Risultati per: Libro sugli antibiotici del WHO AWaRe (Access, Watch, Reserve)

Objective
This study investigates Saudi Arabian physiotherapists’ perspectives on direct access to physiotherapy (DAPT) services, focusing on perceived benefits, barriers and implementation in clinical practice.

Methods
A cross-sectional observational study design was used. Data collection occurred between December 2022 and June 2023 via an online structured questionnaire distributed through email and text messages. The DAPT section comprised items on awareness, endorsement, obstacles/barriers to implementation in Saudi Arabia, perceived benefits and expected benefits of various resources to guide evidence-based practice for physiotherapists. This section featured closed-ended questions using a 5-point Likert scale. The study included licensed physiotherapists currently working in Saudi Arabia.

Results
The study included 401 participants, with a nearly equal distribution of 203 males (50.6%) and 198 females (49.4%). The most common age group was 25–34 years, comprising 70.6% of the participants. A significant proportion (61.6%) were aware of DAPT, and 88% acknowledged its potential to reduce delays in care. However, 49.9% had not engaged with relevant literature. The primary barriers to DAPT identified were laws and regulations (mean=3.69, SD=1.21), physician support (mean=3.59, SD=0.99), entry-level education (mean=3.45, SD=1.17), patient beliefs (mean=3.38, SD=1.24), self-confidence (mean=3.35, SD=1.15) and professional autonomy (mean=3.34, SD=1.22).

Conclusion
Physiotherapists in Saudi Arabia demonstrate substantial awareness of direct access. Organisational initiatives and increased awareness are essential to promote direct access. This study highlights that direct patient access to physiotherapists offers significant benefits to patients, healthcare workers and the broader community.

A study has found that about 29% of the nearly 90 000 retail pharmacies in the US operating between 2010 and 2021 have closed, and they were more likely to shut down if they were in predominantly Black and Latino neighborhoods than in White neighborhoods, in urban vs rural neighborhoods, or were independent pharmacies rather than chains.

Introduction
The PRIME-UK randomised controlled trial (RCT) aims to establish whether a model of care that seeks to be proactive, integrated and empower participants, caregivers and healthcare professionals can improve outcomes in people with parkinsonism. Given that this intervention is novel and complex, understanding whether and how the intervention will be acceptable, implementable, cost-effective and scalable across contexts are key questions beyond that of whether ‘it works’. We describe an embedded process evaluation to answer these questions, which aims to support interpretation of the trial results, refinement of the intervention and support future scaling of the PRIME-Parkinson model of care.

Methods and analysis
A mixed-methods approach will be used to collect data across four process evaluation domains: implementation, mechanism of change, acceptability and context. Quantitative data will be collected prospectively from all participants and analysed descriptively with exploratory tests of relationships as power allows. Qualitative data will be collected through semistructured interviews with a purposively sampled subpopulation of participants, caregivers and staff members as well as case studies where relevant. Interview transcripts will be analysed thematically using interpretive qualitative analysis. Synthesis of quantitative and qualitative data will also be performed to draw conclusions.

Ethics and dissemination
The quantitative data will be collected as part of the main PRIME-UK RCT which was been granted NHS REC approval (21/LO/0387) on 27 July 2021. The qualitative data will be collected as part of a substudy, ‘PRIME-Qual’, which was granted NHS REC approval (21/LO/0388) on 14 July 2021. The mixed-methods process evaluation will be published after the conclusion of the trial in addition to the main trial findings.

Trial registration number
NCT05127057.

La denuncia dei farmacisti, nel 68% dei casi interrotte o sospese le produzioni

New England Journal of Medicine, Ahead of Print.

New England Journal of Medicine, Ahead of Print.

This Viewpoint discusses the growing body of evidence that indicates that mifepristone and misoprostol meet the US Food and Drug Administration’s criteria for over-the-counter sale.

Objective
To explore the barriers and enablers to accessing diabetes eye care services among adults in Auckland.

Design
This was a qualitative study that used semistructured interviews. We performed a thematic analysis and described the main barriers and enablers to accessing services using the Theoretical Domains Framework.

Setting
The study took place in two of the three public funding and planning agencies that provide primary and secondary health services in Auckland, the largest city in Aotearoa New Zealand.

Participants
Thirty people with diabetes in Auckland who had experienced interrupted diabetes eye care, having missed at least one appointment or being discharged back to their general practitioner after missing several appointments.

Results
We identified barriers and enablers experienced by our predominantly Pacific and Māori participants that aligned with 7 (of the 14) domains in the Theoretical Domains Framework. The most reported barriers were transport issues, lack of awareness regarding the importance of retinal screening, time constraints, limited and/or inflexible appointment times and competing family commitments. Enablers included positive interactions with healthcare providers and timely appointment notifications and reminders.

