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Patients with multimorbidity increasingly impact healthcare systems, both in primary care and in hospitals. This is particularly true in Internal Medicine. This population associates with higher mortality rates, polypharmacy, hospital readmissions, post-discharge syndrome, anxiety, depression, accelerated age-related functional decline, and development of geriatric syndromes, amongst others. Internists and Hospitalists, in one of their roles as Generalists, are increasingly asked to attend to these patients, both in their own Departments as well as in surgical areas. The management of polypathology and multimorbidity, however, is often complex, and requires specific clinical skills and corresponding experience. In addition, patients' needs, health-care environment, and routines have changed, so emerging and re-emerging specific competences and approaches are required to offer the best coordinated, continuous, and comprehensive integrated care to these populations, to achieve optimal health outcomes and satisfaction of patients, their relatives, and staff. This position paper proposes a set of emerging and re-emerging competences for internal medicine specialists, which are needed to optimally address multimorbidity now and in the future.

Prevention of cardiovascular disease (CVD) remains one of the largest public health challenges of our time. Identifying individuals at increased cardiovascular risk at an asymptomatic, sub-clinical stage is of paramount importance for minimizing disease progression as well as the substantial health and economic burden associated with overt CVD. Vascular ageing (VA) involves the deterioration in vascular structure and function over time and ultimately leads to damage in the heart, brain, kidney, and other organs. Vascular ageing encompasses the cumulative effect of all cardiovascular risk factors on the arterial wall over the life course and thus may help identify those at elevated cardiovascular risk, early in disease development. Although the concept of VA is gaining interest clinically, it is seldom measured in routine clinical practice due to lack of consensus on how to characterize VA as physiological vs. pathological and various practical issues. In this state-of-the-art review and as a network of scientists, clinicians, engineers, and industry partners with expertise in VA, we address six questions related to VA in an attempt to increase knowledge among the broader medical community and move the routine measurement of VA a little closer from bench towards bedside.

Chronic kidney disease (CKD) is a major public health concern. Despite many potentially life-threatening conditions that can accompany kidney disease, cardiovascular disease (CVD) remains the leading cause of death in these patients. Adjusted-for-age mortality from CVD in patients with end-stage renal disease is 10–30 times higher than in the general population. A decrease in renal function accelerates the development of cardiac pathology. Simultaneous exposure of CVD and CKD plays an important role in the relationship between arterial stiffness (AS) and estimated glomerular filtration rate. But there is a controversy as to whether the AS causes deterioration in kidney function, if renal dysfunction leads to AS, or the relationship is reciprocal. Hence, several studies that recruited high-risk populations reached a conclusion that comorbidities might lead to both AS and decline in kidney function over time. A number of studies have shown that several markers of AS, such as pulse pressure, central and peripheral pressure are associated with the development of CKD. This review takes into account the theoretical background, current status, and future potential of the techniques that measure AS within context of CKD assessment and management.

Background and objectives: At present, there is insufficient evidence to support the use of continuous veno-venous haemofiltration (CVVH) in the early treatment of septic shock. This study focuses on the association between survival and different parameters of oxidative stress (RedOx). Thereby, we evaluated whether RedOx markers are associated with the outcome of septic shock in patients under early-initiated CVVH treatment. Materials and Methods: We conducted a prospective observational study of 65 patients with septic shock who started CVVH within 12 h after hospital admission. Blood samples were taken from each patient prior to the start of CVVH. The following RedOx markers were measured: glutathione peroxidase, glutathione reductase (GR), total antioxidant capacity, superoxide dismutase, nitric oxide, malondialdehyde and 4-hydroxynonenal. The odds ratio (OR) was calculated using binary logistic regression and stepwise multivariable regression. Results: The 65 patients had a median age of 66 years and 39 were male. Based on the outcome, the patients were divided into two groups—non-survivors (n = 29) and survivors (n = 36)—and the levels of RedOx markers were compared between them. Of all the markers, only higher GR activity was found to be significantly associated with the fatal outcome, 100.3 U/L versus 60.5 U/L, OR = 1.027 (95% CI, 1.010–1.044). Following adjustment for the sequential organ failure assessment score and other parameters, GR activity still presented a significant association with the fatal outcome, OR = 1.020 (95% CI, 1.002–1.038). Conclusions: GR activity is associated with in-hospital fatal outcomes among septic shock patients under early-initiated CVVH treatment. Septic shock patients who have a lower GR activity at hospital admission may have a favourable outcome of the early initiation of CVVH.

Glutathione, in its thiol-reduced form (GSH), is the most abundant antioxidant in the airway epithelial lining fluid. It acts as a vital intra- and extracellular antioxidant protecting oxidative/nitrosative stress, interceding the pro-inflammatory processes in the lungs. Aim: Relationship between pneumonia severity and GSH level have been studied. Methods: A case-conrol study took place at P. Stradins Clinical University hospital, Riga, Latvia. Community-acquired pneumonia (CAP) patients with no underlying chronic heart failure (n=32), both males and females of average age 69,0+7,2 and healthy control patients matched for age (n=20) were recruited. CURB 65 (confusion, uremia, respiratory rate, BP, age ≥ 65 years) score was used for CAP severity assessment. The level of plasma GSH was determined. CAP clinical pattern was followed up for 3 weeks. Results: Being compared to control group, GSH level was reduced in CAP patients (mean GSH was 1.12+ 0,22 mmol/L versus 1.60+0,16 mmol/L accordingly). There was no correlation between GSH level and CAP severity by CURB65. However, in 8 patients respiratory failure (RF) has developed. All the patients, in whom RF has developed, demonstrated GSH level below 1,1 mmol/L on admission. Conclusions: A low concentration of plasma GSH indicating low antioxidant capacity could act as a marker for inflammation-related OS in CAP patients for its management and/or risk of complications stratification.

