Risultati per: Terapia antibiotica: breve durata vs. lunga durata

Stroke, Volume 54, Issue Suppl_1, Page AWMP35-AWMP35, February 1, 2023. Background:Long-term disability after stroke is standardly assessed 3m post-onset, using the modified Rankin Scale (mRS), but clinical trial patients lost to follow-up require imputation of likely outcome. An early post-onset, e.g. day 4, mRS is often available but its utility to forecast outcome in ischemic and in hemorrhagic stroke patients has not been delineated.Methods:We analyzed all patients with acute cerebral ischemia (ACI) and with intracranial hemorrhage (ICH) enrolled in the NIH Field Administration of Stroke Therapy- Magnesium (FAST-MAG) Phase 3 trial. The performance of ordinal day 4 mRS, alone and as part of multivariate models, in predicting ordinal day 90 mRS was assessed using Spearman correlation coefficients (rs) and kappa (chance corrected agreement) statistics.Results:Among the 1206 acute cerebral ischemic patients, age was 70.9, 45.5 % were female, and initial NIHSS was 9.28 ± 8.28. In univariate analysis, day 4 mRS and day 90 mRS correlated strongly, rs= 0.76, weighted kappa = 0.71 increasing in multivariate analysis to rs= 0.78 and weighted kappa = 0.76 (Figure 1A). Among the 367 intracranial hemorrhage patients, age was 65.4, 32.7% were female, and initial NIHSS was 18.3 ± 11. In univariate analysis, day 4 mRS and day 90 mRS also correlated moderately rs= 0.64, weighted kappa = 0.63, increasing in multivariate analysis to rs= 0.81 and weighted kappa = 0.78 (Figure 1B). In the multivariate predictive models, day 4 mRS was the most determinative variable along with age and initial NIHSS for both ICH and ACI.Conclusion:For both acute cerebral ischemia and intracranial hemorrhage patients, long-term, 3m mRS disability outcomes can be predicted well using mRS assessment on day 4, alone and even more accurately in combination with baseline prognostic variables. Age and baseline NIHSS exert more additional influence on 3m mRS outcome in ICH than ACI, likely reflecting the better functional recovery among ICH than ACI stroke survivors.

Stroke, Volume 54, Issue Suppl_1, Page AWP1-AWP1, February 1, 2023. Introduction:Patients with large vessel occlusion stroke (LVO) benefit from thrombolysis before thrombectomy. Previous meta-analysis suggested superiority of tenecteplase over alteplase in achieving good clinical outcome at 3 months.Aim:We aimed to compare clinical outcomes after tenecteplase 0.25 mg/kg versus alteplase in patients with LVO.Methods:An experienced librarian searched PubMed and Scopus databases through July 13, 2022 for randomized controlled trials comparing tenecteplase with alteplase in patients with LVO. We included trials using 0.25 mg/kg tenecteplase dose, reporting blindly assessed pre-specified clinical outcomes at 3-4 months among patients with LVO. Two authors independently reviewed eligibility and extracted the data. We used RevMan 5.4 and random effect models with inverse variance weights to calculate odds ratios (OR) and 95% confidence intervals (CI). This systematic review is registered (CRD42022349414).Results:From 585 retrieved abstracts, 3 trials and 1 pooled secondary analysis involving 704 unique patients met the inclusion criteria. Among patients with LVO, tenecteplase 0.25mg/kg is not superior to alteplase in achieving good clinical outcome (defined as modified Rankin Scale [mRS] 0-2, OR 1.82 (95% CI 0.91-3.65, panel A); nor all-cause mortality, OR 0.75 (95% CI 0.49-1.13, panel B); while tenecteplase increases the odds of excellent outcome (mRS 0-1), OR 1.52 (95% CI 1.11-2.09, panel C), and odds of functional improvement (defined as a shift on the ordinal mRS), OR 1.54 (95% CI 1.07-2.20, panel D). High heterogeneity was present (I2 =70%) for the good clinical outcome.Conclusion:Tenecteplase is not superior over alteplase in achieving good clinical outcome. Tenecteplase, as compared to alteplase, increases the odds of functional improvement and excellent outcome. These findings support bridging tenecteplase in patients with LVO.

Stroke, Volume 54, Issue Suppl_1, Page AWP113-AWP113, February 1, 2023. Introduction:Brain-selective hypothermia is a promising neuroprotectant in acute ischemic stroke. However, a non-invasive bedside method to monitor brain temperature during cooling is lacking. We tested the feasibility and accuracy of measuring brain temperature non-invasively using sensors designed to monitor core body temperature.Methods:In this prospective single-center study, 20 patients with large or medium vessel occlusion strokes were enrolled. Patients underwent a 3T MR spectroscopy imaging (MRSI, the reference standard) and zero heat flux (ZHF) core temperature sensor measurements (3MTMBair HuggerTM) within 12-72 hours from admission. Two ZHF sensors were placed on each side of the forehead on the side of stroke and contralateral side and the temperatures were checked before and after MRSI. A 2x2x2 cm voxel was centered on the infarct and matching contralateral location using diffusion weighted imaging. Brain temperature on MRSI was calculated using the relative chemical shifts of water and N-acetyl aspartate. Temperature measurements of the ZHF sensors were compared to MRSI measurements.Results:The brain temperature of stroke and contralateral sides were similar using MRSI or using ZHF sensors when each modality was compared to itself by hemisphere (all p >0.05). However, there was a significant difference for the ipsilateral side: median (SD) temperatures using MRSI was 36.0°C (1.8) vs 36.8°C (0.5) for sensor measurement. Bland-Altman plots showed that 95% of the observations fell within upper and lower limits of agreement of -2.1 to +3.7°C while 61% of observations fell within an agreement limit of +/- 1°C. There was an indication of an overall higher temperature measurements using the ZHF sensors compared to MRSI (Figure 1).Conclusions:More studies are needed to validate the use of ZHF thermometry in ischemic stroke including studies implementing hypothermia.Figure 1. Boxplot of stroke side MRSI compared to zero-heat-flux sensors.