Conclusions
Diabetes eye services could be made more responsive by addressing systemic barriers such as service location and transport links, appointment availability and meaningful information to aid understanding.

Stroke, Volume 56, Issue Suppl_1, Page AWP187-AWP187, February 1, 2025. Introduction:3 to 5% of patients undergoing endovascular thrombectomy present impossible catheter access to the occlusion site from transfemoral access (TFA), largely attributed to complex arterial anatomy. Radial access can be an effective bailout strategy, but intraprocedural delays may negatively impact outcomes. Novel image processing algorithms allow for advanced characterization of vascular pathways from baseline neuroimaging, enabling the exploration of predictive models of impossible TFA before arterial puncture.Methods:A retrospective cohort of patients with an anterior large vessel occlusion who received thrombectomy from TFA between 2017 and 2023 were included in this study. A previously described automatic vascular analysis software was used to generate centerline graphs from the aorta to the intracranial occlusion site from baseline CTA. ArterialGNet, a graph neural network based on graph attention designed to integrate descriptors of centerline pathways extracted at three different distance scales, was trained for impossible TFA prediction. Five-fold cross validation was used for model derivation. The method was compared to a previously introduced random forest ensemble model with extreme gradient boosting (XGBRF) based on six vascular tortuosity descriptors of the aortic and supra-aortic regions.Results:A total of 745 patients (aged 78 years IQR 68-85, 56% women) were included in this study. Patients treated between 2017 to 2022 (n=568, 3.2% with impossible TFA) were used for model training and validation. Patients treated in 2023 (n=177, 3.4% with impossible TFA) were held out for testing. In validation, the best-performing configuration of ArterialGNet achieved a C-statistic of 0.82 (95%CI 0.74-0.90), similar to the baseline model (0.82, 95%CI 0.77-0.88). Comparable outcomes were observed in the final testing for ArterialGNet (0.84, 95%CI: 0.82–0.86). In contrast, the XGBRF model exhibited signs of overfitting (0.65, 95% CI: 0.53–0.78). In final testing, ArterialGNet predicted impossible TFA with a sensitivity of 0.80 (95%CI 0.66-0.94) and a specificity of 0.84 (95%CI 0.76-0.91). Median processing time for ArterialGNet was below 4 min.Conclusions:A novel model for impossible TFA prediction was validated with a large dataset. Impossible TFA prediction before arterial puncture may assist in decision support for initial access selection in thrombectomy, reducing intraprocedural delays and potentially improving clinical outcomes.

Stroke, Volume 56, Issue Suppl_1, Page ATMP48-ATMP48, February 1, 2025. Background:Telestroke may mitigate racial/ethnic and rural disparities in access to acute stroke expertise. Objective: to examine the relationship between patient race/ethnicity and presentation to an emergency department (ED) with acute stroke capabilities, including telestroke, and whether this varied by rurality.Methods:Data maintained by the California Department of Health Care Access and Information identified all statewide acute stroke encounters in 2021. ED capabilities were from the 2021 National ED Inventory-USA database (e.g., telestroke capability). ED acute stroke capabilities were defined as any stroke center status (including acute stroke ready hospital or equivalent) or telestroke capability. Logistic regression models examined the association between patient race/ethnicity, rurality and presentation to an ED with acute stroke capabilities, accounting for age, sex, and expected payer, overall and stratified by rurality. Our first outcome of interest was presentation to an ED with any stroke center status. Then, to examine whether access improved with inclusion of telestroke, the outcome included presentation to an ED with any stroke center status or telestroke capability.Results:In 2021, 264 of 325 California EDs (81%) had acute stroke capabilities, 52% with telestroke (with or without stroke center status). Of 63,252 encounters, 2,050 (3%) presented to an ED without capabilities. Overall, Hispanic, non-Hispanic patients of non-White race and rural patients had lower odds of access to acute stroke capabilities (Table 1). Odds of access did not improve with inclusion of EDs with telestroke (Table 1). When stratified by rurality, there were no differences in access by race/ethnicity for rural patients, but urban Hispanic, urban non-Hispanic Black and urban non-Hispanic patients of other race had lower odds of access relative to urban non-Hispanic White patients (Table 2).Conclusions:Most California EDs have acute stroke capabilities, with few patients presenting to non-capable centers. Overall, rural patients had lower odds of presenting to an ED with capabilities. Racial/ethnic disparities in access were distinct between urban and rural settings, with no racial/ethnic disparity among rural patients but lower odds of access for Hispanic and non-white urban patients. The inclusion of ED telestroke capability in the definition of acute stroke capabilities did not mitigate disparities in access.

