Internal Medicine Setting Research Articles

Electronic Patient Portal Use in Orthopaedic Surgery Is Associated with Disparities, Improved Satisfaction, and Lower No-Show Rates.

Electronic patient portal (EPP) use has been associated with a number of benefits in the internal medicine setting. Few studies have examined the disparities in and the benefits of EPP utilization among surgical patients. The purposes of this study were to examine factors associated with EPP use among patients undergoing an orthopaedic surgical procedure and to determine if EPP use is associated with improved outcomes or satisfaction after orthopaedic surgical procedures. We queried all patients undergoing an orthopaedic surgical procedure from May 2015 to December 2018 at 2 academic medical centers in an integrated hospital system. Patient demographic characteristics, operative characteristics, satisfaction scores, and patient-reported outcome measures (PROMs) were collected. Multivariable logistic regression was used to identify disparities in EPP use. Adjusted logistic and linear regressions were then used to assess the association between EPP use and the various outcome metrics while controlling for confounders identified in the previous analysis. Numerous demographic factors were independently associated with EPP use among patients undergoing an orthopaedic surgical procedure, including English speakers compared with non-English speakers (odds ratio [OR], 2.37 [95% confidence interval (CI), 2.01 to 2.79]); African-American or black race (OR, 0.42 [95% CI, 0.36 to 0.48]) and Hispanic race (OR, 0.52 [95% CI, 0.44 to 0.61]) compared with white race; college education compared with high school education (OR, 2.30 [95% CI, 2.12 to 2.49]); and a surgical procedure for orthopaedic trauma compared with that for the hand or upper extremity (OR, 0.51 [95% CI, 0.45 to 0.58]) (p < 0.001 for all), among others. EPP use was independently associated with the increased likelihood of completing a PROM (OR, 1.57 [95% CI, 1.45 to 1.7]) and a satisfaction survey (OR, 2.38 [95% CI, 2.17 to 2.61]) and improved overall patient satisfaction (mean difference, 2.61 points [95% CI, 1.79 to 3.43 points]) (p < 0.001 for all). Finally, EPP use was independently associated with lower mean no-show rates (6.8% [95% CI, 6.4% to 7.2%] compared with 9.3% [95% CI, 8.9% to 9.7%]). The lower no-show rate for EPP users corresponded to an estimated $218,225 in savings for our institution within the first postoperative year. This study identified significant disparities in EPP use among patients undergoing an orthopaedic surgical procedure. Given that EPP use was independently associated with lower no-show rates and improved patient satisfaction among patients undergoing an orthopaedic procedure, efforts to reduce these disparities are warranted. EPPs are increasingly being used by health-care systems to improve communication between providers and patients; however, providers should be aware of and strive to eliminate disparities in EPP utilization among orthopaedic patients. Within orthopaedic surgery, EPPs are associated with a number of benefits, including lower no-show rates and increased patient satisfaction.

Interventions to Improve Hospital Admission and Discharge Management: An Umbrella Review of Systematic Reviews

The aim of this umbrella review was to summarize the research evidence on programs to improve the transition between ambulatory and hospital care. The MEDLINE database and the Cochrane library were searched. Systematic reviews of randomized controlled trials published between January 2000 and September 2018 in English or German were included. Studies were eligible if an assessment or coordination intervention had been evaluated and if patients had been transferred between hospital (defined as internal medicine, surgery, or unspecified hospital setting) and home (defined as any permanent residence). Risk of bias was assessed using the AMSTAR criteria. Results are presented descriptively and in table format. Thirty-nine systematic reviews comprising 492 different studies were included. More than half of these studies were conducted in the United States, the United Kingdom, Canada, and Australia. All studies evaluated strategies to improve discharge management (introduced after patients' arrival at the hospital); no study assessed strategies to improve admission management (initiated in primary care before patients' transition to hospital). The reviews included focused on a specific patient group, a specific intervention type, or a specific outcome. Overall, interventions focusing on elderly patients and high-intensity interventions seemed to be most effective. An overview of classifications of care transition strategies is provided. Future research should focus on hospital admission management programs.

