Search Results for: Report aggiornato sulla qualità dell’aria in Europa (2015)

This case report describes a young woman with a diffusely swollen lower lip, normal tongue, and no history of local trauma, irritants, or allergies.

This case report describes a woman in her 40s who presented for evaluation of pruritic skin lesions on her chest and all 4 extremities that had developed over several days.

This case report describes a man in his 50s with type 2 diabetes and hyperlipidemia who was admitted for rash and proximal muscle weakness, pain, and unintentional 15-pound weight loss associated with anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) myopathy.

To the Editor I read with interest the recent report from Fulgenzi et al describing the outcomes of immunotherapy vs best supportive care in patients with hepatocellular cancer with Child-Pugh B dysfunction. The article addressed important clinical concerns and has attempted to make a clinical comparison between patients who receive best supportive care (BSC) only, or immune checkpoint inhibitors (ICIs) (either nivolumab or atezolizumab with bevacizumab). Although the study was nonrandomized, the authors reported an association with improved survival in patients who received ICIs.

Objective
To evaluate the knowledge, attitude and practice (KAP) regarding screening and managing diabetic microvascular complications, encompassing diabetic retinopathy (DR), diabetic kidney disease (DKD) and diabetic neuropathy (DN), among general practitioners (GPs).

Design
Cross-sectional study.

Setting
The online questionnaire survey was conducted between April and July 2023.

Participants
GPs from community health centres (CHCs) in all 16 districts of Shanghai were recruited.

Primary and secondary outcome measures
The data of sociodemographic characteristics, KAP scales, training experience and screening instruments for community screening and managing diabetic microvascular complications were collected. Multiple stepwise linear regression was used to explore the influencing factors of KAP. Restricted cubic spline curves with four knots (5%, 35%, 65%, 95%) were used to determine the association between KAP score and duration of general practice.

Results
A total of 1243 questionnaires were included in the analysis. The total KAP score was 66.6±8.8/100, and the knowledge, attitude and practice scores were 64.7±8.7, 83.5±10.5 and 51.6+17.8, respectively. Male (β=–2.419, p=0.012), shorter practice duration (β=–1.033, p=0.031), practice in rural area (β=3.230, p=0.001), not attending training in diabetic microvascular complications (β=–6.346, p

Objectives
Traditionally, patients have had passive roles in medical education; however, there have been increasing efforts to partner with communities to create authentic representation of laypeople in medical education. Communities’ perspectives of these initiatives have rarely been reported in the literature. This study explores the perspectives of members of community-based organisations (CBOs) who were partnered with a community engagement programme for intercalating medical students at Imperial College London.

Design
A qualitative study using semistructured interviews was conducted, employing reflexive thematic analysis.

Setting
London, UK.

Participants
A total of five participants (one member from five CBOs who agreed to participate) were interviewed for this study. The selection criterion was direct involvement in the community engagement programme.

Results
Three key themes were identified aligning with the core principles of co-production: building partnership, reciprocity in partnership and maintenance of relationship. Partnership development was influenced by the CBOs’ perception of students which caused power differentials in the development of learning plans. Reciprocity refers to a multidirectional benefit pathway resulting from the community involvement programme, which had short-term and anticipated long-term effects. Relationships built were maintained via a service evaluation report, and participants discussed how attitudes of academic institutions towards collaboration influence communities’ ability to participate in medical education.

Conclusions
The perspectives of CBOs reported in this study demonstrate that factors important to partnership development in community-engaged medical education are consistent with the key principles of co-production. Supported by literature, the findings emphasise that community involvement can be linked to social accountability and sustainable health practice. Provided that the possible risks/challenges are appropriately identified and mitigated to facilitate co-productive partnerships between stakeholders, the involvement of CBOs in medical education has the potential to provide benefits for communities, students and educational institutions.

