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Catheter ablation encircling the pulmonary veins where they enter the left atrium was evaluated in patients with chronic atrial fibrillation. The procedure maintained sinus rhythm for one year in three quarters of the patients. Both symptoms and the diameter of the left atrium decreased. Catheter ablation is a viable option in patients with symptomatic, chronic atrial fibrillation. Catheter ablation maintained sinus rhythm for one year in three quarters of the patients. Both symptoms and the diameter of the left atrium decreased. Circumferential pulmonary-vein ablation is reported to be effective for paroxysmal and chronic atrial fibrillation. 1 – 5 However, patients with chronic atrial fibrillation typically receive temporary antiarrhythmic-drug therapy after ablation and often require one or more cardioversions to restore sinus rhythm. These are confounding variables that may inflate the efficacy of catheter ablation. Furthermore, prior studies have not systematically monitored patients for asymptomatic recurrences of atrial fibrillation on a frequent basis. Therefore, we conducted a randomized, controlled study to determine the long-term efficacy of circumferential pulmonary-vein ablation in patients with chronic atrial fibrillation while taking into account the confounding variables of antiarrhythmic-drug . . .

Background and Aims In liver disease (LD), multidisciplinary teams (MDTs) support complex decision‐making and may improve care delivery. The present study aims to evaluate the role of a multidisciplinary approach in complex cases of LD in a peripheral hospital. Methods We retrospectively analyzed a prospectively maintained MDT registry. Since November 2023, consecutive complex cases referred to the Liver Disease Outpatient Clinic of Barone Lombardo Hospital were discussed in MDT meetings. The initial proposals of clinicians were compared with the decisions taken by the team to evaluate the appropriateness of prescribing imaging tests and the need for referral. The MDT also re‐reviewed prior imaging and applied guideline‐concordant criteria to minimize low‐value testing. Results Of 52 cases presented, 1 was excluded (non‐hepatic lesion), leaving 51 patients analyzed. The median age was 60 years, 32 patients (62.7%) were female, and 27 patients (52.9%) had chronic LD. A total of 22 imaging tests and 1 liver biopsy were avoided, and no patients were referred to a secondary or tertiary hospital. Conclusions The multidisciplinary approach in a peripheral hospital appears to improve the appropriateness of prescribing imaging tests with consequent reduction of costs and contrast‐related adverse events. It also allows for a better allocation of resources and avoids unnecessary referrals to secondary and tertiary hospitals, with potential benefits for patient experience and diagnostic safety. Summary What's known ◦ Mcommunity /community hospitals across the broader LD spectrum is scarce. What's new ◦ In this real‐world series (n = 51), MDT review avoided 22 imaging tests and 1 biopsy and eliminated referrals to higher‐level hospitals. Clinical implications ◦ Implementing MDTs in community settings may curb low‐value imaging, reduce potential harm from contrast exposure, and optimize local resource use.

An amendment to this paper has been published and can be accessed via the original article.

As the main title ‘COVID-19 revolution: a new challenge for the internist’ states, the global coronavirus infection disease 2019 (COVID-19) pandemic represented a new challenge for the internists. This paper is part of a series of articles written during the difficult period of the ongoing global pandemic and published all together in this fourth issue of the Italian Journal of Medicine, with the aim of sharing the direct experiences of those who were the first to face this severe emergency, expressing each point of view in the management of COVID-19 in relation to other diseases. Each article is therefore the result of many efforts and a joint collaboration between many colleagues from the Departments of Internal Medicine or Emergency Medicine of several Italian hospitals, engaged in the front line during the pandemic. These preliminary studies therefore cover diagnostic tools available to health care personnel, epidemiological reflections, possible new therapeutic approaches, discharge and reintegration procedures to daily life, the involvement of the disease not only in the lung, aspects related to various comorbidities, such as: coagulopathies, vasculitis, vitamin D deficiency, gender differences, etc.. The goal is to offer a perspective, as broad as possible, of everything that has been done to initially face the pandemic in its first phase and provide the tools for an increasingly better approach, in the hope of not arriving unprepared to a possible second wave. This paper in particular deals with hypovitaminosis D and COVID-19.