Eosinopenia as a diagnostic marker of bloodstream infection in a general internal medicine setting: a cohort study

BackgroundLittle is known about the potential use of the eosinophil count as a predictive marker of bloodstream infection. In this study, we aimed to assess the reliability of eosinopenia as a predictive marker of bloodstream infection.MethodsThis retrospective cohort study was performed in the outpatient department and general internal medicine department of a tertiary university hospital in Japan. A total of 189 adult patients with at least 2 sets of blood cultures obtained during the period January 1–December 31, 2018, were included; those with the use of antibiotic therapy within 2 weeks prior to blood culture, steroid therapy, or a history of haematological cancer were excluded. The diagnostic accuracies of each univariate variable and the multivariable logistic regression models were assessed by calculating the areas under the receiver operating characteristic curves (AUROCs). The primary outcome was a positive blood culture indicating bloodstream infection.ResultsSevere eosinopenia (< 24.4 cells/mm3) alone yielded small but statistically significant overall predictive ability (AUROC: 0.648, 95% confidence interval (CI): 0.547–0.748, P < 0.05), and only moderate sensitivity (68, 95% CI: 46–85%) and specificity (62, 95% CI: 54–69%). The model comprising baseline variables (age, sex), the C-reactive protein level, and neutrophil count yielded an AUROC of 0.729, and further addition of eosinopenia yielded a slight improvement, with an AUROC of 0.758 (P < 0.05) and a statistically significant net reclassification improvement (NRI) (P = 0.003). However, the integrated discrimination index (IDI) (P = 0.284) remained non-significant.ConclusionsSevere eosinopenia can be considered an inexpensive marker of bloodstream infection, although of limited diagnostic accuracy, in a general internal medicine setting.

Romanian version of SDM-Q-9 validation in Internal Medicine and Cardiology setting: a multicentric cross-sectional study.

Shared decision making (SDM) is becoming more and more important for the patient-physician interaction. There has not been a study in Romania evaluating patients' point of view in the SDM process yet. Therefore, the present study aims to evaluate the psychometric parameters of the translated Romanian version of SDM-Q-9. A multicentric cross-sectional study was performed comprising eight recruitment centers. The sample consisted of in- and outpatients who referred to Hospital Units for treatment for atrial fibrillation or collagen diseases. Furthermore, patients who were members of Autoimmune Disease Patient Society were able to participate via an online survey. All participants completed the Romanian translated SDM-Q-9. Altogether, 665 questionnaires were filled in within the hospital setting (n = 324; 48.7%) and online (n = 341; 51.3%). The Romanian version had good internal consistency (Cronbach α coefficient of 0.96.) Corrected item correlations were good ranging from 0.64 to 0.89 with low corrected item correlations for item 1 and item 7. PCA found a one-factorial solution (similar with previous reports) but the first item had the lowest loading. SDM-Q-9 is a useful tool for evaluation and improvement in health care that was validated in Romania and can be used in clinical setting in this country.

Using a sociomaterial approach to generate new insights into the nature of interprofessional collaboration: Findings from an inpatient medicine teaching unit

ABSTRACTToday’s hospitals are burdened with patients who have complex health needs. This is readily apparent in an inpatient internal medicine setting. While important elements of effective interprofessional collaboration have been identified and trialled across clinical settings, their promise continues to be elusive. One reason may be that caring for patients requires understanding the size and complexity of healthcare networks. For example, the non-human ‘things’ that healthcare providers work with and take for granted in their professional practice—patient beds, diagnostic imaging, accreditation standards, work schedules, hospital policies, team rounds—also play a role in how care is shaped. To date, how the human and non-human act together to exclude, invite, and regulate particular enactments of interprofessional collaboration has been subject to limited scrutiny. Our paper addresses this gap by attending specifically to the sociomaterial. Drawing on empirical data collected from an Academic Health Sciences Centre’s inpatient medicine teaching unit setting in Ontario, Canada, we explore the influence of the sociomaterial on the achievement of progressive collaborative refinement, an ideal of how teams should work to support safe and effective patient care as patients move through the system. Foregrounding the sociomaterial, we were able to trace how assemblies of the human and the non-human are performed into existence to produce particular enactments of interprofessional collaboration that, in many instances, undermined the quality of care provided. Our research findings reveal the “messiness” of interprofessional collaboration, making visible how things presently assemble within the inpatient setting, albeit not always in the ways intended. These findings can be used to guide future innovation work in this and other similar settings.