Stroke, Volume 56, Issue Suppl_1, Page ATMP37-ATMP37, February 1, 2025. Introduction:Limited studies have examined racial disparities in long-term survival after acute ischemic stroke (AIS) with inconsistent findings. We examined these disparities among Medicare fee-for-service (FFS) beneficiaries in U.S.Methods:We analyzed data on 1,997,487 Medicare FFS beneficiaries aged ≥65 years hospitalized with incident AIS (ICD-10 code I63) and survived >30 days from January 1, 2000 to December 31, 2017, and were followed-up until December 31, 2022. Cox proportional hazard models estimated the adjusted hazard ratio (aHR, 95% CI) and adjusted survival curves by race/ethnicity (non-Hispanic White (White), non-Hispanic Black (Black), Hispanic and Other). Models were adjusted for age, sex, and comorbidities.Results:The median age at AIS hospitalization was 78 years (IQR 72.0-84.0); 57.0% were women; 81.8%, 10.8%, 4.8% and 2.6% were White, Black, Hispanic and Other, respectively. Over a median follow-up of 4.9-years (IQR 1.7-8.8), there were 1,738,452 all-cause deaths. Adjusted 5-year survival after AIS improved from 2000-2004 to 2015-2017 for White (46.5% (95% CI 46.4-46.6) to 50.9% (50.7-51.1)), and Black (46.0% (45.8-46.3) to 48.9% (48.3-49.2)). For Hispanic and Other, survival remained largely unchanged: 54.4% (54.1-54.8) to 54.2% (53.6-54.8)) for Hispanic and 55.9% (55.4-56.4) to 54.7% (54.0-55.5) for Other. A clear pattern of long-term survival after AIS emerged by race/ethnicity showing similar survival between Hispanic and Other and between White and Black people (Figure). Stroke mortality risk was ~25% higher for White and Black compared to Hispanic and Other (aHR 1.25 (1.24-1.26)). This pattern was consistent across age groups and sex.Conclusions:Long-term survival after AIS has improved for White and Black Medicare FFS beneficiaries over time, while it remained largely unchanged for Hispanic and Other groups. This indicates persistent racial disparities in stroke outcomes.

Stroke, Volume 56, Issue Suppl_1, Page ATMP32-ATMP32, February 1, 2025. Introduction:Facilitating evidence-based uptake of new medication regimens for disease prevention is a well-recognized public health challenge. Using data from GWTG-Stroke, researchers previously reported that, after minor ischemic stroke (NIHSS 0-3), the use of aspirin-clopidogrel for stroke prevention is highly variable despite guideline recommendations. We sought to explore potential changes in dual antiplatelet therapy (DAPT) use in patients with moderate ischemic stroke (NIHSS 4-5) after the publication of the THALES (The Acute Stroke or Transient Ischemic Attack Treated With Ticagrelor and ASA for Prevention of Stroke and Death) trial in 2020.Methods:We used the GWTG-Stroke registry to describe patterns of DAPT use in the U.S. from 2019 to 2023. All patients with a final diagnosis of ischemic stroke, NIHSS 4-5, hospital arrival within 24 hours, who lacked an indication for anticoagulation (e.g., atrial fibrillation) and were not treated with thrombolysis/thrombectomy were included in our study. Patients with NIHSS 4-5 (moderate stroke) were not included in prior randomized controlled trials of aspirin-clopidogrel for short-term stroke prevention but were included in THALES. We reported basic demographic features of our cohort and used the Cochran-Armitage trend test to report changes in aspirin-ticagrelor use by year.Results:We identified a total of 40,624 acute ischemic stroke patients with NIHSS 4-5 during the study period. The mean age was 68 years and 47% of patients were women. We found that a total of 20,293 (50%) patients were discharged on aspirin-clopidogrel whereas 1,335 (3.5%) were discharged on aspirin-ticagrelor. The use of both DAPT regimens significantly increased over time (Figure 1, p