Stroke, Volume 56, Issue Suppl_1, Page ATP327-ATP327, February 1, 2025. Self-reported stroke prevalence has increased among US adults aged 18-64 over the past decade and is projected to rise. As younger stroke survivors live longer, access to healthcare is essential for the detection, treatment, and monitoring of cardiovascular disease (CVD) risk factors to prevent recurrent stroke or other acute CVD events. Adults aged 1 personal healthcare provider, the ability to afford to see a doctor in the past year, and a routine checkup within the past year).Most stroke survivors reported healthcare access: 86.3% (95% CI 85.7 – 86.8 had insurance coverage and >1 personal healthcare provider); 26.6% (95% CI 25.9 – 27.3) couldn’t afford a doctor in the past year; and 81.2% (95% CI 80.6 – 81.1) had a routine checkup in the past year. Statistically significant differences (p < 0.05) were found across all sociodemographic groups. Younger adults (aged 18-29 and 30-44), men, and those with lower education reported less healthcare access. Varying measures of access were reported across racial/ethnic groups.Overall, most stroke survivors reported access to healthcare, although opportunities exist to improve access for younger adults, men, different racial/ethnic minorities, and those with lower education. Prior access to healthcare might have contributed to stroke survival for some individuals. Continued and improved healthcare access could help prevent recurrent stroke or other acute CVD event among stroke survivors.

Stroke, Volume 56, Issue Suppl_1, Page ATMP57-ATMP57, February 1, 2025. Introduction:Literature demonstrates that nearly one-third of acute ischemic stroke (AIS) patients with large vessel occlusion (LVO) or severe stenosis arrive at the emergency room with mild symptoms, attributed to favourable collateral status. However, approximately 20~40% of patients with mild symptoms due to LVO or severe stenosis are at risk of early neurological deterioration (END) as a consequence of subsequent collateral failure post arrival. This study aimed to identify the difference of collateral patterns between mild stroke patients with END and those without.Methods:AIS patients presenting within 24 hours from last known well, with a baseline NIHSS≤5 and anterior circulation LVO or severe stenosis were included. Patients who underwent endovascular treatment before END were excluded. END was defined as an increase in total NIHSS≥4 or NIHSS≥2 for any item within 72 hours, without evidence of parenchymal hemorrhage. Collateral flow was rated as the Tan scale (leptomeningeal collaterals) and cerebral blood volume (CBV) index (cerebral blood flow reserve). A good leptomeningeal collateral score (goodCS) was defined as Tan scale≥2 (poorCS: Tan scale 6s lesion over the mean CBV of Tmax0.735 and poorCS (group 4) were most likely to present with END (logistic OR[95%CI]: 5.18[1.22,22.18] P=0.026).Conclusions:Higher CBVindex and poor leptomeningeal collaterals were independent predictors of END in patients with mild symptoms due to anterior circulation LVO or severe stenosis. Therefore, we hypothesize that though higher CBVindex reflects favorable collaterals at baseline, higher CBVindex combined with the absence of goodCS indicates insufficient blood flow reserve, leading to collapse of collateral flow during acute phase, therefore, the occurrence of END.

Stroke, Volume 56, Issue Suppl_1, Page ATP129-ATP129, February 1, 2025. Introduction:An equitable health system requires access to clinical advances across society. In stroke, mechanical thrombectomy (MT) has revolutionized the field by providing an acute therapy with unprecedented reduction in morbidity and mortality. Its benefit depends heavily on the duration between stroke onset and cerebral reperfusion. As such, patient factors associated with delays in care can influence outcomes after MT and lead to health inequities. Communication is paramount to a neurological evaluation. In a predominantly English-speaking medical system, we hypothesized that patients with a primary language other than English who presented to the hospital with large-vessel occlusion ischemic stroke (LVO) might experience delays in care resulting in longer times to MT.Methods:We conducted a single-center retrospective cohort study to investigate the impact of primary language on door-to-puncture time (DTP) among patients with LVO who presented to a single comprehensive stroke center between 01/2020 and 05/2024 and underwent MT. We employed non-parametric statistics to compare patient demographics and clinical outcomes and a LASSO approach to identify independent predictors of DTP.Results:Of the 413 patients who underwent MT, 52 (13%) were non-English-speaking (Table 1). In the overall cohort, patients were on average 71 years of age and majority male (57%). They presented to the hospital 8.1 hours after last known well with a mean NIHSS of 19. Compared with the English-speaking cohort, non-English-speaking patients presented earlier to the hospital after last known well (6.1 hours versus 8.1 hours, p = 0.110), were more likely to receive thrombolysis (33% versus 14%, p < 0.001), and had higher rates of hypertension (63% versus 44%, p < 0.008) and lower rates of congestive heart failure (12% versus 30%, p = 0.005). Neither DTP (60 minutes versus 60 minutes, p = 0.900) nor door to needle time (time to administration of thrombolytic, 43 minutes versus 47 minutes, p = 0.600) differed between non-English and English-speaking patients. Regression analysis identified a history of dyslipidemia (decreased DTP 8 min, 95% CI 2-14 min) and having received IV thrombolysis (increased DTP 13 min, 95% CI 5-21 min), but not primary language, as independent predictors of DTP.Conclusions:Our comprehensive stroke center promotes an equitable health system by providing a timely opportunity for MT after LVO irrespective of patient language.

