Internal and Emergency Medicine最新文献

In heart failure (HF), congestion is a key pathophysiologic hallmark and a major contributor to morbidity and mortality. However, the presence of congestion is often overlooked in both acute and chronic settings, particularly when it is not clinically evident, which can have important clinical consequences. Ultrasound (US) is a widely available, non-invasive, sensitive tool that might enable clinicians to detect and quantify the presence of (subclinical) congestion in different organs and tissues and guide therapeutic strategies. In particular, left ventricular filling pressures and pulmonary pressures can be estimated using transthoracic echocardiography; extravascular lung water accumulation can be evaluated by lung US; finally, systemic venous congestion can be assessed at the level of the inferior vena cava or internal jugular vein. The Doppler evaluation of renal, hepatic and portal venous flow can provide additional valuable information. This review aims to describe US techniques allowing multi-organ evaluation of congestion, underlining their role in detecting, monitoring, and treating volume overload more objectively.

This article recapitulates the discoveries and anti-tumoural therapeutical proposals by Francesco Sanfelice, who in 1931 published an essay entitled The Treatment of Cancer and Sarcoma with Cancrocidin (paraneoforming Blastomycetes). Sanfelice's discoveries are contextualised with subsequent scientific discoveries, especially with those by L. Scott McDaniel and G. Cozad, who evaluated the functionality of murine peritoneal macrophages previously sensitised precisely with Blastomyces dermatitidis antigen extracts. Finally, recent research on the topic of intratumoural microbiota is mentioned showing how Sanfelice's ideas, albeit partly outdated, can still inspire current biomolecular research.

Overcrowding has become a significant issue in Emergency departments (EDs) around the world. Overcrowding contributes to a chaotic, unsafe and disorganized environment, increasing the burden on healthcare teams, and has led to deteriorating working conditions, with subsequent higher rates of burnout. This review aims to discuss different solutions to improve the process of patient discharge from the ED, either to an inpatient unit, another hospital, or to an outpatient setting, and the impact this component of patient flow can have on physician well being. The solutions presented in this paper have been chosen for their translatability to any setting, regardless of their geographical location.

Patients hospitalized in Internal Medicine Units (IMUs) may frequently experience both an increased risk for thrombosis and bleeding. The use of risk assessment models (RAMs) could aid their management. We present a post-hoc analysis of the FADOI-NoTEVole study, an observational, retrospective, multi-center study conducted in 38 Italian IMUs. The primary aim of the study was to evaluate the predictors associated with the prescription of thromboprophylaxis during hospitalization. The secondary objective was to evaluate RAMs adherence. Univariate analyses were conducted as preliminary evaluations of the variables associated with prescribing pharmacological thromboprophylaxis during hospital stay. The final multivariable logistic model was obtained by a stepwise selection method, using 0.05 as the significance level for entering an effect into the model. Thromboprophylaxis was then correlated with the RAMs and the number of predictors found in the multivariate analysis. Thromboprophylaxis was prescribed to 927 out of 1387 (66.8%) patients with a Padua Prediction score (PPS) ≥ 4. Remarkably, 397 in 1230 (32.3%) patients with both PPS ≥ 4 and an IMPROVE bleeding risk score (IBS) < 7 did not receive it. The prescription of thromboprophylaxis mostly correlated with reduced mobility (OR 2.31; 95% CI 1.90-2.81), ischemic stroke (OR 2.38; 95% CI 1.34-2.91), history of previous thrombosis (OR 2.46; 95% CI 1.49-4.07), and the presence of a central venous catheter (OR 3.00; 95% CI 1.99-4.54). The bleeding risk assessment using the IBS did not appear to impact physicians' decisions. Our analysis provides insight into how indications for thromboprophylaxis were determined, highlighting the difficulties faced by physicians with patients admitted to IMUs.

