European Journal of Internal Medicine最新文献

英文中文

Association between socioeconomic and psychosocial factors with use of interventional and surgical treatments and outcomes in patients with myocardial infarction – Inpatient data of the largest European health care system 心肌梗死患者的社会经济和社会心理因素与介入治疗和手术治疗的使用及结果之间的关系 - 欧洲最大医疗保健系统的住院患者数据。

IF 5.9 2区医学 Q1 MEDICINE, GENERAL & INTERNAL

European Journal of Internal Medicine

Pub Date : 2024-10-01 DOI: 10.1016/j.ejim.2024.05.032

Background

Myocardial infarction (MI) is an important driver of both morbidity and mortality on a global scale. Elucidating social inequalities may help to identify vulnerable groups as well as treatment imbalances and guide efforts to improve care for MI.

Methods

All hospitalized patient-cases with confirmed MI 2005-2020 in Germany were included in the study and stratified for socioeconomic or psychosocial factors (SPF) and the impact of SPF on treatment usage and adverse in-hospital events was analyzed.

Results

Overall, 4,409,597 hospitalizations of MI patients were included; of these, 17,297 (0.4 %) were coded with SPF. These patients were more often of female sex (49.4 % vs. 36.9 %, P<0.001), older (median 77.0 [IQR: 65.0–84.0] vs. 73.0 [62.0–81.0] years, P<0.001) and revealed an aggravated cardiovascular profile. Although SPF were independently associated with increased usage of cardiac catheterization (OR 1.174 [95 %CI 1.136-1.212]) and percutaneous coronary intervention (OR 1.167 [95 %CI 1.130-1.205]), they were accompanied by higher risk for a prolonged length of in-hospital stay >7 days (OR 1.236 [95 %CI 1.198-1.276]) and >10 days (OR 1.296 [95 %CI 1.254-1.339]). While SPF were associated with increased risk for deep venous thrombosis and/or thrombophlebitis (OR 1.634 [95 %CI 1.427-1.870]), pulmonary embolism (OR 1.337 [95 %CI 1.149-1.555]), and acute renal failure (OR 1.170 [95 %CI 1.105-1.240), these SPF were inversely associated with in-hospital case-fatality (OR 0.461 [95 %CI 0.433-0.490]).

Conclusions

This study demonstrates that SPF in hospitalized MI patients have significant impacts on treatments and outcomes. Fortunately, our data did not revealed an underuse of interventional treatments in MI patients with SPF.

背景：心肌梗死（MI）是导致全球发病率和死亡率的重要因素。阐明社会不平等现象有助于识别弱势群体和治疗失衡现象，并为改善心肌梗死护理工作提供指导：研究纳入了 2005-2020 年德国所有确诊为心肌梗死的住院患者病例，并根据社会经济或社会心理因素（SPF）进行了分层，分析了 SPF 对治疗使用和院内不良事件的影响：研究共纳入了 4,409,597 例住院的心肌梗死患者，其中 17,297 例（0.4%）的编码中包含 SPF。这些患者多为女性（49.4% 对 36.9%，P7 天（OR 1.236 [95 %CI 1.198-1.276]）和 >10 天（OR 1.296 [95 %CI 1.254-1.339]）。虽然 SPF 与深静脉血栓和/或血栓性静脉炎（OR 1.634 [95 %CI 1.427-1.870]）、肺栓塞（OR 1.337 [95 %CI 1.149-1.555]）和急性肾功能衰竭（OR 1.170 [95 %CI 1.105-1.240）的风险增加有关，但这些 SPF 与院内病死率（OR 0.461 [95 %CI 0.433-0.490]）成反比：本研究表明，住院心肌梗死患者的 SPF 对治疗和预后有重大影响。幸运的是，我们的数据并未显示有SPF的心肌梗死患者未充分利用介入治疗。

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引用次数: 0

Diagnosis of acute aortic syndromes with ultrasound and d-dimer: the PROFUNDUS study 利用超声波和 d-二聚体诊断急性主动脉综合征：PROFUNDUS 研究。

IF 5.9 2区医学 Q1 MEDICINE, GENERAL & INTERNAL

European Journal of Internal Medicine

Pub Date : 2024-10-01 DOI: 10.1016/j.ejim.2024.05.029

Background

In patients complaining common symptoms such as chest/abdominal/back pain or syncope, acute aortic syndromes (AAS) are rare underlying causes. AAS diagnosis requires urgent advanced aortic imaging (AAI), mostly computed tomography angiography. However, patient selection for AAI poses conflicting risks of misdiagnosis and overtesting.

Objectives

We assessed the safety and efficiency of a diagnostic protocol integrating clinical data with point-of-care ultrasound (POCUS) and d-dimer (single/age-adjusted cutoff), to select patients for AAI.

