Journal of Internal Medicine最新文献_第8页

Authors reply: Simple step-counting captures comparable health information to complex accelerometer measurements 作者回复：简单的计步器捕获的健康信息与复杂的加速度计测量值相当。

IF 9.2 2区医学 Q1 MEDICINE, GENERAL & INTERNAL

Journal of Internal Medicine

Pub Date : 2025-07-19 DOI: 10.1111/joim.20121

Jonatan Fridolfsson, Anders Raustorp, Mats Börjesson, Elin Ekblom-Bak, Örjan Ekblom, Daniel Arvidsson

引用次数: 0

Long sleep duration pattern is associated with increased cardiovascular recurrence: Effect of long-term Mediterranean diet from the CORDIOPREV study 长时间睡眠模式与心血管复发增加有关：来自CORDIOPREV研究的长期地中海饮食的影响

IF 9.2 2区医学 Q1 MEDICINE, GENERAL & INTERNAL

Journal of Internal Medicine

Pub Date : 2025-07-17 DOI: 10.1111/joim.20119

Antonio García-Ríos, Juan Luis Romero-Cabrera, Juan Francisco Alcalá-Díaz, Gracia M. Quintana-Navarro, Laura Martín-Piedra, Antonio Pablo Arenas-de Larriva, Jose David Torres-Peña, Fernando Rodriguez-Cantalejo, Stefanos N. Kales, José M. Ordovás, Pablo Pérez-Martínez, Javier Delgado-Lista, José López-Miranda

Background

Evidence suggests interactions between sleep and diet that could modify coronary heart disease (CHD) risk. This study aims to investigate the association between sleep duration and incidence of major cardiovascular events (MACE) and the impact of dietary interventions (Mediterranean or low-fat diet) from the Coronary Diet Intervention with Olive Oil and Cardiovascular Prevention (CORDIOPREV) study (NCT00924937).

Methods

A total of 952 subjects were stratified into reference (>6 to <8 h per night), short (≤6 h), and long sleep duration pattern (≥8 h) based on self-reported data from the Minnesota Leisure-Time Physical Activity questionnaire over 7 years. The main outcome was the incidence of MACE (myocardial infarction, revascularization procedures, ischemic strokes, peripheral artery disease, and cardiovascular mortality).

Results

MACE occurred in 189 participants: 18.1% in the reference group, 17.7% in the short group, and 29% in the long sleep duration group. Accordingly, the long sleep duration group had a higher risk of MACE compared to the reference and short sleep groups (log-rank p < 0.01, hazard ratio [HR]: 1.59 [95% CI: 1.12–2.26]). Participants assigned to a low-fat diet with long sleep duration had a higher risk of MACE (HR: 1.74 [95% CI: 1.11–2.73]), whereas those assigned to a Mediterranean diet did not show significant differences in risk (HR: 1.35 [95% CI: 0.76–2.41]).

Conclusions

A long sleep duration pattern is associated with a higher risk of MACE among CHD patients. Long-term adherence to a Mediterranean diet may mitigate this association. These findings highlight the importance of considering sleep as a cardiovascular risk factor in clinical practice.

背景：有证据表明睡眠和饮食之间的相互作用可以改变冠心病（CHD）的风险。本研究旨在研究橄榄油冠脉饮食干预和心血管预防（CORDIOPREV）研究（NCT00924937）中睡眠时间与主要心血管事件（MACE）发生率之间的关系以及饮食干预（地中海或低脂饮食）的影响。方法：将952名受试者分为参照组（bb6 ~ bb6）。结果：189名受试者发生MACE，参照组18.1%，短睡眠组17.7%，长睡眠组29%。因此，与参考组和短睡眠组相比，长睡眠时间组发生MACE的风险更高（log-rank p）。结论：长睡眠时间模式与冠心病患者发生MACE的风险较高相关。长期坚持地中海饮食可能会减轻这种联系。这些发现强调了在临床实践中将睡眠视为心血管危险因素的重要性。

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引用次数: 0

Regarding: Simple step counting captures comparable health information to complex accelerometer measurements 关于：简单的步数计数捕获的健康信息与复杂的加速度计测量值相当。

