Internal and Emergency Medicine最新文献

This cross-sectional observational study assessed exposure to a selected combustible cigarette (CC) smoke constituent and biomarkers of potential harm (BoPH) in healthy adults who exclusively used a heated tobacco product (direct heating tobacco system, platform 3, generation 3, version a [DT3.0a] group, n = 304), smoked CC (CC group, n = 102), or had never smoked CC (NS group, n = 102), to evaluate biomarker profiles relevant to health risks associated with smoking. Relative to the CC group, exposure to 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone was 39.1% lower in the DT3.0a group (p < 0.01), and several BoPH were lower in the DT3.0a group, including 2,3-dinor-thromboxane-B2 (- 19.4%, p = 0.04), 11-dehydrothromboxane-B2 (- 10.2%, p = 0.25), 8-epi-prostaglandin-F2α (- 7.2%, p = 0.42), and white blood cell count (- 11.6%, p = 0.05). Relative to the CC group, high-density lipoprotein cholesterol was 32.0% higher in the DT3.0a group (p < 0.01) with pulmonary function parameters also being higher, although the differences were not statistically significant. For these biomarkers, the NS group exhibited trends similar to those observed in the DT3.0a group. In contrast to previous findings, soluble intercellular adhesion molecule-1 levels were similar between the CC and NS groups and highest in the DT3.0a group, suggesting that further assessments may be more appropriate in the context of change in values. Except for this point, the DT3.0a group showed BoPH profiles trending in the direction toward those of the NS group, suggesting that the health risks associated with smoking are potentially lower in DT3.0a use compared to CC smoking.Trial Registration : Prior to the recruitment, the study was registered at the UMIN Clinical Trials Registry on December 27, 2022(UMIN000049840).

ST-segment elevation myocardial infarction (STEMI) remains a condition with high morbidity despite advancements in treatment. Physical examination for heart failure and identification of mechanical complications can be inconsistent. Point-of-care ultrasound (POCUS) has proven valuable in acute cardiovascular care. We developed the Focused Assessment in STEMI (FASTEMI) protocol to enhance early evaluation, identify complications, and guide management. This single-center prospective cohort study included patients with presumed STEMI between June 2023 and June 2024. The FASTEMI protocol was performed upon admission and comprised lung ultrasound to assess congestion, and cardiac ultrasound to evaluate ventricular function, detect mechanical complications, measure left-ventricular outflow tract velocity-time integral, and assess the inferior vena cava. A total of 214 patients had a confirmed diagnosis of STEMI, whereas 17 were diagnosed with other conditions. FASTEMI altered diagnosis or management in 33 cases (14%) (CI 95% = 11.2 - 20.9). Identification of left ventricular (OR 1.26, 95% CI = 1.11-1.43; p < 0.001), right ventricular (OR 1.3, 95% CI = 1.04-1.75; p < 0.001), and biventricular dysfunction (OR 1.96, 95% CI 1.14-3.38; p < 0.001) were associated with in-hospital mortality. A normal FASTEMI exam had a 97% negative predictive value for mortality and did not delay door-to-balloon time. FASTEMI enhances early diagnosis, risk stratification, and management of STEMI. It enables rapid identification of complications, optimizes individualized treatment, and provides prognostic information without prolonging door-to-balloon time. Its feasibility supports its role as an adjunctive bedside tool.

