Risultati per: Linee guida sul parto pre-termine

Stroke, Volume 56, Issue Suppl_1, Page ATMP102-ATMP102, February 1, 2025. Background:Atrial Fibrillation (AF) occurs in about one-fourth of patients with Embolic Stroke of Undetermined Source (ESUS). Accurate prediction of post-stroke AF upon discharge from an index stroke admission informs a personalized post-stroke monitoring strategy of AF and interventions. While clinical risk scores predict AF, machine learning (ML) models have shown superior performance.However, traditional ML approaches only use expert-derived predictors available in an electronic health record (EHR) and thus may miss variables that would potentially increase the accuracy of prediction.Aims:This study aims to enhance AF prediction by augmenting expert-derived predictors with an unbiased selection of full diagnostic codes and medication histories up to index strokes. Through embedding learning with hypergraph neural networks, we generate compact representations of high-dimensional data to improve prediction accuracy by capturing complex feature interactions.Methods:We analyzed data from 510 ESUS patients (55.3% female, mean age 61.4 years) from 2015 to 2023 at Emory Healthcare. We focus on experiments using a logistic regression (LR) model to predict AF from different sets of features. At baseline, we use 58 clinically motivated predictors, including comorbidities characterized by 17 ICD codes manually extracted based on literature, and 41 other features extracted from lab results, echocardiographic and ECG. To directly model the full history of comorbidities and medications, another baseline uses the full 1530 ICD codes plus the 41 other features (1571 in total). In contrast, the embedding method uses the full 1530 ICD codes to generate condensed, informative embedding vectors (32-dimensional), eventually getting 32+41=73 features. To generate the embedding, a hypergraph neural network was trained on a larger stroke cohort (n=7956) to model the interactions between the 1530 ICD codes. A nested cross-validation approach was employed within 5-fold splits, and ROC-AUC scores were recorded.Result:Among 510 ESUS patients, 107 (21.0%) developed AF (mean age 67.9 years, 57% female). We compared the performance of LR model with different features from ICD codes (Table 1). The results show that the learned 32-dim embedding vectors improves the prediction of post-ESUS AF.Conclusion:The embedding technique can significantly enhance predictive performance by integrating comprehensive medical information, maximizing the use of available data for improved outcomes.

Stroke, Volume 56, Issue Suppl_1, Page AWMP53-AWMP53, February 1, 2025. Background:Treatment options and outcomes in stroke also depends on pre-hospital delays. The goal of this study is to describe onset-to-door times (ODT) across many countries and also investigate how the mode of arrival affects ODT.Methods:This is an analysis of the data from the Registry of Stroke Care Quality (RES-Q), years 2022&2023. RES-Q is used across the world for audit of clinical care. Data were stratified by the mode of arrival (EMS vs. non-EMS). Median ODT were analyzed, and 95% confidence intervals (CI) were calculated for each country and arrival mode.Results:Of 334,184 patients from 1,130 hospitals in 70 countries, 155,532 patients from 25 countries were diagnosed with acute ischemic stroke after excluding secondary transfers (n=32,349), cases from countries with fewer than 1,000 cases (n=128,660), and those with missing data or typing errors (n=17,643). The median ODT was 193 mins (95% CI: 164-223) for patients arriving by EMS and 309 mins (95% CI: 274-360) for those arriving by non-EMS. The percentage of EMS arrival by region was 34% (Africa), 30% (Asia), 39% (Latin America), and 87% (Europe). The percentage of EMS arrivals is shown in Figure 1. Compared to the patients who reached by non-EMS mode, patients who reached by EMS mode were more likely to receive intravenous thrombolysis (16% vs 44%,). The ODTs by mode of arrival and country are detailed in Figure 2.Conclusions:Transport via EMS was associated with a reduced arrival time nearly by 2 hours and tripled the chance of receiving thrombolysis as compared to non-EMS transportation. The percentage of patients arriving by EMS was higher in European countries as compared to Africa, Asia and Latin America and this is reflected by shorter ODT in many EU countries. Improvements in EMS infrastructure could improve stroke outcomes globally.