IF 9.2 2区医学 Q1 MEDICINE, GENERAL & INTERNAL

Journal of Internal Medicine

Pub Date : 2025-07-16 DOI: 10.1111/joim.20120

Yingjian Ye, Jinfang Yang, Junyan Zhang, Peng An

引用次数: 0

Amiodarone induced thyroid dysfunction: A high cumulative incidence in a nationwide cohort study in Iceland 胺碘酮诱导甲状腺功能障碍：冰岛一项全国性队列研究的高累积发病率。

IF 9.2 2区医学 Q1 MEDICINE, GENERAL & INTERNAL

Journal of Internal Medicine

Pub Date : 2025-07-10 DOI: 10.1111/joim.20115

Páll Guðjónsson, Ari J. Jóhannesson, Elías Eyþórsson, Karl Andersen

Background

Amiodarone induced thyroid dysfunction (AITD) is divided into amiodarone induced thyrotoxicosis (AIT) and amiodarone induced hypothyroidism (AIH). The prevalence of them varies from 1.2% to 12% for AIT and 12%–17% for AIH.

Objectives

To study the incidence and complications of AITD.

Methods

The cohort comprised all euthyroid patients who filled their first amiodarone prescription in Iceland in 2014, 262 persons. Data were gathered with chart review, and diagnosis confirmed with thyroid function tests. The cumulative incidence accounting for death as a competing risk was estimated for AIT, AIH, and AITD with three separate Fine-Gray models.

Results

The overall incidence of AIT, AIH, and AITD was 9.2% (95% CI: 5.6%–12.7%), 13.4% (95% CI: 9.2%–17.5%), and 22.5% (95% CI: 17.4%–27.6%), respectively, and the 5-year cumulative incidence in the same order was 19.0% (95% CI: 11.9%–25.5%), 21.8% (95% CI: 14.7%–28.2%), and 38.5% (95% CI: 30.4%–45.7%). The highest yearly incidence rate of AIT was 9.8% during the third treatment year, and for AIH, it was 9.8% during the first year of treatment. The complications of AIT were hypothyroidism (8%), thyroidectomy (8%), hospitalizations (36%), and death (4%). Most patients (91.7%) with AIH were placed on thyroid replacement therapy.

Discussion

Nearly 40% of patients taking amiodarone for 5 years acquire thyroid dysfunction, which is higher than previously described. Frequent monitoring of thyroid function should be considered during the high-risk periods of the first and third treatment years.

背景：胺碘酮性甲状腺功能障碍（AITD）分为胺碘酮性甲状腺毒症（AIT）和胺碘酮性甲状腺功能减退症（AIH）。aiit的患病率为1.2% - 12%，AIH的患病率为12%-17%。目的：探讨AITD的发病率及并发症。方法：纳入2014年冰岛首次服用胺碘酮处方的所有甲状腺功能正常患者262人。通过图表回顾收集资料，并通过甲状腺功能检查确认诊断。用三种不同的Fine-Gray模型估计AIT、AIH和AITD作为竞争风险的累积发生率。结果：AIT、AIH、AITD的总发病率分别为9.2% （95% CI: 5.6% ~ 12.7%）、13.4% （95% CI: 9.2% ~ 17.5%）、22.5% (95% CI: 17.4% ~ 27.6%)， 5年累计发病率分别为19.0% （95% CI: 11.9% ~ 25.5%）、21.8% （95% CI: 14.7% ~ 28.2%）、38.5% （95% CI: 30.4% ~ 45.7%）。AIT的年发病率最高，在治疗的第三年为9.8%，AIH的年发病率最高，在治疗的第一年为9.8%。AIT的并发症为甲状腺功能减退（8%）、甲状腺切除术（8%）、住院（36%）和死亡（4%）。大多数AIH患者（91.7%）接受甲状腺替代治疗。讨论：近40%服用胺碘酮5年的患者出现甲状腺功能障碍，这一比例高于之前的报道。在治疗第一年和第三年的高危期应考虑频繁监测甲状腺功能。

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引用次数: 0

Overstated association between adolescent physical fitness and adulthood depression risk due to familial factors 由于家族因素，青少年身体健康与成年抑郁症风险之间的关联被夸大。

IF 9.2 2区医学 Q1 MEDICINE, GENERAL & INTERNAL

Journal of Internal Medicine

Pub Date : 2025-07-09 DOI: 10.1111/joim.20109

Marcel Ballin, Örjan Ekblom, Anna Nordström, Viktor H. Ahlqvist, Peter Nordström

Objective

Examine the association between adolescent cardiorespiratory fitness and future risk of depression and dispensation of antidepressants, including the role of familial confounding.

