Internal and Emergency Medicine最新文献

Acute myocardial infarction remains a significant cause of mortality and complications. These complications are usually considered to be primarily associated with left anterior descending coronary artery involvement, i.e., with anterior infarct. The aim was to study the circumstances under which early complications occurred within the first few hours of an acute myocardial infarction. We analyzed data from a prospective, observational, multicenter prehospital registry covering the Greater Paris area. All patients meeting clinical and electrocardiographic criteria for ST-elevation myocardial infarction (STEMI) and having been managed by a mobile intensive care unit between 2006 and 2023 were included. The analysis focused on risk factors, STEMI characteristics, including the presence of complications (Killip class III or IV, conduction or rhythm disturbances, use of catecholamines, defibrillation or chest compressions, orotracheal intubation), treatment administered, response times, and outcomes. We investigated the evolution over time of complications and associated factors. A total of 30,021 patients were analyzed, 23,382 (78%) of whom were male and 6,550 (22%) female, with a median age of 60 (IQR 52-72) years. 5,038 (18%) of these patients experienced early complications. The incidence of early complications decreased significantly over time, from 21% in 2006 to 17% in 2023, with no significant variation based on infarct territory. Killip class III or IV and defibrillation or chest compressions were more common in anterior infarcts (9% vs 5%, respectively), while rhythm/conduction disturbances were more common in non-anterior infarcts (12% vs 10%). Age and response times were the primary factors associated with early complication incidence. Complication's onset was linked to higher mortality rates (15% vs. 2%; p < 0.0001). Over the past 15 years, the incidence of early complications related to STEMI and in-hospital mortality has significantly decreased. Early complication onset was not related to infarction location, but strongly related to age.

Background: In patients with cardiogenic shock (CS), predicting risk of mortality may improve treatment allocation beyond intensive care admission and thereby outcomes. Troponin appears to be a suitable biomarker but has primarily been evaluated in the setting of infarct-related CS, not in heart failure-related CS (HF-CS), which accounts for almost 50% of cases.

Objectives: To assess the association of Troponin T with shock severity and mortality in HF-CS patients.

Methods: Heart failure-related CS patients treated in 15 tertiary care centres (5 European countries, 2016-2021) were retrospectively enrolled (NCT03313687). Association of baseline high-sensitive Troponin T and its 24-h kinetics with shock severity according to the SCAI classification and with in-hospital mortality was assessed by fitting multivariable adjusted regression models.

Results: N = 477 patients (mean age 62 years, 30.2% women). High-sensitive Troponin T at baseline (median 164 ng/l) was significantly associated with in-hospital mortality (HR 1.008, 95%CI 1.002-1.013, p < 0.01). Increasing Troponin within 24 h from baseline indicated a 2.4-fold higher risk of death vs. decreasing Troponin levels (HR 2.439, 95% CI 1.070-5.558, p = 0.03). In addition, higher Troponin T levels correlate with higher SCAI stages (e.g., baseline Troponin T per 250 ng/l increase: OR 5.268, 95%CI: 1.637, 16.953, p < 0.01 for SCAI stage D vs. C).

Conclusions: Troponin T, a marker of myocardial injury, associates with shock severity in patients with heart failure-related CS. It predicts mortality both with its baseline value as well as with its 24-h kinetics. Thus, Troponin may be a suitable marker to guide therapy or clinical trial enrolment in these patients.

Sepsis and septic shock represent significant health concerns in emergency departments due to their high mortality rates. This study aimed to evaluate the prognostic predictive ability of the HOTEL score in patients diagnosed with sepsis and septic shock in the emergency department. This single-center, prospective, observational diagnostic evaluation study included a total of 151 patients who presented to the emergency department between August 1, 2023, and March 1, 2024, and were diagnosed with sepsis or septic shock. The demographic, clinical, and laboratory data of the patients were recorded. The HOTEL score was calculated based on parameters including systolic blood pressure, oxygen saturation, body temperature, electrocardiographic changes, and loss of independence. Statistical analyses included receiver operating characteristic curves, logistic regression, and diagnostic test performance metrics. The median age of the included patients was 75 (interquartile range: 66.5-83.5) years. In terms of 30-day mortality, the HOTEL score (area under the curve [AUC]: 0.607) and SOFA score (AUC: 0.612) demonstrated similar predictive ability. Regarding the need for intubation in the emergency department, the HOTEL score (AUC: 0.773) and SOFA score (AUC: 0.835) were statistically significant. Multivariate analysis identified the HOTEL score, C-reactive protein levels, and the presence of active malignancy as independent predictors of 30-day mortality. Among the parameters of the HOTEL score, loss of independence emerged as the most significant predictor. According to the results of our study, the HOTEL score serves as an independent predictor of short-term mortality in patients with sepsis and septic shock. It may be a useful tool in predicting short-term mortality and the need for intubation in the emergency department for patients with sepsis and septic shock. However, it is recommended that the HOTEL score be used in combination with other clinical parameters rather than alone. In particular, clinical parameters such as loss of independence appear to contribute significantly to the predictive power of the score. Future studies should focus on modifying the HOTEL score and evaluating its utility in different patient populations and larger sample sizes.