Methods

This prospective study involved 12 Emergency Departments from 5 countries. POCUS findings were integrated with a guideline-compliant clinical score, to define the integrated pre-test probability (iPTP) of AAS. If iPTP was high, urgent AAI was requested. If iPTP was low and d-dimer was negative, AAS was ruled out. Patients were followed for 30 days, to adjudicate outcomes.

Results

Within 1979 enrolled patients, 176 (9 %) had an AAS. POCUS led to net reclassification improvement of 20 % (24 %/-4 % for events/non-events, P < 0.001) over clinical score alone. Median time to AAS diagnosis was 60 min if POCUS was positive vs 118 if negative (P = 0.042). Within 941 patients satisfying rule-out criteria, the 30-day incidence of AAS was 0 % (95 % CI, 0–0.41 %); without POCUS, 2 AAS were potentially missed. Protocol rule-out efficiency was 48 % (95 % CI, 46–50 %) and AAI was averted in 41 % of patients. Using age-adjusted d-dimer, rule-out efficiency was 54 % (difference 6 %, 95 % CI, 4–9 %, vs standard cutoff).

Conclusions

The integrated algorithm allowed rapid triage of high-probability patients, while providing safe and efficient rule-out of AAS. Age-adjusted d-dimer maximized efficiency.

CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov, NCT04430400

背景：在主诉胸痛、腹痛、背痛或晕厥等常见症状的患者中，急性主动脉综合征（AAS）是罕见的潜在病因。急性主动脉综合征的诊断需要紧急进行先进的主动脉成像（AAI），主要是计算机断层扫描血管造影。然而，选择患者进行 AAI 会带来误诊和过度检查的风险：我们评估了将临床数据与床旁超声（POCUS）和 d-二聚体（单次/年龄调整截止值）相结合的诊断方案的安全性和效率，以选择患者进行 AAI：这项前瞻性研究涉及 5 个国家的 12 个急诊科。POCUS检查结果与符合指南的临床评分相结合，确定了AAS的综合检测前概率（iPTP）。如果 iPTP 较高，则要求进行紧急 AAI。如果 iPTP 较低且 d-二聚体呈阴性，则排除 AAS。对患者进行为期 30 天的随访，以判定结果：结果：1979 名入选患者中，176 人（9%）有 AAS。与单纯的临床评分相比，POCUS的净重新分类率提高了20%（事件/非事件分别为24%/-4%，P<0.001）。如果 POCUS 呈阳性，AAS 诊断的中位时间为 60 分钟；如果呈阴性，则为 118 分钟（P = 0.042）。在符合排除标准的 941 名患者中，AAS 的 30 天发病率为 0 %（95 % CI，0-0.41 %）；如果没有 POCUS，可能会漏诊 2 例 AAS。规程排除效率为 48 %（95 % CI，46-50 %），41 % 的患者避免了 AAI。使用年龄调整后的 d-二聚体，排除率为 54%（与标准临界值相比，差异为 6%，95% CI，4%-9%）：综合算法可快速分流高概率患者，同时安全有效地排除 AAS。年龄调整后的 d-二聚体能最大限度地提高效率：临床试验注册：Clinicaltrials.gov，NCT04430400。

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引用次数: 0

Red flags for clinical suspicion of eosinophilic granulomatosis with polyangiitis (EGPA) 临床怀疑嗜酸性粒细胞肉芽肿伴多血管炎（EGPA）的警示。

IF 5.9 2区医学 Q1 MEDICINE, GENERAL & INTERNAL

European Journal of Internal Medicine

Pub Date : 2024-10-01 DOI: 10.1016/j.ejim.2024.06.008

Background

Eosinophilic granulomatosis with polyangiitis (EGPA), is a rare ANCA-associated systemic vasculitis. Its overlapping features with other vasculitic or eosinophilic diseases, and the wide and heterogeneous range of clinical manifestations, often result in a delay to diagnosis.

Objective

To identify red flags that raise a suspicion of EGPA to prompt diagnostic testing and to present an evidence-based clinical checklist tool for use in routine clinical practice.

Methods

Systematic literature review and expert consensus to identify a list of red flags based on clinical judgement. GRADE applied to generate a strength of recommendation for each red flag and to develop a checklist tool.

Results

86 studies were included. 40 red flags were identified as relevant to raise a suspicion of EGPA and assessed by the experts as being clinically significant. Experts agreed that a diagnosis of EGPA should be considered in a patient aged ≥6 years with a blood eosinophil level >1000 cells/µL if untreated and >500 cells/µL if previously treated with any medication likely to have altered the blood eosinophil count. The presence of asthma and/or nasal polyposis should reinforce a suspicion of EGPA. Red flags of asthma, lung infiltrates, pericarditis, cardiomyopathy, polyneuropathy, biopsy with inflammatory eosinophilic infiltrates, palpable purpura, digital ischaemia and ANCA positivity, usually anti-myeloperoxidase, among others, were identified.