Methods

A cohort study with sibling-comparisons based on Swedish men who participated in mandatory military conscription examinations from 1972 to 1995. The exposure was cardiorespiratory fitness estimated using a maximal ergometer bicycle test. The outcomes were depression diagnosis in specialized outpatient or inpatient care and dispensation of antidepressants until 31 December 2023.

Results

A total of 1,013,885 men (mean age 18.3 years), of which 410,198 were full siblings, were followed until a median age of 56.8 years, during which 47,283 were diagnosed with depression and 237,409 were dispensed antidepressants. In cohort analysis, the highest decile of fitness had lower risks of depression (adjusted hazard ratio [HR] 0.54, [95% confidence interval, 0.52, 0.57]) and antidepressants (HR 0.63; 0.62, 0.65) compared to the lowest decile, with differences in the standardized cumulative incidence by age 65 of −3.9% and −12.3%, respectively. In sibling-comparison analyses accounting for unobserved familial confounders, the associations attenuated for both depression (HR 0.67, 0.59–0.75; incidence difference −2.4%) and antidepressants (HR 0.76, 0.72–0.80; incidence difference −7.2%). Hypothetically shifting everyone to the highest decile of fitness was associated with a preventable fraction of 29.1% for depression and 17.8% for antidepressants in cohort analysis, which attenuated to 17.6% and 10.4% in sibling-comparisons.

Conclusions

High levels of adolescent cardiorespiratory fitness are associated with lower risks of future depression and antidepressants, but the associations might be overstated due to familial confounding.

目的：探讨青少年心肺健康与未来抑郁风险和抗抑郁药物配用的关系，包括家族混杂因素的作用。方法：对1972 ~ 1995年参加征兵考试的瑞典男性进行兄弟姐妹比较队列研究。暴露是通过最大测力器自行车测试来估计心肺适能。结果是在2023年12月31日之前在专科门诊或住院治疗中诊断出抑郁症，并配发抗抑郁药。结果：共有1,013,885名男性（平均年龄18.3岁），其中410,198名是全兄妹，随访至中位年龄56.8岁，其中47,283人被诊断为抑郁症，237,409人被分配抗抑郁药物。在队列分析中，健康水平最高的十分位数患抑郁症（校正风险比[HR] 0.54，[95%可信区间，0.52,0.57]）和抗抑郁药物(HR 0.63；0.62, 0.65)与最低十分位数相比，65岁时标准化累积发病率的差异分别为-3.9%和-12.3%。在考虑未观察到的家族混杂因素的兄弟姐妹比较分析中，两种抑郁症的相关性减弱(HR 0.67, 0.59-0.75；发病率差-2.4%)和抗抑郁药(HR 0.76, 0.72-0.80；发病率差-7.2%)。在队列分析中，假设将每个人都转移到健康水平最高的十分之一，与抑郁症的可预防比例（29.1%）和抗抑郁药物的可预防比例（17.8%）相关，而在兄弟姐妹比较中，这一比例分别降至17.6%和10.4%。结论：青少年高水平的心肺健康与未来抑郁和抗抑郁药物的风险较低相关，但由于家族混杂，这种关联可能被夸大了。

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引用次数: 0

Soluble urokinase plasminogen activator receptor and interleukin-6 improves prediction of all-cause mortality and major adverse cardiovascular events in Type 1 diabetes 可溶性尿激酶纤溶酶原激活物受体和白介素-6改善1型糖尿病全因死亡率和主要不良心血管事件的预测

IF 9.2 2区医学 Q1 MEDICINE, GENERAL & INTERNAL

Journal of Internal Medicine

Pub Date : 2025-07-07 DOI: 10.1111/joim.20108

Hashmat Sayed Zohori Bahrami, Peter Godsk Jørgensen, Jens Dahlgaard Hove, Ulrik Dixen, Line Jee Hartmann Rasmussen, Jesper Eugen-Olsen, Peter Rossing, Magnus T. Jensen

Background

Type 1 diabetes (T1D) increases premature mortality risk, with cardiovascular disease being the leading cause. Chronic inflammation may play a role. Associations between inflammatory biomarkers and mortality are not well-known in T1D.

