A szívinfarktus incidenciája, a betegek ellátásának és prognózisának összehasonlítása Magyarország különböző fejlettségű járásaiban

Bevezetés: Az infarktusos betegek társadalmi-gazdasági helyzetének fontosságát – a betegellátás és a prognózis tekintetében – több nemzetközi tanulmány igazolta. Magyarországon ilyen jellegű országos vizsgálat – ismereteink szerint – még nem történt. A probléma tanulmányozását az tette lehetővé, hogy 2014. január 1-jétől az infarktusdiagnózissal kezelt betegek adatainak rögzítése kötelező minden ellátó számára a Nemzeti Szívinfarktus Regiszter adatbázisában. Célkitűzés: A szerzők jelen tanulmányukban arra kerestek választ, hogy Magyarország 174 járásának és 23 fővárosi kerületének komplex fejlettségi indexe (KFI) befolyásolja-e az infarktusos betegek ellátását és prognózisát. Módszer: A szerzők a Központi Statisztikai Hivatal által kidolgozott KFI-k alapján a járásokat alacsony (KFI_A), közepes (KFI_K) és magas (KFI_M) KFI-jű csoportokba osztották. Vizsgálták ezen területi egységekben a szívinfarktus incidenciáját, a kórházi ellátást és a betegek prognózisát. A Nemzeti Szívinfarktus Regiszterben (NSZR) 2015 és 2019 között 66 253 olyan, infarktus miatt kezelt beteg szerepelt, akinek lakóhelyét az irányítószám alapján egyértelműen sikerült azonosítani és meghatározni, hogy az melyik járásban van. A vizsgált populációban 29 101 beteg ST-elevációval járó (STEMI), 37 152 beteg ST-elevációval nem járó (NSTEMI) infarktus miatt kapott ellátást. Eredmények: A STEMI életkorral korrigált incidenciája – a 15 évnél idősebb népességben – a KFI_A csoportban 68,8/10 000 lakos/év, a KFI_M-csoportban 52,7/10 000 lakos/év volt. Az NSTEMI-betegcsoport mindhárom KFI-alcsoportban közel azonos incidenciaértékeket találtak (69,5, illetve 67/10 000 lakos/év). A percutan coronariaintervenció gyakorisága a STEMI-diagnózis esetén nagyobb volt, mint NSTEMI-ben, de a csoportokon belül a KFI nem befolyásolta e kezelés elvégzését. STEMI esetén a katéteres beavatkozás elvégzésének aránya a KFI_A, KFI_K és KFI_M alcsoportokban 83,5%, 83,7%, 83,5%, NSTEMI esetén 57,4%, 57,7%, 57,3% volt. A halálozás vizsgálatakor Cox többváltozós, regressziós elemzést végeztek. A KFI egyik infarktustípus esetén sem befolyásolta a 30 napon belül bekövetkezett halálozást: STEMI esetén a ’hazard ratio’ (HR) 0,906 és 0,914 (p = 0,04659; p = 0,04686), NSTEMI esetén 1,067, illetve 1,001 (p = 0,16520; p = 0,98933) volt. STEMI-diagnózis esetén a 30–364 napos, illetve az első éven túli időszakban bekövetkező halálozás tekintetében a KFI_M-régióban a halálozás kockázata szignifikánsan alacsonyabb volt (HR = 0,822 és 0,816), mint a KFI_A-járásokban (p = 0,00096 és p = 0,00001). NSTEMI-diagnózis mellett az 1 éven túli halálozás kockázata esetén találtak különbséget: a KFI_A- és a KFI_M-járások összehasonlításakor ez utóbbi területen a halálozás HR-értéke 0,876 volt, ami szignifikánsan (p = 0,00029) alacsonyabbnak bizonyult, mint a KFI_A-járásokban megfigyelt érték. Következtetés: A KFI önálló prognosztikai jelentőséggel bír az infarktus miatt kezelt betegek késői prognózisának meghatározásában. Orv Hetil. 2022; 163(47): 1862–1871.

