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Chronische Atemwegserkrankungen stellen eine weltweite Epidemie dar. Ihre Inzidenz und Prävalenz in der Weltbevölkerung nimmt zu, und insbesondere bei älteren Menschen treten sie häufig in Verbindung mit anderen Krankheiten auf, was häufig zu einen Status hoher klinischer Komplexität. Fachärzte für Neurologie, Innere Medizin und Pneumologen sollten sich des gemeinsamen Hintergrunds dieser Erkrankungen bewusst sein, um den komorbiden Zustand des Patienten richtig zu behandeln und die Therapie unter Berücksichtigung möglicher Überschneidungen zu optimieren. In dieser Übersichtsarbeit konzentrieren wir uns auf die Beziehungen zwischen chronischen Atemwegserkrankungen und chronischen neurodegenerativen Erkrankungen auf verschiedenen Ebenen; wir untersuchen die gemeinsamen Risikofaktoren und die Wechselwirkungen zwischen den Erkrankungen, die Indikationen für die Untersuchung der Atemfunktion bei neurodegenerativen Erkrankungen und die Wechselwirkungen zwischen Pathologie und Pathologie sowie zwischen Medikamenten und Pathologie bei Patienten, die sowohl von chronischen neurologischen als auch von respiratorischen Krankheiten betroffen sind.

Chronic respiratory disorders represent a world epidemic. Their incidence and prevalence in the world population is increasing, and especially among elderly subjects, they are commonly associated with other pathologies, often generating a status of high clinical complexity. Neurology, internal medicine, and pneumology specialists should be aware of the common background of these disorders in order to treat correctly the patient’s comorbid state and optimize the treatment considering potential overlaps. In this review, we aimed to focus on the relationships between chronic respiratory disorders and chronic neurodegenerative diseases at different levels; we review the shared risk factors and the interactions between disorders, the indications to explore respiratory function in neurodegenerative diseases, pathology-pathology and drug-pathology interactions in patients affected by both chronic neurologic and respiratory diseases.

To reduce intensive care unit overcrowding and optimize resources, elderly patients affected by suspected infection with declining clinical conditions could be managed in internal medicine departments with stepdown beds. However, commonly used prognostic scores, as Sequential Organ Failure Assessment (SOFA) or quick SOFA (qSOFA) have never been studied in this specific setting. The aim of this study was to evaluate the role and the accuracy of SOFA and qSOFA as prognostic scores in a population of elderly patients with suspected infection admitted to stepdown beds of two internal medicine departments. Elderly patients admitted from the emergency department in the stepdown beds of two different internal medicine departments for suspected infection were assessed with SOFA and qSOFA scores at the admission. All patients were treated according to current guidelines. Age, sex, comorbidities, Charlson comorbidity index, SOFA and qSOFA were assessed. In-hospital death and length of hospital admission were also recorded. 390 subjects were enrolled. In-hospital death occurred in 144 (36.9%) patients; we observed that both SOFA (HR 1.189; 95% CI 1.128–1.253; p

Book of the XXIV Congresso Nazionale della Società Scientifica FADOI, Firenze, 11-14 maggio 2019.

Elderly patients affected by suspected infection and declining clinical conditions can be admitted to stepdown units (SDU), but a risk stratification is necessary to optimize their management. Admission troponin I (aTnI) has a prognostic role, however, one of the most commonly used stratification tools, the Sequential Organ Failure Assessment score (SOFA), does not consider myocardial injury. With this paper, we aimed to evaluate the prognostic accuracy of a new score, named SOFA-T, considering both SOFA score and aTnI in a cohort of elderly patients admitted to the stepdown beds of two Internal Medicine departments. Patients aged > 65 years admitted in SDU of two different hospitals of the same region in a 12-months timeframe were retrospectively assessed obtaining age, sex, days of admission, in-hospital death, SOFA, aTnI and comorbidities. The best aTnI cutoff for in-hospital death was calculated with ROC curve analysis; dichotomous variables were compared with chi-squared test; continuous variables were compared with t test or Mann–Whitney test. We obtained a cohort of 390 patients. The best aTnI cutoff was 0.31 ng/ml: patients with increased aTnI had higher risk of in-hospital death (OR: 1.834; 95% CI 1.160–2.900; p = 0.009), and higher SOFA (6.81 ± 2.71 versus 5.97 ± 3.10; p = 0.010). Adding aTnI to SOFA increased significantly the area under the curve (AUCSOFA = 0.68; 95% CI 0.64–0.73; AUCSOFA-T = 0.71; 95% CI 0.65–0.76; p = 0.0001), with a slight improvement of the prognostic performance. In elderly patients admitted to SDU for suspected infection, sepsis or septic shock, aTnI slightly improves the accuracy of SOFA score of the in-hospital death prediction.