Conclusion

The identification of a comprehensive set of red flags could be used to raise a suspicion of EGPA in patients with eosinophilia, providing clinicians with an evidence-based checklist tool that can be integrated into their practice.

背景：嗜酸性粒细胞肉芽肿伴多血管炎（EGPA嗜酸性粒细胞肉芽肿伴多血管炎（EGPA）是一种罕见的ANCA相关性系统性血管炎。它与其他血管炎或嗜酸性粒细胞疾病的特征重叠，临床表现广泛且异质性强，往往导致诊断延误：目的：确定引起对 EGPA 怀疑的红色信号，以促使进行诊断检测，并提出基于证据的临床核对表工具，供常规临床实践使用：方法：系统性文献回顾和专家共识，根据临床判断确定红旗信号列表。结果：共纳入 86 项研究：结果：共纳入 86 项研究。结果：共纳入了 86 项研究，其中 40 项红旗被确定为与怀疑 EGPA 相关，并被专家评估为具有临床意义。专家们一致认为，如果患者年龄≥6 岁，且血液中嗜酸性粒细胞水平>1000 cells/µL（如果未接受治疗），或>500 cells/µL（如果之前接受过任何可能会改变血液中嗜酸性粒细胞数量的药物治疗），则应考虑诊断为 EGPA。哮喘和/或鼻息肉病的存在应加强对 EGPA 的怀疑。此外，还确定了哮喘、肺部浸润、心包炎、心肌病、多发性神经病、活检有炎症性嗜酸性粒细胞浸润、可触及的紫癜、数字缺血和 ANCA 阳性（通常为抗骨髓过氧化物酶）等红旗：结论：识别出一整套红旗可用于怀疑嗜酸性粒细胞增多症患者患有 EGPA，为临床医生提供了一种循证核对表工具，可将其纳入临床实践中。

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引用次数: 0

A group-based intervention for diabetes-related emotional distress among emerging adults with type 1 diabetes: A pilot study 针对 1 型糖尿病新成人患者与糖尿病相关的情绪困扰的小组干预：试点研究。

IF 5.9 2区医学 Q1 MEDICINE, GENERAL & INTERNAL

European Journal of Internal Medicine

Pub Date : 2024-10-01 DOI: 10.1016/j.ejim.2024.06.002

Aims

To assess diabetes-related emotional distress (DD) in emerging adults with type 1 diabetes (T1D) and assess a group-based intervention's impact.

Methods

To investigate DD we used data from the Problem Areas in Diabetes Questionnaire comprising 20 items (PAID-20). Furthermore, changes in the WHO Well-Being Index comprising five items (WHO-5) and glycated haemoglobin (HbA1c) were analysed. The intervention was evaluated using follow-up data from the emerging adults who participated.

Results

From 2021 to 2023, we screened 180 emerging adults using PAID-20. DD (PAID-20≥30) was prevalent in 25.0 % (95 % CI 18.9; 32.0 %), and associated with the female sex, higher HbA1c and WHO-5 < 50. Continuous subcutaneous insulin infusion at baseline was associated with PAID-20<30. 21 individuals attended a group-based intervention. At one-week follow up PAID-20 was reduced (29.1 ± 15.4 vs. 41.3 ± 12.1 at baseline, p = 0.003), and at nine-twelve months' follow-up HbA1c was reduced (59.3 ± 15.3 mmol/mol vs. 68.0 ± 17.4 mmol/mol at baseline, p = 0.012).

Conclusions

This pilot study demonstrated that 25 % of the investigated emerging adults with T1D experienced DD (PAID-20≥30) associated with four clinical factors. We found a reduction in HbA1c and a short-term reduction in PAID-20 following the group-based intervention.

目的：评估新发 1 型糖尿病（T1D）成人患者与糖尿病相关的情绪困扰（DD），并评估以小组为基础的干预措施的效果：方法：我们使用了由 20 个项目组成的糖尿病问题领域问卷（PAID-20）中的数据来调查 DD。此外，我们还分析了由五个项目组成的世界卫生组织幸福指数（WHO-5）和糖化血红蛋白（HbA1c）的变化。我们利用参与干预的新成人的随访数据对干预措施进行了评估：从 2021 年到 2023 年，我们使用 PAID-20 对 180 名新成人进行了筛查。DD（PAID-20≥30）的发病率为 25.0 %（95 % CI 18.9; 32.0 %），与女性性别、较高的 HbA1c 和 WHO-5 < 50 有关。基线时持续皮下注射胰岛素与 PAID-20 有关：这项试点研究表明，25% 的接受调查的新发 T1D 成人患者经历了与四个临床因素相关的 DD（PAID-20≥30）。我们发现，在采取以小组为基础的干预措施后，HbA1c 有所下降，PAID-20 也在短期内有所下降。