Risk, prevalence, and impact of hospital malnutrition in a Tertiary Care Referral University Hospital: a cross-sectional study.

Hospital malnutrition is still underestimated among physicians, even in internal medicine settings. This is a cross-sectional study, aiming to estimate the risk, the prevalence and the impact of malnutrition in an Internal Medicine and Gastroenterology Department of a large Italian hospital (Fondazione PoliclinicoUniversitario A. GemelliIRCCS, Rome). Patients were evaluated within 72h from admission according to Nutritional Risk Screening-2002 (NRS-2002) and European Society for Clinical Nutrition and Metabolism (ESPEN) Criteria. Anthropometric, laboratory tests and Bioelectrical Impedance Analysis (BIA) derived phase angle were also performed. Length of hospital stay (LOS) and in-hospital mortality were collected. Univariate and multivariate analyses were conducted to correlate nutritional status with LOS and hospital mortality. In 10months, 300 patients were enrolled: male patients were 172 (57.3%); mean age was 63.7 (± 17.6). At admission, 157 (52.3%) patients were at risk of malnutrition; 116 (38.7%) were malnourished. Malnourished patients had a mean LOS of 11.5 (± 8.0) days, not-malnourished 9.4 (± 6.2) days (p < 0.05). In-hospital mortality did not significantly differ between the two groups. Multivariate analysis shows that both malnutrition (p = 0.04; 95% CI 0.03-3.41) and phase angle (p = 0.004; 95% CI - 1.92 to - 0.37) independently correlate with LOS. In an Internal Medicine and Gastroenterology Department, over half (52.3%) of the patients were found at risk of malnutrition, and over a third (38.7%) were malnourished at hospital admission. Malnutrition and BIA-derived phase angle are independently associated with LOS. ESPEN Criteria and phase angle could be performed at admission to identify patients deserving specific nutritional support.

Characterization of Pharmacy Resident Interventions on an Academic Inpatient Internal Medicine Rotation

Purpose: To characterize the clinical interventions of postgraduate year 1 (PGY-1) pharmacy residents on a required, 1-month, inpatient adult internal medicine service at an academic medical center. Methods: The interventions completed by PGY-1 pharmacy residents on a required, adult internal medicine rotation were analyzed. Documentation of clinical interventions was performed by the PGY-1 residents, and the significance of the intervention was subsequently determined. Acceptance rates of clinical interventions were also documented and reviewed. Results: A total of 2161 interventions were documented by 14 PGY-1 pharmacy residents between January 2016 and May 2017. Of these interventions, 2016 (93.3%) had a positive, or accepted, outcome. The significance of the majority of interventions was moderate (93.5%), indicating that either an improvement in drug therapy effectiveness, decreased hospital length of stay, reduction in cost, or prevention in harm had occurred. The most common intervention types were recommendations to add, change, or discontinue a medication therapy, completion of a pharmacy dosing consult or conducting an admission medication reconciliation. Conclusion: PGY-1 pharmacy residents have a positive impact on patient care in the inpatient adult internal medicine setting.