In the last years, artificial intelligence has had a strong impact on health sciences, including emergency medicine. There are different fields of application, from pre-hospital to in-hospital issues. Concerning pre-hospital care, it may be useful in controlling patient' transportation by public ambulance in emergency departments and improve transport time outliers. In hospital management may benefit from its ability to read out imaging or to rapidly calculate predictive scores or suggest therapeutic strategies. While the application of artificial intelligence in emergency medicine is surely intriguing, it is not free from potential risks, which in turn may overcome benefits. Since the majority of the studies are very small rather than pilot, a clear discussion among EM physicians is now necessary in order to better define the application of this technology in the real world by maximizing benefits and reducing risks.

In this retrospective study, we aimed to find reliable criteria that allow the identification of patients, treated with NIV for acute respiratory failure in the High-Dependency Unit in the earliest phase, who could continue treatment safely in the ordinary ward. We included all patients treated with NIV in the ED-HDU at Careggi University-Hospital, from July 2021 to December 2022. The HACOR score was calculated daily, and the discharge to the ward was considered Appropriate in the presence of the following criteria: 1) HACOR score ≤ 2; 2) not being dependent on NIV, which meant the possibility of alternating NIV with conventional oxygen treatment or High-Flow Nasal Cannula. The primary endpoint was all-cause in-hospital mortality. We included 297 patients, with a mean age of 79 ± 11 years, 57% female, 69% with hypercapnic respiratory failure. After 24 h, the HACOR score was ≤ 2 in 113 (38%) patients, with a mortality of 11% vs 21% for those with an HACOR score > 2 (p = 0.029). In total, 235 (79%) patients were transferred to the general ward, 110 as Inappropriate and 125 as Appropriate. In-hospital mortality rate was higher in the Inappropriate than in the Appropriate group (21% vs 7%, p = 0.004). After excluding the 64 patients treated with NIV as the ceiling treatment, 28 in the "Appropriate transfer" and 36 "Inappropriate transfer", we confirmed the increased mortality in patients with inappropriate transfer (14% vs 4%, p = 0.026). Therefore, patients with an HACOR score ≤ 2, not dependent on NIV, could be safely transferred to the ordinary ward to continue their ventilatory support.

Fibromyalgia (FM) is more prevalent in patients with Sjögren's disease (SjD) than in the general population and a bidirectional association between the two conditions has been proposed. However, the clinical profile of patients with concomitant FM and SjD remains poorly characterized. This study aimed to assess the prevalence and clinical correlates of FM in a multicenter Italian cohort of patients with SjD. Patients fulfilling the 2016 ACR-EULAR classification criteria for SjD were retrospectively evaluated. FM was defined according to the 2016 diagnostic criteria. Clinical, serological, and therapeutic data were compared between patients with and without FM. Logistic regression models identified factors associated with FM. Among 267 patients with SjD (95% female, median age 60), FM was diagnosed in 30%. Patients with FM reported significantly higher symptom burden, as measured by the EULAR Sjögren's Syndrome Patient-Reported Index (median 7.7 vs. 6.0; p < 0.001), with all individual domains, namely pain, fatigue, and dryness, being significantly increased (p < 0.01, for all). In contrast, EULAR Sjögren's Syndrome Disease Activity Index scores were comparable between groups (p = 0.808). In the logistic regression model, three variables were independently associated with FM: higher symptom burden (adjusted odds ratio (aOR 1.36, 95% CI 1.13-1.62; p = 0.001), mixed anxiety-depressive disorder (aOR 3.24, 95% CI 1.13-9.30; p = 0.029), and corticosteroid use (aOR 2.76, 95% CI 1.02-7.48; p = 0.046). In patients with SjD, FM is associated with a higher symptom burden despite similar disease activity level. These findings highlight the need to distinguish symptom amplification from true inflammatory activity, limiting unnecessary corticosteroid use.