Community and environmental data-driven monitoring of waste management

Environmental operators perform their activities in accordance with the relevant legal provisions; however, this does not mean that they operate at their technological optima using the operational information available. The possible negative effects (odor, noise, etc.) of a sub-optimal operation can be felt first and foremost by those living in the immediate vicinity of the given object. It would be important to make effective use of these citizens feedback (quickly to revealing the root causes) thus minimize negative environmental impact of operations. The solution proposed in this paper is a portal called EnviroMind, which allows citizens feedback to be recorded in an easy, immediate, and structured way via a form and on the other hand, it provides a real-time graphical odor transmission model output in a dashboard to operators. Using this portal as a monitoring system the magnitude of the odor effect could be reduced and a smaller area around the industrial object could be affected. In a landfill monitoring pilot project where this monitoring system was used the decrease in the number of indicated odor observations was 85% and the decrease in maximal distance from landfill to odor detection positions was 45%. It is proposed to use EnviroMind monitoring system for all industrial objects which have a significant odor effect on the environment, because by using it we can make the odor effect visible to operators in real time, thus, the reaction time for solving the problem can be minimized.Implications: monitoring is available online to the surrounding community, the affected population, so that quick responses and interventions are available; in the knowledge of the current technological activity carried out on the site its expected odor effect in the area can be determined, whether a protected area can be reached and what odor concentration is expected; in every 15 minutes model results to accurately track expected odor emission values; possibility of intervention, stopping or modification of the technology steps. Experience and main achievements of portal operation in a landfill monitoring pilot project from recent 3 years: the decreasing number of odor perceptions (the decrease in the number of indicated observations was 85%) and the cessation of odor effects in certain areas (and the decrease in maximal distance from landfill to odor detection positions was 45%).

Incidence, pre-hospital delay and prognosis of acute myocardial infarction in big regions of Hungary: Population data from the Hungarian myocardial infarction registry

AIM

To examine the incidence and treatment of acute myocardial infarction (AMI) as well as 30-day and 1-year prognoses of patients in different regions of Hungary. According to the statistical system of the European Union, Hungary can be divided into three major socio-economic regions-west Hungary, central Hungary and east Hungary.

METHODS AND RESULTS

The Hungarian Myocardial Infarction Registry (HUMIR) is a prospective comprehensive and mandatory disease registry for patients with AMI. The total population of Hungary is currently 9.8 million: 39% live in the eastern region (ER), 31% in the central region (CR) and 30% in the western region (WR). Population over 30 years, the age-standardised incidence of AMI was 177.5 (175.7-179.3) per 100 000 person-year. During hospital treatment, 82.5%-84.6% of patients with ST-elevation (STEMI) and 54.8%-58.8% without ST-elevation (NSTEMI) myocardial infarction underwent PCI. The total ischaemic time of patients with STEMI was shortest in WR (221 minutes) compared with two other regions (CR: 225 minutes and ER: 262 minutes). In the STEMI group, the 30-day mortality rates of male patients were lowest in the WR (P = .03). If PCI was performed, mortality rates for both sexes were lowest in the WR (P < .01; P = .04). The 1-year mortality rate in the male population who received PCI was lowest in the WR. In the NSTEMI group, the 30-day mortality rate exhibited no differences. Regarding 1-year mortality, those who underwent PCI in the WR showed the lowest mortality.

CONCLUSION

The major regions of Hungary revealed significant differences regarding the incidence, prehospital delay, treatment and mortality of AMI. Logistic regression analysis confirmed the independent prognostic significance of the region on the 30-day mortality of patients with STEMI (hazard ratio = 0.88, P = .0114; CI: 0.80-0.97).

