Risultati per: Colite ulcerosa negli adulti: review

BackgroundThe current guidelines of the American Heart Association and European Society of Cardiology recommend that patients experiencing RVMI are not administered nitrates, due to the risk that decreasing preload in the setting of already compromised right ventricular ejection fraction may reduce cardiac output and precipitate hypotension. The cohort study (n = 40) underlying this recommendation was recently challenged by several new studies suitable for meta-analysis (cumulatively, n = 1206), suggesting that this topic merits systematic review.MethodThe protocol was registered on PROSPERO and published in Evidence Synthesis. Six databases were systematically searched in January 2021: PubMed, Embase, MEDLINE Complete, Cochrane CENTRAL Register, CINAHL, and Google Scholar. Identified studies were assessed for quality and bias and data extracted by two investigators using JBI tools and methods. Risk ratios and 95% confidence intervals were calculated, and meta-analysis performed using the random effects inverse variance method.ResultsFive studies (n=1113) were suitable. Outcomes included haemodynamics, GCS, syncope, arrest, and death. Arrest and death did not occur in the RVMI group. Meta-analysis was possible for sublingual nitroglycerin 400 mcg (2 studies, n=1050) and found no statistically significant difference in relative risk to combined inferior and RVMI at 1.31 (95%CI 0.81–2.12, p=0.27), with an absolute effect of 2 additional adverse events per 100 treatments. Results remained robust under sensitivity analysis. Other studies are severely limited by sample sizes well below optimal information size. ConclusionThis review suggests that the contraindication on nitrate administration during RVMI is not supported by the evidence informing this appraisal for 400 mcg sublingual nitroglycerin. Key limitations include not evaluating beneficial effects, low certainty of evidence, and only two studies being suitable for synthesis. As adverse events are transient and easily managed, nitrates are a reasonable treatment modality to consider during RVMI on current evidence. Conflict of interestNone to declare.FundingMWS received a faculty funding grant.

BackgroundDistraction therapies are widely used to manage pain and anxiety in paediatric emergency departments (ED). Paediatric patients also comprise up to 13% of some ambulance services workloads1 yet only a single study exists outlining the ad-hoc use of paramedic-initiated distraction therapy.2 Building rapport with frightened, unwell children is challenging for paramedics, but is essential to facilitate rapid assessment and care.1,3.This review aims to identify effective ED distraction techniques potentially suitable for use in paediatric patients in the prehospital setting.MethodDatabases and grey literature sources including Ovid Medline, EMBASE and CINAHL and Google Scholar were searched from their beginning to October 2021. English language interventional or observational studies were included if they reported on distraction techniques suitable for use in the prehospital setting, paediatric ED presentations, and pain and/or anxiety.ResultsOf the 4,054 records screened, 27 met the eligibility criteria. Twenty randomised trials and seven interventional studies involved children aged three months to 18 years. Distraction techniques were digital, non-digital and environmental adaptations and included virtual-reality, cartoons, music, vibration devices, bubble-blowing and ambient lighting. Ten studies reported significant reductions in self-reported pain and seven for self-reported anxiety. Some reported reduced pharmacological administration and improved patient cooperation, and parent and/or healthcare provider satisfaction when using distraction. Studies were highly heterogeneous with 17 distractors and 21 pain and/or anxiety measurement tools used.ConclusionA range of effective distraction techniques exist in paediatric EDs that may be suitable for the prehospital setting to manage pain and/or anxiety and improve patient outcomes.ReferencesFowler J, Beovich B, Williams B. Improving paramedic confidence with paediatric patients: a scoping review. Australasian Journal of Paramedicine 2017;15(1).Preston C and Bray L. Developing understanding and awareness of children’s distress, distraction techniques and holding. Journal of Paramedic Practice 2015;7(3):122–130.Cushman JT, Fairbanks RJ, O’Gara KG, et al. Ambulance personnel perceptions of near misses and adverse events in pediatric patients. Prehosp Emerg Care 2010;14:477–84.Conflict of interestNone.FundingAU$4000 in funding has been provided by the Australia and New Zealand College of Paramedicine, and AU$11,000 in funding was provided through a Monash University Advancing Womens Research Success Grant for this program of research. Dr Eastwood, Dr Howell and Professor Cameron are supported by the National Health and Medical Research Council (NHMRC) Prehospital Emergency Care Centre for Research Excellence (PEC-ANZ; #1116453).