The aim of this study was to evaluate the prevalence of severe hypocalcemia in patients attending the emergency department. Symptoms, causes, treatment, and outcome of severe hypocalcemia as well as course of calcium concentrations were assessed. This retrospective case series included all adult patients with measurements of serum calcium concentrations presenting to the emergency department of the Bürgerspital Solothurn between January 01 in 2017 and December 31 in 2020. Medical record reviews were performed of all patients with severe hypocalcemia, defined by a serum calcium concentration < 1.9 mmol/L, to assess clinical presentation and management. 1265 (3.95%) patients had a serum calcium concentration of < 2.1 mmol/L of which 139 (11%) had severe hypocalcemia of < 1.9 mmol/L. 113 patients had at least one measurement of albumin. Of these, 43 (3.4%) had an albumin-corrected serum calcium < 1.9 mmol/L defining true, severe hypocalcemia. Hypocalcemia was identified and documented in 35% of all cases. The mean serum calcium concentration was 1.74 ± 0.14 mmol/L. Calcium concentrations in malignancy-related hypocalcemia were similar to non-malignancy-related hypocalcemia. The main symptoms attributed to hypocalcemia were cardiac and neurologic. 12% of patients with severe hypocalcemia received intravenous and 23% oral calcium replacement. Active malignancy was the main cause of severe hypocalcemia in 28%, while in most cases, the main cause remained unclear. 41.9% of severely hypocalcemic patients reattended the emergency department for another episode of hypocalcemia within 1 year. Hypocalcemia is common in patients attending the emergency department, however, appears to be neglected frequently. The disorder is often a manifestation of severe disease, triggered by multiple causes. Calcium replacement was administered in less than half of the patients with severe hypocalcemia in this study. Due to frequent readmissions to the emergency department and a high mortality, increased awareness of the disorder and careful follow-up are desirable.

Inflammatory bowel disease (IBD) is a chronic condition characterized by inflammation in the gastrointestinal tract. Previous studies have suggested a potential association between mental disorders, such as depression and anxiety, and the risk and flare of IBD. However, the findings have been inconsistent. This study aimed to conduct a systematic review and meta-analysis to assess the relationship between mental disorders and IBD. A comprehensive literature search was performed to identify relevant studies. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to determine the association between mental disorders and the risk and flare of IBD. Heterogeneity between studies was assessed using the I² statistic. Sensitivity analysis was conducted to evaluate the stability of the results. A total of seven studies met the inclusion criteria and were included in the meta-analysis. The pooled results demonstrated a significant association between symptoms of depression at baseline and an increased risk of disease activity flare during longitudinal follow-up, with an OR of 1.69 (95% CI 1.34, 2.13). However, there was high heterogeneity between studies (I² = 82%). Furthermore, patients who underwent surgery had a higher risk of disease activity flare (OR: 1.49, 95% CI 1.13, 1.95), and hospitalization was also identified as a contributing factor (OR: 1.22, 95% CI 1.10, 1.36). This meta-analysis provides evidence for a significant association between symptoms of depression and the risk of disease activity flare in IBD. However, the high heterogeneity observed between studies suggests the need for further research to explore potential moderators and underlying mechanisms. These findings highlight the importance of addressing mental health in the management and treatment of patients with IBD.

Reverse dipping blood pressure, generally regarded as a pathological condition, is frequently observed in patients with acute stroke. We aimed to assess the association of reverse dipping blood pressure with in-hospital mortality among critically ill patients with ischemic stroke. This is a retrospective study of patients in the Medical Information Mart for Intensive Care IV database with ischemic stroke requiring intensive care unit admission. Diurnal (9:00-21:00) and nocturnal (1:00-6:00) mean arterial pressures (MAPs) were collected. Reverse dipping was defined as having an average nocturnal MAP higher than the average diurnal MAP. Multivariable binary logistic regression analysis was used to assess the association of reverse dipping with in-hospital mortality. A total of 2080 patients (median age, 73 years; 50.3% female) were enrolled, among which 681 patients (32.7%) had reverse dipping. Patients with reverse dipping blood pressure had a higher in-hospital mortality compared to those without (19.8% vs. 11.4%, p < 0.001). After adjusting for potential confounders, reverse dipping was associated with a higher likelihood of in-hospital mortality (adjusted OR, 1.59; 95% CI 1.21-2.11; p = 0.001). Reverse dipping blood pressure was associated with a higher mortality rate among critically ill patients with ischemic stroke. The circadian rhythm of blood pressure should warrant more attention in cerebrovascular neurocritical care.