Stroke, Volume 56, Issue Suppl_1, Page AWMP76-AWMP76, February 1, 2025. Importance:The COVID-19 pandemic significantly disrupted healthcare systems worldwide, impacting the management of acute ischemic stroke (AIS). Understanding changes in AIS admissions, treatment patterns&outcomes during the pandemic is essential for optimizing stroke care in future public health crises.Objective:To evaluate the impact of the COVID-19 pandemic on AIS admissions, treatment utilization, complications&outcomes in the U.S. from 2016 to 2021, focusing on the pre-pandemic (2016-2019)&peri-pandemic (2020-2021) periods.Methods:A retrospective observational cohort study utilizing the National Inpatient Sample (NIS) nationwide database, analyzing weighted hospital discharge records over 6 years, encompassing urban, rural, teaching &non-teaching hospitals.Participants were AIS patients aged 18 years&older (n=3,154,154), identified using ICD-10 codes. Sociodemographic characteristics such as age, sex, race&comorbidities were evaluated. The mean patient age was 70.0 ± 0.03 years, with an average length of stay of 5.1 ± 0.01 days&an adjusted mean cost of $16,765 ± 71. Men accounted for 50.5% of the cohort. AIS hospitalizations from 2016 to 2021 were collected, comparing pre-&peri-pandemic periods. Primary outcomes included AIS admission trends, while secondary outcomes included reperfusion therapy utilization, intubation&ventilation rates, discharge disposition&complications.Results:AIS admissions increased from 507,920 in 2016 to 535,694 in 2021. A demographic shift was observed, with the proportion of male patients rising from 49.8% to 51.4%&the mean age decreasing from 70.3 to 69.7 years (p < 0.0001). Most patients were White (69.5% in 2016), but their proportion decreased over time, while Black, Hispanic&Asian/Pacific Islander cases increased (p 0.5734). Reperfusion therapy usage increased, with mechanical thrombectomy (MT) rising from 2.2% to 5.6% in 6 years. Intubation/ventilation rates grew from 4.8% pre-COVID to 5.5% peri-COVID (p < 0.0001). Subarachnoid&intracerebral hemorrhage rates had increased throughout the 6 years in the group with MT-only intervention (p .011&.002, respectively).Conclusions:The COVID-19 pandemic led to significant shifts in AIS hospitalization patterns, including changes in age distribution, increased reperfusion therapy use&rising complications. These findings highlight the need for adaptive public health strategies&resource allocation to maintain stroke care during future crises.

Stroke, Volume 56, Issue Suppl_1, Page AWMP54-AWMP54, February 1, 2025. Background and Objectives:Transportation to comprehensive stroke centers (CSCs) from primary stroke centers (PSCs) is key to achieving fast reperfusion in endovascular treatment (EVT)-eligible patients. We aimed to evaluate outcomes and workflow times of patients treated PSCs vs CSCs and additional key metrics for those transported from PSCs to CSCs for EVT.Methods:We performed a pre-specified analysis of the Alteplase compared to Tenecteplase (AcT) multicenter, randomized, controlled, trial in patients with acute ischemic stroke within 4.5 hours of onset. We compared baseline characteristics, workflow times, and clinical outcomes at 90 days between PSCs and CSCs. Mixed effects regression analyses were performed adjusting for age, sex, National Institute of Health Stroke Scale (NIHSS), location of intracranial occlusion, IVT drug and door-to-needle-time as fixed effects; and study site as a random effect.Results:Of 1,577 patients enrolled in the trial, 99 (6.27%) were treated in PSCs while 1,478 (93.72%) were treated in CSCs. Patients in both groups had similar age (median 72 [64 – 82] vs 74 [63 – 83] years), proportion of females (42.42% vs 48.24%), baseline stroke severity (median NIHSS 9 [6 – 16] vs 10 [6 – 16.5]), presence of large vessel occlusion (24.24% vs 24.70%; p=0.919) and EVT utilization (24.24% vs 32.61%). Patients treated in PSCs had longer onset-to-needle (median, 139 [100 – 190] vs 128 [94 – 185] minutes) and door-to-needle times (median, 56.5 [42 – 70] vs 35 [27 – 47] minutes) compared to those treated at CSCs. For patients transferred from PSCs to CSCs, patients who received tenecteplase had shorter needle-to-puncture times than those who received alteplase (median, 35.5 [21 – 58] vs 52 [18 – 74] minutes, p

