Internal and Emergency Medicine最新文献

Aim:  To ascertain the potential value of pelvic point-of-care ultrasound (POCUS) in the timely management of Emergency Department (ED) patients presenting with first trimester pregnancy complications.

Objectives:  To perform a systematic review and meta-analysis with the primary outcome being the comparison of ED length of stay (ED LoS), time to ultrasound (US) diagnosis and time to operative room (OR) treatment in patients under 20 weeks gestation with complications of first trimester pregnancy when comparing POCUS to traditional specialist radiology ultrasound (RADUS).

Method: In accordance with PRISMA guidelines we performed a literature search based on specific inclusion criteria and used 2 reviewers to screen appropriate studies for inclusion. Papers were then critically appraised using RoB-2 and ROBINS-I assessment tools before having data extracted for inclusion in meta-analysis where possible.

Results:  We identified 13 papers for inclusion in systematic review which measured a single or multiple outcome measures. 10 papers addressed the ED LOS outcome, 5 studied time to ultrasound diagnosis and 4 measured time to operative treatment. Of those studies, 6 contained sufficient data to be included in meta-analysis for ED LoS and 3 could be pooled for time to US diagnosis outcome. Insufficient usable studies were identified for time to OR treatment meta-analysis. The POCUS group had a reduced ED LoS of 59.6 min (95% CI 23.6-95.5, P = 0.008) when compared to RADUS. The POCUS group also had a reduced time to US diagnosis of 81.8 min (95%CI 32.2-195.9, P = 0.09). Whilst all time to OR studies reported time savings in this area, no reliable conclusions could be drawn due to insufficient paper numbers and reported data. For all outcomes there was substantial heterogeneity between the studies relating to differing institutional workflows, measured timestamps, triage bias and range of disease severity. Almost all included studies were felt to be at serious risk of bias.

Conclusion:  Whilst the use of POCUS shows promise in improving efficiency of care for ED patients presenting with early pregnancy complications, there are significant concerns regarding the heterogeneity and generalisability of the study data. European EDs need to explore this POCUS modality more with large scale RCTs, including clearly defined patient cohorts and POCUS protocols, to reliably confirm causality of patient benefit in this area.

We aimed to assess whether the MEESSI-AHF score for 30-day mortality stratification in acute heart failure (AHF) patients presenting to the emergency department (ED) is equally accurate in men and women. As a secondary objective, we explored whether sex influences decision-making in aspects that largely depend on severity as estimated by MEESSI-AHF. We analyzed patients diagnosed with AHF in 56 Spanish ED that were consecutively included in the EAHFE registry during eight different time points between 2007 and 2022 for whom sex and MEESSI-AHF score were available. Patients were classified into the four MEESSI-AHF risk groups (low, intermediate, high, and very high) and by sex (men/women) as stated in the administrative records. We compared 30-day mortality in men and women (to independently assess the reliability of MEESSI-AHF in men and women, as MEESSI-AHF was derived to estimate the risk of death at 30 days); ED physicians' decisions regarding hospitalization and extended (> 24 h) ED observation in patients discharged home after ED care; and for hospital physicians' decisions regarding prolonged hospitalization (> 7 days) in hospitalized patients. We supposed that ED and hospital physicians' decisions should not differ between men and women in the same MEESSI-AHF risk category. These associations were tested using logistic regression and interaction analyses. The same analyses were repeated treating the MEESSI-AHF score as a continuous variable, modeled with restricted cubic splines. We included 13,042 patients (median age 83 years; 56% women). MEESSI-AHF accurately stratified 30-day mortality overall (2.9%, 9.6%, 18.2%, and 39.7% across risk groups; with a c-statistic of 0.78; p < 0.001), with no differences according to patient's sex (c-statistics of 0.77 for men and 0.78 for women, p > 0.05). We did not find sex interaction for the relationship between MEESSI-AHF score and 30-day mortality in categorical or continuous analyses (all p > 0.05). Hospital admission decisions (76%) and extended ED observation among discharged patients (9%), both made by ED physicians, as well as prolonged hospitalization (47%) determined by hospital physicians, increased with higher MEESSI-AHF risk (all p < 0.05). No sex interaction was observed in either categorical or continuous analyses (all p > 0.05).The MEESSI-AHF scale, as originally derived, provides equally reliable estimations of risk in men and women. Clinical decisions taken by ED and hospital physicians in patients with AHF did not differ in men and women with the same risk.

We report the first documented case of thrombotic microangiopathy highly suggestive of thrombotic thrombocytopenic purpura (TTP) associated with Vibrio parahaemolyticus bacteremia in an immunocompetent adult. A 62-year-old man developed acute gastroenteritis following seafood ingestion and rapidly progressed to bacteremia with severe thrombocytopenia, microangiopathic hemolytic anemia, acute kidney injury, and neurological impairment. Laboratory evaluation revealed  ~ 3% schistocytes, markedly elevated lactate dehydrogenase, indirect hyperbilirubinemia, preserved coagulation parameters, and a negative direct Coombs test. The PLASMIC score indicated a high probability of severe ADAMTS13 deficiency. Given the classical clinical presentation, urgent plasma exchange (PLEX) was initiated, resulting in rapid and sustained hematologic and clinical recovery. Blood cultures confirmed Vibrio parahaemolyticus, and targeted ciprofloxacin therapy was administered. Although ADAMTS13 activity testing was unavailable, the constellation of findings and dramatic response to PLEX strongly support a diagnosis of TTP triggered by Vibrio bacteremia. This case highlights the importance of early recognition of TTP-like TMA, even when triggered by uncommon pathogens, and demonstrates the lifesaving role of prompt PLEX therapy.