The present study investigated the association between smoking and undifferentiated peripheral inflammatory arthritis (UPIA) compared with healthy controls. Data were derived from the Connective Tissue Diseases Research Center Undifferentiated Arthritis (CTDRC-UA) cohort, which includes patients older than 16 years with persistent inflammatory arthralgia or arthritis for more than two weeks who do not fulfill classification criteria for any established rheumatic disease. A current smoker was defined as an individual actively smoking at study entry, while past smokers were those who had quit; both groups were categorized as ever smokers. After propensity score matching, 413 UPIA patients were compared with 413 matched controls. The prevalence of ever smoking was similar between UPIA and controls (9.3% vs. 9.4%). Multivariate analysis adjusted for age, sex, marital status, body mass index, and educational level showed no significant association between smoking and UPIA risk (OR 0.81, 95% CI 0.43-1.54, p = 0.523). During a median follow-up of 39 months, patients exhibited three disease trajectories: self-limited disease, progression to another rheumatic disease, or persistent undifferentiated arthritis. Smoking status did not differ significantly across these outcome groups. These findings suggest that smoking is not a universal risk factor for UPIA and does not substantially influence disease outcomes, underscoring the heterogeneity of UPIA and its complex gene-environment interactions. Future prospective studies with detailed exposure assessment should address current limitations-particularly in defining and quantifying smoking exposure-before integrating these results into broader evidence syntheses.

Dual use of electronic and combustible cigarettes among adolescents is an emerging public health concern, particularly in countries experiencing rapid shifts in tobacco and nicotine product availability. This study examined the prevalence and correlates of ever and current dual use among adolescents aged 13-15 in Saudi Arabia. We analysed data from the 2022 Saudi Arabia Global Youth Tobacco Survey (GYTS), a nationally representative, school-based cross-sectional survey. Ever dual use was defined as having ever tried both cigarettes and e-cigarettes, while current dual use was defined as past 30-day use of both products. We used survey-weighted logistic regression to examine predictors of dual use. In the 2022 GYTS, 12.6% of adolescents had ever smoked cigarettes and 14.4% had ever used e-cigarettes; 2.9% and 5.4% were current users, respectively. Among 5,436 adolescents aged 13-15, 5.3% (95% CI: 4.3-6.4) reported ever dual use and 1.4% (95% CI: 1.1-1.9) reported current dual use. Ever dual use was associated with being aged 15 compared to 13 years (AOR = 1.82, 95% CI: 1.14-2.91, p = 0.013), having ≥ 50 SAR weekly spending money compared to none (AOR = 1.60, 95% CI: 1.04-2.45, p = 0.032), having at least one parent who smoked vs none (AOR = 1.64, 95% CI: 1.18-2.28, p = 0.004), having close friends who smoked vs none (AOR = 5.01, 95% CI: 3.62-6.92, p < 0.001), being offered free nicotine products vs not offered (AOR = 2.96, 95% CI: 2.30-3.81, p < 0.001), and perceiving quitting nicotine as difficult vs not difficult (AOR = 1.85, 95% CI: 1.41-2.43, p < 0.001). Supporting both indoor and outdoor smoking bans vs not supporting bans (AOR = 0.40, 95% CI: 0.29-0.55, p < 0.001) and perceiving tobacco as less attractive vs more attractive (AOR = 0.63, 95% CI: 0.43-0.94, p = 0.023) were protective. Similar correlates were found for current dual use, notably having close friends who smoked vs none (AOR = 8.61, 95% CI: 4.21-17.61, p < 0.001) and being offered free nicotine products vs not offered (AOR = 2.82, 95% CI: 1.59-5.01, p = 0.001). Dual use among Saudi adolescents appears to be influenced by peer dynamics, product availability, and permissive social norms. Caution is warranted in interpreting associations due to potential reverse-causal explanations. These findings highlight the urgent need for tailored prevention and stronger policy enforcement.

Background: Focal liver lesions cannot always be characterized with certainty by using CT, MRI, or PET. In these cases, the Radiologist or Nuclear Medicine specialist often recommends performing CEUS.

Purpose: the main aim was to determine the accuracy of CEUS in characterizing (as benign or malignant) focal liver lesions for which CT, MRI, and/or PET have not provided conclusive results.

Material and methods: a retrospective study was conducted by enrolling patients referred to our ultrasound unit to undergo CEUS examination based on the recommendation of the radiologist to characterize a focal liver lesion identified by CT, MRI, or PET. The reference gold standard was the histological examination in cases where it was performed; otherwise, findings from radiological and clinical follow-up were considered.

