European Journal of Internal Medicine最新文献

Background: Although patent foramen ovale (PFO) transcatheter closure lowers recurrent cryptogenic stroke (CS), identifying patients who benefit most remains challenging. We developed, validated and assessed the diagnostic performance of a new scoring system to predict high-risk PFO patients who may benefit from PFO transcatheter closure in secondary prevention.

Methods: The CRISP-PFO score was derived from 936 PFO patients with a RoPE score ≥7, enrolled in a single-center prospective registry from March 2003 to March 2025. The score was derived from 624 patients and validated in 312 patients. Significant baseline variables (p < 0.1) from univariable logistic regression were entered into a multivariable model. Model performance was assessed via receiving operating curves and calibration slope. Patients were stratified into low-, intermediate-, and high-risk groups.

Results: In the derivation cohort, multivariate analysis identified four independent predictors of CS: permanent right-to-left shunt (2 points), ischemic brain lesions (2 points), an antero-posterior left atrial (LA) diameter ≥43 mm (1 point), and atrial septal aneurysm (1 point). Based on these factors, patients were stratified into low (0-2 points), intermediate (3-4 points), and high (5-6 points) risk categories, with event rates increasing across these groups (p<0.001). The CRISP-PFO score demonstrated strong diagnostic performance, with an AUC of 0.80-0.81, C-statistics of 0.78-0.79, and Hosmer-Lemeshow p-values of 0.44-0.47 in the derivation and validation cohorts, respectively.

Conclusions: The CRISP-PFO score is a novel and straightforward tool that accurately identifies PFO patients at high risk for CS who may benefit from transcatheter PFO closure.

Background: Adrenal insufficiency (AI) is a common complication following glucocorticoid (GC) therapy. However, reliable predictors of AI and GC regimens that mitigate this risk remain unclear. Previous systematic reviews (SRs) have included many observational studies with imprecise reporting of GC dose and duration. We conducted a systematic review focusing exclusively on studies with well-defined GC exposure.

Methods: We searched Embase, Web of Science, and MEDLINE for original studies published since 2000 that investigated adults receiving protocolised systemic GC regimens and assessed all participants for AI using the adrenocorticotropic hormone (ACTH) stimulation test. Data extracted included AI prevalence, diagnosis, administration route, GC dose and tapering, treatment duration and timing of outcome assessment. Risk of bias was assessed using an adapted Newcastle-Ottawa Scale. Meta-analysis was performed using random-effects models in R.

Results: Of 1340 unique records identified, 12 studies (1170 participants) met inclusion criteria. AI was present in 423 individuals, with a pooled prevalence of 30% (95% CI: 19-45%) at the earliest time point tested. Reported prevalence ranged from 0 to 70%, and was not consistently associated with diagnosis, administration route, treatment duration, or study quality. AI was significantly less common in studies that included tapering (p < 0.01) and in those assessing AI ≥15 days after stopping GCs (15%, 95% CI: 8-26%) compared to testing at cessation (48%, 95% CI: 35-62%).

Conclusion: AI is frequent following systemic GC use, with considerable variability. Tapering regimens and delayed testing post-cessation appear to reduce the observed prevalence. No specific GC regimen reliably prevents AI.

Objective: Lactate kinetics between prehospital and in-hospital measurements have been associated with prognosis in acute conditions. This study aimed to evaluate the prognostic value of the prehospital-to-hospital lactate ratio in patients with severe diabetic ketoacidosis (DKA).

Methods: This was a prospective, multicenter cohort study including adults attended by emergency medical services (EMS) with a diagnosis of severe DKA or hyperosmolar hyperglycemic state. The lactate ratio was calculated by dividing the initial prehospital point-of-care lactate value by the in-hospital measurement. The optimal cutoff point was identified via locally weighted scatter plot smoother curve analysis. Survival was analyzed using Kaplan-Meier curves and Cox regression, adjusted for age, age-adjusted Charlson comorbidity index (ACCi), precipitating factor, and prehospital Glasgow Coma Scale (GCS) score.

Results: A total of 128 patients were included (median age 71 years [IQR 58.5-80], 47.7 % female). The median ACCi was 7 (IQR 5-9), and in-hospital mortality was 34.4 %. Patients were stratified by lactate ratio <1.23 or ≥1.23;baseline characteristics were broadly similar between groups, except for a higher prehospital GCS score in patients with a lactate ratio ≥1.23. Mortality was 57.3 % in the <1.23 group versus 14.5 % in the ≥1.23 group (log-rank p<0.001). A lactate ratio <1.23 was independently associated with higher mortality (HR 105.21; p<0.001), along with ACCi (p=0.023) and infectious cause (HR 3.43; p=0.014). Higher prehospital GCS was protective (HR 0.89; p=0.018).

Conclusion: Prehospital-to-hospital lactate ratio was independently associated with in-hospital mortality in severe DKA. This accessible biomarker may contribute to risk stratification and support clinical decision-making in this setting.

Background: Systemic inflammation is a central feature of advanced chronic liver disease (AdvCLD). However, the relationship between inflammatory status, as reflected by the systemic immune-inflammation index (SII), and frailty in this population remains undefined.

Methods: We performed a retrolective analysis of a prospective cohort of 291 patients with AdvCLD evaluated for liver transplantation (LT). Frailty was assessed using the Liver Frailty Index (LFI), gait speed test (GST) and the 6-minute walk test (6MWT). The SII, calculated as (platelets x neutrophils) / lymphocytes. Patients were categorized into low and high SII groups. Associations between SII and frailty were examined using multivariable logistic and linear regression. The prognostic value of SII for one-year all-cause mortality was evaluated using a competing-risk model with LT as the competing event.

Results: Among 291 patients, 46 (16%) met criteria for LFI ≥ 4.5, and 56 (19%) had a 6MWT <250 m. High SII (≥3.52) was associated with higher MELD 3.0 scores, greater LFI ≥ 4.5 prevalence (23% vs. 9%), slower GS (0.8 m/s vs 1.0 m/s) and a higher proportion walking <250 m (27% vs 12%). Median SII increased progressively across LFI categories and was significantly higher in individuals walking <250 m. High SII remained independently associated with frailty (LFI ≥ 4.5), 6MWT <250 m and GST in multivariable models. After MELD 3.0 adjustment, high SII was associated with increased mortality (aSHR 2.74; 95% CI 1.18-6.33).

Conclusion: SII reflects systemic inflammation, and higher SII values are associated with increased frailty and higher mortality in AdvCLD.