Positioning document on incorporating point-of-care ultrasound in Internal Medicine departments

This positioning document describes the most important aspects of clinical ultrasonography in the internal medicine setting, from its fundamental indications to the recommended training period. There is no question as to the considerable usefulness of this tool in the standard clinical practice of internists in numerous clinical scenarios and settings (emergencies, hospital ward, general and specific consultations and home care). Ultrasonography has a relevant impact on the practitioner's ability to resolve issues, increasing diagnostic reliability and safety and providing important information on the prognosis and progression. In recent years, ultrasonography has been incorporated as a tool in undergraduate teaching, with excellent results. The use of ultrasonography needs to be widespread. To accomplish this, we must encourage structured training and the acquisition of equipment. This document was developed by the Clinical Ultrasonography Workgroup and endorsed by the Spanish Society of Internal Medicine.

Documento de posicionamiento sobre la incorporación de la ecografía clínica en los servicios de Medicina Interna

This positioning document describes the most important aspects of clinical ultrasonography in the internal medicine setting, from its fundamental indications to the recommended training period. There is no question as to the considerable usefulness of this tool in the standard clinical practice of internists in numerous clinical scenarios and settings (emergencies, hospital ward, general and specific consultations and home care). Ultrasonography has a relevant impact on the practitioner's ability to resolve issues, increasing diagnostic reliability and safety and providing important information on the prognosis and progression. In recent years, ultrasonography has been incorporated as a tool in undergraduate teaching, with excellent results. The use of ultrasonography needs to be widespread. To accomplish this, we must encourage structured training and the acquisition of equipment. This document was developed by the Clinical Ultrasonography Workgroup and endorsed by the Spanish Society of Internal Medicine.

Adult bacterial myositis: report of a single-center series of 26 cases

Bacterial infections involving muscle are quite uncommon and generally require specific predisposing factors. Bacterial myositis is more rarely described in the typical kind of patients observed in Internal Medicine (presence of multiple co-morbidities, partial/limited immune-deficiency, advanced age). Twenty-six patients suffering from bacterial myositis (8 women and 18 men; mean age 58.5 years, range 27-82) observed in a single Internal Medicine Unit were reported. Muscles involved were ileopsoas, thigh, paravertebral, gluteus, calf, forearm and rectus abdomen. Simultaneous presence of arthritis was registered in 17 patients and all patients presented relevant comorbidity. Main cultured bacteria were &lt;em&gt;Staphylococcus aureus, Escherichia coli&lt;/em&gt;, other Gram-negative bacteria, &lt;em&gt;Streptococcus spp.&lt;/em&gt; Multi-drug-resistance was observed in 14 out 26 (53.8%). Computed tomography, ultrasound and magnetic resonance imaging were utilized for diagnostic purposes. Antibiotic treatment was administered to all patients. Surgical debridement and drainage were performed in 12 patients; 7 patients were treated with percutaneous aspiration and drainage. At discharge, relevant functional impairment was present in 17 patients (65.3%). Four patients died (in-hospital mortality 7.6%, global mortality at three months 15.3%). Management of bacterial myositis is difficult and its prognosis is poor. In the near future, this demanding infection will be more frequently observed in Internal Medicine setting as comorbidity, which is very often the main characteristic of these patients.

Clinical calculators in hospital medicine: Availability, classification, and needs

ObjectiveClinical calculators are widely used in modern clinical practice, but are not generally applied to electronic health record (EHR) systems. Important barriers to the application of these clinical calculators into existing EHR systems include the need for real-time calculation, human–calculator interaction, and data source requirements. The objective of this study was to identify, classify, and evaluate the use of available clinical calculators for clinicians in the hospital setting. MethodsDedicated online resources with medical calculators and providers of aggregated medical information were queried for readily available clinical calculators. Calculators were mapped by clinical categories, mechanism of calculation, and the goal of calculation. Online statistics from selected Internet resources and clinician opinion were used to assess the use of clinical calculators. ResultsOne hundred seventy-six readily available calculators in 4 categories, 6 primary specialties, and 40 subspecialties were identified. The goals of calculation included prediction, severity, risk estimation, diagnostic, and decision-making aid. A combination of summation logic with cutoffs or rules was the most frequent mechanism of computation. Combined results, online resources, statistics, and clinician opinion identified 13 most utilized calculators. ConclusionAlthough not an exhaustive list, a total of 176 validated calculators were identified, classified, and evaluated for usefulness. Most of these calculators are used for adult patients in the critical care or internal medicine settings. Thirteen of 176 clinical calculators were determined to be useful in our institution. All of these calculators have an interface for manual input.