Fecal microbiota transplantation (FMT) has emerged as a potential therapeutic strategy for modulating gut dysbiosis in diabetes mellitus. This review critically evaluates preclinical and clinical evidence on FMT in type 1 (T1D) and type 2 diabetes (T2D). Studies suggest that FMT can restore microbial diversity, improve glycemic control, and modulate immune responses, with varying effects across diabetes subtypes. In T1D, preclinical models demonstrate that FMT influences regulatory T-cell expansion and β-cell preservation, though clinical translation remains limited. In T2D, FMT has shown transient improvements in insulin sensitivity, with sustained effects observed only in patients with specific microbiome signatures. However, heterogeneity in patient responses, donor variability, and methodological limitations complicate its clinical application. This review highlights the interplay between FMT, immune modulation, and microbial metabolism, advocating for phenotype-stratified trials and multi-omics integration to enhance therapeutic precision.

Patients on hemodialysis (HD) who undergo surgery represent a high risk group requiring careful perioperative management to avoid electrolyte imbalance and hemodynamic instability. The aim of the study was to analyze the postoperative outcome in terms of complications and survival of a group of patients on HD who had undergone pulmonary resection for non‐small cell lung cancer (NSCLC). Six patients on HD underwent seven pulmonary resections at our institution from 1998 to 2003. The underlying kidney disease was nephrosclerosis in two patients and glomerulonephritis in four. The mean levels of blood urea nitrogen and serum creatinine were 107 ± 11.5 mg/dl and 7.9 ± 0.64 mg/dl, respectively. The mean preoperative PO2 and FEV1 were 77.6 ± 2.4 mmHg and 2.4 ± 0.16 liters, respectively. The histologic diagnosis was squamous cell carcinoma in four cases and adenocarcinoma in three. One patient underwent two lung resections in 4 years for two primary lung cancers. Five patients underwent lobectomy, one underwent a wedge resection, and in one case pneumonectomy was performed after neoadjuvant chemotherapy. There was no operative mortality. Postoperatively, atrial fibrillation occurred in two patients associated with sputum retention in both, and two other patients had hyperkalemia (complication rate 57%). One patient died of cardiac complications 27 months after surgery. The remaining five patients are currently alive with no evidence of disease. Patients on HD who undergo lung resection have a high rate of postoperative complications. Although the underlying disease influences long‐term survival, radical lung resection in NSCLC patients is recommended in selected cases. Careful metabolic, hematologic, and pharmaceutical management is mandatory during the perioperative period.

Despite advances in diagnostic methods, surgical techniques, and supportive therapy, chronic parapneumonic empyema is still associated with considerable morbidity and mortality. A prospective study was performed on a consecutive series of patients with chronic parapneumonic empyema to analyze the results of surgical treatment and identify clinical predictors of poor outcome. From 1993 to 2000 a total of 40 patients underwent decortication for chronic parapneumonic empyema. There was no mortality. All 40 patients had definitive resolution of the empyema. Altogether, 34 patients (87.5%) had an uneventful postoperative course, and 5 (12.5%) experienced complications (2 prolonged febrile syndromes, 3 cases of sepsis requiring mechanical respiratory assistance). All complications resolved well with adequate treatment without further consequences. Definitive results of the surgical procedures assessed at the 6‐month follow‐up examination were good in 21 patients and satisfactory in 19. No unsatisfactory results were observed in any of the patients. Univariate analysis showed that three variables predicted morbidity: co‐morbidities (p = 0.039), symptom duration ≥ 60 days (p = 0.009), and duration of preoperative conservative treatment ≥ 30 days (p = 0.006). Multivariate analysis showed that only symptom duration ≥ 60 days (p = 0.041) and duration of conservative treatment ≥ 30 days (p = 0.025) were associated with morbidity. Decortication is a highly effective treatment for chronic parapneumonic empyema and may be performed with low morbidity and mortality. Because prolonged duration of symptoms and conservative treatment increase morbidity, early surgical intervention seems to be the optimal modality for the treatment of chronic parapneumonic empyema.