Stroke, Volume 56, Issue Suppl_1, Page ATP124-ATP124, February 1, 2025. Value-based medicine places the patient and their health status at the center of the intervention through the use of Patient-Reported Outcome Measures (PROMs). The ideal would be that these outcome measurements were answered directly by the patient but in many cases it is a caregiver or a healthcare professional who collects the person’s health status perception. This reason could lead to a bias in the results.Our aim was to compare whether there were differences in the perception of health status depending on who answered these questionnaires.Stroke patients discharged from six European hospitals were included in a 1-year follow-up program based on a holistic communication tool (web platform for professionals and app for patients/caregivers) called NORA. PROMs at 7-90 days were collected through NORA-app. In case that the patient or caregiver didn’t have access to a smartphone, the data collection was carried out by a professional healthcare who contacted them to manage PROMs by a phone call.Main outcome measures include: HAD-depression and HAD-anxiety (defined as pathological by a score ≥10 points in each of the subscales) and PROMIS-10 (cut-offs raws values of normality were defined as: Physical-PROMIS >13 and Mental-PROMIS >11). Median scores per collector were compared. In addition, a social questionnaire was collected from app-users’.Over two years, 5116 stroke patients were included in Harmonics project, 60% were men with a mean age of 70.2 years and median mRS of 2(1- 3) at hospital discharge. From them, 2432 were actively monitored and 1498 reported PROMs (428 patients (28.6%), 376 (25.1%) caregivers and 694 (46.3%) professionals). P-value < 0.05 was considered significant for all tests at 90 days. Median PROMs results are shown in Table-1.The social questionnaire (Figure-1) showed significant differences between male and female patients. From the total, 26.6% women and 11.7% men leave alone (p-value = 0.005).At the patients group 77.9% women considered they can take care of their basic needs’ vs 85.9% men (p-value= 0.036).Significant differences were found between the three groups of collectors, with professionals being the ones who perceive a better state of patient health through the collected PROMs collected. Among patients and caregivers groups, worse outcomes were reported by the last one.When using PROMs the collector should avoid bias in reporting the results and direct patient response should be encouraged.

Stroke, Volume 56, Issue Suppl_1, Page ATMP80-ATMP80, February 1, 2025. Introduction:In 2015, mechanical thrombectomy (MT) was established as an essential treatment for large-vessel occlusion ischemic stroke (LVO). Since then, trials have expanded the population eligible for MT by demonstrating its benefit in patients with LVO who present later to care and with more extensive infarct. As the eligibility criteria for MT ease, more patients will undergo the procedure who have risk factors for complications – such as malignant edema or hemorrhagic conversion – that require decompressive craniectomy (DC). Though MT and DC in ischemic stroke have been studied independently, the outcomes of patients who undergo both procedures is unknown. We present a case series using a national database of patients who underwent MT and required DC to understand their profile and health outcomes.Methods:Using the National Inpatient Sample (NIS), an all-payer national healthcare utilization database, patients admitted between the years 2016 and 2021 for ischemic stroke who underwent MT and required DC were identified via ICD-10 codes. Logistic regression was performed to identify patient factors independently associated with DC after MT.Results:Of the 31,234 patients admitted for LVO who received MT between 2016-2021, 764 (2%) underwent DC (Table 1). Younger age (p < 0.001), non-white race (p < 0.001), a higher NIHSS (p < 0.001), and lower rates of atrial fibrillation were independently associated with DC after MT. Although the number of patients undergoing MT plus DC increased annually, this rise was proportional to the overall number of MT patients. Admissions with MT and DC were nearly 2.5 times longer than those with MT alone (20 days versus 8.4 days, p < .001, Table 2) and associated with increased rates of mortality (25% versus 12%, p < 0.001) and a higher level of care after discharge (p < 0.001).Conclusion:Rates of DC after MT did not change following extension of the thrombectomy window to 24 hours. DC after MT resulted in a heavy burden of morbidity and mortality, similar to levels previously published for DC after ischemic stroke without MT. In conclusion, our findings suggest that expansion of MT eligibility criteria has not increased the risk for DC and that practice guidelines developed from trials in stroke patients who underwent DC but not MT may also be applicable to patients with DC after MT. Recent large core trials have further expanded the MT population, necessitating continued examination of the relationship between MT and DC.