Stroke, Volume 56, Issue Suppl_1, Page ATP314-ATP314, February 1, 2025. Introduction:Blood pressure (BP) control after a stroke is crucial in lowering the risk of stroke recurrence. Our prior work found that over 60% of patients recently discharged from a regional health system with stroke did not achieve BP control according to current guidelines. Less is known about the impact of insurance type and co-morbidities on post-stroke BP control.Objective:To analyze the relationship between insurance type, comorbidities and post-stroke BP control among patients within a regional health system.Methods:This report is an observational cohort study. Patients were admitted between 2013-2021 for ischemic and hemorrhagic stroke and had seen a PCP/PCAPP (primary care physician/primary care advance practice provider) in a regional health system or affiliated outpatient clinics using the EPIC electronic health record. We excluded patients who died during hospitalization, were lost to follow-up, or were on dialysis.Results:The analysis included 2,750 patients. Six months after hospital discharge, the insurance coverage among stroke survivors with uncontrolled BP ( >130/80 mm Hg) was 61.1% for public, 35.8% for private, 1.9% for other/unknown, and 1.3% for self-pay. In comparison, among those with controlled BP (

Stroke, Volume 56, Issue Suppl_1, Page ATP325-ATP325, February 1, 2025. Introduction:The Cameron County Hispanic Cohort (CCHC) represents a random sample of the Hispanic community residing in Cameron County, Texas. Participants were invited, regardless of their medical history, to participate every five years and went through extensive interviews and laboratory workout. This is the first report on the incidence of stroke in this cohort and provides a comprehensive examination for the associations between strokes and several cardiometabolic indicators.Methods:We conducted a case-cohort analysis to measure the associations between incident stroke and several cardiometabolic risk factors in the CCHC. Strokes were self-reported and we exclude subjects who reported strokes at their first visit as well as those who did not report on their stroke status. Chi square and Student t-test were used to test for univariate associations of several cardiometabolic indicators with incident strokes. We ran logistic regression models to estimate the associations of several cardiometabolic indicators with incident strokes after adjusting for age, diabetes, and hypertension. We used multiple imputation to estimate missing values for variables with more than 25% missingness. All analyses were conducted in R software (version 4.4.2)Results:The cumulative incidence for strokes was 0.02 (87 out of 4692 subjects). Those who presented with incident strokes were older (mean(sd): 61.4 (13.9) vs. 45.3 (15.9)), more likely to be diabetic (44 (50.6%) vs. 759 (16.5%)), and hypertensive (58 (66.7%) vs. 1194 (25.9%)), have higher inflammatory profile (e.g., C-Reactive Protein) (11.0 (26.3)vs. 7.92 (14.8)), thicker carotid intima (0.796 (0.250) vs. 0.681 (0.179)), lower left ventricular ejection fraction (60.8 (8.69) vs. 63.9 (4.89)), and higher left ventricular mass (159 (45.7) vs. 141 (36.9)) when compared to those without strokes at baseline. Adjusted logistic regression models comparing those with strokes to those without strokes at baseline showed that Low Density Lipoprotein (OR: 0.99, 95%CI: 0.98 – 0.99) and metabolic syndrome (OR: 0.53, 95%CI: 0.33-0.84) to be significantly associated (p