Stroke, Volume 53, Issue 5, Page 1772-1787, May 1, 2022. Perceptual disorders relating to hearing, smell, somatosensation, taste, touch, and vision commonly impair stroke survivors’ ability to interpret sensory information, impacting on their ability to interact with the world. We aimed to identify and summarize the existing evidence for perceptual disorder interventions poststroke and identify evidence gaps. We searched 13 electronic databases including MEDLINE and Embase and Grey literature and performed citation tracking. Two authors independently applied a priori–defined selection criteria; studies involving stroke survivors with perceptual impairments and interventions addressing those impairments were included. We extracted data on study design, population, perceptual disorders, interventions, and outcomes. Data were tabulated and synthesized narratively. Stroke survivors, carers, and clinicians were involved in agreeing definitions and organizing and interpreting data. From 91 869 records, 80 studies were identified (888 adults and 5 children); participant numbers were small (median, 3.5; range, 1–80), with a broad range of stroke types and time points. Primarily focused on vision (34/80, 42.5%) and somatosensation (28/80; 35.0%), included studies were often case reports (36/80; 45.0%) or randomized controlled trials (22/80; 27.5%). Rehabilitation approaches (78/93; 83.9%), primarily aimed to restore function, and were delivered by clinicians (30/78; 38.5%) or technology (28/78; 35.9%; including robotic interventions for somatosensory disorders). Pharmacological (6/93; 6.5%) and noninvasive brain stimulation (7/93; 7.5%) approaches were also evident. Intervention delivery was poorly reported, but most were delivered in hospital settings (56/93; 60.2%). Study outcomes failed to assess the transfer of training to daily life. Interventions for stroke-related perceptual disorders are underresearched, particularly for pediatric populations. Evidence gaps include interventions for disorders of hearing, taste, touch, and smell perception. Future studies must involve key stakeholders and report this fully. Optimization of intervention design, evaluation, and reporting is required, to support the development of effective, acceptable, and implementable interventions.Registration:URL:https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42019160270.

Stroke, Volume 53, Issue 5, Page e193-e194, May 1, 2022.

Stroke, Ahead of Print. Background:Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high mortality and morbidity. We aimed to determine the relative benefits of pharmacological prophylactic treatments in patients with aneurysmal subarachnoid hemorrhage by performing a network meta-analysis of randomized trials.Methods:We searched Medline, Web of Science, Embase, Scopus, ProQuest, and Cochrane Central to February 2020. Pairs of reviewers independently identified eligible trials, extracted data, and assessed the risk of bias. Eligible trials compared the prophylactic effects of any oral or intravenous medications or intracranial drug-eluting implants to one another or placebo or standard of care in adult hospitalized patients with confirmed aneurysmal subarachnoid hemorrhage. We used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to assess the certainty of the evidence.Results:We included 53 trials enrolling 10 415 patients. Nimodipine likely reduces all-cause mortality compared to placebo (odds ratio [OR],0.73 [95% CI, 0.53–1.00]; moderate certainty; absolute risk reduction (ARR), −3.35%). Nimodipine (OR, 1.46 [95% CI, 1.07–1.99]; high certainty; absolute risk increase, 8.25%) and cilostazol (OR, 3.73 [95% CI, 1.14–12.18]; moderate certainty; absolute risk increase, 23.15%) were the most effective treatments in improving disability at the longest follow-up. Compared to placebo, clazosentan (10 mg/kg; OR, 0.39 [95% CI, 0.22–0.68]; high certainty; ARR, −16.65%), nicardipine (OR, 0.48 [95% CI, 0.24–0.94]; moderate certainty; ARR, −13.70%), fasudil (OR, 0.55 [95% CI, 0.31–0.98]; moderate certainty; ARR, −11.54%), and magnesium (OR, 0.66 [95% CI, 0.46–0.94]; high certainty; ARR, −8.37%) proved most effective in reducing the likelihood of delayed cerebral ischemia.Conclusions:Nimodipine and cilostazol are likely the most effective treatments in preventing morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage. Clazosentan, nicardipine, fasudil, and magnesium showed beneficial effects on delayed cerebral ischemia and vasospasm but they were not found to reduce mortality or disability. Future trials are warranted to elaborately investigate the prophylactic effects of medications that may improve mortality and long-term functional outcomes, such as cilostazol and clazosentan.REGISTRATION:URL:https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42019122183.

