The American journal of the medical sciences最新文献

Background: Diabetes mellitus (DM) is a key risk factor for atherosclerotic cardiovascular diseases (ASCVDs), which remain a leading cause of morbidity and mortality worldwide. We aim to evaluate trends and disparities in ASCVD-related mortality in US adults aged 45+ with DM from 1999-2019.

Methods: We extracted data from the CDC WONDER database using ICD-10 codes E10-E14 for DM and I25.0 and I25.1 for ASCVDs. Age-adjusted mortality rates (AAMRs) and crude death rates (CDRs) per 100,000 by sex, race/ethnicity, age group, and geographic regions were used. AAMRs and CDRs were analyzed using the Joinpoint Regression Program to calculate annual percentage changes (APCs) and average APCs (AAPCs).

Results: From 1999 to 2019, 453,572 ASCVD-related deaths occurred in 45+ year adults with DM. Overall, AAMR decreased from 22.22 to 16.11 [AAPC: -1.63 %, (-1.83 to -1.47)]. Females experienced a larger decline (AAPC -2.76 %) than males (-0.80 %). By race/ethnicity, non-Hispanic American Indians/Alaska Natives had the highest AAMR (32.36), and Asian/Pacific Islanders the lowest (12.85); Hispanics saw the steepest decline (-3.41 %). CDRs rose with age, from 3.16 (45-54 years) to 84.17 (85+), with the greatest decrease in the 65-74 group (-2.04 %). Regionally, the Midwest had the highest AAMR (19.86), and the South had the smallest decline (-1.44 %). Non-metropolitan areas had higher AAMRs (20.33) and smaller declines (-0.52 %) than metropolitan areas (18.17; -1.94 %).

Conclusions: Our study reveals a decline in ASCVD-related mortality in DM patients in the US from 1999-2019. However, marked disparities persist across demographics and regions. Targeted health policy measures are needed to address these disparities.

Background: Diabetes mellitus (DM) is a metabolic disorder that lacks specific early diagnostic markers and is often associated with serious complications and comorbidities. The triglyceride-glucose index (TyG) and the triglyceride-glucose-body mass index (TyG-BMI) are key metabolic indicators related to insulin resistance and β-cell dysfunction. However, their association with the development of type 2 diabetes mellitus (T2DM) remains unclear. This study aimed to examine the relationship between TyG and TyG-BMI levels and the incidence of T2DM, evaluate their predictive performance, and support the identification of populations at high risk for T2DM.

Methods: Data were obtained from the 2009 China Health and Nutrition Survey (CHNS), including 9498 participants. TyG and TyG-BMI were calculated, and their associations with T2DM risk were assessed using a Cox regression model. Predictive performance was evaluated with receiver operating characteristic (ROC) curve analysis.

Results: In the overall population, including both sexes, individuals aged >50 years and ≤50 years, and both urban and rural residents, higher TyG and TyG-BMI levels were independently associated with T2DM, showing a linear dose-response relationship. Both indicators demonstrated predictive value for T2DM, with TyG-BMI showing stronger associations, a larger area under the ROC curve, and greater clinical relevance.

Conclusions: These results suggest that both TyG and TyG-BMI are useful predictors of T2DM, with TyG-BMI providing superior predictive accuracy. These findings support the use of these indices in the early screening of high-risk T2DM populations.

Background: Frailty has been linked to worse health outcomes, longer hospital stays, higher complications, and mortality. In general, higher morbidity and mortality especially with any invasive cardiac procedure. The impact of frailty on TEER of MR is further explored in this study.

Methods: The NRD was queried between 2016-2020 to compare different outcomes between LF vs HF who underwent TEER. The multivariate regression was used to compare the primary and secondary outcomes between the two cohorts and generate univariate and multivariate odd ratios (OR) . STATA V.17 was used to compute the analysis.

