Risultati per: Nota 31

I non vaccinati in Italia sopra i 5 anni sono 6,77 milioni

Il tasso di copertura nazionale è rispettivamente del 31,1% e del 14,8%

Stroke, Volume 54, Issue Suppl_1, Page A31-A31, February 1, 2023. Background:ATTICUS is the third prospective randomized controlled trial that compared a direct oral anticoagulant (DOAC) vs. acetylsalicylic acid (ASA) for secondary prevention after embolic stroke of undetermined source (ESUS). Aim of ATTICUS was to determine whether apixaban, initiated within 28 days after ESUS, is superior to ASA in preventing new ischemic lesions on 12-month follow- up MRI (primary endpoint) in subjects with remote atrial fibrillation (AF) monitoring.Methods:Multicenter (14 German centers) open-label randomized (1:1) controlled trial with blinded endpoint assessment. ESUS patients with at least one risk factor for AF/cardiac thromboembolism (i.e., left atrium (LA) size > 45 mm, spontaneous echo contrast in LA appendage, LA appendage flow velocity ≤ 0.2 m/s, atrial high-rate episodes, CHA2DS2-VASc ≥ 4, patent foramen ovale (PFO)) were enrolled. Study drug was initiated 3 to 28 days after minor/moderate stroke and ≥ 14 to 28 days after major stroke. ClinicalTrials.gov: NCT02427126. Funding by Bristol Meyers Squibb-Pfizer Alliance (Euro 2.2 Mio.) and Medtronic.Results:352 patients were available for final analysis. New ischemic lesion(s) were found in 13.6% vs. 16.0% of patients in the apixaban and the ASA arm, respectively (p=0.57), intention-to-treat. AF was detected in 25.6 % of patients. No difference between study arms was found for other thromboembolism, death, SAE, major and clinically relevant bleeds.Conclusions:ATTICUS was the first trial testing the concept of DOAC vs. ASA in an enriched ESUS population. Mandatory cardiac monitoring, vessel imaging, and MRI in all ATTICUS patients will help to better understand this complex condition. We will present secondary analyses including on-treatment analysis, prevention of embolic/disabling lesions/strokes, association of stroke pattern with AF occurrence/macroangiopathic changes.

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New England Journal of Medicine, Volume 387, Issue 25, Page 2367-2375, December 2022.

Objectives
To measure the disease burden of ageing based on age-related diseases (ARDs), the sex and regional disparities and the impact of health resources allocation on the burden in China.

Design
A national comparative study based on Global Burden of Diseases Study estimates and China’s routine official statistics.

Setting and participants
Thirty-one provinces of Mainland China were included for analysis in the study. No individuals were involved.

Methods
We first identified the ARDs and calculated the disability-adjusted life years (DALYs) of ARDs in 2016. We assessed the ARD burden disparities by province and sex and calculated the provincial ARD burden-adjusted age. We assessed historical changes between 1990 and 2016. Fixed effects regression models were adopted to evaluate the impact of health expenditures and health workforce indicators on the ARD burden in 2010–2016.

Results
In 2016, China’s total burden of ARDs was 15 703.7 DALYs (95% uncertainty intervals: 12 628.5, 18 406.2) per 100 000 population. Non-communicable diseases accounted for 91.9% of the burden. There were significant regional disparities. The leading five youngest provinces were Beijing, Guangdong, Shanghai, Zhejiang and Fujian, located on the east coast of China with an ARD burden-adjusted age below 40 years. After standardising the age structure, western provinces, including Tibet, Qinghai, Guizhou and Xinjiang, had the highest burden of ARDs. Males were disproportionately affected by ARDs. China’s overall age-standardised ARD burden has decreased since 1990, and females and eastern provinces experienced the largest decline. Regression results showed that the urban–rural gap in health workforce density was positively associated with the ARD burdens.

Conclusion
Chronological age alone does not provide a strong enough basis for appropriate ageing resource planning or policymaking. In China, concerted efforts should be made to reduce the ARDs burden and its disparities. Health resources should be deliberately allocated to western provinces facing the greatest health challenges due to future ageing.

New England Journal of Medicine, Volume 387, Issue 15, Page 1415-1424, October 2022.

Il dispositivo «rimane un presidio importante» soprattutto nei contesti di lavoro in ambienti chiusi e condivisi da più lavoratori o aperti al pubblico o dove comunque non sia possibile il distanziamento interpersonale di un metro

Objectives
Preterm babies born between 27 and 31 weeks of gestation in England are usually born and cared for in either a neonatal intensive care unit or a local neonatal unit—with such units forming part of Operational Delivery Networks. As part of a national project seeking to optimise service delivery for this group of babies (OPTI-PREM), we undertook qualitative research to better understand how decisions about place of birth and care are made and operationalised.

Design
Qualitative analysis of ethnographic observation data in neonatal units and semi-structured interviews with neonatal staff.

Setting
Six neonatal units across two neonatal networks in England. Two were neonatal intensive care units and four were local neonatal units.

Participants
Clinical staff (n=15) working in neonatal units, and people present in neonatal units during periods of observation.