Management of patients treated for myocardial infarction in different regions of Hungary and patient survival for 10 years

Összefoglaló. Előzmény: A szívinfarktus miatt kezelt betegek ellátásának regionális adataira és a betegek hosszú távú kórlefolyására vonatkozó hazai kutatás eddig nem történt. Célkitűzés: A vizsgálat célja a Magyar Infarktus Regiszter pilotidőszakában rögzített betegeknél az ellátás és a 10 éves túlélés elemzése a magyarországi nagyrégiókban. Módszer: A Magyar Infarktus Regiszter (későbbi neve: Nemzeti Szívinfarktus Regiszter) 2010. január 1. és 2013. december 31. között a centrumok önkéntes részvételével 23 142 beteg adatait rögzítette, akik írásban hozzájárultak egészségügyi és klinikai adataik kezeléséhez. Az adatgyűjtés a Kutatásetikai Bizottság engedélyével rendelkezett. A vizsgált populációban 12 104, ST-elevációval járó myocardialis infarctuson (STEMI) és 10 768, ST-elevációval nem járó myocardialis infarctuson (NSTEMI) átesett beteg szerepelt. A feldolgozott adatok 128 220 betegévre vonatkoznak, amelyeket nagyrégiók szerint (Nyugat-, Közép- és Kelet-Magyarország) hasonlítottunk össze. Eredmények: A STEMI-betegek 78,4%-ánál, az NSTEMI-betegek 51,6%-ánál történt katéteres érmegnyitás (PCI). NSTEMI esetén a Közép-Magyarország és Nyugat-Magyarország régiókban a beavatkozás gyakoribb volt, mint a Kelet-Magyarország régióban (p<0,01). Az utánkövetés során a PCI a Nyugat-Magyarország régióban, a revascularisatiós szívműtét (CABG) a Nyugat-Magyarország és a Kelet-Magyarország régióban szignifikánsan gyakoribb volt, mint a Közép-Magyarország régióban (p<0,01). A STEMI-betegek között a 10 év alatt a férfiak 49,2%-a, a nők 46,6%-a halt meg, az NSTEMI-csoportban 63%, illetve 57,6%. Az akut szakban elvégzett PCI mindkét betegcsoportban, nemben, az utánkövetés minden időpontjában és a vizsgált régiókban csökkentette a halálozást (p<0,01). A STEMI-betegek esetén a túlélés a régiók között nem különbözött (p = 0,72), míg az NSTEMI után a 10 éves túlélés a Nyugat-Magyarország régióban jobb volt (p<0,01). Következtetés: A magyarországi nagyrégiók között az infarktusos betegek ellátásában és prognózisában regionális különbségek vannak. Orv Hetil. 2021; 162(36): 1438-1450.

SUMMARY

HISTORY

Regional data on patients' care for myocardial infarction and the long-term follow up of patients have not yet been studied in Hungary.

OBJECTIVE

The study aims to analyze the care and 10-year survival of patients recorded during the Hungarian Myocardial Infarction Registry's pilot period in large regions of Hungary.

METHOD

Between Jan 1, 2010 and Dec 31, 2013, the Hungarian Myocardial Infarction Registry recorded data on 23 142 patients with voluntary participation. The Research Ethics Committee approved the program. The study included 12 104 patients with ST-elevation myocardial infarction (STEMI) and 10 768 patients with non-ST-elevation myocardial infarction (NSTEMI). The data processed refer to 128 220 patient years based on large regions (West, Central and East Hungary).

RESULTS

Percutaneous coronary intervention occurred in 78.4% of STEMI patients and 51.6% of NSTEMI patients. In the NSTEMI group, percutaneous coronary interventions (PCIs) in the Central-Hungary and West-Hungary regions were significantly more common than in the East-Hungary region (p<0.01). During follow-up, PCI in the West-Hungary region, revascularization surgery in the West-Hungary and East-Hungary regions were significantly more common than in the Central-Hungary region (p<0.01). Among STEMI patients, 49.2% of men and 46.6% of women died within 10 years, while in the NSTEMI group 63% and 57.6%, respectively. PCI reduced mortality in both patient groups, sex, at all times of follow-up and in the regions studied (p<0.01). As for STEMI patients, survival was similar in all regions (p = 0.72), while after NSTEMI, 10-year survival in the West-Hungary region was better (p<0.01).