Stroke, Volume 53, Issue 4, Page 1114-1133, April 1, 2022. Raised blood pressure (BP) is the leading cause of death and disability worldwide, and its particular strong association with stroke is well established. Although systolic BP increases with age in both sexes, raised BP is more prevalent in males in early adulthood, overtaken by females at middle age, consistently across all ethnicities/races. However, there are clear regional differences on when females overtake males. Higher BP among males is observed until the seventh decade of life in high-income countries, compared with almost 3 decades earlier in low- and middle-income countries. Females and males tend to have different cardiovascular disease risk profiles, and many lifestyles also influence BP and cardiovascular disease in a sex-specific manner. Although no hypertension guidelines distinguish between sexes in BP thresholds to define or treat hypertension, observational evidence suggests that in terms of stroke risk, females would benefit from lower BP thresholds to the magnitude of 10 to 20 mm Hg. More randomized evidence is needed to determine if females have greater cardiovascular benefits from lowering BP and whether optimal BP is lower in females. Since 1990, the number of people with hypertension worldwide has doubled, with most of the increase occurring in low- and-middle-income countries where the greatest population growth was also seen. Sub-Saharan Africa, Oceania, and South Asia have the lowest detection, treatment, and control rates. High BP has a more significant effect on the burden of stroke among Black and Asian individuals than Whites, possibly attributable to differences in lifestyle, socioeconomic status, and health system resources. Although pharmacological therapy is recommended differently in local guidelines, recommendations on lifestyle modification are often very similar (salt restriction, increased potassium intake, reducing weight and alcohol, smoking cessation). This overall enhanced understanding of the sex- and ethnic/racial-specific attributes to BP motivates further scientific discovery to develop more effective prevention and treatment strategies to prevent stroke in high-risk populations.

Stroke, Ahead of Print. Background:Limited data exist regarding the prevalence of clinical and neuroimaging manifestations among patients diagnosed with cerebral amyloid angiopathy (CAA). We sought to determine the prevalence of clinical phenotypes and radiological markers in patients with CAA.Methods:Systematic review and meta-analysis of studies including patients with CAA was conducted to primarily assess the prevalence of clinical phenotypes and neuroimaging markers as available in the included studies. Sensitivity analyses were performed based on the (1) retrospective or prospective study design and (2) probable or unspecified CAA status. We pooled the prevalence rates using random-effects models and assessed the heterogeneity using the CochranQandI2statistics.Results:We identified 12 prospective and 34 retrospective studies including 7159 patients with CAA. The pooled prevalence rates were cerebral microbleeds (52% [95% CI, 43%–60%]; I2=93%), cortical superficial siderosis (49% [95% CI, 38%–59%]; I2=95%), dementia or mild cognitive impairment (50% [95% CI, 35%–65%]; I2=97%), intracerebral hemorrhage (ICH; 44% [95% CI, 27%–61%]; I2=98%), transient focal neurological episodes (48%; 10 studies [95% CI, 29%–67%]; I2=97%), lacunar infarcts (30% [95% CI, 25%–36%]; I2=78%), high grades of perivascular spaces located in centrum semiovale (56% [95% CI, 44%–67%]; I2=88%) and basal ganglia (21% [95% CI, 2%–51%]; I2=98%), and white matter hyperintensities with moderate or severe Fazekas score (53% [95% CI, 40%–65%]; I2=91%). The only neuroimaging marker that was associated with higher odds of recurrent ICH was cortical superficial siderosis (odds ratio, 1.57 [95% CI, 1.01–2.46]; I2=47%). Sensitivity analyses demonstrated a higher prevalence of ICH (53% versus 16%;P=0.03) and transient focal neurological episodes (57% versus 17%;P=0.03) among retrospective studies compared with prospective studies. No difference was documented between the prevalence rates based on the CAA status.Conclusions:Approximately one-half of hospital-based cohort of CAA patients was observed to have cerebral microbleeds, cortical superficial siderosis, mild cognitive impairment, dementia, ICH, or transient focal neurological episodes. Cortical superficial siderosis was the only neuroimaging marker that was associated with higher odds of ICH recurrence. Future population-based studies among well-defined CAA cohorts are warranted to corroborate our findings.