Background Circadian disruption and deranged molecular clockworks are involved in carcinogenesis. The cryptochrome genes ( CRY1 and CRY2 ) encode circadian proteins important for the functioning of biological oscillators. Their expression in human colorectal cancer (CRC) and in colon cancer cell lines has not been evaluated so far. Methods We investigated CRY 1 and CRY 2 expression in fifty CRCs and in the CaCo2, HCT116, HT29, SW480 cell lines. Results CRY 1 ( p  = 0.01) and CRY 2 ( p  < 0.0001) expression was significantly changed in tumour tissue, as confirmed in a large independent CRC dataset. In addition, lower CRY 1 mRNA levels were observed in patients in the age range of 62-74 years ( p  = 0.018), in female patients ( p  = 0.003) and in cancers located at the transverse colon ( p  = 0.008). Lower CRY 2 levels were also associated with cancer location at the transverse colon ( p  = 0.007). CRC patients displaying CRY 1 ( p  = 0.042) and CRY 2 ( p  = 0.043) expression levels over the median were hallmarked by a poorer survival rate. Survey of selected colon cancer cell lines evidenced variable levels of cryptochrome genes expression and time-dependent changes in their mRNA levels. Moreover, they showed reduced apoptosis, increased proliferation and different response to 5-fluorouracil and oxaliplatin upon CRY 1 and CRY 2 ectopic expression. The relationship with p53 status came out as an additional layer of regulation: higher CRY1 and CRY2 protein levels coincided with a wild type p53 as in HCT116 cells and this condition only marginally affected the apoptotic and cell proliferation characteristics of the cells upon CRY ectopic expression. Conversely, lower CRY and CRY2 levels as in HT29 and SW480 cells coincided with a mutated p53 and a more robust apoptosis and proliferation upon CRY transfection. Besides, an heterogeneous pattern of ARNTL , WEE and c-MY C expression hallmarked the chosen colon cancer cell lines and likely influenced their phenotypic changes. Conclusion Cryptochrome gene expression is altered in CRC, particularly in elderly subjects, female patients and cancers located at the transverse colon, affecting overall survival. Altered CRY 1 and CRY 2 expression patterns and the interplay with the genetic landscape in colon cancer cells may underlie phenotypic divergence that could influence disease behavior as well as CRC patients survival and response to chemotherapy.

In recent years, significant progress has been made in furthering our knowledge of chronic liver disease (CLD) and evaluating the therapeutic approaches. These have been updated in the form of recommendations by international scientific societies. Through a retrospective analysis, this study aimed to verify whether these recommendations have been applied in real practice. The study design included data gathered from all patients consecutively hospitalized for decompensated liver cirrhosis during one year. A pre-made master form was used to record data on the patients’ past knowledge of the etiology and management of their liver disease. As expected, hepatitis C virus (HCV) was the most frequent cause of CLD, while 41 cases were cryptogenic. In 69 of 263 patients with HCV infection, viral genotyping had been performed, although only 39 of these cases had been treated. Only 3 of 44 patients suffering from hepatitis B virus (HBV)-related liver cirrhosis had been treated in the past, while 11 patients were still being treated. Among the remaining patients, 15 were not aware that they had CLD and 15 had never been considered for antiviral treatment. In 81 cases, the disease had progressed to hepatocellular carcinoma, but only 19 patients had discovered the tumor following regular ultrasound screening. Thirty-seven patients were receiving specific treatment consistent with the stage of their disease. The management of HBV- and HCV-related CLD in Sicily is far from optimal, and although the natural history and management practices of these diseases are well known, this knowledge is a long way from being applied in our daily practice.

Background The burden of cardiovascular (CV) complications in patients hospitalised for community-acquired pneumonia (CAP) is still uncertain. Available studies used different designs and different criteria to define CV complications. We assessed the cumulative incidence of acute of CV complications during hospitalisation for CAP in Internal Medicine Units (IMUs). Methods This was a prospective study carried out in 26 IMUs, enrolling patients consecutively hospitalised for CAP. Defined CV complications were: newly diagnosed heart failure, acute coronary syndrome, new onset of supraventricular or ventricular arrhythmias, new onset hemorrhagic or ischemic stroke or transient ischemic attack. Outcome measures were: in-hospital and 30-day mortality, length of hospital stay and rate of 30-day re-hospitalisation. Results A total of 1266 patients were enrolled, of these 23.8% experienced at least a CV event, the majority (15.5%) represented by newly diagnosed decompensated heart failure, and 75% occurring within 3 days. Female gender, a history of CV disease, and more severe pneumonia were predictors of CV events. In-hospital (12.2% vs 4.7%, p  < 0.0001) and 30-day (16.3% vs 8.9%, p  = 0.0001) mortality was higher in patients with CV events, as well as the re-hospitalisation rate (13.3% vs 9.3%, p  = 0.002), and mean hospital stay was 11.4 ± 6.9 vs 9.5 ± 5.6 days (p < 0.0001). The occurrence of CV events during hospitalisation significantly increased the risk of 30-day mortality (HR 1.69, 95% CI 1.14–2.51; p  = 0.009). Conclusion Cardiovascular events are frequent in CAP, and their occurrence adversely affects outcome. A strict monitoring might be useful to intercept in-hospital CV complications for those patients with higher risk profile. Trial registration NCT03798457 Registered 10 January 2019 - Retrospectively registered