A sociological exploration of the tensions related to interprofessional collaboration in acute-care discharge planning

ABSTRACTPatient discharge is a key concern in hospitals, particularly in acute care, given the multifaceted and challenging nature of patients’ healthcare needs. Policies on discharge have identified the importance of interprofessional collaboration, yet research has described its limitations in this clinical context. This study aimed to extend our understanding of interprofessional interactions related to discharge in a general internal medicine setting by using sociological theories to illuminate the existence of, and interplay between, structural factors and microlevel practices. An ethnographic approach was employed to obtain an in-depth insight into healthcare providers’ perspectives, behaviours, and interactions regarding discharge. Data collection involved observations, interviews, and document analysis. Approximately 65 hours of observations were undertaken, 23 interviews were conducted with healthcare providers, and government and hospital discharge documents were collected. Data were analysed using a directed content approach. The findings indicate the existence of a medically dominated division of healthcare labour in patient discharge with opportunities for some interprofessional negotiations; the role of organizational routines in facilitating and challenging interprofessional negotiations in patient discharge; and tensions in organizational priorities that impact an interprofessional approach to discharge. The findings provide insight into the various levels at which interventions can be targeted to improve interprofessional collaboration in discharge while recognizing the organizational tensions that challenge an interprofessional approach.

A novel organizational model to face the challenge of multimorbid elderly patients in an internal medicine setting: a case study from Parma Hospital, Italy.

Continuous increase of elderly patients with multimorbidity and Emergency Department (ED) overcrowding are great challenges for modern medicine. Traditional hospital organizations are often too rigid to solve them without consistently rising healthcare costs. In this paper we present a new organizational model achieved at Internal Medicine and Critical Subacute Care Unit of Parma University Hospital, Italy, a 106-bed internal medicine area organized by intensity of care and specifically dedicated to such patients. The unit is partitioned into smaller wards, each with a specific intensity level of care, including a rapid-turnover ward (mean length of stay <4days) admitting acutely ill patients from the ED, a subacute care ward for chronic critically ill subjects and a nurse-managed ward for stable patients who have socio-economic trouble preventing discharge. A very-rapid-turnover ("come'n'go") ward has also been instituted to manage sudden ED overflows. Continuity, effectiveness, safety and appropriateness of care are guaranteed by an innovative figure called "flow manager," with skilled clinical experience and managerial attitude, and by elaboration of an early personalized discharge plan anticipating every patient's needs according to lean methodology principles. In 2012-2014, this organizational model, compared with other peer units of the hospital and of other teaching hospitals of the region, showed a better performance, efficacy and effectiveness indexes calculated on Regional Hospital Discharge Records database system, allowing a capacity to face a massive (+22%) rise in medical admissions from the ED. Further studies are needed to validate this model from a patient outcome point of view.

Development of a Primary Care-Based Clinic to Support Adults With a History of Childhood Cancer: The Tactic Clinic

Describe the development and evolution of a primary-care-based, multidisciplinary clinic to support the ongoing care of adult survivors of childhood cancer. A consultative clinic for adult survivors of childhood cancer has been developed that is located in an adult, academic internal medicine setting and is based on a long-term follow-up clinic model available at Children's Hospital Colorado. The clinic opened in July 2008. One hundred thirty-five patients have been seen as of April 2014. Referrals and clinic capacity have gradually increased over time, and a template has been developed in the electronic medical record to help facilitate completion of individualized care plan letters. A primary care-based, multidisciplinary consultative clinic for adults with a history of childhood cancer survivor is feasible and actively engages adult primary care resources to provide risk-based care for long-term pediatric cancer survivors. This model of care planning can help support adult survivors of pediatric cancer and their primary care providers in non-academic, community settings as well.

Combat internist: the internal medicine experience in a combat hospital in Afghanistan.