Results: A total of 109 patients were enrolled in the study. Of these, 11 (10.1%) were not included in the analysis. The remaining 98 patients underwent ultrasound and CEUS examinations. Regarding the diagnostic accuracy of CEUS to characterize the nature of focal liver lesions in comparison with the reference standard, the method was characterized by an area under the curve (AUC) of 0.92 (95% CI: 0.83-1.00). The sensitivity of CEUS was 88.9% (95% CI: 65.3%-98.6%) and the specificity was 97.5% (95% CI: 91.2%-99.7%). For lesions smaller than 1 cm in diameter, all lesions in this category were characterized as benign on CEUS. For lesions between 1 and 2 cm in size, the AUC reached 1.00, with both sensitivity and specificity at 100%, suggesting an optimal performance of CEUS for this category of lesions. Regarding lesions larger than 2 cm, the AUC was 0.96 (95% CI: 0.85-1.00). Sensitivity was 90.9% (95% CI: 58.7%-99.8%), and specificity was 100% (95% CI: 78.2%-100%).

Conclusions: CEUS proves to be a valuable diagnostic tool in the characterization of focal liver lesions, improving clinical management with a less invasive approach. CEUS may be an integral part of the diagnostic pathway for patients with indeterminate focal liver lesions. Key results CEUS demonstrated an overall AUC of 0.92 in characterizing indeterminate focal liver lesions. Sensitivity was 88.9%, with specificity of 97.5%. For lesions measuring 1-2 cm, CEUS achieved 100% sensitivity and specificity.

As point-of-care echocardiography (POCE) has expanded beyond cardiology into general emergency medical practice, there has been a lack of standardized, evidence-based imaging protocols and training, thus leading to challenges with respect to the quality of cardiac imaging for acute cardiovascular syndromes. The ENDEMIC study aims to assess the effectiveness of POCE based on structured training for noncardiologists on the management of patients with acute chest pain in emergency departments. A total of 150 patients presenting with acute chest pain possibly of cardiovascular aetiology were enrolled in this prospective randomized clinical trial. Patients were assigned to either the POCE-assisted management group or the standard management group. Physicians performing POCE examinations received focused training based on the British Society of Echocardiography level 1 standard. The primary outcome was the length of stay in the emergency department (ED), and the secondary outcomes included the time to decision, the time to coronary angiography and diagnostic accuracy of the initial examination. Quality of acquired images was also evaluated. The results revealed that the POCE group had a significantly shorter length of ED stay (209.0 vs. 271.0 min, median difference 64 (31-97) min., p = 0.0003), time to decision (138.0 vs. 252.0 min, p < 0.0001) and time to coronary angiography (29.6 vs. 120.3 h, p = 0.027) than the control group. Furthermore, the error of initial diagnoses was lower in the POCE group (6.3% vs. 30.4%, RR = 0.21 [0.047-0.90]). The implementation of POCE by trained noncardiologists significantly reduced the duration of ED stay and enhanced the management of patients with acute chest pain in the ED. Systematic training enables physicians without prior echocardiography experience to perform POCE accurately and efficiently. Preregistered number of clinical trial: NCT05306730 registered 2022-04-01.

Background: Acute pain is a common reason for emergency department visits. Opioids remain important for moderate to severe pain but their use is controversial due to safety concerns and variable prescribing practices. Differences in training between emergency medicine specialists and general practitioners may influence opioid administration and prescribing.

Objectives: To compare opioid administration and prescribing practices between emergency medicine specialists and general practitioners working in Turkish EDs, focusing on comfort, training, guideline adherence, and multimodal analgesia use.

Methods: This nationwide cross-sectional survey included 200 physicians (100 emergency medicine specialists, 100 general practitioners) from various hospital types. Data were collected through a 17-item online questionnaire distributed via institutional mailing lists and professional societies. Statistical analyses included Chi-square tests, Mann-Whitney U tests, Spearman correlations, and binary logistic regression.

