Internal and Emergency Medicine最新文献

Emergency Medicine (EM) is facing a global crisis. System demands and utilization are increasing, while resources are constrained, putting society's healthcare safety net at risk. In order to approach this crisis, many areas of reform have been suggested (Heymann et al. in Intern Emerg Med, 2024). The first step is the recognition of EM as a specialty of its own. This will give Emergency Physicians (EPs) the potential to take control of their profession. Similar to other examples of bottom-up and horizontalization approaches ( Laloux, F., & Wilber, K. (2014). Reinventing organizations: A guide to creating organizations inspired by the next stage of human consciousness.), empowering EPs to provide solutions to wellbeing and resilience issues can only occur if EPs are allowed to organize and control their training, activity, research, and field of action. Traditional models have seen EM as a subspecialty or a secondary degree completed after initial training in an already established profession (e.g., internal medicine). These models ultimately result in longer training pathways and risk trainee and trainer fatigue. Furthermore, in these models, the profession is directed by specialties who do not face the daily challenges of modern EM. The following paper discusses the advantages of recognizing EM as a specialty and how this benefits wellbeing and resilience. The result is that EM recognition protects a cornerstone of the healthcare system.

Elderly patients (≥ 75 years) often require resuscitation room (RR) care in the emergency department (ED), yet decisions regarding intensive care unit (ICU) admission remain complex. Assessment of quality of life and frailty is necessary to determine the level of care required for elderly patients. The Clinical Frailty Scale (CFS) is a validated tool for assessing frailty and predicting mortality, but its role in ICU triage remains unclear. The aim of this study was to compare the CFS of patients admitted to the ICU with those admitted to the general inpatient unit (GIU) after receiving initial intensive care. This was a retrospective, single-center study including patients aged ≥ 75 years admitted to the ED RR from November 1, 2023, to March 31, 2024. The primary outcome was the comparison of CFS between ICU and GIU admissions after RR management. Secondary outcomes included predictive performance of CFS for ICU admission and in-hospital mortality. Of the 392 patients enrolled, 170 (43%) were admitted to the ICU and 222 (57%) to the GIU. The median CFS was 3 (2-4) in ICU-admitted patients and 4 (3-5) in GIU-admitted patients (p < 0.001). In-hospital mortality rate was 30/170 (18%) in the ICU-admitted group and 35/222 (16%) in the GIU-admitted group (p = 0.72). CFS predictive value for ICU admission had an area under the curve of 0.68 (95% confidence interval (95%CI): 0.63-0.73) and for in-hospital mortality of 0.62 (95%CI: 0.55-0.69). In elderly patients admitted to the RR, CFS values differed between those admitted to ICU and those admitted to GIU. However, the discriminative performance of CFS for hospital orientation and in-hospital mortality was limited. These findings suggest that frailty assessment may contribute to the overall evaluation of elderly patients in the ED RR but should be interpreted in conjunction with acute severity scores and clinical judgment.

Use of menthol-flavored (vs. tobacco-flavored) electronic nicotine delivery systems (ENDS) may be associated with higher rates of complete switching among adults who smoke (AWS). This paper evaluates the association over 2 years, while considering robustness across different missing-data approaches. 22,905 US AWS and purchased JUUL ENDS were enrolled in a longitudinal cohort study and completed up to 10 follow-ups. To assess potential bias due to missingness, analyses: (a) compared participant characteristics by levels of missingness and (b) assessed whether tobacco or menthol JUUL was associated with missingness. The association of menthol (vs. tobacco) JUUL with switching (no past 30-day smoking) was evaluated using four missing-data treatments: (1) non-missing data-only; (2) imputing smoking for missing ('missing-as-smoking'); imputing outcome from participant characteristics and previous switching (3) one time, and (4) Multiple Imputations. Survey completion was minimally associated with participant characteristics (each explaining < 0.4% of variance) or flavor (< 2% between-flavor difference). In observed data, menthol was significantly associated with a higher switch rate than tobacco (adjusted risk ratio = 1.12 [95% CI = 1.09-1.16], model-based average switching probability: 51.6% vs. 45.9%). Effects were similar across all approaches, including Missing-as-Smoking (1.15 [1.11-1.18]; 44.1% vs. 38.4%), Single Imputation (1.12 [1.09-1.16]; 51.3% vs. 45.7%), and Multiple Imputation (1.11 [1.08-1.15]; 51.9% vs. 46.6%). The added benefit of menthol- (vs. tobacco-flavored) JUUL was concentrated among adults smoking non-mentholated cigarettes. AWS using menthol JUUL, especially those smoking non-menthol cigarettes, were more likely to switch completely than those using tobacco JUUL. Consistent results across several approaches suggested minimal bias due to missing data.