Few data are available regarding the adherence to treatment guidelines in individuals with type 2 diabetes mellitus (T2DM) admitted to Internal Medicine Wards (IMW) while no information is available concerning the possible efficacy of an educational intervention aimed at improving adherence in this setting. To explore guidelines adherence and the associated impact on glycemic control in subjects with T2DM hospitalized in IMW before and after an educational intervention, we conducted a 3-phase, cluster-randomized, multicenter study. During Phase 1, we retrospectively collected data from patients with T2DM hospitalized for any cause in IMW for ≥5 days. In Phase 2, an educational training, based on the method of the educational outreach visits (EOV), was developed in 36 out of the 54 centers involved. In Phase 3, conducted 6 months after the training, we replicated the collection of data performed in Phase 1. Overall, we analyzed data from 1909 and 1662 individuals with T2DM during Phase 1 and Phase 3 of the study, respectively. No changes were observed in the difference between mean fasting glycemia levels at discharge vs at admission in Phase 3 comparing EOV vs NO EOV groups. A statistically significant increase in adherence to guidelines was observed from Phase 1 to Phase 3 and a trend toward higher adherence was detected when comparing the EOV and the no EOV groups. A structured educational intervention improves adherence to guidelines for managing T2DM in individuals admitted to IMW but has no effect on short-term glycemic control.

High-dose dexamethasone (HDD) is widely used as first-line therapy for immune thrombocytopenia (ITP) and is administered at a fixed dose regardless of body weight. The impact of body mass index (BMI) on treatment response to HDD remains unclear. This retrospective, two-center study included 60 adult patients with newly diagnosed ITP who received HDD as first-line therapy. Demographic characteristics, BMI, baseline laboratory values, and treatment responses at 1, 6, and 12 months were analyzed. BMI was evaluated using cut-off values of 25, 27, and 30. The median number of HDD cycles administered was 1 (range: 1-4), and the median BMI at diagnosis was 27.0 kg/m² (range: 18.0-44.0). No significant differences were observed between BMI categories with regard to treatment responses at months 1 and 6 (p > 0.05 for both). However, at month 12, a complete response (CR) was more likely in patients with BMI < 30, and a partial response (PR) in those with BMI ≥ 30 (p = 0.023). Across all time points, no other demographic or clinical variable emerged as an independent predictor of treatment response (p > 0.05). The results of this study indicate that in newly diagnosed ITP patients receiving HDD as first-line treatment, BMI does not influence early or durable treatment responses, although it may have a modest adverse effect on late response. Larger prospective studies are needed to clarify underlying mechanisms and assess whether obesity-related factors should inform individualized treatment.

This study aimed to describe the competence profiles, practices, job satisfaction, and interprofessional collaboration among nurses working in Italian anticoagulation clinics (ACs) affiliated with the Italian federation of centres for the surveillance of anticoagulant therapy (FCSA). Data were collected via a web survey from December 2023 to May 2024. The information was condensed into two stochastic components using the t-distributed stochastic neighbour embedding (t-SNE) algorithm as part of the hierarchical clustering procedure, revealing two distinct clusters labelled "substandard profile" (n = 21 nurses) and "proficient profile" (n = 38 nurses). Results indicated significant variability in nursing practices, with differences in educational activities, self-reported competence, and levels of interprofessional collaboration between the two clusters. The findings underscore the importance of tailored interventions to enhance nursing practices, nursing education, and interprofessional collaboration within ACs. Future corroboration of the emerging results is warranted with longitudinal studies.

Excessive dietary salt consumption is a significant public health concern, yet awareness and behaviors regarding salt intake remain underexplored in Saudi Arabia. This cross-sectional study evaluated the knowledge, attitudes, and behaviors related to salt intake among 1,308 adults residing in Saudi Arabia, surveyed online between December 2022 and May 2023. Most respondents (95.8%) recognized health risks associated with excessive salt intake, particularly hypertension (95.5%) and kidney disease (79.4%). However, awareness of its association with heart disease (50.5%) and stroke (28.3%) was considerably lower. Although nearly half acknowledged population-level salt overconsumption, only 25.9% were aware of the recommended daily salt limit, and just 17.5% considered their personal consumption excessive. Behaviorally, around 62% rarely or never checked sodium content on food labels, and over 75% rarely or never requested low-salt meals when dining out. Significant demographic variations emerged, with women and older adults displaying greater awareness and healthier practices. These findings underscore critical gaps in knowledge and self-awareness regarding salt intake among Saudi adults. Implementing clear front-of-pack nutrition labeling and strengthening public educational campaigns are vital steps. Moreover, targeted interventions involving food manufacturers and restaurants are crucial to effectively promote healthier salt intake behaviors and support national public health goals.