Stroke, Volume 56, Issue Suppl_1, Page ATP302-ATP302, February 1, 2025. Background:Multiple randomized clinical trials failed to show benefit of anticoagulation over antiplatelets in the secondary prevention for embolic stroke of undetermined source (ESUS). However, the benefit of combination antithrombotic regimens remains unexplored in the same patient population.Methods:This is a subgroup analysis of a multicenter retrospective observational cohort of consecutive adult patients with ESUS (n=27 sites, 2015-2024). Comparisons were made between patients treated with single (SAPT) or dual antiplatelet therapy (DAPT), exclusive anticoagulation (AC) (direct oral anticoagulant, vitamin K antagonist, low molecular weight heparin) and combination anticoagulation and antiplatelet therapy initiated within the first 7 days of index stroke. The primary composite outcome of recurrent ischemic stroke, major bleeding, or death was assessed using unadjusted and adjusted Cox proportional hazards regression. Secondary outcomes were individual outcomes of recurrent ischemic stroke, major bleeding, or death.Results:Of the 2201 included patients, 1456 (66.1%) were on SAPT, 527 (23.9%) were on DAPT, 195 (8.8%) were on exclusive AC and 23 (1.0%) were on AC+AP (all of which were on DAPT). Patients treated with AC+AP were older (median 66 years [IQR 51-78]), more likely to have history of hypertension, stroke, hyperlipidemia, PFO and left atrial enlargement. Compared to SAPT, all treatment strategies were associated with similar risk of the primary outcomes in the unadjusted and adjusted cox regression. Similarly, there was no difference in individual outcomes including recurrent stroke, major bleeding and death in the adjusted cox regression. However, there was an increased risk of major bleeding with AC+AP in the unadjusted cox regression (HR 4.0, [95% CI 1.2-12.8], p=0.02) but not in the adjusted model when compared to SAPT. Also, DAPT was associated with lower risk of death than SAPT in the unadjusted model (HR 0.61 [95% CI 0.4-0.8],p=0.005) but not the adjusted model. Additionally, when adjusted by the HASBLED score, there was no difference in major bleeding when AC+AP was compared to SAPT.Conclusion:Over 90% of ESUS patients in this cohort were prescribed SAPT or DAPT. Antithrombotic therapy with DAPT, exclusive AC, or AC+AP was not associated with any lower risk of recurrent ischemic stroke, major bleeding and death compared with SAPT in an unselected cohort of ESUS patients.

Stroke, Volume 56, Issue Suppl_1, Page ATMP20-ATMP20, February 1, 2025. Background:Despite the increasing use of intravenous (IV) tenecteplase (TNKase) for acute ischemic stroke (AIS), little is known about the characteristics of patients who suffer intracerebral hemorrhage (ICH) and opportunities to prevent this often-fatal complication.PURPOSE:The aim of this retrospective review was to investigate the characteristics of AIS patients with ICH complication and opportunities in patient management after receiving IV TNKase in the emergency departments (EDs) and to report preliminary results.Methods:Retrospectively, the EHRs that suffered ICH complication after receiving TNKase (0.25 mg/kg) were reviewed from 21 hospitals in a large integrated health system between November 2020 to December 2023. Data collection included demographics, risk factors, blood pressures (BPs), and other variables such as the National Institute of Health Stroke Score (NIHSS), presence and types of large vessel occlusion, and severity of the hemorrhage (symptomatic or asymptomatic).Results:The mean age of the 195 cases was 75.4 (SD = 13.46). There were no sex differences (p=.87). Race breakdown was 50% (n = 98) Whites; 15% (n = 98) Hispanics/Latinos; 20% (n = 39) Asians, and 10% (n = 20) Blacks. Majority of patients (73%) arrived via EMS. History of was present in 75.4% of patients, followed by diabetes (58%), hyperlipidemia (55%), atrial fibrillation (20%), and history of stroke (18%). Anti-coagulants use was 8% (n=17). The initial mean NIHSS in the ED was 11.8 (SD=8.65). On initial presentation, the mean systolic and diastolic BPs was 164 (SD=27.1) and 90 (SD=19.46) respectively. Large vessel occlusions (LVOs) were identified in 35.9% (n=70) of patients. Of the LVO cases (n=70), 68.6% (n=48) of the ICH were asymptomatic.Conclusions:Based on the preliminary results, there were some patient-level risk factors that may have contributed to ICH complications after IV TNKase. Tighter control of BPs with anti-hypertensives before and after IV TNKase may also decrease bleeding risk. There were a few opportunities identified with patient assessment and monitoring. The use of both “full” NIHSS and abbreviated NIHSS varied between facilities, which may have delayed the identification of post-TNKase ICH as the abbreviated NIHSS did not provide a total score to assess for change in patient condition and about 40% of patients did not have an increase in the NIHSS. In-depth data reviews and analysis would be necessary to ascertain clinical significance.