Chronic thromboembolic pulmonary hypertension (CTEPH) is an uncommon complication of acute pulmonary embolism (PE), resulting in elevated pulmonary pressure and higher risk of PE recurrence. Therefore, lifelong anticoagulant therapy is mandatory in patients diagnosed with this condition. Despite anticoagulation with vitamin K antagonists (VKAs) has always represented the standard of care in this setting, the spread of direct oral anticoagulants (DOACs) raised the question of the potential applicability of their use also in CTEPH. We performed a systematic review and meta-analysis of randomized and observational studies focusing on patients with CTEPH treated with either VKAs or DOACs. Key clinical outcomes as venous thromboembolism (VTE) recurrence, bleedings (major bleeding, clinically relevant non-major bleeding, and intracranial hemorrhage), and mortality were evaluated. Overall, 12 studies including 4071 patients were selected in the quantitative analysis, 10 had an observational design. We found no difference between DOACs and VKAs for VTE recurrence (RR 0.99, 95% CI 0.40-2.43), overall bleedings (RR 0.77, 95% CI 0.45-1.32), and all-cause death (RR 0.58, 95% CI 0.30-1.14). These results were consistent for the aforementioned outcomes also in a sensitivity analysis pooling the results of RCTs and prospective studies only (OR 0.75, 95% CI 0.24-2.38; OR 0.59, 95% CI 0.22-1.56; OR 0.69, 95% CI 0.01-74.68; respectively). DOACs appear to be as effective and safe as VKAs for patients with CTEPH, therefore their use may be considered in the absence of clinical contraindications. Larger randomized controlled trials are warranted to further confirm our findings.

Heart rate control is an important strategy for the management of patients with atrial fibrillation (AF). However, there remains some uncertainty for the optimal target heart rate of AF patients. COOL-AF was a prospective multicenter registry of patients with non-valvular AF. Patients were followed-up every 6 months until 3 years. The primary outcome was the composite of cardiovascular death, heart failure, and ischemic stroke/systemic embolism (SSE). A total of 3405 patients were studied (mean age 67.8 ± 11.3 years; 41.8% female). Mean heart rate was 77.4 ± 16.2 bpm. Number of patients with baseline heart rate < 60, 60-80, 80-100, and ≥ 100 bpm was 371 (10.9%), 1616 (47.4%), 1116 (32.8%), and 302 (8.9%), respectively. The overall incidence rates of the composite outcome, heart failure event, CV death, and SSE were 4.97 (4.51-5.47), 2.84 (2.49-3.21), 1.34 (1.11-1.60), and 1.51 (1.26-1.78) per 100 person-years, respectively. When compared to those with heart rate in the range 60-80 bpm, AF patient with heart rate > 100 bpm had the highest incidence rate of the composite outcome (7.06 per 100 person-years) with the unadjusted and adjusted hazard ratios (95%CI) of 1.59 (1.17, 2.16) (p = 0.003) and 1.51 (1.11-2.07) (p = 0.009), respectively. The analysis of dynamic changes in heart rate demonstrated more prominent results with the unadjusted and adjusted hazard ratios (95%CI) of 1.84 (1.40, 2.40) (p < 0.001) and 1.76 (1.34-2.37) (p < 0.001), respectively. In conclusion, there is a J-curve pattern for the relation of baseline resting heart rate and the composite outcome in patients with AF. Patients with heart rate greater than 100 are the highest risk group.

This retrospective cohort study, conducted between December 2022 and December 2023, aims to observe the efficacy of bedside ultrasound-informed cardiopulmonary resuscitation (CPR) in determining the possible etiology of cardiac arrest, increase the success rate of CPR, shorten the recovery of spontaneous circulation (ROSC) time, and improve the prognosis. The patients were placed into two groups: ultrasound and conventional, to find the causes of cardiac arrest and promptly address them. The differences in the discovery rate of the possible causes of cardiac arrest, CPR success rate, and ROSC time between the two groups of patients were statistically significant (P < 0.05). The effect of the right-sided peak systolic velocity (PSV) of the common carotid artery (CCA) (CCA-PSV) on the success rate of CPR was statistically significant (P < 0.05). The difference between the mean hospital stay and 28-day survival rate of the two groups was not statistically significant (P > 0.05). The use of bedside ultrasound-informed CPR can help in determining the possible causes of cardiac arrest in some patients and can improve the success rate of CPR and shorten the time of ROSC. However, there was no significant difference in shortening the mean hospital stay and increasing the 28-day survival rate. A correlation was noted between the right-sided CCA-PSV and the CPR success rate and ROSC time in patients in the ultrasound group.

Gastrointestinal bleeding (GIB) and acute myocardial infarction (AMI) are major emergencies with rising evidence of a bidirectional relationship. Post-AMI antithrombotics increase GIB risk, while GIB may worsen cardiac outcomes. While short-term effects are recognized, long-term mortality trends for co-occurring GIB and AMI remain understudied. We examined temporal and demographic mortality patterns in the U.S. from 1999 to 2020. We used CDC WONDER mortality data for adults aged ≥25 years. Deaths listing both GIB and AMI as underlying or contributing causes were included. Age-adjusted mortality rates (AAMRs) per 100,000 were calculated, and Joinpoint regression was used to estimate annual percent change (APC) and average APC (AAPC), stratified by sex, age, race/ethnicity, and urban-rural status. A total of 51,113 deaths were attributed to GIB and AMI. AAMR declined from 1.72 in 1999 to 0.81 in 2020 (AAPC -3.9%), with the steepest decline from 2002 to 2010 (APC -7.5%). Males had higher mortality than females (1.43 vs. 0.81). Non-Hispanic Black individuals had the highest AAMR (1.26) but also a steep decline (AAPC -4.43%). AAMRs were higher in rural (1.01) than urban areas (0.94). The 85+ age group had the highest mortality but greatest decline (AAPC -4.15%). The Northeast had the highest regional AAMR (1.15). From 1999 to 2020, U.S. mortality from GIB and AMI declined significantly, likely due to improved cardiovascular and bleeding risk management. However, persistent disparities by sex, race, age, and geography remain, underscoring the need for more targeted and equitable strategies.