Results: The total patients were 27,062 (HF 7,456 & LF 19,606). The mean age was 81.9±7.4 and 77.2±8.6 (P<0.001) in HF vs LF, respectively. The average LOS was higher in HF at 9.22±10.58 vs 2.12±2.7 days in LF. HF had higher and statistically significant values for the following outcomes in comparison with LF: in-hospital mortality (OR 21, [13.07-33.71,] P<0.001), AKI (OR 15.91, [13.49-18.77], P<0.001), CHF (OR 1.4, [1.17-1.68], P<0.001), MI (OR 8.42, [5.44-13.03], P<0.001), needs of MCS (OR 13.27, [8.28-21.25], P<0.001), MACCE (OR 14.13, [11.03-18.1], P<0.001), PPB (OR 2.42, [1.72-3.42], P<0.001), and CT (OR 3.99, [2.22-7.15], P<0.001). The median total cost of hospitalization was higher in HF patients ($51,374 [IQR 37,277-75,989]) in comparison with LF patients ($38,492 [IQR 29,713-50,030], P<0.001).

Conclusion: HF individuals who underwent TEER of MR have higher in-hospital mortality, worse health outcomes and complications, longer hospital stay, and hence higher total healthcare costs in comparison with LF patients.

Background: Septic shock is a leading cause of mortality. Yet, blood cultures are negative in many cases, questioning the diagnosis. In the quest for characterization of "culture negative septic shock", the impact of chronic vasodilating medications was questioned.

Methods: This was a retrospective analysis of patients with vital signs compatible with septic shock (fever > 37.9 or < 36 °C and systolic blood pressure < 90 mmHg).

Results: The study included 3,726 patients (ages 65 to 90). Of these, 1,382 (37.1%) took chronic vasodilators. This group of patients had a lower rate of positive blood cultures compared to the group that did not receive vasodilators (28.5% vs. 32%; P = 0.026). They were older (median 80 vs. 78 years; P = 0.001), and their background included more cardiovascular diseases (P < 0.001). Their total length of hospital stay was shorter (median 4 vs. 6 days; P < 0.001) yet, they had a higher risk of in-hospital mortality (39% vs. 35.1%; P = 0.019). Taking chronic vasodilators was associated with decreased risk for bacteremia by 16% (P = 0.023). Older age, positive bacterial culture, and chronic vasodilation treatment were independently associated with increased risk for in-hospital mortality by 3% (HR = 1.03, 95% CI 1.02 - 1.04; P < 0.001), 36% (HR = 1.36, 95% CI 1.18 - 1.57; P < 0.001), and 21% (HR = 1.21, 95% CI 1.05 - 1.4; P = 0.009) respectively.

Conclusions: Chronic use of vasodilators amongst elderly patients presenting with fever and hypotension is associated with a higher incidence of negative blood cultures. We suggest these patients exhibit a combination of sepsis and shock rather than frank septic shock.

Cardiac Sarcoidosis (CS) is a potentially life-threatening manifestation of sarcoidosis that presents significant diagnostic and management challenges. While only 2-5 % of patients with sarcoidosis are diagnosed with CS, autopsy studies have demonstrated a prevalence as high as 25 % suggesting the condition is often under recognized likely because of lack of or nonspecific symptoms or diagnostic limitations. Considering the unreliability and invasiveness of endomyocardial biopsy, cardiac magnetic resonance imaging (CMR) and Fluorodeoxyglucose F18 (FDG) positron emission tomography (PET) have become useful diagnostic modalities in suspected cases of CS. However, there is scarce data in support of one imaging modality over the other and each has its limitations. Such limitations are depicted in the case of a patient with complete heart block and newly diagnosed sarcoidosis showing conflicting results on FDG-PET and CMR. A narrative review of current knowledge on this condition and about the imaging modalities available for the workup of CS is provided.

Objective: Sepsis remains a major global health challenge, with high mortality associated with multi-organ dysfunction, faster identification and assessment of sepsis is beneficial to guide treatment. Studies have found changes in the composition of bile acids (BAs) in the serum and stool of patients with sepsis compared to healthy individuals, so we sought to explore changes in serum BAs in patients with sepsis and their correlation with prognosis.

Methods: This prospective study enrolled healthy individuals and sepsis patients admitted to the Intensive Care Unit of the Second Affiliated Hospital of Nanjing Medical University between January 2023 and January 2024. Clinical data were collected, and serum levels of 15 BAs were quantified using liquid chromatography-tandem mass spectrometry. Patients were categorized into groups based on 28-day outcomes, severity of illness, and infection source for subsequent analysis.

