Pub Date : 2025-02-01DOI: 10.1016/j.ejim.2024.11.031
Chiara Di Blasi , Federica Nobile , Alberto Maria Settembrini , Massimo Stafoggia , Marina Davoli , Paola Michelozzi , Matteo Renzi , Pier Mannuccio Mannucci
<div><h3>Introduction</h3><div>The association between air pollution and cardiovascular diseases is well established. However, fewer studies focused on the relationship between air pollution and peripheral artery disease (PAD), notwithstanding that not only it is a predictor of CVD mortality but also that incidence is globally rising, particularly in low-middle income countries.</div></div><div><h3>Objectives</h3><div>The aim of this study is to estimate the association between long-term exposure to air pollutants and the incidence of PAD in the Rome Longitudinal Study (RLS) during 2011–2019.</div></div><div><h3>Methods</h3><div>Using the Health Information Systems, we identified the first episodes of hospitalizations with discharge diagnosis for PAD (ICD-9 codes: 440.20-24; 444.0; 444.21; 444.22; 444.81; 447.1), lower limb vascular surgery (ICD-9 codes: 38.18; 39.29; 39.50; 39.90; 84.11; 84.12; 84.15; 84.17) or drug prescription (ATC code: B01AC23) in the period 2011–2019. In order to focus on incidence, we excluded from the population at risk prevalent cases based on hospital discharges in the 10 years before enrolment (October 9th, 2011). We assigned to the participants one-year average exposure to PM<sub>2.5</sub>, NO<sub>2</sub> and black carbon (BC) from the ELAPSE Europe-wide hybrid land-use regression (LUR) models at 100 m<sup>2</sup> spatial resolution on the basis of their baseline geocoded addresses. We also applied Cox regression models adjusted for individual and area-level covariates. The estimates were expressed as hazard ratios (HR) and 95 % confidence intervals (95 % CI) per pollutant-specific interquartile range (IQR) increase. We also analyzed any effect modification by socio-demographic and comorbidity variables and explored concentration-response curves using natural splines with 3 degrees of freedom.</div></div><div><h3>Results</h3><div>Starting from a population at risk of 1,719,475 subjects aged 30 years or above, a total of 14,629 incident cases were identified. An IQR (1.13 μg/<span><math><msup><mrow><mi>m</mi></mrow><mn>3</mn></msup></math></span>) increase in PM<sub>2.5</sub> was positively associated with a HR of 1.011 (95 % CI: 0.988, 1.034). Positive associations were also obtained for NO<sub>2</sub> ([IQR 7.86 μg/<span><math><msup><mrow><mi>m</mi></mrow><mn>3</mn></msup></math></span>] HR: 1.022 (95 % CI: 0.998, 1.048)) and black carbon ([IQR 0.39 x<span><math><msup><mrow><mn>10</mn></mrow><mrow><mo>−</mo><mn>5</mn></mrow></msup></math></span>/m] HR: 1.020 (95 % CI: 0.994, 1.047)). Effect modification analysis showed stronger associations when considering males and individuals in the 55–69 age class. Concentration-response curve for NO<sub>2</sub> showed a linear shape, with increases of risk already at low concentrations.</div></div><div><h3>Conclusions</h3><div>Long-term exposure to PM<sub>2.5</sub>, NO<sub>2</sub> and BC is associated with an increased incidence of PAD, and male subjects and individuals aged bet
{"title":"Association between long-term exposure to air pollution and incidence of peripheral artery disease: Evidence from a longitudinal study","authors":"Chiara Di Blasi , Federica Nobile , Alberto Maria Settembrini , Massimo Stafoggia , Marina Davoli , Paola Michelozzi , Matteo Renzi , Pier Mannuccio Mannucci","doi":"10.1016/j.ejim.2024.11.031","DOIUrl":"10.1016/j.ejim.2024.11.031","url":null,"abstract":"<div><h3>Introduction</h3><div>The association between air pollution and cardiovascular diseases is well established. However, fewer studies focused on the relationship between air pollution and peripheral artery disease (PAD), notwithstanding that not only it is a predictor of CVD mortality but also that incidence is globally rising, particularly in low-middle income countries.</div></div><div><h3>Objectives</h3><div>The aim of this study is to estimate the association between long-term exposure to air pollutants and the incidence of PAD in the Rome Longitudinal Study (RLS) during 2011–2019.