CONCLUSION

There are regional differences in the care and prognosis of patients with myocardial infarction. Orv Hetil. 2021; 162(36): 1438-1450.

[Emergency care of patients with myocardial infarction: from the onset of symptoms until opening the vessel]

Introduction and aim: The authors analyse emergency care data for 6878 patients treated for acute myocardial infarction (AMI) using data from the Hungarian Myocardial Infarction Registry (HUMIR) and the National Ambulance Service (NAS). Method: Patients received treatment between 01/01/2017 and 31/12/2018, and all patients underwent percutaneous coronary intervention (PCI): 47.5% of patients had ST-elevation myocardial infarction (STEMI) and 3614 patients (52.5%) had non-ST-elevation myocardial infarction. The time between the beginning of the complaint and notification of NAS was regarded as the patient delay (PD). The time from the notification of NAS until arrival on the scene (M1), that of the on-site care (M2) and of the transport from the scene to the hospital (M3) were recorded. In-hospital care was evaluated from admission until opening the vessel ("door to balloon time"). The results were also broken down by counties. The median values and the quartiles (Q1, Q3) were given when the time was reported. Results: Patient delay in both types of infarction was unfavourably long: 101 minutes for STEMI and 687 minutes for NSTEMI. Immediate ambulance action was recorded in 58.7% for STEMI patients and 43.7% for NSTEMI patients. In both types of myocardial infarction, the median M1 time was 13 minutes, on-site care (M2) was 23 minutes, and M3 time was 30 minutes. In patients treated for STEMI, the time from hospital admission until opening the infarct-related artery was 37 minutes, and the total ischemic time was 243 minutes. In 9.5% of STEMI patients, the infarct-related artery was opened within 2 hours, in 49.1% within 4 hours, and in 88.1% within 12 hours. Significant differences were found between the counties for each of the periods examined. Conclusions: The PD is currently the biggest problem in providing optimal care timely for myocardial infarction patients. There are significant regional differences in rescue times, and further analysis is needed to investigate the causes. Orv Hetil. 2020; 161(12): 458-467.

[Analysis of pre-hospital delay time of patients with myocardial infarction]

INTRODUCTION AND AIM

The authors examined the pre-hospital delay of patients with ST-elevation myocardial infarction receiving percutaneous coronary revascularization.

METHOD

In the Hungarian Myocardial Infarction Registry (HUMIR), between January 1, 2014 and March 31, 2016, 7146 patients were found who had all necessary time intervals available. In the database of the National Ambulance Service (OMSZ), 3288 patients were found who had the necessary time intervals. The following time intervals were investigated: the time from the beginning of the complaint to the rescue service notification (patient delay time = PDT), the time of the rescue service to arrive at the scene (R1), the on-site care time (R2) and the time from the scene until arriving to the centre (R3). The case of care at the centre, we investigated the time from the onset of symptoms until the balloon inflation (SBI). If the first hospital had no cardiac catheterization laboratory, we measured the transfer time to the cath centre. The methodological details related to the operation of the HUMIR had been described in our earlier communication. Rescue times (R1, R2, R3) were investigated on the basis of the paper-based records of the National Emergency Service. The patients were divided into two groups based on the fact that the first admission hospital is a centre with a heart catheter facility (C) or a non-invasive hospital (H).

RESULTS

2621 patients (79.7%) were admitted to a hospital with cath lab (C) and 667 patients with secondary transport. Patients with primary transport to C were younger, but for other data, the two groups did not differ. The median of PDT for patients in group C was 114, and 121 minutes for patients in group H. There was no significant difference between R1 and R2 time between the two groups. R3 time in group C was longer than for H patients. In the case of secondary transport, the median time was 98 minutes until the centre. The median time from the beginning of the complaint to the balloon inflation (total ischemic time) was 260 minutes in group C and 356 minutes in group H.