Results: Compared with healthy individuals, the secondary BAs in sepsis patients were significantly lower, among which ursodeoxycholic acid (UDCA) is below the reference range. Compared with the survivors, the taurocholic acid (TCA) and taurodeoxycholic acid (TDCA) of the non-survivors of sepsis were significantly increased, while the UDCA was further decreased. Patients with pulmonary infection exhibited higher overall BA levels than those with abdominal infection. Both TCA and TDCA correlated positively with bilirubin, while UDCA correlated negatively with SOFA scores, C-reactive protein, and procalcitonin. In univariate COX regression, UDCA was associated with 28-day mortality (HR =0.990, P=0.042). ROC analysis showed that the area under the curve for UDCA predicting 28-day mortality was 0.643 (P=0.034).

Conclusions: Secondary BAs were significantly reduced in sepsis patients, with UDCA showing the most pronounced decrease. This reduction becomes even more substantial in non-survivors. The overall BA levels were significantly higher in patients with pulmonary infection than in those with abdominal infection. UDCA was negatively correlated with SOFA score, CRP, and PCT in sepsis patients, and combining it with other indicators improves the prediction of sepsis prognosis. These results indicate that UDCA may exert a protective effect in sepsis.

Background: Hemodynamic instability is a relative contraindication for noninvasive ventilation (NIV). However, there is limited evidence supporting this contraindication.

Methods: This prospective multicenter observational study across 18 Chinese and Turkish hospitals enrolled acute hypoxemic respiratory failure patients receiving NIV. Hemodynamic instability was defined as requiring vasoactive agents to maintain mean arterial pressure (MAP) >70 mmHg within 24 h of NIV. Reversible instability indicated vasoactive agent discontinuation by 24 h, while irreversible instability required persistent vasopressor use.

Results: Among 2137 enrolled patients, 279 (13 %) developed hemodynamic instability. Compared to hemodynamically stable patients, those with instability had significantly higher rates of NIV failure (56 % vs. 37 %; adjusted OR =1.89, 95 % CI: 1.37-2.59). NIV failure rates increased with the severity of hemodynamic impairment: 37 % in patients requiring no vasopressors, 54 % in those on one vasopressor, and 70 % in those requiring multiple vasopressors (p < 0.01 across groups). Within the unstable cohort, 55 patients (20 %) achieved hemodynamic stabilization within 24 h. Subsequent analysis showed that reversible instability was not significantly associated with NIV failure (adjusted OR =0.60, 95 % CI: 0.30-1.21), whereas irreversible instability was strongly associated with NIV failure (adjusted OR =2.48, 95 % CI: 1.75-3.53).

Conclusions: Hemodynamic instability is associated with NIV failure. The likelihood of failure increases with the severity of the hemodynamic instability. However, if the instability is effectively reversed within the first 24 h, it is no longer associated with an increased risk of NIV failure.

Invasive Aspergillosis (IA) is a severe fungal infection primarily caused by Aspergillus species, notably Aspergillus fumigatus. However, newly emerging species, some exhibiting antifungal resistance, are becoming increasingly common. IA mainly affects immunocompromised individuals, including those with hematological malignancies and solid organ transplant recipients. In recent years, however, new at-risk populations have been identified, regardless of immune status, particularly those with severe viral infections requiring intensive care unit admission. This condition has gained prominence in intensive care unit settings following the recent H1N1 influenza and COVID-19 pandemics. Virus-associated pulmonary Aspergillosis (VAPA) encompasses two distinct entities: influenza-associated pulmonary Aspergillosis (IAPA) and COVID-19-associated pulmonary Aspergillosis (CAPA). These conditions are typically diagnosed in 10-20% of patients with severe influenza or COVID-19 when appropriate diagnostic methods are employed. Key diagnostic tools include bronchoalveolar lavage for fungal culture, galactomannan testing, and Aspergillus PCR, complemented by bronchoscopy to detect invasive Aspergillus tracheobronchitis visually. Azole antifungals are the first-line treatment, with liposomal amphotericin B serving as an alternative in regions with azole resistance. Despite antifungal interventions, IAPA and CAPA are linked to poor outcomes, with fatality rates often surpassing 50%. This review article discusses the pathophysiological mechanisms, clinical characteristics, diagnosis, and treatment of IAPA and CAPA. Additionally, it highlights key knowledge gaps and suggests potential areas for future research.