European Journal of Internal Medicine最新文献

Background: The rise in global prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) has highlighted the importance of developing sex-specific risk profiles for MASLD based on readily available self-reported lifestyle characteristics and plasma biomarkers.

Objectives: We aimed to develop sex-specific risk profiles for MASLD according to lifestyle characteristics and plasma biomarkers.

Methods: We included 3282 women and 2167 men from the Copenhagen General Population Study cohort with a computed tomography (CT) scan of the liver. All individuals had information on 17 lifestyle characteristics and plasma biomarkers from standard hospital assays. MASLD was defined by non-contrast CT scan Hounsfield Units (≤48 and ≤56HU) or liver/spleen ratios <1 in addition to at least one cardiometabolic risk factor.

Results: For the same value of most lifestyle characteristics and plasma biomarkers, women had less liver fat on CT scans than men. For abnormal categories of most lifestyle characteristics and plasma biomarkers, odds ratios for MASLD were more pronounced in women than in men (p-values for sex-interaction 4 × 10^-7 to 3 × 10^-25). Risk profiles for severe MASLD included waist circumference, smoking, alanine transaminase, and HDL cholesterol for both sexes. For women, risk profiles further included body mass index, systolic blood pressure, and remnant cholesterol, while for men, risk profiles further included diastolic blood pressure. Risk profiles for severe+moderate MASLD and for liver/spleen MASLD included many of the same characteristics; although liver/spleen in women merely included three characteristics.

Conclusion: Risk profiles for MASLD according to 17 lifestyle characteristics and plasma biomarkers differ by sex.

Incretin-based therapies, including mono-, dual-, and emerging triple-agonists, have transformed the pharmacological management of obesity by inducing substantial and sustained weight loss together with marked improvements in cardiometabolic risk factors. However, growing evidence from randomized withdrawal trials and meta-analyses demonstrates that discontinuation of these agents is consistently followed by rapid and clinically meaningful weight regain, often approaching two-thirds of the initial weight loss within one year, alongside early deterioration of cardiometabolic parameters. These observations reinforce the concept of obesity as a chronic, relapsing disease that generally requires long-term pharmacological management rather than time-limited treatment. This Opinion article examines the biological, clinical, and health-system factors that complicate discontinuation of incretin-based therapies, including adaptive neuroendocrine responses to weight loss, interindividual variability in treatment response, persistence of "obesity memory" at the adipose tissue level, and real-world challenges related to adherence, tolerability, and cost. We discuss emerging strategies aimed at mitigating post-withdrawal weight regain, such as dose de-escalation, low-dose maintenance, extended dosing intervals, and intensive lifestyle interventions, while highlighting the current lack of robust randomized evidence supporting these approaches. Finally, we propose reframing the concept of precision medicine in obesity toward a "precision physician-patient relationship," emphasizing individualized, longitudinal decision-making to guide treatment continuation, tapering, or discontinuation in the absence of reliable predictive biomarkers.

Background: Acute stroke is frequently complicated by new-onset cardiac or thromboembolic events, referred to as Stroke-Heart Syndrome (SHS). The role of stroke subtype and lesion location in determining SHS risk remains underexplored.

Methods: We conducted a retrospective analysis of data from the hospital-based Perugia Stroke Registry (March 2005-September 2019). Patients with acute neurological symptoms were classified as ischaemic stroke (IS) or haemorrhagic stroke (HS) based on neuroimaging. Logistic regression identified predictors of stroke subtype and in-hospital complications. Subgroup analyses compared first-ever versus recurrent strokes, and lesion location (lacunar, non-lacunar anterior, or non-lacunar posterior for IS; typical versus atypical for HS). The primary outcome was a composite of all-cause death, cardiac events and venous thromboembolic events during Stroke Unit stay. Secondary outcomes were each component.

Results: Among 2080 patients (mean age 72.8 ± 12.5 years; 57% male), 1788 (86%) had IS and 292 (14%) HS. During Stroke Unit stay (median 8 days, IQR 5-14), HS patients had higher rates of the composite outcome (26% vs 14%) and all-cause death (21.2% vs 8.8%) than IS. In IS, non-lacunar posterior and anterior strokes were associated with increased risk of composite outcome (OR 1.97, 95%CI 1.10-3.63; OR 1.61, 95%CI 0.96-2.81) and all-cause death (OR 3.35, 95%CI 1.35-9.51; OR 2.90, 95%CI 1.28-7.79) versus lacunar strokes. Among HS, atypical lesions increased risk of composite outcome (OR 2.51, 95%CI 1.24-5.22) and all-cause death (OR 2.80, 95%CI 1.31-6.17).

Conclusions: Lesion location is a key determinant of SHS. Non-lacunar posterior stroke and atypical HS predict higher mortality and cardiovascular complications.

None.