Methods

We evaluated a prospective clinical cohort with T1D without known cardiovascular disease. The inflammatory biomarkers soluble-urokinase-plasminogen-activator-receptor (suPAR) and interleukin-6 (IL-6) were measured. Patients were stratified by elevated/low suPAR or IL-6, or simultaneously elevated suPAR and IL-6. Primary and secondary endpoints were all-cause mortality and major adverse cardiovascular events (MACE), respectively. Cox models were adjusted for 10 Steno T1 Risk Engine variables and inflammatory biomarkers. Net reclassification improvement (NRI) and C-statistics were calculated.

Results

Among 962 participants (52% male, median age 50, median follow-up 13.1 years), mortality was higher in patients with elevated inflammation: 31% for elevated versus 9% for low suPAR; 30% for elevated versus 11% for low IL-6; and 50% for simultaneously elevated suPAR and IL-6 versus 5% for low suPAR and IL-6. In fully adjusted models, elevated inflammation was associated with mortality (hazard ratios [95% confidence intervals]: suPAR 2.0 [1.4–3.0, p < 0.001], IL-6 1.8 [1.3–2.6; p = 0.001], and combined 4.0 [2.3–7.2, p < 0.001]) and MACE (suPAR 1.9 [1.4–2.6, p < 0.001], IL-6 1.4 [1.0–1.8, p = 0.034], and combined 2.6 [1.7–4.1, p < 0.001]). Adding suPAR, IL-6, and their combination to the Steno T1 Risk Engine improved NRI for mortality by 61%, 53%, and 84%, respectively, whereas C-statistics improved from 0.808 to 0.829, 0.826, and 0.881, respectively.

Conclusions

suPAR, IL-6, and especially their combination independently predicts all-cause mortality and MACE in T1D without known cardiovascular disease.

背景：1型糖尿病（T1D）增加过早死亡风险，心血管疾病是主要原因。慢性炎症可能起作用。炎症生物标志物与T1D患者死亡率之间的关系尚不清楚。方法：我们评估了一个没有已知心血管疾病的T1D患者的前瞻性临床队列。检测炎症生物标志物可溶性尿激酶-纤溶酶原激活物受体（suPAR）和白细胞介素-6 （IL-6）。根据suPAR或IL-6升高/降低或suPAR和IL-6同时升高对患者进行分层。主要终点和次要终点分别是全因死亡率和主要不良心血管事件（MACE）。Cox模型根据10个Steno T1风险引擎变量和炎症生物标志物进行调整。计算净重分类改善（NRI）和c -统计量。结果：在962名参与者中（52%为男性，中位年龄50岁，中位随访13.1年），炎症升高患者的死亡率更高：suPAR升高患者为31%，低suPAR患者为9%；IL-6升高30%，低11%；同时升高的suPAR和IL-6为50%，低suPAR和IL-6为5%。在完全调整的模型中，炎症升高与死亡率相关（危险比[95%置信区间]:suPAR 2.0 [1.4-3.0, p]）。结论：suPAR、IL-6，尤其是它们的联合独立预测无已知心血管疾病的T1D患者的全因死亡率和MACE。

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引用次数: 0

Colchicine and cardiovascular events: An updated meta-analysis of published randomized controlled trials 秋水仙碱与心血管事件：已发表的随机对照试验的最新荟萃分析。

IF 9.2 2区医学 Q1 MEDICINE, GENERAL & INTERNAL

Journal of Internal Medicine

Pub Date : 2025-07-07 DOI: 10.1111/joim.20107

Sining Xie, Federica Galimberti, Elena Olmastroni, Alberico L. Catapano, Manuela Casula

Background

Colchicine shows promise in reducing cardiovascular risk, but a recent study raised the question whether this is really the case. We conducted a meta-analysis of randomized controlled trials (RCTs) to assess its impact on cardiovascular outcomes in secondary prevention.

