Risultati per: Focus su febbre gialla, tifo e epatite A, Meningite

Objectives
The ambulance service plays a pivotal role in the provision of care in out-of-hospital maternity emergencies. Telephone triage of this patient group is complex and must be sensitive to an emergency situation to prevent unnecessary delays in treatment. This study aimed to explore emergency medical dispatchers’ (EMDs) perceptions of the structured protocol they use.

Design
Voluntary participation in semistructured phenomenological focus groups. The participants were asked to discuss their experiences of using Medical Priority Dispatch System Protocol 24 (pregnancy, childbirth and miscarriage). Thematic analysis was applied to code and group topics. Discussion between the EMDs is presented for each theme and their experiences, including quotes, are presented to offer an overview of the maternity protocol and its use.

Setting
A large urban UK ambulance service.

Participants
23 control room staff.

Results
Perceptions of maternity emergencies, challenges with key questions, the need for sensitivity surrounding miscarriage, using prearrival instructions and postdispatch instructions to help patients and ideas for additional ProQA functionality emerged as the five overarching themes. Protocol 24 was considered to reflect many of the clinical factors EMDs associate with maternity emergencies although further factors, including some non-clinical, were suggested for inclusion. Miscarriage and termination-related calls were thought to be challenging as the language of the protocol is designed for pregnancy. However, instructions were generally considered well written and user-friendly, although some were thought to be unnecessary. EMDs were largely positive regarding the ProQA software, but felt backward navigation was difficult if a situation changed.

Conclusions
Maternity calls were considered rewarding but complex by EMDs. We suggest changes including the use of more sensitive language in response to miscarriage and termination and make recommendations for the omission and inclusion of specific instructions, as well as enhancements to key questions and functionality. Further research is needed to ensure focus group findings are generalisable to other services, particularly in other countries.

We read with great interest the paper by Camilleri and El-Omar ‘10 reasons that gastroenterologists and hepatologists should be treating obesity’1 and concur that these clinicians are pivotal in addressing the prevailing obesity crisis. We agree that in developing this scope of practice, inherent professional and systemic challenges will need to be overcome and believe that the authors’ well-articulated points could be expanded towards alternative approaches to dealing with the obesity epidemic. This will involve clinicians traversing perceived specialty boundaries and actively engaging in obesity management, which will require relevant undergraduate and postgraduate curricula development to provide clinicians with the requisite theoretical and practical knowledge base. This is challenging in a time of competing demands in medical curricula; however, the advent of more integrated and stochastic learning would improve awareness and basic competence in disease management compared with didactic ‘systems-biology’ teaching methodologies. Importantly, we would also suggest…

A Bologna un evento per fare il punto della situazione

Circulation, Ahead of Print. Cardiogenic shock continues to portend poor outcomes, conferring short-term mortality rates of 30% to 50% despite recent scientific advances. Age is a nonmodifiable risk factor for mortality in patients with cardiogenic shock and is often considered in the decision-making process for eligibility for various therapies. Older adults have been largely excluded from analyses of therapeutic options in patients with cardiogenic shock. As a result, despite the association of advanced age with worse outcomes, focused strategies in the assessment and management of cardiogenic shock in this high-risk and growing population are lacking. Individual programs oftentimes develop upper age limits for various interventional strategies for their patients, including heart transplantation and durable left ventricular assist devices. However, age as a lone parameter should not be used to guide individual patient management decisions in cardiogenic shock. In the assessment of risk in older adults with cardiogenic shock, a comprehensive, interdisciplinary approach is central to developing best practices. In this American Heart Association scientific statement, we aim to summarize our contemporary understanding of the epidemiology, risk assessment, and in-hospital approach to management of cardiogenic shock, with a unique focus on older adults.