Introduction: Retinal vascular alterations were reported in patients with SSc suggesting a potential role for OCTA in the evaluation of SSc-related microangiopathy. The aim of the study is to evaluate the microangiopathic alterations in the retina of patients with SSc and to evaluate their correlation with the clinical manifestations of the disease and the capillaroscopic findings MATERIALS AND METHODS: This is a case-control study comparing SSc patients to healthy controls. OCTA acquisition consisted on scans of the superficial capillary plexus (SCP) and deep capillary plexus (DCP) of both the macula and the optic nerve, performed using Canon OCT. Vascular density (VD), vascular length density (VLD), foveal avascular zone (FAZ) and retinal thickness in the fovea and in the perifoveal region were obtained using dedicated software.

Results: 41 SSc patients (11 were VEDOSS) were compared with 20 healthy controls. SSc patients showed reduced VD and VLD values ​​in all areas evaluated both in the SCP and DCP (p < 0.001 for both). At the optic nerve level, both VD and VLD values ​​were reduced at the SCP (p < 0.001 for both) and DCP levels (p = 0.009 and p < 0.001). Retinal thickness in the parafoveal region was increased in SSc patients (p = 0.013) and correlated with blood flow at nailfold videocapillascopy (p = 0.030). VD and VLD at the foveal level in DCP were associated with the presence of avascular areas (p = 0.018 and p = 0.019) and neoangiogenesis (p = 0.023 and p = 0.025).

Conclusion: Ocular microangiopathy is present in scleroderma patients since the early stages of the disease and is correlated with capillaroscopic alterations.

Rationale: Real-world effectiveness of cardiovascular and LABA/LAMA treatment in patients with heart failure (HF) during hospitalized exacerbation of COPD (ECOPD) is limited.

Objectives: To investigate associations of guideline-directed medical therapy (GDMT) during hospitalization with in-hospital and post-discharge all-cause mortality and readmission risk.

Methods: HF patients aged ≥18 years hospitalized for ECOPD were included in this Belgian nationwide observational cohort between 2017-2022. HF GDMT was defined as use of at least beta-blockers in combination with angiotensin-converting enzyme inhibitors, angiotensin receptor blockers or angiotensin receptor-neprilysin inhibitors following 2016 ESC guidelines, whereas COPD GDMT was defined as use of at least LABA+LAMA following 2017 GOLD report. Multivariable adjusted logistic regression and time-to-event analyses were used to investigate the associations.

Main results: Among 14,582 patients (mean age 76.8 years, 40.7% females), GDMT was dispensed for HF only (20.4%), COPD only (23.6%) or both HF and COPD (11.9%). During hospitalization, 14.1% (2,058/14,582) died: 18.1% (no GDMT), 11.1% (HF GDMT), 11.0% (COPD GDMT) and 7.9% (both GDMT), respectively. HF GDMT was significantly associated with a 38% lower in-hospital mortality odds (aOR 0.62, 95%CI 0.55-0.70), while COPD GDMT was independently associated with a 40% lower odds (aOR 0.60, 95%CI 0.53-0.67). HF GDMT, alone (aHR 0.83, 95%CI 0.77-0.88) or combined with COPD GDMT (aHR 0.82, 95%CI 0.75-0.89), was associated with a significantly lower post-discharge mortality risk, whereas no significant associations between GDMT and readmission were observed.

Conclusions: These results highlight the importance of HF GDMT, alongside optimised COPD management during hospitalization, to reduce in-hospital and post-discharge mortality risk.

Background and aim: The role of exercise testing in the follow up of patients with persistent dyspnea after pulmonary embolism (PE) is currently limited, with cardiopulmonary exercise test (CPET) mainly recommended in patients with a low probability of pulmonary hypertension (PH) at rest.

Methods: We conducted a comprehensive systematic review of studies retrieved from EMBASE and MEDLINE. When appropriate, meta-analysis was conducted.

Results: Twenty-eight studies were included. At CPET, pooled VE/VCO₂ slope was lower in CTEPD without PH compared to chronic thromboembolic pulmonary hypertension (CTEPH) (mean difference = 12.34, 95% CI =17.19 to 7.48, I² =76%). CPET parameters indicated more severe cardiopulmonary impairment in CTEPH than in pulmonary arterial hypertension (PAH), with a lower pooled Peak VO₂ (mean difference=-0.57 mL·kg⁻¹·min⁻¹, 95% CI=-0.94 to -0.20, I²=0%), higher VE/VCO₂ slope (mean difference=8.44, 95% CI=3.31 to 13.57, I²=19%), lower peak PETCO₂ (mean difference=-3.55 mmHg, 95% CI=-4.75 to -2.34 mmHg, I²=0%), and lower PETCO₂ at anaerobic threshold (mean difference=-3.55 mmHg, 95% CI=-4.75 to -2.34 mmHg, I²=0%). In CTEPH, peak VO2 correlated with mPAP and survival: in two studies, different VO2 thresholds were associated with survival differences of 30% and 35%, respectively. The prevalence of exercise-induced PH, assessed by exercise right heart catheterization (exRHC), was reported as 50% and 45% in two studies.

Discussion: CTEPH is associated with worse CPET profile compared with both CTEPD without PH and PAH. Peak VO₂ and ventilatory efficiency may have prognostic value in CTEPH, while evidence in CTEPD without PH remains largely exploratory and hypothesis-generating.