Military internists and internal medicine subspecialists are physicians who generally work in traditional internal medicine settings. However, when deployed to combat settings, they must prepare and adapt their skills for a wide spectrum of complex, polytrauma, and multinational patients. There are limitations in personnel, equipment, and technical resources that make the circumstances complex and demanding. This article highlights some of the unique roles, challenges, and experiences of four military internists at the NATO Role 3, a deployed combat hospital in Afghanistan.

Comorbidities and disease severity as risk factors for carbapenem-resistant Klebsiella pneumoniae colonization: report of an experience in an internal medicine unit.

BackgroundCarbapenem-resistant Klebsiella pneumoniae (CRKP) is an emerging multidrug-resistant nosocomial pathogen, spreading to hospitalized elderly patients. Risk factors in this setting are unclear. Our aims were to explore the contribution of multi-morbidity and disease severity in the onset of CRKP colonization/infection, and to describe changes in epidemiology after the institution of quarantine-ward managed by staff-cohorting.Methods and FindingsWith a case-control design, we evaluated 133 CRKP-positive patients (75 M, 58 F; mean age 79±10 years) and a control group of 400 CRKP-negative subjects (179 M, 221 F; mean age 79±12 years) admitted to Internal Medicine and Critical Subacute Care Unit of Parma University Hospital, Italy, during a 10-month period. Information about comorbidity type and severity, expressed through Cumulative Illness Rating Scale-CIRS, was collected in each patient. During an overall 5-month period, CRKP-positive patients were managed in an isolation ward with staff cohorting. A contact-bed isolation approach was established in the other 5 months. The effects of these strategies were evaluated with a cross-sectional study design. CRKP-positive subjects had higher CIRS comorbidity index (12.0±3.6 vs 9.1±3.5, p<0.0001) and CIRS severity index (3.2±0.4 vs 2.9±0.5, p<0.0001), along with higher cardiovascular, respiratory, renal and neurological disease burden than control group. CIRS severity index was associated with a higher risk for CRKP-colonization (OR 13.3, 95%CI6.88–25.93), independent of comorbidities. Isolation ward activation was associated with decreased monthly incidence of CRKP-positivity (from 16.9% to 1.2% of all admissions) and infection (from 36.6% to 22.5% of all positive cases; p = 0.04 derived by Wilcoxon signed-rank test). Mortality rate did not differ between cases and controls (21.8% vs 15.2%, p = 0.08). The main limitations of this study are observational design and lack of data about prior antibiotic exposure.ConclusionsComorbidities and disease severity are relevant risk factors for CRKP-colonization/infection in elderly frail patients. Sanitary measures may have contributed to limit epidemic spread and rate of infection also in internal medicine setting.

Improving Depression Care in OB-GYN Settings

Improving Depression Care in OB-GYN Settings

Characteristics and clinical management of acute pulmonary embolism in real world: findings from TUSCAN-PE Study