Chronic Pancreatitis: Problems of ClassificationThe article encompasses a review of those classifications of chronic pancreatitis (CP) that are of value for clinical practice. None of them gives a reliable description of the severity of clinical presentation and severity of CP course. Clinical pancreatic index (CPI), introduced by the authors, is a clinical classification aimed at solving this problem. CPI gives a quantitative degree of clinical symptom intensity and the severity of clinical course of CP. The application of CPI is useful both when completing clinical researches and in clinical practice. CPI is designed to help choose the best CP treatment option and its intensity.

Chronic obstructive pulmonary disease (COPD) exacerbations are associated with increased inflammation followed by oxidative stress (OS). Malondialdehyde (MDA) negatively correlation with PFT was demonstrated (Upasana J. et al. ERJ vol. 44 no. Suppl 58 P3958) In patients who survive their first COPD-related hospitalization up to 50% have been reported for re-admission within 6 months of discharge. Up to 84% of direct costs associated with COPD are due to inpatient hospitalizations. Aim: Relationships between exacerbation recoveries, and Malondialdehyde as an indicator of oxidative stress have been studied. Methods: The case-control study took place at P. Stradins Clinical hospital, Riga, Latvia. Spirometry data was obtained, also C-reactive protein, WBC counts, MDA serum level was measured in 19 COPD patients when at exacerbation (on admission), at 14 and 30 days post-exacerbation. Recurrent exacerbation was followed up during 60 days. Results: The MDA level was correlated with CRP levels and WBCcount (P=0.000; P=0.0001, respectively) during exacerbations. Those patients (n=12) who had recurrent exacerbations within 60 days had significantly higher levels of serum MDA at day 14 and 30, compared with those without recurrences (n=7): 3.48 mkM versus 1.75 mkM accordingly. No correlation between MDA level and spirometry data was revealed. Conclusions: Persistently heightened systemic inflammation followed by OS seems to support COPD exacerbation. A high serum MDA 14 day after may be used as a predictor of recurrent exacerbations within 60 days.

Approximately 20-25 % of the World’s adult population aged 40 - 75 years have metabolic syndrome (MS). MS is one of the most widespread risk factors for: diabetes mellitus, cardiovascular disorders and skin disorders MS, due to the oxidative stress, supports a chronic inflammatory reaction in the skin and in the other parts of the body. During oxidative stress the net amount of reactive oxygen species (ROS) exceeds the antioxidant capacity of the body causing lipid peroxidation, protein oxidation and oxidative DNA damage. The role of oxidative stress in pathogenesis of early skin changes in patients with MS is not clearly defined. The aim of our study was to compare visual skin changes between patients with MS and without it, and to reveal early histological manifestations of MS in the skin. The study was conducted at the Clinic of Aesthetic Dermatology, Riga, Latvia. 50 patients aged 45-55 were enrolled. The research consisted of a clinical examination, biochemical testing and Punch biopsies. Tissue samples were stained with haematoxylin-eosin, Masson’s Trichrome and also immunohistochemically stainining with antibodies to CD34, CD117, CD20, CD8 and bcl-2. CD1a positive Langerhans cells were evaluated in 3 fields of vision. Data was analyzed with Microsoft Excel 2010 software. Gender ratio was women: men= 1.6:1. Histological changes in the skin of patients with MS were: hyperkeratosis, acanthosis, dermal fibrosis, elastosis and mild thickening of the stratum spinosum. Infiltrates around blood vessels were composed of T lymphocytes (CD3+). More significant expression and accumulation of apoptotic protein Bcl2 in skin of patients with MS in comparison to patients without MS was noted. Initial skin histological changes in MS are dermal elastosis, thickening of stratum spinosum and acanthosis. Mild T lymphocytic infiltration around capillaries possibly reflects the inflammatory component of MS. Increased accumulation of bcl2 anti-apoptotic protein in epidermis was more significantly expressed in patients with MS.

AIM: To study the effect of selenium on adrenocortical function in patients taking glucocorticosteroids (GCS) long/MATERIAL AND METHODS: The study included 56 patients who had been long taking oral GCS for the underlying disease. Adrenocortical function was evaluated by a short synacthen test; adrenal insufficiency (mean cortisol level 8.2 µg/dl) was identified in 52 patients. A study group of patients (n=35) was given selenium 200 µg/day. A control group (n=17) with the detected adrenal insufficiency did not take it. All the patients (n=52) continued to receive standard therapy for the underlying disease, including oral GCS/RESULTS: Adrenal function was reexamined 6 months later; the two paired-samples t-test indicated a statistically significant increase in cortisol levels up to 23.20±4.2 µg/dl (p≤0.05) in the patient group receiving selenium in addition to the basic therapy. In the control group, the function did not recover (cortisol levels were 8.6 and 9.8 µg/dl at baseline and at 6 months, respectively; p≤0.05)/CONCLUSION: The experience with selenium 200 µg/day given long to patients with adrenal insufficiency caused by the long-term use of GCS shows that the agent is effective in recovering adrenocortical function.