</div></div><div><h3>Methods</h3><div>Using the Health Information Systems, we identified the first episodes of hospitalizations with discharge diagnosis for PAD (ICD-9 codes: 440.20-24; 444.0; 444.21; 444.22; 444.81; 447.1), lower limb vascular surgery (ICD-9 codes: 38.18; 39.29; 39.50; 39.90; 84.11; 84.12; 84.15; 84.17) or drug prescription (ATC code: B01AC23) in the period 2011–2019. In order to focus on incidence, we excluded from the population at risk prevalent cases based on hospital discharges in the 10 years before enrolment (October 9th, 2011). We assigned to the participants one-year average exposure to PM<sub>2.5</sub>, NO<sub>2</sub> and black carbon (BC) from the ELAPSE Europe-wide hybrid land-use regression (LUR) models at 100 m<sup>2</sup> spatial resolution on the basis of their baseline geocoded addresses. We also applied Cox regression models adjusted for individual and area-level covariates. The estimates were expressed as hazard ratios (HR) and 95 % confidence intervals (95 % CI) per pollutant-specific interquartile range (IQR) increase. We also analyzed any effect modification by socio-demographic and comorbidity variables and explored concentration-response curves using natural splines with 3 degrees of freedom.</div></div><div><h3>Results</h3><div>Starting from a population at risk of 1,719,475 subjects aged 30 years or above, a total of 14,629 incident cases were identified. An IQR (1.13 μg/<span><math><msup><mrow><mi>m</mi></mrow><mn>3</mn></msup></math></span>) increase in PM<sub>2.5</sub> was positively associated with a HR of 1.011 (95 % CI: 0.988, 1.034). Positive associations were also obtained for NO<sub>2</sub> ([IQR 7.86 μg/<span><math><msup><mrow><mi>m</mi></mrow><mn>3</mn></msup></math></span>] HR: 1.022 (95 % CI: 0.998, 1.048)) and black carbon ([IQR 0.39 x<span><math><msup><mrow><mn>10</mn></mrow><mrow><mo>−</mo><mn>5</mn></mrow></msup></math></span>/m] HR: 1.020 (95 % CI: 0.994, 1.047)). Effect modification analysis showed stronger associations when considering males and individuals in the 55–69 age class. Concentration-response curve for NO<sub>2</sub> showed a linear shape, with increases of risk already at low concentrations.</div></div><div><h3>Conclusions</h3><div>Long-term exposure to PM<sub>2.5</sub>, NO<sub>2</sub> and BC is associated with an increased incidence of PAD, and male subjects and individuals aged bet","PeriodicalId":50485,"journal":{"name":"European Journal of Internal Medicine","volume":"132 ","pages":"Pages 113-117"},"PeriodicalIF":5.9,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142792462","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-01DOI: 10.1016/j.ejim.2025.01.028
Mohamed G Shiha, David S Sanders
Coeliac disease is the most common immune-mediated enteropathy, affecting approximately 1 % of the population worldwide. Currently, the vast majority of individuals remain undiagnosed. Coeliac disease is triggered by gluten ingestion in genetically predisposed individuals carrying the human leukocyte antigen (HLA) genes; HLA-DQ2 and HLA-DQ8. Patients with coeliac disease present with a wide spectrum of gastrointestinal and extraintestinal manifestations and, in some cases, without any symptoms. The diagnosis of coeliac disease in adults is based on a combination of clinical suspicion, positive serological markers and histological evidence of small intestinal atrophy on duodenal biopsies. The only effective treatment is a strict, lifelong gluten-free diet. However, up to 20 % of patients report persistent or recurrent symptoms. In this review, we provide a comprehensive update on coeliac disease, focusing on its relevance to the different medical specialities and highlighting the need for a multidisciplinary approach to its diagnosis and management. Clinicians practicing internal medicine have a unique opportunity to diagnose this multisystem autoimmune disease. By doing so, they would avoid delays in diagnosis for these patients. A low threshold for serological testing is recommended.