Results: Emergency medicine specialists reported significantly greater comfort with opioid administration and prescribing (29% vs. 21% "very comfortable"; p = 0.0155), more frequent use of clinical guidelines (67% vs. 35%; p < 0.001), and more recent formal training (14% vs. 0% within the past year; p < 0.001). Familiarity with multimodal analgesia was also higher among specialists (96% vs. 89%; p = 0.0372). No significant differences were observed in opioid types used, side-effect concerns, or prescribing frequency. Correlation analysis showed that age and years of experience were positively associated with comfort (ρ = 0.17, p = 0.019; ρ = 0.16, p = 0.020), but not with actual opioid use. In logistic regression, specialty, training recency, and adherence to clinical guidelines independently predicted safe and consistent opioid practice.

Conclusion: Opioid administration and prescribing in emergency departments differ substantially between emergency medicine specialists and general practitioners, driven mainly by education and guideline adherence rather than institutional factors. Targeted training and standardized protocols are needed to reduce variability and improve safe, effective pain management in emergency care.

The growing number of patients with multimorbidity and increasing disease complexity presenting to the Emergency Department (ED) poses a global challenge, with overcrowding as a major consequence. To address these pressures, various interdisciplinary short-term monitoring and treatment units, such as Acute Medical Units, Frailty Units, Observation Units, and Chest Pain Units, have been implemented to improve patient flow from presentation to discharge. This systematic review, conducted according to PRISMA guidelines, aimed to evaluate the reported effects of these units on patient outcomes and ED crowding. We searched multiple databases and included studies reporting at least one primary outcome measure (length of stay, mortality, costs, readmissions, or staff satisfaction) following implementation of such a unit. The search yielded 2972 results, of which 50 studies met the inclusion criteria. Reported outcomes included reductions in hospital length of stay (0.24 to 6.16 days), cost savings (ranging from €162 to nearly €2 million across eight studies), and stable or decreased mortality in some settings. However, the evidence base is heterogeneous, with units differing substantially in patient populations, aims, and models of care, and cost analyses often relying on limited methods. Consequently, strong general conclusions across all unit types are not possible. Nonetheless, these findings suggest that when well-matched to local system bottlenecks and patient populations, specialized acute care units can improve patient flow and contribute to the accessibility of emergency care without compromising quality.Trial Registration: https://doi.org/10.17605/OSF.IO/A9EF7.

Endovascular thrombectomy (EVT) is the standard treatment for large vessel occlusion (LVO) acute ischemic stroke (AIS), with a target door-to-device time of under 90 min. While prior reports have indicated that artificial intelligence (AI) software can reduce door-to-procedure times, we set out to study its impact in our own patient population. A retrospective cohort study was conducted at a comprehensive stroke center located in a densely populated, urban region consisting of a majority Hispanic population. Data were analyzed from 222 patients who underwent EVT between July 2018 and July 2022. The study compared workflow and patient outcomes before (n = 84) and after (n = 138) the implementation of an AI software (Viz LVO, Viz.ai, Inc.) in July 2020. The primary outcome was the fraction of EVT patients who received thrombectomy within 90 min. The proportion of patients undergoing thrombectomy within 90 min increased significantly from 26.5% (95% CI 17.9-36.8%) to 68.1% (95% CI 60.0-75.5%, p < 0.001). The median door-to-groin (DTG) time decreased from 109 min pre-Viz to 75 min post-Viz (p < 0.001). An interrupted time-series analysis confirmed a significant reduction in DTG time following the AI software implementation (p = 0.001). The percentage of AIS patients who received EVT went up between pre- and post-AI periods. No differences were found in TICI scores, length of stay, or mortality/hospice rates. Implementation of an AI-powered platform was associated with a significant increase in the fraction of patients who received EVT within 90 min and decrease in DTG time. An AI-based system helped optimize stroke care workflow in an urban center with a diverse patient population.