Book of the XXIII Congresso Nazionale della Società Scientifica FADOI, Bologna, 12-15 maggio 2018.

Background and Objectives: bedside cardiac ultrasound is a widely adopted method in Emergency Departments (ED) for extending physical examination and refining clinical diagnosis. However, in the setting of hemodynamically-stable pulmonary embolism, the diagnostic role of echocardiography is still the subject of debate. In light of its high specificity and low sensitivity, some authors suggest that echocardiographic signs of right ventricle overload could be used to rule-in pulmonary embolism. In this study, we aimed to clarify the diagnostic role of echocardiographic signs of right ventricle overload in the setting of hemodynamically-stable pulmonary embolism in the ED. Materials and Methods: we performed a systematic review of literature in PubMed, Web of Science and Cochrane databases, considering the echocardiographic signs for the diagnosis of pulmonary embolism in the ED. Studies considering unstable or shocked patients were excluded. Papers enrolling hemodynamically stable subjects were selected. We performed a diagnostic test accuracy meta-analysis for each sign, and then performed a critical evaluation according to pretest probability, assessed with Wells’ score for pulmonary embolism. Results: 10 studies were finally included. We observed a good specificity and a low sensitivity of each echocardiographic sign of right ventricle overload. However, once stratified by the Wells’ score, the post-test probability only increased among high-risk patients. Conclusions: signs of echocardiographic right ventricle overload should not be used to modify the clinical behavior in low- and intermediate- risk patients according to Wells’ score classification. Among high-risk patients, however, echocardiographic signs could help a physician in detecting patients with the highest probability of pulmonary embolism, necessitating a confirmation by computed tomography with pulmonary angiography. However, a focused cardiac and thoracic ultrasound investigation is useful for the differential diagnosis of dyspnea and chest pain in the ED.

Sepsis is one of the leading causes of death in hospitalized patients and its management involves a lot of specialist. Internist is required to demonstrate his competence since the beginning when the diagnosis is not so easy to be clarified. A rapid clinical suspicion permits a prompt management of the patient that means important mortality reduction. However, it is essential to understand the source of infection and echography represents a rapid, economic, useful and widespread tool with whom Internist should become more and more confident. The following review is a practical guide to manage septic patients according to the most recent literature, underlining aspects of antibiotic therapy, hemodynamic stabilization and supportive therapy. To limit sepsis mortality, a valid Internist should be culturally prepared and especially able to cooperate with other specialists, because a strong enemy requires a strong team.