Methods

We systematically searched major databases up to March 2025 for RCTs comparing colchicine to placebo over a treatment duration of ≥12 months, reporting major adverse cardiovascular events (MACEs). Both fixed- and random-effects models were used to compute pooled risk ratios (RRs) and 95% confidence intervals.

Results

Six RCTs comprising 21,774 patients were included. Colchicine significantly reduced the risk of MACEs (RR 0.74 [0.60–0.92]) and specific components of primary outcome (myocardial infarction, RR 0.85 [0.73–0.98]; stroke, RR 0.79 [0.65–0.95]), with no significant effect on cardiac death and revascularization.

Conclusion

These results support the efficacy of low-dose colchicine in reducing MACEs when added to standard care for at least 12 months.

背景：秋水仙碱显示出降低心血管风险的希望，但最近的一项研究提出了是否真的如此的问题。我们进行了一项随机对照试验（rct）的荟萃分析，以评估其对二级预防心血管结局的影响。方法：我们系统地检索了截至2025年3月的主要数据库，以比较秋水仙碱和安慰剂治疗时间≥12个月的rct，报告了主要不良心血管事件（mace）。固定效应和随机效应模型均用于计算合并风险比（rr）和95%置信区间。结果：纳入6项随机对照试验，共21,774例患者。秋水仙碱可显著降低mace （RR 0.74[0.60-0.92]）和主要转归的特定成分（心肌梗死，RR 0.85[0.73-0.98]；卒中，RR 0.79[0.65-0.95]）的风险，但对心源性死亡和血运重建无显著影响。结论：这些结果支持低剂量秋水仙碱在标准治疗中添加至少12个月后降低mace的疗效。

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引用次数: 0

Gaucher disease, state of the art and perspectives 戈谢病的研究现状与展望。

IF 9.2 2区医学 Q1 MEDICINE, GENERAL & INTERNAL

Journal of Internal Medicine

Pub Date : 2025-07-03 DOI: 10.1111/joim.20114

Fabrice Camou, Marc G. Berger

Knowledge about Gaucher disease (GD), considered a model for rare diseases, has considerably increased since its discovery. The pathophysiology of this lysosomal disorder is better known, and specific therapies that can control many aspects of the disease have been developed, particularly for the most common form, Type 1 GD. Yet, in part because of the rarity of GD, but also because of a lack of awareness by physicians, diagnostic delay too often leads to a belated management of patients having accumulated comorbidities. Gaucher cells, the most visible consequence of glucocerebrosidase deficiency, have been known for many years. However, the pathophysiological mechanisms underlying some major lesions, such as bone disease, predisposition to Parkinson's disease in Type 1 GD, or neurological involvement in Type 2 and Type 3 GD, remain poorly understood. Diagnostic, therapeutic, and follow-up issues associated with these symptoms remain critical to optimize the care of these patients. In this review, clinical characteristics, pathophysiology, diagnosis, treatment, and prognosis of GD are successively considered, highlighting for each of them the remaining challenges. Continued efforts to better understand pathophysiological mechanisms, use of the most modern methods such as artificial intelligence, international collaboration, and development of new therapeutic strategies seem essential for the future of this rare disease.

戈谢病（GD）被认为是罕见疾病的典范，自发现以来，有关该病的知识已大大增加。这种溶酶体疾病的病理生理学已经被人们所熟知，并且已经开发出可以控制该疾病许多方面的特定疗法，特别是针对最常见的1型GD。然而，部分由于GD的罕见性，但也因为医生缺乏认识，诊断延误往往导致对积累了合并症的患者的治疗迟到。戈谢细胞是葡萄糖脑苷酶缺乏症的最明显的后果，已被发现多年。然而，一些主要病变的病理生理机制，如骨病、1型GD的帕金森病易感性，或2型和3型GD的神经系统受累，仍然知之甚少。与这些症状相关的诊断、治疗和随访问题对于优化这些患者的护理仍然至关重要。本文将从GD的临床特点、病理生理、诊断、治疗、预后等方面进行综述，重点介绍GD面临的挑战。继续努力更好地了解病理生理机制，使用最现代的方法，如人工智能，国际合作，以及开发新的治疗策略，似乎对这种罕见疾病的未来至关重要。