Stroke, Ahead of Print. Stroke family caregiver and dyad literature has expanded over the past few years. The purpose of this review was to build upon 2 prior systematic reviews to critique, analyze, and synthesize the evidence pertaining to the impact of family caregiver and dyad interventions on stroke survivor and family caregiver outcomes. CINAHL, PsychINFO, PubMed, and reference lists were searched from December 1, 2016 through March 31, 2021. Using PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), articles were identified that tested outcomes from stroke family caregiver or dyad interventions that targeted the health or well-being of family caregivers. Data from the articles were abstracted into tables for analysis, then compared with recommendations from the 2 prior systematic reviews. A total of 18 articles met inclusion criteria (10 caregiver interventions; 8 dyad interventions) representing sample sizes ranging from 7 to 349 caregivers or dyads. Most were randomized controlled trials (n=13); 2 were cluster randomized trials; and 3 were single-group quasi-experimental designs. Of the 18 studies, 8 had

Stroke, Ahead of Print. Background:Cerebral venous thrombosis (CVT) has recently been reported as a common thrombotic manifestation in association with vaccine-induced thrombotic thrombocytopenia, a syndrome that mimics heparin-induced thrombocytopenia (HIT) and occurs after vaccination with adenovirus-based SARS-CoV-2 vaccines. We aimed to systematically review the incidence, clinical features, and prognosis of CVT occurring in patients with HIT.Methods:The study protocol was registered with PROSPERO (CRD42021249652). MEDLINE, EMBASE and Cochrane CENTRAL were searched up to June 1, 2021 for HIT case series including >20 patients, or any report of HIT-related CVT. Demographic, neuroradiological, clinical, and mortality data were retrieved. Meta-analysis of proportions with random-effect modeling was used to derive rate of CVT in HIT and in-hospital mortality. Pooled estimates were compared with those for CVT without HIT and HIT without CVT, to determine differences in mortality.Results:From 19073 results, we selected 23 case series of HIT (n=1220) and 27 cases of HIT-related CVT (n=27, 71% female). CVT developed in 1.6% of 1220 patients with HIT (95% CI,1.0%–2.5%,I2=0%). Hemorrhagic brain lesions occurred in 81.8% of cases of HIT-related CVT and other concomitant thrombosis affecting other vascular territory was reported in 47.8% of cases. In-hospital mortality was 33.3%. HIT-related CVT carried a 29% absolute increase in mortality rate compared with historical CVT controls (33.3% versus 4.3%,P

Stroke, Ahead of Print. Background:Despite the prevalence of cognitive impairment poststroke, there is uncertainty regarding interventions to improve cognitive function poststroke. This systematic review and meta-analysis evaluate the effectiveness of rehabilitation interventions across multiple domains of cognitive function.Methods:Five databases were searched from inception to August 2019. Eligible studies included randomized controlled trials of rehabilitation interventions for people with stroke when compared with other active interventions or standard care where cognitive function was an outcome.Results:Sixty-four randomized controlled trials (n=4005 participants) were included. Multiple component interventions improved general cognitive functioning (MD, 1.56 [95% CI, 0.69–2.43]) and memory (standardized MD, 0.49 [95% CI, 0.27–0.72]) compared with standard care. Physical activity interventions improved neglect (MD, 13.99 [95% CI, 12.67–15.32]) and balance (MD, 2.97 [95% CI, 0.71–5.23]) compared with active controls. Noninvasive brain stimulation impacted neglect (MD, 20.79 [95% CI, 14.53–27.04) and functional status (MD, 14.02 [95% CI, 8.41–19.62]) compared with active controls. Neither cognitive rehabilitation (MD, 0.37 [95% CI, −0.94 to 1.69]) nor occupational-based interventions (MD, 0.45 [95% CI, −1.33 to 2.23]) had a significant effect on cognitive function compared with standard care.Conclusions:There is some evidence to support multiple component interventions, physical activity interventions, and noninvasive brain stimulation improving cognitive function poststroke. Findings must be interpreted with caution given the overall moderate to high risk of bias, heterogeneity of interventions, and outcome measures across studies.