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引用次数: 0

Predictive performance of HAS-BLED, ORBIT, ABC, and DOAC scores for major bleeding in atrial fibrillation patients on DOACs HAS-BLED、ORBIT、ABC 和 DOAC 评分对服用 DOAC 的心房颤动患者大出血的预测性能。

IF 5.9 2区医学 Q1 MEDICINE, GENERAL & INTERNAL

European Journal of Internal Medicine

Pub Date : 2024-10-01 DOI: 10.1016/j.ejim.2024.06.027

引用次数: 0

Long-term inhaled corticosteroid treatment in patients with chronic obstructive pulmonary disease, cardiovascular disease, and a recent hospitalised exacerbation: The ICSLIFE pragmatic, randomised controlled study 慢性阻塞性肺病、心血管疾病和近期住院加重期患者的长期吸入皮质类固醇治疗：ICSLIFE 实用随机对照研究。

IF 5.9 2区医学 Q1 MEDICINE, GENERAL & INTERNAL

European Journal of Internal Medicine

Pub Date : 2024-10-01 DOI: 10.1016/j.ejim.2024.07.001

Introduction

Patients with chronic obstructive pulmonary disease (COPD) frequently have cardiovascular comorbidities, increasing the risk of hospitalised COPD exacerbations (H-ECOPDs) or death. This pragmatic study examined the effects of adding an inhaled corticosteroid (ICS) to long-acting bronchodilator(s) (LABDs) in patients with COPD and cardiac comorbidities who had a recent H-ECOPD.

Methods

Patients >60 years of age with COPD and ≥1 cardiac comorbidity, within 6 months after discharge following an H-ECOPD, were randomised to receive LABD(s) with or without ICS, and were followed for 1 year. The primary outcome was the time to first rehospitalisation and/or all-cause death.

Results

The planned number of patients was not recruited (803/1032), limiting the strength of the conclusions. In the intention-to-treat population, 89/403 patients (22.1 %) were rehospitalised or died in the LABD group (probability 0.257 [95 % confidence interval 0.206, 0.318]), vs 85/400 (21.3 %) in the LABD+ICS group (0.249 [0.198, 0.310]), with no difference between groups in time-to-event (hazard ratio 1.116 [0.827, 1.504]; p = 0.473). All-cause and cardiovascular mortality were lower in patients receiving LABD(s)+ICS, with relative reductions of 19.7 % and 27.4 %, respectively (9.8 % vs 12.2 % and 4.5 % vs 6.2 %), although the groups were not formally statistically compared for these endpoints. Fewer patients had adverse events in the LABD+ICS group (43.0 % vs 50.4 %; p = 0.013), with 4.9 % vs 5.4 % reporting pneumonia adverse events.

Conclusions

Results suggest addition of ICS to LABDs did not reduce the time-to-combined rehospitalisation/death, although it decreased all-cause and cardiovascular mortality. ICS use was not associated with an increased risk of adverse events, particularly pneumonia.

简介：慢性阻塞性肺病（COPD）患者经常合并心血管疾病，这增加了慢性阻塞性肺病住院加重（H-ECOPD）或死亡的风险。这项实用性研究探讨了在长效支气管舒张剂（LABDs）的基础上添加吸入性皮质类固醇（ICS）对近期发生过 H-ECOPD 的 COPD 和心脏病患者的影响：年龄大于 60 岁、患有慢性阻塞性肺病且合并有≥1 种心脏疾病的患者，在 H-ECOPD 出院后 6 个月内，随机接受含或不含 ICS 的 LABD，并随访 1 年。主要结果是首次再入院和/或全因死亡的时间：结果：未招募到计划的患者人数（803/1032），限制了结论的力度。在意向治疗人群中，LABD 组有 89/403 例患者（22.1%）再次入院或死亡（概率为 0.257 [95% 置信区间为 0.206, 0.318]），而 LABD+ICS 组有 85/400 例患者（21.3%）（概率为 0.249 [0.198, 0.310]），两组患者的死亡时间无差异（危险比为 1.116 [0.827, 1.504]；P = 0.473）。接受LABD(s)+ICS治疗的患者全因死亡率和心血管死亡率较低，相对降幅分别为19.7%和27.4%（9.8% vs 12.2%和4.5% vs 6.2%），但两组患者在这些终点上没有进行正式的统计学比较。LABD+ICS组发生不良事件的患者较少（43.0% vs 50.4%；p = 0.013），其中4.9% vs 5.4%报告了肺炎不良事件：结果表明，在LABDs基础上加用ICS并不能缩短合并再入院/死亡的时间，但能降低全因死亡率和心血管死亡率。使用 ICS 与不良事件（尤其是肺炎）风险增加无关。

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