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引用次数: 0

Use of dipeptidyl peptidase-4 inhibitors is associated with lower risk of severe renal outcomes in pre-dialysis patients with Type 2 diabetes 使用二肽基肽酶-4抑制剂与透析前2型糖尿病患者严重肾脏结局的风险降低相关。

IF 9.2 2区医学 Q1 MEDICINE, GENERAL & INTERNAL

Journal of Internal Medicine

Pub Date : 2025-07-03 DOI: 10.1111/joim.20112

Tung-Ying Hung, Tzu-Chieh Lin, Ying-Jay Liou, Tzu-Han Lin, Yu-Juei Hsu, Liang-Yu Lin, Meng-Ting Wang

Objectives

Patients with diabetes and Stage 5 chronic kidney disease (CKD) not on dialysis are susceptible to renal replacement therapy and severe complications. Among limited antidiabetic options in this vulnerable population, dipeptidyl peptidase-4 (DPP-4) inhibitors (DPP-4i) are widely used; however, supporting evidence is scant. This study assessed severe renal outcomes associated with DPP-4i in diabetic and pre-dialysis patients.

Methods

This study employed an active-comparator and propensity score–based inverse probability of treatment weighting approach, using Taiwan's nationwide healthcare claims database from 2012 to 2020. We identified patients with diabetes and CKD stage 5 not on dialysis who received erythropoietin (erythropoietin-stimulating agent), a drug reimbursed for patients with an estimated glomerular filtration rate <15 mL/min/1.73 m². The primary outcome was a composite of renal replacement therapy, renal death, and kidney-related hospitalization events, and secondary outcomes included each component of the composite and hypoglycemia.

Results

We included 7271 diabetic and pre-dialysis patients with CKD stage 5, of whom 5028 received DPP-4i and 2243 received meglitinides. DPP-4i were associated with a 14% reduced risk of the renal composite outcome compared to meglitinides (weighted hazard ratio [HR], 0.86; 95% confidence interval, 0.81–0.92). Individual component analysis revealed that the decreased risk was confined to renal replacement therapy, with a 17% reduction. DPP-4i was related to a 41% decreased severe hypoglycemia risk.

Conclusions

In diabetic and pre-dialysis patients with CKD stage 5, DPP-4i are related to a lower risk of the renal composite outcome, primarily driven by lower renal dialysis risk, and a lower hypoglycemia risk compared with meglitinides.

目的：未透析的糖尿病和5期慢性肾脏疾病（CKD）患者易接受肾脏替代治疗和严重并发症。在这些易感人群有限的抗糖尿病选择中，二肽基肽酶-4 （DPP-4）抑制剂（DPP-4i）被广泛使用；然而，支持这一观点的证据很少。该研究评估了糖尿病和透析前患者与DPP-4i相关的严重肾脏结局。方法：本研究以2012 - 2020年台湾医保理赔数据库为研究对象，采用主动比较器和基于倾向得分的治疗加权逆概率法。我们确定了没有透析的糖尿病和CKD 5期患者，他们接受了促红细胞生成素（促红细胞生成素刺激剂），这是一种为肾小球滤过率估计的患者报销的药物。主要结局是肾脏替代治疗、肾性死亡和肾脏相关住院事件的综合结果，次要结局包括综合结果的各个组成部分和低血糖。结果：我们纳入了7271例糖尿病和透析前CKD 5期患者，其中5028例接受DPP-4i治疗，2243例接受美列替尼治疗。与美格列尼特相比，DPP-4i与肾脏综合结局风险降低14%相关(加权风险比[HR]， 0.86；95%置信区间为0.81-0.92)。个体成分分析显示，降低的风险仅限于肾脏替代治疗，降低了17%。DPP-4i与严重低血糖风险降低41%相关。结论：在CKD 5期糖尿病和透析前患者中，DPP-4i与肾脏综合结局的风险较低有关，主要是由于肾脏透析风险较低，与美格列尼特相比，低血糖风险较低。

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引用次数: 0

Promoting function-oriented, primary care approaches to improve the management of cognitive impairment and dementia 促进以功能为导向的初级保健方法，以改善认知障碍和痴呆的管理。