CONCLUSION

Based on the analysis of the total ischemic time and the pre-hospital delay, it is clear that the care of myocardial infarction patients can be further improved by reducing the patient's decision time and increasing the proportion of primary transport. Rescue times (R1, R2, R3) met the expectations, however, further analysis of the M2 time should be considered. Orv Hetil. 2019; 160(1): 20-25.

[Prognostic significance of the total ischemic time in patients with ST-elevation myocardial infarction]

INTRODUCTION

The significance of the total ischemic time (from the beginning of the complaint to the opening of the vessel) is an important factor for myocardial salvage.

AIM

The aim of the study was to determine the prognostic significance of the TIT in patients with ST elevation myocardial infarction in Hungary.

METHOD

From 1 January 2014 all patients with myocardial infarction were recorded by law in an on-line database of the Hungarian Myocardial Infarction Registry. Between 1 January 2014 and 31 March 2016, 27 157 patients with 28 408 myocardial infarction events were recorded. To investigate TIT, 7146 STEMI patients were selected who were treated with percutaneous coronary intervention (PCI) within 24 hours of the beginning of the complaint and all of its components were known.

RESULTS

Average follow-up was 740 ± 346 days. The median time of the TIT is 260 minutes, within which the earliest prehospital time was found (median 205 minutes). The TIT influenced survival: if this time was less than 400 minutes, the 30-day and the 1-year deaths were 7.5% and 12.2%, respectively. In longer TIT, higher mortality rate was found (9.2% versus 19.7%, respectively). Multivariate analysis was performed for short (<30 days), medium (30-364 days) and long-term (≥365 days) survival. Diabetes mellitus is a short-term prognostic factor, abnormal creatinine, and severe coronary status have affected short and medium survival. PCI was significant in terms of medium and long-term survival. Previous myocardial infarction and TIT influenced the long-term survival significantly.

CONCLUSIONS

In Hungary, TIT is too long, and its dominant part falls within the prehospital period. The TIT is an independent prognostic factor, so reducing this time can improve the long-term prognosis of patients with ST-elevation myocardial infarction. Orv Hetil. 2018; 159(27): 1113-1120.

Serum osteocalcin is associated with improved metabolic state via adiponectin in females versus testosterone in males. Gender specific nature of the bone-energy homeostasis axis

OBJECTIVE

The osteoblast-derived protein osteocalcin (OCN) is known to be involved in glucose metabolism by increasing adiponectin secretion from adipocytes. Recently, OCN was also found to enhance testosterone production in mouse testes, suggesting that OCN effects on energy metabolism may be mediated through testosterone. Our aim was to assess a possible gender difference in the metabolic effect of OCN in humans.

METHODS

We included 135 women and 155 men exhibiting changes in glucose tolerance in our study. Oral and intravenous glucose tolerance tests (OGTT and IVGTT, respectively) and a hyperinsulinemic normoglycemic clamp were performed. For clamp indices, whole body (M1) and muscle (M2) glucose uptake values were used. Leptin, adiponectin serum lipid, lipoprotein, total serum OCN and testosterone levels, and body composition were determined.

RESULTS

Higher OCN values were associated with improving metabolic state in both genders. Adiponectin and OCN correlated significantly only in females (r=+0.254, p=0.0029), while in men, testosterone and OCN values showed a significant positive correlation (r=+0.243, p=0.0023), independent of age, BMI, HbA1c and body composition. In women, adiponectin was confirmed by feature selection analysis as being an independent determinant of OCN, in addition to age and three of the IVGTT glucose values. In men, besides M1, BMI, M2, leptin, body fat percent, and the 90-minute OGTT glucose reading testosterone, but not adiponectin were identified as independent contributors for OCN.

CONCLUSION

We confirmed the 'classic' adiponectin-mediated insulin-sensitising effect of OCN only in females. In men, a testosterone-mediated OCN metabolic effect is more likely.