{"title":"What is new in the management of coeliac disease?","authors":"Mohamed G Shiha, David S Sanders","doi":"10.1016/j.ejim.2025.01.028","DOIUrl":"https://doi.org/10.1016/j.ejim.2025.01.028","url":null,"abstract":"<p><p>Coeliac disease is the most common immune-mediated enteropathy, affecting approximately 1 % of the population worldwide. Currently, the vast majority of individuals remain undiagnosed. Coeliac disease is triggered by gluten ingestion in genetically predisposed individuals carrying the human leukocyte antigen (HLA) genes; HLA-DQ2 and HLA-DQ8. Patients with coeliac disease present with a wide spectrum of gastrointestinal and extraintestinal manifestations and, in some cases, without any symptoms. The diagnosis of coeliac disease in adults is based on a combination of clinical suspicion, positive serological markers and histological evidence of small intestinal atrophy on duodenal biopsies. The only effective treatment is a strict, lifelong gluten-free diet. However, up to 20 % of patients report persistent or recurrent symptoms. In this review, we provide a comprehensive update on coeliac disease, focusing on its relevance to the different medical specialities and highlighting the need for a multidisciplinary approach to its diagnosis and management. Clinicians practicing internal medicine have a unique opportunity to diagnose this multisystem autoimmune disease. By doing so, they would avoid delays in diagnosis for these patients. A low threshold for serological testing is recommended.</p>","PeriodicalId":50485,"journal":{"name":"European Journal of Internal Medicine","volume":" ","pages":""},"PeriodicalIF":5.9,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143081964","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-01DOI: 10.1016/j.ejim.2024.09.014
Ombretta Para , Joel Byju Valuparampil , Alberto Parenti , Carlo Nozzoli , Alessandro Della Puppa
{"title":"Co-management hospitalist services for neurosurgery. Where are we?","authors":"Ombretta Para , Joel Byju Valuparampil , Alberto Parenti , Carlo Nozzoli , Alessandro Della Puppa","doi":"10.1016/j.ejim.2024.09.014","DOIUrl":"10.1016/j.ejim.2024.09.014","url":null,"abstract":"","PeriodicalId":50485,"journal":{"name":"European Journal of Internal Medicine","volume":"132 ","pages":"Pages 148-149"},"PeriodicalIF":5.9,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142331645","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-01DOI: 10.1016/j.ejim.2024.10.012
George Ntaios , Mayank Dalakoti
For any physician treating a patient with a medical condition of unclear etiology, the differential diagnosis aims to identify the actual most probable cause among various potential etiologies, in order to tailor treatment options. In patients with embolic stroke of undetermined source (ESUS), this can be challenging due to the frequent presence of multiple potential embolic sources, raising difficulties to identify the most likely cause. Additionally, despite targeted preventive measures for the presumed embolic source, patients may remain at risk for stroke and cardiovascular events due to other unrecognized or underestimated pathologies.
The multi-level complexity and multimorbidity typically associated with ESUS, represents a challenge that requires broad knowledge of the cardiovascular pathophysiology, deep expertise of the available diagnostic and therapeutic options, and interdisciplinary approach. At the same time, it is an ideal opportunity to assess thoroughly the overall cardiovascular status of the patient, which in turn can allow us to optimize therapeutic and preventive strategies in a holistic approach, and prevent future strokes, cardiovascular events and disability through different parallel pathways.
In this context, rather than narrowing our perspective on identifying the specific embolic source presumed to be the most likely cause of ESUS, it is crucial to shift our focus from the disease to the patient, and evaluate the overall cardiovascular profile by assessing the risk of all cardiovascular comorbidities present, no matter if causally associated with ESUS or not. In order to bring across these points and more, this article is centred around a clinical case that serves as a starting point to illustrate the holistic approach to the management of patients with ESUS.
After all, this is the beauty, the magic and the art of Internal Medicine: to treat the patient, not the disease, the system or the organ.