Stroke, Volume 56, Issue Suppl_1, Page A87-A87, February 1, 2025. Background:Minimally invasive surgical evacuation improved outcomes for patients with acute, spontaneous intracerebral hemorrhage (ICH) in the Early MiNimally-Invasive Removal of ICH (ENRICH) trial. Eligibility for this therapy amongst ICH patients encountered in routine clinical practice is unknown. Using a population-based study, we aimed to determine the percentage of patients with acute ICH eligible for minimally invasive surgical evacuation based on the ENRICH trial inclusion and exclusion (I/E) criteria.Methods:We ascertained all adults ( >18 years) with acute (1.4, mechanical valve, and ESRD as exclusion criteria, 3.6% (n= 7) of all acute ICH patients (6.7%, n =7 of lobar ICH and 0%, n=0 of BG ICH) were eligible for hematoma evacuation.Conclusion:In a population-based study, only 3.0% of all acute ICH patients and 5.7% of lobar ICH patients were eligible for minimally invasive surgical evacuation. Further research is needed to establish effective therapies for more patients with acute ICH.

Stroke, Volume 56, Issue Suppl_1, Page ATMP11-ATMP11, February 1, 2025. Introduction:Moyamoya disease (MMD) is a rare cerebrovascular disease causing nonatherosclerotic intracranial arterial stenosis in children and young adults. TheRNF213gene variant plays an important role in the pathophysiology of MMD, particularly among East Asian populations. However, this variant is rarely found in patients of other ethnicity. Previous studies have shown thatRNF213gene variant is related to vascular structures such as the extent of moyamoya collaterals and posterior cerebral artery involvement. In this study, we utilize an imaging-based approach to investigate vascular structural features in MMD, which may offer novel insights into the pathophysiology of MMD.Methods:We retrospectively reviewed 770 patients with MMD or Moyamoya syndrome (MMS) from diverse ethnic backgrounds at Stanford University Medical Center treated between 2015 and 2024 (Fig. 1). After selecting sporadic non-hemorrhagic bilateral MMD patients aged 18-50 years old, the vascular structures acquired on MRA were visually assessed to evaluate the degree of intracranial arterial stenosis and basal moyamoya collaterals. T2 weighted images were reviewed to assess negative remodeling – shrinkage of the outer diameter of middle cerebral arteries (MCA) and internal cerebral arteries (ICA) as defined by Kuroda et al.2015, Neurol Med Chir (Tokyo).Results:Detailed demographic and clinical characteristics of 107 patients evaluated were listed in Table 1. By reviewing MRA, we have identified a subset of patients with unique imaging features characterized by ICA stenosis localized proximal to the terminal portion of ICA, differing from the typical lesion sites seen in MMD (Fig. 2). This non-terminal ICA stenosis was more frequently observed in Caucasian than in Asian patients (17.5% vs. 5.7%, P=0.007). Compared to patients with terminal ICA and/or MCA stenosis, patients with non-terminal ICA stenosis were older (P=0.03), had less advanced disease stages (P