Introduction
The COVID-19 pandemic demonstrated how vaccine hesitancy impacts are translated nationally and internationally. A predictor of vaccine hesitancy is religious beliefs (eg, the body being sacred and should be healed by God). Additionally, the perceived content of vaccines can conflict with religious dietary restrictions. Despite the main faith organisations in the UK endorsing COVID-19 vaccination, vaccine hesitancy remains a challenge. Most faith-based research and interventions have been investigated in individual faiths, in isolation from others. Therefore, the aim of our research is to inform the development of interfaith interventions to address COVID-19 vaccine hesitancy, following the identification of potential facilitators and barriers and codesign of interfaith intervention(s).

Methods and analysis
We will facilitate six face-to-face focus groups in London, each comprising eight participants. There will also be the option of joining an online focus group. A semistructured topic guide will include questions on experiences around interfaith, vaccine hesitancy, facilitators and barriers, and potential interfaith interventions to increase vaccine acceptance. Focus group participants will be invited to join a subsequent interfaith codesign workshop where the researchers will share the tentative findings and facilitate discussion to develop one or more interventions. Purposive sampling will be used to recruit 48 participants from different faith groups, ethnicities and backgrounds to capture diversity in the sample. Reflexive thematic analysis will guide a systematic process of constant comparison, coding data into categories and refining into overarching themes.

Ethics and dissemination
The University College London (UCL) Research Ethics Committee granted ethics approval (Project ID 4359.006) on 3 May 2022. Minor amendments to the study were approved on 15 May 2023 to accommodate participants’ requests for online or face-to-face focus groups at a UCL venue. Informed consent is required from all participants. The findings will be disseminated in journals and to the public and key stakeholders.

Stroke, Volume 55, Issue Suppl_1, Page AWP55-AWP55, February 1, 2024. Background and Issue:Providing stroke patient education is a fundamental core measure for all levels of stroke centers with a generalized focus of topics including activation of emergency medical services, need for follow up after discharge, medications prescribed at discharge, risk factors for stroke, warning signs and stroke symptoms. A gap exists in patient education focusing on advanced stroke treatment procedures such as thrombolytic administration and mechanical thrombectomy. Available educational topics in the electronic medical record are often too generic and do not address the post procedural stroke patient population.Purpose:The purpose of this project was to develop a standardized set of post stroke procedural education topics and design a method of documentation to enhance and augment the stroke patients’ educational experience.Methods:Using Lean Six-Sigma methods, a multidisciplinary workgroup reviewed current literature on education topics, examined the existing EMR post procedure topics available, and queried other stroke centers for best practices in stroke post procedural patient education. Based on the results of findings, we created new procedural education topics focusing on thrombolytic administration, mechanical thrombectomy, aneurysm repair procedures, diagnostic angiogram, and carotid procedures. We developed an automated process to pre-populate the topics, specific to the procedural order set into the EMR.Results:In 2021, procedural stroke patient education documentation compliance was 63% (n=191); through improvement efforts compliance increased to 77% (n=210), year to date 2023.Conclusion:Creating a standardized set of education topics focusing on stroke treatment procedures and embedding education into procedural order sets helps to minimize education omission, increase education documentation compliance, and enhance the stroke patient’s educational experience overall.

Stroke, Volume 55, Issue Suppl_1, Page ATP266-ATP266, February 1, 2024. Methods:This project was a collaborative partnership between a healthcare organization, academic institute, and the local Faith Health Network. A 34-question survey (n=54 respondents) collected data on rural community knowledge of stroke risk factors, symptoms, and prevention. Three focus groups (n=40 total participants) were conducted to better understand experiences with stroke and obstacles to accessing wellness and healthcare in rural communities. The focus group questions centered on barriers, stroke impact, and solutions. Thematic summaries were aligned with stroke referral heat maps and demographics to develop a targeted plan for intervention.Results:Survey respondents reported gaps in awareness of stroke risk factors, stroke identification, and emergency response. Lack of motivation, followed by lack of time or energy, stress, lack of access to healthy foods, and community of support were barriers to healthy living. Cost, followed by transportation, access to medications, time, lack of insurance, and language differences were barriers to accessing medical care. Thematic analysis of focus group discussions was conducted for the three initial topics of barriers, stroke impact, and solutions. Dialogue on barriers revealed themes of lifestyle, access, and advocacy. Themes within stroke impact included mental health, access, and advocacy. For solutions, themes emerged as health education, lifestyle, access, and advocacy. Each theme had additional subthemes and direct participant quotes. Survey responses, focus group themes, and referral demographics were synthesized to form a plan to impact stroke prevention and care in these rural areas.Conclusion:A multi-faceted, targeted approach is necessary to increase rural stroke awareness, address disparities in care, and decrease barriers to healthy living and care access.