IF 9.2 2区医学 Q1 MEDICINE, GENERAL & INTERNAL

Journal of Internal Medicine

Pub Date : 2025-07-01 DOI: 10.1111/joim.20116

Marco Canevelli

<p>Primary care is currently at the forefront of a profound reorienting of healthcare systems worldwide, aimed at enhancing the health and well-being of older persons for various compelling reasons. Due to population aging, primary care, including community-based healthcare, will serve as the initial point of contact for an increasing number of older adults facing common age-related conditions and declines in capacity. The current supply of many specialists and healthcare professionals, especially those with geriatric competencies, is inadequate to address the rising demand and health needs of large and rapidly growing aging populations [<span>1</span>]. Additionally, primary care is increasingly recognized as the ideal setting to implement risk reduction strategies, including lifestyle changes, to mitigate modifiable risk factors for highly prevalent chronic diseases [<span>2</span>].</p><p>In this context, a perspective paper published in the Journal of Internal Medicine by a group of experts on Alzheimer's disease and related dementias (ADRD) in the United States outlines the opportunities, challenges, and potential solutions related to the early detection of cognitive impairment within primary care settings [<span>3</span>]. ADRD is among the foremost causes of mortality, disability, and dependency globally, posing a serious threat to the sustainability of social and healthcare systems, especially in low-resource settings. Cognitive impairment frequently goes underdiagnosed or is identified only after significant delays. This situation limits access to preventive, therapeutic, and rehabilitative interventions, intensifies the burden on caregivers, and potentially increases the risk of adverse outcomes. In light of these considerations, the paper emphasizes the critical role of primary care in conducting early cognitive evaluations, promoting brain health, facilitating lifestyle modifications, addressing reversible factors contributing to cognitive decline, and enhancing health and safety outcomes for both at-risk individuals and those already affected [<span>3</span>]. Practical solutions are also proposed to overcome existing barriers to detecting ADRD in primary care [<span>3</span>].</p><p>The paper by Fowler et al. reaffirms the centrality of primary care in the management of ADRD [<span>3</span>]. However, primary care approaches to ADRD should ideally be nested within broader care models aimed at improving the overall health, functioning, and well-being of older adults. There is growing recognition that disease-oriented frameworks may fail to capture critical health aspects relevant to older persons and their carers [<span>4</span>]. A primary focus on specific nosological conditions may result in healthcare systems that are poorly responsive to the multifaceted needs and priorities of older people and may inadvertently lead to misclassification, mistreatment, malpractice, and inequalities [<span>4, 5</span>]. Furthermore, disease-centr