{"title":"Treat the patient, not the disease: The embolic stroke of undetermined source as an opportunity to optimize cardiovascular prevention in a holistic approach","authors":"George Ntaios , Mayank Dalakoti","doi":"10.1016/j.ejim.2024.10.012","DOIUrl":"10.1016/j.ejim.2024.10.012","url":null,"abstract":"<div><div>For any physician treating a patient with a medical condition of unclear etiology, the differential diagnosis aims to identify the actual most probable cause among various potential etiologies, in order to tailor treatment options. In patients with embolic stroke of undetermined source (ESUS), this can be challenging due to the frequent presence of multiple potential embolic sources, raising difficulties to identify the most likely cause. Additionally, despite targeted preventive measures for the presumed embolic source, patients may remain at risk for stroke and cardiovascular events due to other unrecognized or underestimated pathologies.</div><div>The multi-level complexity and multimorbidity typically associated with ESUS, represents a challenge that requires broad knowledge of the cardiovascular pathophysiology, deep expertise of the available diagnostic and therapeutic options, and interdisciplinary approach. At the same time, it is an ideal opportunity to assess thoroughly the overall cardiovascular status of the patient, which in turn can allow us to optimize therapeutic and preventive strategies in a holistic approach, and prevent future strokes, cardiovascular events and disability through different parallel pathways.</div><div>In this context, rather than narrowing our perspective on identifying the specific embolic source presumed to be the most likely cause of ESUS, it is crucial to shift our focus from the disease to the patient, and evaluate the overall cardiovascular profile by assessing the risk of all cardiovascular comorbidities present, no matter if causally associated with ESUS or not. In order to bring across these points and more, this article is centred around a clinical case that serves as a starting point to illustrate the holistic approach to the management of patients with ESUS.</div><div>After all, this is the beauty, the magic and the art of Internal Medicine: to treat the patient, not the disease, the system or the organ.</div></div>","PeriodicalId":50485,"journal":{"name":"European Journal of Internal Medicine","volume":"132 ","pages":"Pages 9-17"},"PeriodicalIF":5.9,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142512195","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-01DOI: 10.1016/j.ejim.2024.11.001
Ke-qian Chen , Shu-zhi Wang , Zong-bao Wang , Hai-bo Lei , Xiang Liu
{"title":"The potential impact of educational attainment on NAFLD risk","authors":"Ke-qian Chen , Shu-zhi Wang , Zong-bao Wang , Hai-bo Lei , Xiang Liu","doi":"10.1016/j.ejim.2024.11.001","DOIUrl":"10.1016/j.ejim.2024.11.001","url":null,"abstract":"","PeriodicalId":50485,"journal":{"name":"European Journal of Internal Medicine","volume":"132 ","pages":"Pages 131-132"},"PeriodicalIF":5.9,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142631849","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-01DOI: 10.1016/j.ejim.2024.10.016
Stefano Masi , Herman Dalpiaz , Sara Piludu , Federica Piani , Giulia Fiorini , Claudio Borghi
Renin-angiotensin-aldosterone system inhibitors (RAASi) and mineralocorticoid receptor antagonists (MRAs) are key drugs in the management of patients with cardiovascular diseases (CVD), particularly those with hypertension, diabetes, chronic kidney disease and heart failure (HF), given their demonstrated effectiveness in reducing the risk of both surrogate and hard endpoints. Despite their positive impact on the outcome, patients with RAASi and MRAs are particularly vulnerable to hyperkalaemia, with approximately 50 % of these individuals experiencing two or more recurrences annually. The common practice of reducing the dose or discontinuing the treatment with RAASi and MRAs in conditions of hyperkalaemia results in suboptimal management of these patients, with a potential impact on their mortality and morbidity risk. Recent guidelines from cardiovascular and renal international societies increasingly recognize the need for alternative strategies to manage the risk of hyperkalaemia, allowing the continuation of RAASi and MRA therapies. In this review, we summarise the new potential options available to manage hyperkalaemia in patients with CVD and the recommendations of the most recent guidelines on the topic.
{"title":"New strategies for the treatment of hyperkalemia","authors":"Stefano Masi , Herman Dalpiaz , Sara Piludu , Federica Piani , Giulia Fiorini , Claudio Borghi","doi":"10.1016/j.ejim.2024.10.016","DOIUrl":"10.1016/j.ejim.2024.10.016","url":null,"abstract":"<div><div>Renin-angiotensin-aldosterone system inhibitors (RAASi) and mineralocorticoid receptor antagonists (MRAs) are key drugs in the management of patients with cardiovascular diseases (CVD), particularly those with hypertension, diabetes, chronic kidney disease and heart failure (HF), given their demonstrated effectiveness in reducing the risk of both surrogate and hard endpoints. Despite their positive impact on the outcome, patients with RAASi and MRAs are particularly vulnerable to hyperkalaemia, with approximately 50 % of these individuals experiencing two or more recurrences annually. The common practice of reducing the dose or discontinuing the treatment with RAASi and MRAs in conditions of hyperkalaemia results in suboptimal management of these patients, with a potential impact on their mortality and morbidity risk. Recent guidelines from cardiovascular and renal international societies increasingly recognize the need for alternative strategies to manage the risk of hyperkalaemia, allowing the continuation of RAASi and MRA therapies. In this review, we summarise the new potential options available to manage hyperkalaemia in patients with CVD and the recommendations of the most recent guidelines on the topic.</div></div>","PeriodicalId":50485,"journal":{"name":"European Journal of Internal Medicine","volume":"132 ","pages":"Pages 18-26"},"PeriodicalIF":5.9,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142570142","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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