Background Despite progresses in the treatment of the thromboembolic risk related to atrial fibrillation (AF), the management of recurrences remains a challenge. Hypothesis To assess if congestive heart failure or left ventricular systolic dysfunction (CHA2DS2‐VASc) score is predictive of early arrhythmia recurrence after AF cardioversion. Methods Systematic review and individual patient pooled meta‐analysis following Preferred Reporting Items for Systematic reviews and Meta‐Analyses guidelines. Inclusion criteria: observational trials in patients with AF undergoing cardioversion, available data on recurrence of AF and available data on CHA2DS2‐VASc score. Clinical studies of interest were retrieved by PubMed, Cochrane Library, and Biomed Central. Seven authors were contacted for joining the patient level meta‐analysis, and three shared data regarding anthropometric measurements, risk factors, major comorbidities, and CHA2DS2‐VASc score. The primary outcome was the recurrence of AF after cardioversion in patients free from antiarrhythmic prophylaxis. Univariate and multivariate logistic regression was performed. Results Overall, we collect data of 2889 patients: 61% were male, 50% with hypertension, 12% with diabetes, and 23% with history of ischemic heart disease. The median CHA2DS2‐VASc score was 2.. At the multivariate analysis, chronic kidney disease (odds ratio [OR] 1.94; 95% confidence interval [CI] 1.12‐3.27; P = 0.01), peripheral artery disease (OR 1.65; 95% CI 1.23‐2.19; P < 0,0001), previous use of beta blockers (OR 1.5; 95% CI 1.19‐1.88; P < 0.0001), and CHA2DS2‐VASc score > 2 (OR 1.37; 95% CI 1.1‐1.68; P = 0.002) were independent predictors of early recurrence of AF. Conclusions CHA2DS2‐VASc score predicts early recurrence of AF in the first 30 days after electrical or pharmacological cardioversion. Protocol registration PROSPERO (CRD42017075107).

book of the XX Congresso Nazionale della Società Scientifica FADOI, Torino, 9-12 maggio 2015.

Background: Serum uric acid (SUA) is a normal product of purine metabolism in humans. Uric acid crystals have the capacity to adhere to the surface of epithelial cells and induce an acute inflammatory response, characterized by systemic cytokine production, tumor necrosis factor, and the local expression of chemokines, monocyte chemotactic protein and cyclooxygenase 2 in blood vessels. Moreover, literature reports a relationship between SUA and different cardiovascular risk factors, including hypertension, metabolic syndrome, chronic kidney disease (CKD), as well as with coronary artery disease, peripheral artery disease, electrocardiographic alterations, cerebrovascular disease, atrial fibrillation, and all-cause mortality. With this study we aimed to evaluate the role of SUA in severe sepsis and septic shock. Materials and Methods: in the period between 2014 and 2015 we enrolled all the patients admitted to our Internal Medicine department for severe sepsis or septic shock. For each patent, at the admission in our department, we evaluated age, sex, the most common comorbidities (hypertension, diabetes, active cancer, CHF, COPD) and smoking attitude. Blood gas analysis, SUA and troponin were collected at the admission. SOFA score was calculated for each subject. Days of hospitalization, death or UTI/SUTI transfer were collected as measures of outcome. Informed consent was required to participate to the study. All patients were treated according to current guidelines. All the data were synthesized in an electronic database. Pearsons bivariate correlation was used to explore relationships between variables. Continuous variables were compared with t-test, dichotomous and ordinal variables with chi-squared test. A GLM/univariate model was used to confirm the preliminary observations controlling for covariates. Statistics was performed with SPSS 13.0 for Windows systems. Results: We obtained a final sample of 71 patients. Mean age was 76.82(±15.37) years, males representing 49.3%. Hypertension affected 72.9%, diabetes 28.2%, cancer 25.4%, CHF 43.7%, COPD 12.7% of the enrolled patients. Mean SUA was 6.49(±0.41) mg/dl, mean troponin I was 0.30(±0.81) mg/dl. Mean SOFA score was 4.34(±0.241). Mean hospitalization was 11.65(±0.68) days. Death or UTI/SUTI transfer was observed in 32.4% of the patients. SUA levels resulted statistically associated to both SOFA score (p

Chronic kidney disease and hyperuricemia have been associated to an increased risk and a worse prognosis in acute ischemic stroke. Several mechanisms, including platelet dysfunction, coagulation disorders, endothelial dysfunction, inflammation, and an increased risk of atrial fibrillation could be implicated. The role of serum uric acid in this setting is still object of debate. We enrolled all the consecutive patients admitted to our department for acute ischemic stroke. Cox regression analysis was used to evaluate the risk of in-hospital death considering serum uric acid levels and all the comorbidities. In the overall sample, hyperuricemia was independently associated to an increased risk of in-hospital mortality. This effect was stronger in patients with chronic kidney disease while, in the group of patients with normal renal function, the relationship between hyperuricemia and increased stroke mortality was not confirmed. Hyperuricemia could be associated to higher in-hospital mortality for ischemic stroke among elderly patients when affected by kidney disease. Survival does not seem to be affected by hyperuricemia in patients with normal kidney function.