Acute pulmonary embolism (PE) remains one of the leading causes of mortality and morbidity in cardiovascular setting. Despite much information about clinical aspects and recommendations or clinical guidelines is available from literature, few data exist about the management of PE in real world of internal medicine scenario. Therefore the aim of the present study was to report on characteristics and management of PE patients admitted in this setting. TUSCAN-PE study was a multicenter, observational, retrospective, cohort study aimed to analyze data of PE patients admitted in Internal Medicine wards of Tuscany. Each center was invited to submit anonymously data of at least ten patients consecutively discharged for acute PE in 2012. Data were referred to demographic, clinical, instrumental, prognostic and therapeutic characteristics. A total of 452 patients from 28 Tuscan centers (60.2% F), with mean age 76.01±12.34 years, were enrolled. A total of 87% of patients was admitted from Emergency Department, but only 65.2% of patients with diagnosis of PE. Around one third of diagnoses of PE was performed by internists. In 14.8% of diagnoses was incidental. In 86% of patients, diagnosis was performed by computer tomography pulmonary angiography. Overall mortality was 9.5%, 5.75% being PE-related. Main risk factors enclosed recent respiratory tract infections (55.3%), immobility (42.25%), recent hospital admissions (33.6%) and cancer (30.3%). In 65.8% of patients, PE was associated with deep vein thrombosis. 16.6% of patients had a shock index ≥1 and 84.75% simplified pulmonary embolism severity index (PESI) score ≥1. A number of 51.5% of patients presented echocardiographic right heart dysfunction, 50.6% and 55.9% of patients presented increased values of troponins and natriuretic peptides, respectively. The following percentage, 6.5%, 71.1% and 22.4%, were defined as high, intermediate and low risk according to the European Society of Cardiology (ESC) criteria, respectively. Antithrombotic treatment was started in Internal Medicine wards in 60.6% of patients. 4.9% of patients were treated with systemic thrombolysis, 15.1% with intravenous unfractionated heparin, whereas low molecular weight heparins and fondaparinux were performed in 39.2% and 39.8% of patients, respectively. Vitamin K antagonists were prescribed in 52.1% of patients at hospital discharge. Fatal and non-fatal major bleedings occurred in 1.7% of patients. TUSCAN-PE study contributes to the knowledge of real life management of acute PE in the Internal Medicine setting.

End-stage anorexia nervosa in a young man: multifaceted metabolic, endocrine and infectious derangements managed in an internal medicine setting

Anorexia nervosa (AN) in males is an overlooked disease which requires early diagnosis and proper treatment. Clinical presentation is often severe and the risk of death is not negligible. We report the case of a young man with a 1-year history of AN who was admitted to our internal medicine department for a dramatic malnutrition (BMI: 10.5 kg/m(2)). Several biochemical and hormonal alterations were ascertained. Partial parenteral nutrition and a balanced diet were started. Asymptomatic refeeding syndrome occurred and was managed by enhanced electrolyte parenteral supplementation. Many hematologic abnormalities (anaemia, leukopenia and thrombocytopenia) were present and worsened during the occurrence of sepsis which required hemotransfusions and targeted parenteral antibiotics with improvement of both clinical condition and hematologic parameters. Bone marrow aspiration and cytofluorimetric evaluation showed hyperplasia and dysplasia of erythroid lineage and reduction of myeloid lineage. Significant body weight gain (+17 % vs. admission) was obtained and the patient was discharged with stable cardiovascular parameters and referred to an eating disorders centre where is currently followed.

Pain Prevalence and Management in an Internal Medicine Setting in Italy

Background. Since data on pain evaluation and management in patients admitted to internal medicine wards (IMWs) are limited, we aimed to evaluate these aspects in a cohort of internistic patients. Methods. We considered all patients consecutively admitted from June to December 2011 to our unit. Age, gender, and length-of-hospital-stay (LOS) were recorded. Comorbidities were arbitrarily defined, and pain severity was evaluated by Numeric Rating Scale (NRS) on admission and discharge. Results. The final sample consisted of 526 patients (mean age 74 ± 14 years; 308 women). Significant pain (NRS ≥ 3) was detected in 63% of cases, and severe (NRS ≥ 7) in 7.6%. Pain was successfully treated, and NRS decreased from 4.65 ± 2.05 to 0.89 ± 1.3 (P < 0.001). Compared with subjects with NRS < 3, those with significant pain were older (75.5 ± 13.9 versus 72.9 ± 14.5 years, P = 0.038), and had a higher LOS (7.9 ± 6.1 versus 7.3 ± 6.8, P = 0.048). Significant pain was independently associated with age (OR 0.984, P = 0.018), cancer (OR 3.347, P < 0.001), musculoskeletal disease (OR 3.054, P < 0.0001), biliary disease (OR 3.100, P < 0.01), and bowel disease (OR 3.100, P < 0.003). Conclusion. In an internal medicine setting, multiple diseases represent significant cause of pain. Prompt pain evaluation and management should be performed as soon as possible, in order to avoid patients' suffering and reduce the need of hospital stay.