Results
In the context of real-world neonatal practice, with multiple (and rapidly-evolving) uncertainties relating to mothers, babies and unit/network capacity, ‘best place of care’ protocols were only one element of much more complex decision-making processes. Staff often made judgements from a less-than-ideal starting point, and were forced to respond to evolving clinical and organisational factors. In particular, we report that managerial considerations relating to demand and capacity organised decision-making; demand and capacity management was time-consuming and generated various pressures on families, and tensions between staff.

Conclusions
Researchers and policymakers should take account of the organisational context within which place of care decisions are made. The dominance of demand and capacity management considerations is likely to limit the impact of other improvement interventions, such as initiatives to integrate families into the neonatal care provision. Demand and capacity management is an important element of neonatal care that may be overlooked, but significantly organises how care is delivered.

Objectives
To describe the prescribing trends of antihypertensive drugs in primary care patients and assess the trajectory of antihypertensive drug prescriptions, from first-line to third-line, in patients with hypertension according to changes to the United Kingdom (UK) hypertension management guidelines.

Design
Population-based cohort study.

Setting and participants
We used the UK Clinical Practice Research Datalink, an electronic primary care database representative of the UK population. Between 1988 and 2018, we identified all adult patients with at least one prescription for a thiazide diuretic, angiotensin-converting enzyme (ACE) inhibitor, angiotensin receptor blocker, beta-blocker or calcium channel blocker (CCB).

Primary and secondary outcome measures
We estimated the period prevalence of patients with antihypertensive drug prescriptions for each calendar year over a 31-year period. Treatment trajectory was assessed by identifying patients with hypertension newly initiating an antihypertensive drug, and treatment changes were defined by a switch or add-on of a new class. This cohort was stratified before and after 2007, the year following important changes to UK hypertension management guidelines.

Results
The cohort included 2 709 241 patients. The prevalence of primary care patients with antihypertensive drug prescriptions increased from 7.8% (1988) to 21.9% (2018) and was observed for all major classes except thiazide diuretics. Patients with hypertension initiated thiazide diuretics (36.8%) and beta-blockers (23.6%) as first-line drugs before 2007, and ACE inhibitors (39.9%) and CCBs (31.8%) after 2007. After 2007, 17.3% were not prescribed guideline-recommended first-line agents. Overall, patients were prescribed a median of 2 classes (IQR 1–2) after first-line treatment.

Conclusion
Nearly one-quarter of primary care patients were prescribed antihypertensive drugs by the end of the study period. Most patients with hypertension initiated guideline-recommended first-line agents. Not all patients, particularly females, were prescribed recommended agents however, potentially leading to suboptimal cardiovascular outcomes. Future research should aim to better understand the implication of this finding.

L’introduzione della Nota 100 da parte dell’Agenzia italiana del farmaco ha riconfigurato le modalità di prescrizione di alcune classi di farmaci per il trattamento del diabete mellito di tipo 2, che possono essere prescritti anche dal medico di famiglia

Stroke, Volume 53, Issue Suppl_1, Page A31-A31, February 1, 2022. Background:Critical access hospitals (CAHs) provide emergency and inpatient care in rural communities. CAHs have higher 30-day mortality after stroke, but little is known about long-term outcomes. We compared 1-year outcomes after ischemic stroke for patients treated at CAHs versus other hospitals.Methods:We identified all Medicare fee-for-service beneficiaries aged ≥65 years discharged alive from US hospitals with a principal diagnosis of ischemic stroke in 2015. Patients were followed 1 year for death or stroke recurrence, accounting for competing risks. We balanced characteristics between CAH and non-CAH patients using stabilized inverse probability weights (IPW) based on patient demographic and clinical characteristics. We created adjusted Kaplan-Meier curves based on the IPW and fit Cox models to assess differences in 1-year mortality and recurrent stroke weighted by the IPW.Results:There were 4,487 patients discharged with stroke from CAHs and 202,502 from non-CAHs. CAH vs non-CAH patients were older (mean age 82.8y vs 78.6y) and more often women (61.8% vs 53.9%), white (94.3% vs 83.7%), and dual Medicare-Medicaid eligible (21.6% vs 17.1%). Discharge to home (29.6% vs 36.8%) and inpatient rehabilitation (4.2% vs 18.9%) was less common for CAH patients, whereas discharge to an intermediate care/skilled nursing facility was more common (26.7% vs 23.9%). For CAHs and non-CAHs, respectively, 1-year mortality rates were 27.8% (95% CI 26.5-29.0) and 22.2% (22.0-22.4), and 1-year recurrence rates were 4.3% (3.6-4.9) and 4.6% (4.5-4.7) (Figure). In IPW-adjusted analyses, stroke patients treated at CAHs vs non-CAHs had higher risk of 1-year mortality (HR 1.29, 95% CI 1.22-1.37) but not recurrent stroke (0.91, 0.78-1.06).Conclusions:Stroke patients discharged from CAHs vs non-CAHs had greater risk of 1-year mortality but not recurrence. Further work is needed to understand the observed disparity, potentially with a focus on post-acute care services.