Stroke, Ahead of Print. The stroke burden continues to grow across the globe, disproportionally affecting developing countries. This burden cannot be effectively halted and reversed without effective and widely implemented primordial and primary stroke prevention measures, including those on the individual level. The unprecedented growth of smartphone and other digital technologies with digital solutions are now being used in almost every area of health, offering a unique opportunity to improve primordial and primary stroke prevention on the individual level. However, there are several issues that need to be considered to advance development and use this important digital strategy for primordial and primary stroke prevention. Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines we provide a systematic review of the current knowledge, challenges, and opportunities of digital health in primordial and primary stroke prevention.

Stroke, Volume 53, Issue Suppl_1, Page ATP49-ATP49, February 1, 2022. Background:With the advent of extended window endovascular therapy (EVT) for acute ischemic stroke (AIS), interhospital transfer is increasingly frequent. However, not all patients who are transferred undergo EVT. To use resources judiciously, stroke centers need to identify which patients are most likely to benefit from EVT prior to transfer.Methods:We performed a retrospective study of AIS patients transferred for potential EVT at our neurovascular center between 2015 and 2018. We noted whether pre-acceptance imaging was available for visual review on LifeImage, RAPID perfusion software, or Telestroke PACS. The primary outcome was EVT on arrival.Results:530 AIS patients were included. 270 underwent EVT (50.9%); 156 (29.4%) had pre-acceptance imaging reviewed; 275 (51.9%) received IVtPA. Of all patients who were transferred, performance of pre-transfer CTA was significantly associated with EVT (57% vs 40%, p

Stroke, Volume 53, Issue Suppl_1, Page AWP89-AWP89, February 1, 2022. Introduction:Enrollment of populations that bear the real-world burden of ischemic strokes is critical to development of generalizable and clinically relevant randomized clinical trials (RCTs). Despite well-recognized historical patterns of underrepresentation for women, older adults, and certain racial/ethnic minorities, major knowledge gaps remain regarding representation in modern trials. We aimed to determine representativeness by age, sex, and race/ethnicity of participants in acute ischemic stroke RCTs performed in the US or CanadaMethods:We conducted a systematic review and meta-analysis in accordance with PRISMA, and prospectively registered with PROSPERO (CRD42021247730). ClincalTrials.gov was searched for ischemic stroke RCTs with acute interventions (

Stroke, Volume 53, Issue Suppl_1, Page AWMP49-AWMP49, February 1, 2022. Background:D-dimer has been evaluated as an independent marker of ischemic stroke. The non-existence of a clear consensus and pooled data about the use of D-dimer as a predictive biomarker for assessing the risk of stroke recurrence led us to perform this systematic review and meta-analysis.Methods:Studies reporting the risk of stroke recurrence with varying degrees of high D-dimer levels were screened through August 2021 using PubMed/Medline, Scopus, EMBASE and Web of Science databases and relevant keywords. Random effects models by Dersimonian & Laird were used for meta-analysis and subgroup analysis. I2statistics were used for heterogeneity assessment. The leave-one-out method was used for sensitivity analysis.Results:This systematic review included 5040 patients from 9 studies consisting of >60% males. There was a high burden of cardiovascular comorbidities, smoking and diabetes in stroke patients with or without associated diagnoses and high D-dimer levels. Compared to low D-dimer levels, higher plasma D-dimer levels were associated with ~80% (aOR 1.79, 95% CI: 1.24-2.59) increased risk of stroke recurrence. The odds of stroke recurrence were significantly high in the stroke cohorts including patients with mean age