Book del XVII Congresso Nazionale FADOI 5-8 maggio 2012, Rimini

Chronic diseases are increasing worldwide. Association of two or more chronic conditions is related with poor health status and reduced life expectancy, particularly among elderly patients. Comorbidities represent a risk factor for adverse events in several critical illnesses. We aimed to evaluate if elderly patients are affected by multiple chronic pathologies, assessed by Charlson comorbidity index (CCI), showed a reduced in-hospital survival after ischemic stroke. In a 3-year period, we evaluated all the subjects admitted to our internal medicine department for ischemic stroke. Age, sex, NIHSS score and all the comorbidities were recorded. Days of hospitalization, hospital-related infections and in-hospital mortality were also assessed. For each patient, we evaluated CCI, obtaining four classes: group 1 (CCI: 2–3), group 2 (CCI: 4–5), group 3 (CCI: 6–7) and group 4 (CCI: ≥8). Survival was evaluated with Kaplan–Meier and Cox regression analyses. The complete model considered in-hospital death as the main outcome, days of hospitalization as the time variable and CCI as the main predictor, adjusting for NIHSS, sex and nosocomial infections. Patients in CCI group 3 and 4 had an increased risk of in-hospital mortality, independently of NIHSS, sex and nosocomial infections. Elderly patients with multiple comorbidities have higher risk of in-hospital death when affected by ischemic stroke.

The aim of this study was to evaluate the management practices of internal medicine clinicians for patients with cardiovascular risk factors, with particular respect to treatment thresholds, medication choices and target goals. A sample of internists - representatives of Internal Medicine Units (IMUs) from all the regions in Italy - were identified by the cardiovascular medicine study group of the Italian Internal Medicine FADOI (Federazione delle Associazioni dei Dirigenti Ospedalieri Internisti) Society and invited to fill out a questionnaire about hypertension, dyslipidemia and hyperuricemia. From the 101 questionnaires collected, it was found that despite large heterogeneity between IMUs in terms of patient management and adherence to guidelines, internists were experts in the management of patients with multiple cardiovascular risk factors and associated comorbidities. We hope that these data prompt the internal medicine community to consider the value of producing shared, real-world guidelines on the management of cardiovascular disease.

Book of the XXII Congresso Nazionale della Società Scientifica FADOI, Sorrento, 13-16 maggio 2017.

Background In hemodynamically stable patients, mortality and morbidity related to atrial fibrillation are mainly due to cardioembolic disorder. No difference in the survival rate and incidence of embolic events has been described in patients undergoing rhythm or rate control if the latter is combined with an appropriate anticoagulant therapy. CHA2DS 2-VASc is a score that allows clinicians to stratify embolic risk in patients affected by nonvalvular atrial fibrillation. Each item can be involved in triggering and maintaining atrial fibrillation. Thus, we hypothesized that CHA2DS2-VASc may help to predict early recurrences after cardioversion. Methods A total of 319 consecutive patients, admitted to our emergency department or hemodynamically stable persistent atrial fibrillation, were enrolled and treated with electrical or pharmacological sinus rhythm restoration. Outcome was defined as recurrence of atrial fibrillation 5 days after cardioversion. Predicted probability of sinus rhythm stability was assessed with an ordinal regression model using CHA2DS 2-VASc as an independent variable. Results The model showed a progressive decrease in the predicted probability of sinus rhythm stability after electrical or pharmacological cardioversion along with an increase in the CHA2DS2-VASc score. A logarithmic relationship was the best-fit trend among CHA2DS2-VASc ranks and the predicted probability of sinus rhythm stability in patients undergoing both electrical and pharmacological cardioversion (r2=0.98, P

book of the XXI Congresso Nazionale della Società Scientifica FADOI, Roma, 14-17 maggio 2016.

book of the XIX Congresso Nazionale della Società Scientifica FADOI, Bologna, 10-13 maggio 2014.