Tedros, chiediamo l’accesso libero e sicuro agli aiuti medici

Objectives
Public health interventions are designed to improve specific health-related outcomes; however, they may also produce negative side effects, such as substitution use, psychological or social harms. Knowledge about the unintended effects of school-based smoking preventive interventions is sparse. Hence, this study examined these potential unintended effects of the smoking-reducing intervention, Focus, among students in the vocational education and training setting.

Design
Cluster randomised controlled trial stratified by school type with 5 months follow-up.

Setting and participants
Across Denmark, eight schools were randomised to the intervention group (n=844 students, response proportion 76%) and six schools to the control group (n=815 students, response proportion 75%). This study focused solely on students who smoked at baseline (N=491).

Interventions
The intervention was developed systematically based on theory and a thoroughly mixed-methods needs assessment. Intervention components included a comprehensive school tobacco policy (smoke-free school hours) supported by a 3-day course for school staff and launched by an edutainment session for students; class-based lessons and a quit-and-win competition; and individual telephone smoking cessation support.

Outcomes
Alternative tobacco and nicotine products (regular use of smokeless tobacco, hookah and e-cigarettes), regular cannabis use, boredom and loneliness at school, stress and perceived stigmatisation among smokers.

Results
We found no statistically significant unintended effects of the intervention. Nonetheless, insignificant findings indicated that students in the intervention group were less likely to be bored during school hours (OR 0.59, 95% CI 0.32 to 1.10) and experience stress (OR 0.62, 95% CI 0.35 to 1.10), but more likely to report feeling stigmatised compared with the control group (OR 1.55, 95% CI 0.71 to 3.40).

Conclusions
Overall, findings suggested no unintended effects of the Focus trial with respect to substitution use, psychological, nor group or social harms. Future research is encouraged to report potential harmful outcomes of smoking preventive interventions, and interventions should be aware of the possible stigmatisation of smokers.

Trial registration number
ISRCTN16455577.

Objectives
In older patients, the diagnosis of acute pyelonephritis (APN) is challenging. The aim was to evaluate the added value of CT to history, physical examination and urinalysis for the diagnosis of APN in older patients with suspected infection with an unknown focus.

Design
Retrospective diagnostic study.

Setting
Department of General Medicine in an acute care hospital in Japan.

Participants
Patients aged ≥65 years who underwent blood cultures, a urine culture, and chest and abdominal CT to detect the focus of infection were included.

Primary outcome measures
Two radiologists independently reviewed four non-contrast CT signs: perirenal fat stranding, pelvicalyceal wall thickening, enlargement of the kidney and thickening of Gerota’s fascia. Findings on contrast-enhanced CT could not be evaluated due to an insufficient number of patients in whom contrast-enhanced CT was performed. An expert panel was used as the reference standard for APN. The added value of CT findings was quantified by comparing the diagnostic performance between a model based on 10 predictors available before CT and an extended model including the CT findings.

Results
Of 473 patients, 61 (14.8%) were diagnosed with APN. When the laterality of the CT findings was taken into account, the model fit was not improved by adding them. In the laterality-insensitive analysis, the model performance was significantly improved by adding the CT signs (likelihood-ratio test p=0.03; c-index 0.89 vs 0.91, p=0.03). However, their clinical utility was only to improve the classification of 11.5% of patients with APN.

Conclusions
The added value of non-contrast CT findings to history, physical examination and urinalysis was limited for the diagnosis of APN in older patients with a suspected infection with an unknown focus.

