Autoinflammatory diseases: a possible cause of thrombosis?

Autoinflammatory diseases are a group of disorders due to acquired or hereditary disfunction of innate immune system and characterized by systemic or localized manifestations. The prototype is Familial Mediterranean Fever, a monogenic hereditary disorder, whose causing gene (MeFV gene) was identified in 1997 and opened the way to a new fascinanting chapter of rheumatology. A growing body of monogenic and poligenic autoinflammatory disorders has been described since then. Arterial and venous thrombosis is a common medical problem, with significant morbidity and mortality. Strong evidences from basic research and clinical epidemiological studies support the theory that inflammation and thrombosis can be associated. Because of their recurrent/chronic inflammatory nature, autoinflammatory diseases are a putative cause of thrombotic manifestations. In the present work, we reviewed the available evidences about monogenic autoinflammatory disorders, complicated by thrombotic manifestations

Behçet’s Disease as a Model of Venous Thrombosis

Behçet’s disease (BD) is a chronic inflammatory disease of unknown aetiology characterized by recurrent oral, genital aphthous ulcerations, uveitis, skin lesions and other multisystem affections associated with vasculitis. Different types of vessels, predominantly veins, can be affected in BD. The frequency of vascular lesions in BD, such as superficial and deep venous thromboses, arterial aneurysms and occlusions, ranges between 7-29%

Clinical Features, Short-Term Mortality, and Prognostic Risk Factors of Septic Patients Admitted to Internal Medicine Units: Results of an Italian Multicenter Prospective Study

Only a few studies provided data on the clinical history of sepsis within internal Medicine units.The aim of the study was to assess the short-term mortality and to evaluate the prognostic risk factors in a large cohort of septic patients treated in internal medicine units.Thirty-one internal medicine units participated to the study. Within each participating unit, all admitted patients were screened for the presence of sepsis.A total of 533 patients were included; 78 patients (14.6%, 95%CI 11.9, 18.0%) died during hospitalization; mortality rate was 5.5% (95% CI 3.1, 9.6%) in patients with nonsevere sepsis and 20.1% (95%CI 16.2, 28.8%) in patients with severe sepsis or septic shock. Severe sepsis or septic shock (OR 4.41, 95%CI 1.93, 10.05), immune system weakening (OR 2.10, 95%CI 1.12, 3.94), active solid cancer (OR 2.14, 95% CI 1.16, 3.94), and age (OR 1.03 per year, 95% CI 1.01, 1.06) were significantly associated with an increased mortality risk, whereas blood culture positive for Escherichia coli was significantly associated with a reduced mortality risk (OR 0.46, 95%CI 0.24, 0.88).In-hospital mortality of septic patients treated in internal medicine units appeared similar to the mortality rate obtained in recent studies conducted in the ICU setting

Are multiple-choice questions a good tool for the assessment of clinical competence in Internal Medicine?

There are many feasible tools for the assessment of clinical practice, but there is a wide consensus on the fact that the simultaneous use of several different methods could be strategic for a comprehensive overall judgment of clinical competence. Multiple-choice questions (MCQs) are a well-established reliable method of assessing knowledge. Constructing effective MCQ tests and items requires scrupulous care in the design, review and validation stages. Creating high-quality multiple-choice questions requires a very deep experience, knowledge and large amount of time. Hereby, after reviewing their construction, strengths and limitations, we debate their completeness for the assessment of professional competence

Approach to leg edema

Edema is defined as a palpable swelling caused by an increase in interstitial fluid volume. Leg edema is a common problem with a wide range of possible causes and is the result of an imbalance in the filtration system between the capillary and interstitial spaces. Major causes of edema include venous obstruction, increased capillary permeability and increased plasma volume secondary to sodium and water retention. In both hospital and general practice, the patient with a swollen leg presents a common dilemma in diagnosis and treatment. The cause may be trivial or life-threatening and it is often difficult to determine the clinical pathway. The diagnosis can be narrowed by categorizing the edema according to its duration, distribution (unilateral or bilateral) and accompanying symptoms. This work provides clinically oriented recommendations for the management of leg edema in adults

Complexity in hospital internal medicine departments: What are we talking about?

