Internal and Emergency Medicine最新文献

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.

Point-of-care ultrasound (PoCUS) has emerged as a critical tool for diagnosing intrauterine pregnancy (IUP) in symptomatic first-trimester patients, particularly in emergency settings. This meta-analysis aims to evaluate the test characteristics of PoCUS in diagnosing IUP. As a secondary objective, this study will also examine the accuracy of PoCUS in detecting fetal cardiac activity (FCA). This systematic review and meta-analysis was conducted following the PRISMA-DTA guidelines with the protocol registered in PROSPERO (ID: CRD42024596206). We performed a comprehensive search of PubMed, Scopus, Web of Science, Cochrane Library and Google Scholar up to November 2024, identifying studies that compared PoCUS to reference standards for IUP diagnosis. Seven studies (n = 1716) were included in the meta-analysis. Two independent reviewers performed study selection, data extraction, and quality assessment using the QUADAS-2 tool. A bivariate random-effects model was used to pool the diagnostic accuracy metrics. In this meta-analysis, PoCUS demonstrated a pooled sensitivity of 86.3% (95% CI: 75.6%-92.8%, I² = 89.8%) and a specificity of 98.2% (95% CI: 86.6%-99.8%, I² = 72.6%) for the identification of IUP. Sensitivity analysis showed a significant decrease in heterogeneity for specificity (from 72.6% to 0%), along with a slight increase in sensitivity (88.5%). The pooled positive likelihood ratio was 39.01 (95% CI: 16.00-95.1), and the negative likelihood ratio was 0.10 (95% CI: 0.05-0.21). Moreover, subgroup analysis revealed higher sensitivity (92%) in studies using transvaginal ultrasound as the reference standard. In addition, PoCUS demonstrated high specificity (100%) and variable sensitivity (81-96%) for identifying FCA across three studies, but the limited number of studies prevented further meta-analysis. PoCUS is highly effective for diagnosing IUP in symptomatic first-trimester patients, allowing for the ruling out of ectopic pregnancy. However, when PoCUS is negative or indeterminate, follow-up strategies such as serial β-hCG, repeat ultrasound, or clinical reassessment remain essential to ensure diagnostic safety.

Smoke inhalation is a leading cause of fire-related deaths, primarily due to toxic gases like carbon monoxide (CO) and hydrogen cyanide (HCN). Both gases often coexist in fire victims, but while CO poisoning is commonly recognized in emergency settings, HCN intoxication is often underdiagnosed, partly due to the lack of rapid diagnostic tools and the overlapping clinical presentation with CO poisoning. Diagnosis must therefore rely on presumptive clinical suspicion based on clinical and laboratory findings. Early recognition is crucial for initiating appropriate treatment. The objective of the study was to describe the prevalence and clinical characteristics of presumptive HCN poisoning among fire victims, using clinical and analytical criteria. This study also aims to evaluate the overlap with CO poisoning and discuss surrogate markers that may aid in clinical suspicion. A retrospective observational study over 10 years was conducted at a tertiary-care hospital emergency department. Fire victims were identified through electronic records, and those with arterial blood gas analysis were included. Presumptive HCN diagnosis was established according to predefined criteria, including the presence of neurological or cardiovascular symptoms, carboxyhemoglobin > 15%, or lactate > 7.5 mmol/L. These criteria, while based on literature, are also commonly associated with severe CO poisoning. Therefore, the diagnosis of HCN poisoning remains non-confirmatory. Out of 172 patients, 26.2% had CO poisoning and 8.1% met criteria for presumptive HCN poisoning, all of whom also had CO intoxication. The presence of nasal soot was associated with a high negative predictive value, but failed to identify positive cases, suggesting its utility primarily as a tool to rule out HCN intoxication. Neurological symptoms were common, but frequently unrecognized. Only 42.9% of HCN intoxications were correctly identified in the emergency department, with a significant number of cases missed, particularly those with neurological signs. No patients had lactate > 7.5 mmol/L, although HCN-intoxicated patients showed higher mean levels than other groups. Among the correctly diagnosed, all received hydroxocobalamin, while undiagnosed patients did not. One patient, who was not given hydroxocobalamin, died with concurrent presumptive HCN poisoning. It is unknown whether this contributed to his death. HCN poisoning remains underrecognized in fire victims. Because confirmatory testing is lacking, diagnosis must be considered presumptive based on predefined criteria. Clinical signs traditionally used for CO severity may also suggest possible HCN exposure, but their specificity is limited and must be interpreted with caution. The absence of airway soot may help rule out HCN poisoning. Our findings underscore the importance of clinical vigilance in the absence of confirmatory testing.

The aim is to investigate the value and mechanism of action of LINC00963 in septic cardiomyopathy (SCM). A total of 85 patients with cardiomyopathy (control group) and 108 SCM patients were enrolled. An in vitro model was created by treating cardiomyocytes with 1 μg/mL of LPS. A sepsis mouse model was created using cecal ligation and puncture (CLP). Cox analysis was used to identify factors independently influencing mortality. Kaplan-Meier curves were used to record patient prognosis. RT-qPCR was used to detect gene expression. CCK8 and flow cytometry were employed to evaluate cell function. ELISA was used to detect inflammatory factor expression. Dual luciferase reporter and RIP validation were employed to confirm gene-targeted interactions. Upregulation of LINC00963 was observed in serum from patients with septic cardiomyopathy, heart tissue from septic mice, and LPS-infected cardiomyocytes, while miR-98-5p was downregulated. Patients with high LINC00963 expression had lower survival rates and were more likely to experience fatal outcomes. Both LINC00963 and BNP/NT-proBNP were both independent factors influencing patient mortality, and it was predicted that miR-98-5p was a target gene of LINC00963. Following si-LINC00963 transfection, apoptosis was reduced and inflammatory levels decreased in cardiomyocytes and myocardial tissue from sepsis-induced mice, and miR-98-5p was downregulated. However, the use of a miR-98-5p inhibitor reversed the cellular functional and inflammatory changes induced by LINC00963 knockdown. Knocking down LINC00963 reduces apoptosis and inflammation levels, and promotes cell proliferation by targeting miR-98-5p. This reduces the damage caused by sepsis to cardiomyocytes.