Stroke, Volume 56, Issue Suppl_1, Page AWMP91-AWMP91, February 1, 2025. Background and Objective:Carotid artery stenting (CAS) is a procedure that has been established as a safe and effective alternative to carotid endarterectomy in high surgical risk patients. There are procedural questions that remain unanswered, specifically, the safety of pre-stent balloon angioplasty versus post-stent versus both. The objective of our study is to understand the risk and safety of these procedural techniques.Methods:Multicenter retrospective data related to angioplasty balloons, stents, complications due to pre and post-stent angioplasty along with the modified Rankin score (mRS) before and after the procedure were collected from January of 2015 until December of 2022. Statistical analysis was performed to correlate this data with risks of complications and clinical outcomes.Results:A total of 1355 patients were enrolled. We found that patients who underwent pre-stent angioplasty, or both (pre and post-stent angioplasty) had a higher risk of complications compared to those who only had post-stent angioplasty. There were more complications in patients who did not undergo post-stent angioplasty as compared to those who did undergo angioplasty (p=0.018, OR=0.513). Follow-up MRS at 30-90 days was higher if the balloons in both pre-stent angioplasty (p=0.016) and post-stent angioplasty (p=0.020) stent angioplasty were not inflated to nominal pressure. Follow up MRS was statistically higher (p=0.01) in patients with open-cell stents than closed-cell stents. Open-cell stents were more likely to undergo post-stent angioplasty (p

Stroke, Volume 56, Issue Suppl_1, Page ADP11-ADP11, February 1, 2025. Introduction:We examined whether prestroke cardiovascular risk is associated with faster cognitive decline and higher dementia risk after stroke independent of prestroke cognition.Methods:We included 1,808 dementia-free individuals with incident stroke (91% ischemic, 7% hemorrhagic, 2% other; 52% women, 38% Black, median age 75) from 4 cohorts (1971-2019): Atherosclerosis Risk In Communities Study, Cardiovascular Health Study, Framingham Offspring Study, and REasons for Geographic And Racial Differences in Stroke. We assessed prestroke atherosclerotic cardiovascular disease (ASCVD) risk with the American Heart Association’s Predicting Risk of cardiovascular disease EVENTs (PREVENT) 10-year ASCVD risk score, which has age and sex as risk factors. Outcomes were global cognition (primary), executive function, memory, and dementia. Linear mixed-effects and Cox regression models examined continuous and categorical (quintiles) 10-year ASCVD risk scores and adjusted for mean prestroke cognition, race, education, and cohort. Median (IQR) follow-up was 4.4 (2.0, 7.9) years for global cognition and 5.1 (2.4, 8.8) for dementia. Dementia cases totaled 142 at 5 years and 182 at 10 years.Results:Median (IQR) 10-year prestroke ASCVD risk was 14.0% (9.9%, 18.5%). Higher prestroke 10-year ASCVD risk was associated with lower adjusted initial poststroke global cognition, memory, and executive function (changes to intercept, Table 1). The quintile analysis showed a dose-response relationship between higher prestroke ASCVD risk and lower initial poststroke cognition scores (changes to intercept, Table 1). The overall stroke survivor group had unadjusted mean declines of -0.59 points/year (95%CI, -0.66 to -0.52 points/year; P

Stroke, Volume 56, Issue Suppl_1, Page ADP17-ADP17, February 1, 2025. Introduction:Following a large vessel occlusion acute ischemic stroke (LVO-AIS), cerebral autoregulation is notably compromised, making cerebral blood flow maintenance and optimal blood pressure (BP) crucial to preserving the penumbral tissue until reperfusion. While intraprocedural BP drops and high post mechanical thrombectomy (MT) BP are associated with unfavorable outcomes, data on pre-admission BP’s impact on infarct growth is markedly scarce.Methods:This retrospective cohort study from two centers included anterior circulation LVO-AIS patients treated with MT from Jan-2018 to Dec-2021. Admission CTP parameters were: Initial infarct volume (rCBF4s,6s,8s,10s). Hypoperfusion intensity ratio (HIR, Tmax 10s/6s) served as a collateral status surrogate. Infarct growth rate (IGR) was defined as rCBF