初级保健目前处于全球卫生保健系统深刻调整的最前沿，其目的是出于各种令人信服的原因，增进老年人的健康和福祉。由于人口老龄化，初级保健，包括以社区为基础的保健，将成为越来越多面临与年龄有关的常见疾病和能力下降的老年人的最初接触点。目前许多专家和保健专业人员的供应，特别是那些具有老年能力的人，不足以满足大量和迅速增长的老龄化人口日益增长的需求和健康需求。此外，人们日益认识到初级保健是实施降低风险战略（包括改变生活方式）的理想场所，以减轻高流行慢性病的可改变风险因素。在此背景下，美国阿尔茨海默病和相关痴呆（ADRD）专家小组发表在《内科学杂志》上的一篇前瞻性论文概述了在初级保健机构中早期发现认知障碍的机遇、挑战和潜在解决方案[10]。ADRD是全球范围内导致死亡、残疾和依赖的主要原因之一，对社会和卫生保健系统的可持续性构成严重威胁，特别是在资源匮乏的环境中。认知障碍经常没有得到充分的诊断，或者在严重延误后才被发现。这种情况限制了获得预防、治疗和康复干预措施的机会，加重了护理人员的负担，并可能增加不良后果的风险。鉴于这些考虑，本文强调初级保健在开展早期认知评估、促进大脑健康、促进生活方式改变、解决导致认知能力下降的可逆因素以及提高高危个体和已受bbb影响者的健康和安全结果方面的关键作用。此外，还提出了切实可行的解决方案，以克服在初级保健领域发现ADRD的现有障碍。Fowler等人的论文重申了初级保健在ADRD管理中的中心地位[10]。然而，针对ADRD的初级保健方法应该理想地嵌套在旨在改善老年人整体健康、功能和福祉的更广泛的护理模式中。人们日益认识到，面向疾病的框架可能无法捕捉到与老年人及其照顾者有关的关键健康方面[b]。对特定疾病的主要关注可能导致医疗保健系统对老年人的多方面需求和优先事项反应不良，并可能无意中导致错误分类、虐待、医疗事故和不平等[4,5]。此外，以疾病为中心的方法可能导致护理的碎片化，而不是一体化。例如，许多被确定为在初级保健中加强痴呆症的检测和管理的关键措施——包括采用简短的筛查和评估工具、使用生物标志物以及实施健康促进和预防战略——也适用于一系列慢性、与年龄有关的疾病，如糖尿病、心血管疾病和癌症。这种冗余可能造成重叠的垂直护理路径，使本已有限的医疗资源分配复杂化，并给初级保健专业人员带来额外压力。相比之下，横向的、以功能为导向的初级保健模式更符合老年人优质护理的核心原则。这些原则强调全面和协调的方法，侧重于医疗和非医疗健康决定因素，建立以人为本的目标，确保实施有意义和可接受的干预措施，并为长期监测和重新评估提供基础[1,5]。在这些基础上，世界卫生组织（世卫组织）出版了《老年人综合护理手册》，以维持保健和护理工作者在初级保健方面的能力建设，以实现老年人综合护理计划。ICOPE方法旨在优化内在能力（即个人所有身体和精神能力的组合）和功能能力（即使所有人都能成为并做他们有理由重视的事情的属性），使其接近于人的居住地。ICOPE方法的核心是全面评估和监测六个相互关联的内在能力领域，即运动，认知，心理能力，活力，视觉和听力，以及个人参与的社会和物理环境。这些能力的丧失可以通过一系列有针对性的、以证据为基础的多模式干预措施和社会支持加以预防和管理。加强初级保健对于加强ADRD的管理也至关重要，从而产生巨大的临床效益和积极的公共卫生结果。然而，正如ICOPE手册所概述的那样，实施一个简短、全面的评估，最好包括跨文化工具，可能会发现认知功能的潜在损害，同时也提供了一个机会来探索与老年人福祉类似的其他健康领域。评估内在能力域的下降可能有助于早期识别可能对认知产生有害作用的因素和条件，如听力损失、视力障碍、抑郁症状和营养不良，深入评估与认知受损相关的疾病和风险因素，发现认知衰退的可逆原因，以及评估和管理社会和物理环境。最后，ICOPE为促进和预防健康（包括脑健康）提供了机会。通过个性化干预、生活方式建议和公共卫生政策等“基态”预防方法，可以加强认知保护和痴呆症预防。总的来说，采用这种以功能为导向的初级保健方法并没有忽视痴呆症的独特方面。相反，它将痴呆症的预防、检测和管理整合到老年人更广泛的临床复杂性中，考虑到影响衰老相关疾病的各种生理、临床和社会环境因素。然而，这种医疗保健的重新定位不能局限于临床（微观）层面。为老年人，包括有ADRD风险和患有ADRD的老年人实现综合卫生和社会护理，还需要在服务（中观）和系统（宏观）层面进行重大变革。这对于确保该方法的可持续性和可扩展性以及优化医疗保健资源的分配至关重要。在这方面，世卫组织ICOPE实施框架概述了针对包括决策者、资助者和决策者在内的各利益攸关方的一系列行动，就如何实施ICOPE并将其与地方卫生和社会保健服务相结合提供了指导。将护理从被动模式转变为主动和预防模式的最终目标是确保持续的综合护理，使老年人能够根据其不断变化的需求从及时的干预措施中受益。这意味着(1)清楚地了解老年人的需求和优先事项，(2)绘制可用资源的地图，(3)重新分配资源，以建立多学科综合护理模式。换句话说，为了为我们的护理系统建立一个更具包容性和可持续性的未来，有必要跨越部门和能力，超越单一的疾病范式，更务实地接受老年人的临床和社会复杂性。作者没有需要披露的利益冲突。

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