Stroke, Volume 56, Issue Suppl_1, Page AWP8-AWP8, February 1, 2025. Introduction:Current guidelines recommend 24-hours of high-intensity monitoring (HIM) for acute ischemic stroke patients post-intravenous thrombolysis (IVT) due to risk of bleeding complications including symptomatic intracranial hemorrhage (sICH). We report the outcomes of a 12-hour targeted-intensity monitoring (TIM) pathway for low-risk post-IVT patients.Methods:Post-IVT patients were considered low-risk if their NIHSS < 10, blood pressure < 180/105 without medical intervention, level of consciousness was preserved, and no high-risk vessel stenosis/occlusion was present. All patients meeting these criteria between Oct 2020-April 2024 were included in our study; those who presented prior to March 2022 utilized the conventional HIM pathway and those presented afterwards utilized the TIM pathway. In the TIM pathway neurological exams and vital sign assessments were conducted every 15 minutes for the first hour, every 1 hour for the next 3 hours, every 2 hours for the next 8 hours, and every 4 hours for the next 12 hours (14 total neurochecks/vital sign assessments over 24 hours compared to 36 neurochecks/vital sign assessments with HIM). Patients utilizing the TIM pathway were admitted to an intermediate care unit bypassing the ICU.We examined the number of TIM patients who required transfer from IMC to the ICU and the duration of time in the ICU for HIM patients. Additionally, we compared the length of hospital admission, rate of sICH, 24-hour NIHSS scores, and 90-day mRS scores in matched post-IVT HIM and TIM patients.Results:A total of 95 patients were included in the study: 47 HIM (median age 71 [IQR 56-75.5], median NIHSS 4) and 48 TIM (median age 65, [IQR 60-81.25], median NIHSS 4). There were no significant differences in age, presenting blood pressure, or NIHSS between the two groups. The mean length of ICU-stay for the HIM group was 32.8 hours. No patient in the TIM pathway required transfer to the ICU for a higher level of care. The median length of hospital stay for the HIM group was 49.8 hours [IQR: 43.8-83.3] and 49.6 hours [IQR: 32.6-99.7] for the TIM group (p=0.716). No sICH was noted in either group. Median discharge NIHSS = 1 for both groups (p=0.125) and 90-day mRS = 2 for both groups (p=0.599)Conclusion:In our study, post-IVT TIM was feasible without safety concerns. Post-IVT TIM pathways may conserve healthcare resources and increase ICU bed availability. Further studies defining the optimal post-IVT TIM criteria are indicated.

Stroke, Volume 56, Issue Suppl_1, Page ATMP16-ATMP16, February 1, 2025. Lipoprotein (a) [Lp(a)] is a type of lipoprotein that is genetically inherited. Elevated levels of Lp(a) are an independent and causal risk factor for atherosclerotic cardiovascular diseases through mechanisms associated with increased atherogenesis, inflammation, and thrombosis. Having elevated Lp(a) can increase risk of heart attack, stroke, and peripheral artery disease.It is estimated that as many as 20% of the American population have elevated Lp(a) levels. There are currently no specific targeted treatments to lower Lp(a). There are currently no universal guidelines for diagnosing and providing risk assessment. There is a clinical need to understand variation in Lp(a) levels in various ancestry groups.In March 2023, a field to include measures for Lp(a) was added to the Get With The Guidelines® IQVIA Registry Platform™ (GWTG). This registry is utilized by each of the hospitals in a current six hospital system. A configurable measure report including Lp(a) measurement obtained and Lp(a) level was added in April 2024.Methods:Beginning in January 2024, Lp(a) levels obtained at six hospitals in our health system in New York City have been entered into GWTG. We used the newly developed measure reports for patients with ischemic stroke and TIA to determine whether Lp(a) levels were being obtained during hospitalization for stroke, and prior to these events. These hospitals are all certified by The Joint Commission®, and include one academic comprehensive stroke center, two thrombectomy centers, and three primary stroke centers.Results:In general, measurement of Lp(a) was low. Only one hospital had more than 10% of patients where Lp(a) was measured. One hospital, a primary stroke center had significantly more patients tested due to specific interest in Lp(a). The hospital with the highest percentage of measurement prior to the stroke was a tertiary care academic hospital.Conclusion:These results point out the need for initiatives across our health system to raise awareness of Lp(a) as an emerging stroke risk factor, and to improve on its measurement. This data will serve as a baseline to evaluate improvement in recognition and eventually treatment of elevated Lp(a) values.