Internal medicine (IM) patients are mostly elderly, with multiple complex co-morbidities, usually chronic. The complexity of these patients involves the intricate entanglement of two or more systems (e.g. body and disease, family-socio-economic and environmental status, coordination of care and therapies) and this requires comprehensive, multi-dimensional assessment (MDA). Despite attempts to improve management of chronic conditions, and the availability of several MDA tools, defining the complex patient is still problematic. The complex profile of our patients can only be described through the best assessment tools designed to identify their characteristics. In order to do this, the Federation of Associations of Hospital Doctors on Internal Medicine FADOI has created its own vision of IM. This involves understanding the different needs of the patient, and analyzing diseases clusters and the possible relationships between them. By exploring the real complexity of our patients and selecting their real needs, we can exercise holistic, anthropological and appropriate choices for their treatment and care. A simpler assessment approach must be adopted for our complex patients, and alternative tools should be used to improve clinical evaluation and prognostic stratification in a hierarchical selection of priorities. Further investigation of complex patients admitted to IM wards is needed

Physical and Stressful Psychological Impacts of Prolonged Personal Protective Equipment Use During the COVID-19 Pandemic: A Cross-Sectional Survey Study

BACKGROUND: Healthcare workers (HCWs) caring for COVID-19 infected patients are exposed to stressful and traumatic events with potential for severe and sustained adverse mental and physical health consequences. Our aim was to assess the magnitude of physical and mental health outcomes of HCWs due to the prolonged use of personal protective equipment (PPE) treating COVID-19 patients. METHODS: This cross-sectional study assessed the symptoms of stress, anxiety, insomnia, and psychological resilience using the Stress and Anxiety to Viral Epidemics (SAVE) scale, Insomnia Severity Index (ISI), and Resilience Scale (RS), respectively, in Italy between 1st February and 31st March 2022. The physical outcomes reported included vertigo, dyspnea, nausea, micturition desire, retroauricular pain, thirst, discomfort at work, physical fatigue, and thermal stress. The relationships between prolonged PPE use and psychological outcomes and physical discomforts were analyzed using Generalized Linear Models (GLMs). We calculated the factor mean scores and a binary outcome to measure study outcomes. FINDINGS: We found that 23% of the respondents reported stress related symptoms, 33% anxiety, 43% moderate to severe insomnia, and 67% reported moderate to very low resilience. The GLMs suggested that older people (\u3e55 years old) are less likely to suffer from stress compared to younger people (\u3c35 \u3ey.o); conversely, HCW aged more than 35 years are more inclined to suffer from insomnia than younger people (\u3c35 \u3ey.o). Female HCW reported a lower probability of resilience than males. University employed HCWs were less likely to report anxiety than those who worked in a community hospital. The odds of suffering from insomnia for social workers was significantly higher than for other HCWs. Female HCW\u3e3 years old, enrolled in training programs for nursing, social work, technical training and other healthcare professionals increased the probability of reported physical discomforts. HCW that worked on non COVID-19 wards and used PPE for low-medium exposure level, were at lower risks for lasting physical side effects as compared to the HCW who worked in high-risk PPE intense, COVID-19 environments. INTERPRETATION: The study suggests that frontline HCWs who had extensive PPE exposure while directly engaged in the diagnosis, treatment, and care for patients with COVID-19 are at significant risks for lasting physical and psychological harm and distress

Could clustering of comorbidities be useful for better defining the internal medicine patients’ complexity?

Internal medicine patients are mostly elderly with multiple comorbidities, usually chronic. The high prevalence of comorbidity and multimorbidity has a significant impact on both positive responses to treatment and the occurrence of adverse events. Clustering is the process of nosography grouping into meaningful associations with some index disease, so that the objects within a cluster have high similarity in comparison with one another. In the decision-making process it is imperative that, in addition to understanding the immediate clinical problems, we are able to explicit all the contextual factors that have to be taken into account for the best outcome of care. Cluster analysis could be leveraged in developing better interventions targeted to improve health outcomes in subgroups of patients

Predictive scores, complexity assessment tools and fruit salads. One, none and one hundred thousand?

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Hypertension in the elderly

IntroductionThere is a high prevalence of hypertension in the elderly, as evidenced by clinical and health behavioral policies. Still, there are uncertainties on the treatment of hypertension, especially treatment of the very elderly. These considerations have largely been ignored in clinical trials due to concern regarding contamination by other pathologies that are difficult to frame and manage.Methods We performed an effective and ample literature review and provided reflections on the Consensus Conference ACCF/AHA 2011 on the principle types of hypertension found in the elderly. We also considered the associated principle pathologies for various treatments and related organs.Discussion Even if the goal of treatment of elevated blood pressure in the elderly is same as in younger population, it is no longer certain that a target systolic blood pressure (SBP) &lt;140 mmHg should be persistently reached in the very elderly. It is important to note that for all studies these values have never been reached. In the treatment of isolated systolic hypertension (ISH) the preferred target is a SBP &gt;160 mmHg. Treating hypertension in the elderly and very elderly reduces the risk of stroke and heart failure, though the evidence is inconclusive for all-cause mortality.Conclusion Hypertension in the elderly is very common and needs to be treated with criteria that consider the patient's age, comorbidities, lifestyle and adherence. Above all, in the very elderly, therapeutic treatment should be personalized according to the above criteria. Where possible pharmaceutical therapy should be limited at the preference of healthy lifestyle changes (physical activity, diet, etc.).</p