Stroke, Volume 56, Issue Suppl_1, Page AWP238-AWP238, February 1, 2025. Introduction:As more patients with stroke, including those with large cores, are treated with endovascular thrombectomy (EVT), understanding the pathophysiology of hemorrhagic transformation (HT) is becoming increasingly important. Pre-EVT infarct topography may have implications for treatment decisions acutely (e.g. stenting) and for post EVT care (e.g. antithrombotics and blood pressure goals). We sought to identify associations between HT and brain regions involved in ischemic lesions.Methods:Consecutive patients with LVO treated with EVT who underwent pre-EVT MRI were identified from two tertiary referral centers (2011-2019). Acute ischemic lesions were extracted through a deep learning enabled pipeline from DWI and spatially normalized. Individual lesions were parcellated (atlas-defined 94 cortical regions, 14 subcortical nuclei, 20 white matter tracts) and reduced to ten essential lesion patterns using unsupervised dimensionality reduction techniques. HT, defined as ECASS PH1 or PH2, was modeled via Bayesian regression, taking the ten lesion patterns as inputs, and controlling for total lesion volume, age, sex, initial NIH Stroke Scale (NIHSS), thrombolysis treatment, good reperfusion (TICI2b-3), acute stenting, last known well-to-puncture time, diabetes mellitus, hypertension, coronary artery disease, smoking, atrial fibrillation, and site of enrollment.Results:A total of 567 (mean age 69 ±15 years; 45% female) patients had pre-EVT DWI without significant artifacts that could undergo lesion segmentation and registration. The median NIHSS was 16 (IQR 11-20) and mean total infarct volume was 22.5 ±36.7ml. Thrombolysis was administered in 51% and good reperfusion was achieved in 83%. HT occurred in 10%. Lesion locations predictive of HT (Figure) involved bilateral caudate, putamen, pallidum, and anterior thalamic radiation; and, right more than left thalamus, corticospinal tract, and inferior fronto-occipital fasciculus (area under the curve: 0.73).Conclusions:These data from a large, multicenter cohort with precise MRI-defined infarcts underscore the significance for HT of specific brain regions involved in ischemic lesions before EVT. An understanding of this pathophysiology can inform not only current clinical practice but also the development of future novel therapeutic strategies to prevent HT and reperfusion injury as more patients with large infarct cores are treated with EVT.

Introduction
The global prevalence of people living with overweight has tripled since 1975 and more than 40% of Danish women enter pregnancy being overweight. With the increasing rates of obesity observed in children, adolescents and adults, there is an urgent need for preventive measures. Risk factors for childhood obesity include maternal overweight or obesity before conception and excessive weight gain during pregnancy. Interventions aimed at modifying maternal lifestyle during pregnancy have demonstrated minimal positive or no impact on the health of the children. The ‘healthy lifestyle before and during pregnancy to prevent childhood obesity — the PRE-STORK trial’ aims to provide insights into the effect of a lifestyle intervention initiated before conception and continued during pregnancy in women with overweight or obesity, on neonatal adiposity in their children.

Methods and analysis
In this randomised, two-arm, parallel-group, controlled trial, we will include 360 women with overweight or obesity (aged 18–40; body mass index 25–44 kg/m2) and their partners. The women will be randomised to receive either standard of care or a lifestyle intervention focused on preconception body weight reduction, regular physical exercise, healthy diet and support from a mentor before and during pregnancy. The primary outcome is the difference in neonatal adiposity measured in their children at birth. Children conceived during the trial will constitute a birth cohort, monitoring the effects on their health until the age of 18 years.

Ethics and dissemination
The trial has been approved by the Regional Committee on Health Research Ethics in the Capital Region of Denmark (identification number H-22011403) and will be conducted in agreement with the Declaration of Helsinki. All results, whether positive, negative and inconclusive, will be disseminated at national or international scientific meetings and in peer-reviewed scientific journals.

Trial registration number
ClinicalTrials.gov: NCT05578690 (October 2022).

Objectives
To improve on the implementation and uses of HIV pre-exposure prophylaxis (PrEP) programmes, factors affecting HIV PrEP willingness must be investigated. This study aims to determine not only the willingness to use HIV PrEP but also to establish whether awareness and attitude affect this.

Design
This study used a cross-sectional survey research design to examine the awareness, attitude and willingness to use HIV PrEP in Davao City. The survey was adapted from multiple studies and was validated and pilot tested. Statistical analysis included descriptive and inferential statistics like correlation, linear regression and structural modelling.

Settings
This research was conducted in Davao City, Philippines. This is one of the regions in the country with a high HIV incidence. The survey was conducted from March to June 2024.

