.7 and 2.9 × 100pt-years; p = 0.05). Elderly AF patients switched from VKAs to DOACs are at increased risk of thrombotic events than patients who remain on VKAs but with a lower risk of mortality. Switching to low-dose DOACs may expose patients to a higher risk of adverse outcomes.

Artificial Intelligence (AI) represents an innovative technological support for clinical practice. The Italian Society of Internal Medicine (SIMI) emphasizes the need for clear guidance on the use of AI in medicine, recognizing that knowledge in this field is continuously evolving. This position paper presents a comprehensive vision for the responsible integration of AI into clinical practice. AI should serve as a support tool-not a replacement-for clinicians. It has the potential to improve diagnostic accuracy, reduce administrative workload, and strengthen the physician-patient relationship. In the light of these characteristics, SIMI advocates for transparency, data privacy, equity, and sustainability in the development and implementation of AI systems. SIMI also highlights several ethical, legal, and methodological challenges that must be addressed, including algorithmic bias, environmental impact, and disparities in access. Ultimately, SIMI envisions a future in which AI augments human expertise, enabling more efficient, personalized, and compassionate care. SIMI calls for active clinician participation in the co-design and validation of AI tools to ensure alignment with real-world clinical needs. Key recommendations include the preferential use of certified AI systems, the integration of AI education into medical training, and continuous monitoring after deployment.