Promoting the science and art of medicine for the betterment of human health is central to JAMA’s mission and is fulfilled in part by publishing articles with up-to-date evidence on common health problems that are timely and practical for clinicians. Narrative reviews, an important component of JAMA’s Clinical Review and Education section, provide evidence-based and timely summaries of topics relevant for the practicing generalist clinician. Recent JAMA narrative reviews have covered prediabetes, hyperthyroidism, and care of adults who survived childhood cancer.

Objectives
To generate qualitative data on the views of Occupational Therapists and Physiotherapists about why people do not receive the Royal College of Physicians’ recommended minimum of 45 minutes (min) of daily therapy after stroke, in order to inform a Delphi study.

Design
Focus group study.

Setting
Stroke services in the South of England.

Participants
A total of nine participants, in two groups, including therapists covering inpatient and Early Supported Discharge (ESD) services with awareness of the 45 min guideline.

Results
Thematic analysis of focus group data identified five factors that influence the amount of therapy a person receives: The Person (with stroke), Individual Therapist, Stroke Multidisciplinary Team, the Organisation and the Guideline. Study findings suggest that the reasons why a person does not receive the therapy recommendation in inpatient and ESD services relate to either the suitability of the guideline for the person with stroke, or the ability of the service to deliver the guideline.

Conclusion
This study provides evidence for possible reasons why some people do not receive a minimum of 45 minutes of therapy, 5 days per week, related to (1) the suitability of the guideline for people with stroke and (2) services’ ability to deliver this amount of intervention. These two factors are related; therapists decide who should receive therapy and how much in the context of (a) resource availability and (b) people’s need and the benefit they will experience. The study findings, combined with the findings from other studies, will be used to initiate a Delphi study, which will establish consensus among therapists regarding the reasons why some people do not receive the guideline amount of therapy.

A new committee focused on digital health technologies, including artificial intelligence, machine learning, and virtual reality, will advise the US Food and Drug Administration (FDA) on the risks, benefits, and clinical outcomes linked with these tools, the agency announced.

Circulation, Volume 148, Issue Suppl_1, Page A18190-A18190, November 6, 2023. Introduction:Guideline-directed medical therapy (GDMT) has proven to significantly reduce morbidity and mortality in Heart Failure. We highlighted the differences in renal function among HF patients managed on GDMT, comparing those within a dedicated HF unit (HFU) to those under General Medical (GM) and Geriatrics (GER).Aim:The purpose of this single-centre cohort study is to highlight differences in renal function outcome between these groups.Methods:Our database consists of 540 patients with AHF admitted to HFU or GM/GER from 01/08/2021 to 31/07/2022. We divided this group as follows:Group A: 267 patients from GM/GER.Group B: 273 patients in HFU.Groups were classified by ejection fraction(HFrEF/HFmrEF/HFpEF). We analyzed eGFR, K+ and Creatinine(Cr) on admission(adm) and discharge(dc).Results:Group A(GM/GER): HFrEF patients had average eGFR of 45.70(mL/min) on adm and 43.58 on dc. HFmrEF subgroups had eGFR of 48.60 on adm and 46.54 on dc. HFpEF subgroups had eGFR of 50.16 on adm and 47.75 on dc.Group B(HFU):Patients with HFrEF had eGFR of 53.50 on adm and 50.74 on dc. HFmrEF subgroup had adm eGFR of 49.48 and 47.01 on dc. HFpEF subgroups had eGFR of 45.95 on adm and 41.72 on dc.Group A and B comparison: We have previously demonstrated (Fig.1) that among patients with AHF managed in HFU, there is better optimisation of GDMT. Within the HFrEF cohort, eGFR decreased -2.76 in Group B, with reduction of -2.12 in Group A. Group B HFmrEF showed reduced eGFR of -2.47; Group A decreased -2.06. In HFpEF, eGFR reduced -4.23 in Group B. In Group A, eGFR decreased -2.41. An inpatient mortality of 15.73% was calculated in Group A, contrasting significantly with 6.23% among the HFU cohort.Conclusion:This study highlights differences in renal function outcome between these two groups. It demonstrates that despite optimisation and initiation of GDMT in Group B – which may lead to concern for its impact on renal function – eGFR, Cr and K+ levels were not markedly different between both cohorts.