Participants
Participants were at least 18 years of age, currently living in Davao City and a permanent resident of the city.

Results
A total of 258 respondents were gathered in this study, of which 53.10% of all respondents were fully aware of HIV PrEP, while 27.13% were partially aware. The study found the mean attitude and willingness to be 4.21±0.686 and 4.08±0.685, respectively. There was a significant difference in the awareness when grouped according to identity category (X2=24.428; p value=0.002) and highest education attained (X2=15.919; p value=0.044). Being fully aware positively affected willingness to use HIV PrEP by indirectly contributing positively to attitude towards HIV PrEP (β=0.180; p value=0.012).

Conclusion
Generally, the awareness, attitude and willingness to use HIV PrEP is high. However, some respondents are hesitant to use HIV PrEP if it is not a hundred percent effective and unable to adhere to it. The results imply a need for action programmes involving various multidisciplinary stakeholders to ensure that the community possesses full awareness, positive attitudes and increased willingness to use HIV PrEP.

Objectives
Prehospital notifications (pre-alerts) enable emergency department (ED) staff to prepare for the arrival of patients requiring a time-critical response. Effective communication of the pre-alert is key to enabling the ED to prepare appropriately, but evidence on communication practices is lacking. We undertook qualitative research to understand how pre-alert communication may be improved to optimise the ED response for pre-alerted patients.

Design, setting and participants
Data collection took place within three UK Ambulance Services and six EDs between August 2022 and April 2023. We undertook semi-structured interviews with 34 ambulance and 40 ED staff and 156 hours non-participation observation of pre-alert practice (143 pre-alerts). Verbatim interview transcripts and observation notes were imported into NVivo and analysed using a thematic approach.

Results
We identified significant variation in how pre-alerts were communicated that influenced how effectively information was transferred. Ambulance and ED staff demonstrated a shared recognition that pre-alerts need to be communicated concisely, but both received minimal training in how to give and receive pre-alerts. Efficient pre-alerting was influenced by clinician experience and seniority. ED and ambulance clinicians following different information-sharing formats sometimes led to interruptions, information loss and tensions, particularly when an early ‘headline’ clinical concern had not been shared. Ambulance clinicians sometimes questioned the appropriateness of their pre-alert when ED clinicians did not explain the rationale for not giving the expected response (that is, being accepted into a high-priority area of the ED). Additional sources of frustration included technological problems and poor communication of estimated time of arrival and caller/responder identities.

Conclusions
Use of a shared format, including a headline ‘cause for concern’, may improve the clarity, usefulness and civility of pre-alerts, particularly when the clinician’s concern is not obvious from observations. Basic training on how to undertake pre-alerts for both ED and ambulance clinicians may improve understanding of the importance of pre-alert communication.

Trial registration number
ISRCTN12652860.

Objectives
Explore, understand and analyse how women with pre-existing diabetes can be better supported during the inter-pregnancy interval—the time after a baby loss and before a subsequent pregnancy.

Design
Qualitative, semi-structured online interviews took place between November 2020 and July 2021. Data were analysed using Reflexive Thematic Analysis.

Setting
Participants reflected on care received at primary and secondary centres across the UK.

Participants
Twelve predominantly White, British women with type 1 (n=9) and type 2 (n=3) diabetes with experience of baby loss and subsequent pregnancy were recruited through social media.

Results
Three interrelated themes: (1) decisions around becoming pregnant after baby loss, (2) the triple burden of baby loss, diabetes and preparing for pregnancy, (3) gaps in the inter-pregnancy interval. Most (n=10) participants wanted to become pregnant again as soon as possible. The short inter-pregnancy interval (median=7 months) highlights a potentially small window of opportunity to support women to grieve and prepare for pregnancy. Providing timely access to care and support in the inter-pregnancy interval without overburdening women might be challenging due to structural issues in services and gaps in referral pathways.

Conclusion
Women with pre-existing diabetes may experience challenges in accessing appropriate pre-pregnancy care in the inter-pregnancy interval. Our findings suggest that one-size-fits-all approaches are likely to be less effective in meeting diverse needs of this group and that more personalised, targeted support is needed. All healthcare professionals across the different parts of the care provision structure need greater awareness of the issues faced by this group to maximise timely access to the appropriate pre-pregnancy care and support.