Circulation, Volume 148, Issue Suppl_1, Page A18492-A18492, November 6, 2023. Background:Icosapent ethyl was approved in Dec 2019 to reduce CV event risk in statin-treated adults with elevated TG (≥150 mg/dL) and established CVD or diabetes with other risk factors of CVD.Hypothesis:Patients who take icosapent ethyl have demographic/clinical characteristics consistent with its indication.Aims:This study describes demographic/clinical characteristics of US patients taking icosapent ethyl, focusing on those with diabetes.Methods:A database of >89 million US electronic medical records identified patients taking icosapent ethyl (ie, ≥2 prescriptions on 2 separate days). Patient demographic/clinical baseline data were retrieved.Results:As of Jan 19, 2023, 40,408 patients taking icosapent ethyl were identified, with a mean (SD) age of 60.3 (12.9) y, BMI of 31.9 (6.07) kg/m2, HbA1c of 7.24% (1.88), and glucose level of 143 (67.8) mg/dL. Most were men (60.5%), White (75.2%), and taking statins (71.8%). Mean (SD; median) TG in the 3 mo before icosapent ethyl initiation was 422 (506; 300) mg/dL; 8.1% of patients had TG ≥500 mg/dL. In line with the indication of icosapent ethyl, 65.3% had prior atherosclerotic CVD or diabetes and ≥1 risk factor. Among 16,564 patients with diabetes (Figure), 13.0% had a history of myocardial infarction, 12.5% had stroke, and 10.4% had revascularization. Overall, 14.2% had chronic kidney disease and 5.5% had type 2 diabetes mellitus with diabetic kidney disease. Common risk factors for CVD were hypertension (68.4%), obesity (40.9%), and history of cigarette smoking (21.6%). Common antidiabetic medications were metformin (37.4%), insulin (27.9%), and sulfonylurea (15.1%).Conclusions:Patients using icosapent ethyl often had diabetes and/or CVD, took statins, and had elevated TG, meeting indications for its use. However, the high median TG before therapy suggests that many physicians reserve icosapent ethyl for more severe TG; thus many patients with more moderate levels ( >150 mg/dL) could potentially benefit.

Objectives
Vaccination averts an estimated 2–3 million deaths annually. Although vaccine coverage improvements across Africa and South Asia have remained below global targets, several countries have outperformed their peers with significant increases in coverage. The objective of this study was to examine these countries’ vaccination programmes and to identify and describe critical success factors that may have supported these improvements.

Design
Multiple case study design using qualitative research methods.

Setting
Three countries with high routine immunisation rates: Nepal, Senegal, and Zambia.

Participants
We conducted 207 key informant interviews and 71 focus group discussions with a total of 678 participants. Participants were recruited from all levels, including government officials, health facility staff, frontline workers, community health workers, and parents. Participants were recruited from both urban and rural districts in Nepal, Senegal, and Zambia.

Results
Our data revealed that the critical success factors for vaccination programmes relied on the cultural, historical, and statutory context in which the interventions were delivered. In Nepal, Senegal, and Zambia, high immunisation coverage was driven by (1) strong governance structures and healthy policy environments; (2) adjacent successes in health system strengthening; (3) government-led community engagement initiatives, and (4) adaptation considering contextual factors at all levels of the health system.

Conclusions
Throughout this project, our analysis returned to the importance of defining and understanding the context, governance, financing, and health systems within a country, rather than focusing on any one intervention. This paper augments findings from existing literature by highlighting how contextual factors impact implementation decisions that have led to improvements in childhood vaccine delivery. Findings from this research may help identify transferable lessons and support actionable recommendations to improve national immunisation coverage in other settings.