Stroke, Volume 54, Issue Suppl_1, Page AWMP104-AWMP104, February 1, 2023. Background:Approximately 14% of the US population resides in rural areas, which have higher rates of chronic disease and are often medically underserved. We compared 1-year outcomes after ischemic stroke for Medicare beneficiaries living in urban vs rural areas.Methods:We identified all Medicare fee-for-service beneficiaries aged ≥65 years discharged alive from US acute-care hospitals with ischemic stroke in 2015 to 2017. Patients were followed up to 1 year through 2018 for death or ischemic stroke recurrence and categorized according to geographic remoteness of their residence using the Rural-Urban Community Area codes. We balanced patient characteristics between the rural/urban categories using stabilized inverse probability weights (IPW) based on patient demographic and clinical characteristics. We created adjusted Kaplan-Meier curves based on the IPW and fit Cox models to assess differences in 1-year all-cause mortality and recurrent stroke weighted by the IPW and accounting for competing risks.Results:There were 536,930 stroke patients (32,635 isolated rural, 40,240 small rural, 66,320 large rural, 397,735 urban; mean age 79.0 years, 54.7% women, 82.5% White). For isolated rural, small rural, large rural, and urban residents, 1-year adjusted mortality rates were 24.1%, 24.6%, 24.7%, and 22.9%, and 1-year stroke recurrence rates were 8.0%, 7.8%, 7.9%, and 8.1%, respectively. Compared with urban residents, isolated rural (HR 1.07, 95% CI 1.04-1.09), small rural (1.09, 1.07-1.12), and large rural (1.10, 1.08-1.12) residents had greater risk of death within 1 year after stroke, but there was little difference in recurrence (Fig. A). Urban residents had the lowest mortality across regions, but there was variation among the rural subcategories and for recurrence in region-stratified analyses (Fig. B).Conclusions:Ischemic stroke patients living in urban areas had a lower risk of mortality within 1 year compared with those living in more rural areas.

Stroke, Volume 54, Issue Suppl_1, Page ANS1-ANS1, February 1, 2023. Background:Post-stroke depression (PSD) affects up to one-third of stroke survivors and remains under-recognized. The optimal time for PSD screening seems to be about 30-45 days post-stroke. However, screening and follow up remains insufficient.Methods:Our stroke certified registered nurse contacted stroke patients admitted to Kaiser Permanente Los Angeles in 2021 to assess depression within 30-45 days post discharge using the Patient Health Questionnaire Screening Tool (PHQ9). Two call attempts were made. Based on the PHQ9 scores, patients were referred to different clinical care pathways. Patients who scored10-19 were referred to depression care management (DCM), while 20 and above were referred to psychiatry directly. We collected the demographics, stroke types and discharge disposition inpatients who were lost to follow up and patients who completed the follow up. Data were analyzed using R-Statistics.Results:Among 92 patients, 41 (45%) had follow-up depression screening completed; 13 (32%)received psychiatry referral given severity of depression, and 28 (68%) received a depression care management referral. Of 51 patients who did not complete follow-up screening, 27 (53%)declined to participate in screening, while 22 (43%) could not be reached. Patients who did not receive follow-up screening were older (P=0.02). Race, gender, discharge mRS or length of acute hospital stay did not have a significant effect on patient’s depression screening follow-up status. Patients discharged home with home health showed a trend for better completed follow-ups despite not reaching statistical significance (P=0.07).Conclusion:Raising awareness about the necessity of depression screening and its treatment is of utmost importance for reaching optimal recovery and rehabilitation potential in stroke patients. Post-discharge follow-up and education can be implemented to narrow the PSD recognition gap.

Stroke, Volume 54, Issue Suppl_1, Page ATP44-ATP44, February 1, 2023. Introduction:Telestroke is the use of videoconferencing technology by a stroke specialist to assess and treat acute ischemic stroke patients who present elsewhere. It has been well-studied previously in a “Hub-and-Spoke” model. In 2021, Telestroke was used to assess and treat acute ischemic stroke patients who presented primarily after-hours to our comprehensive stroke center because we were concerned the COVID-19 pandemic could affect the timeliness of in-person code stroke assessments. After implementation, we determined the efficacy and safety outcomes for patients treated with Telestroke versus in-person assessments.Hypothesis:We hypothesized that there will be no difference in the efficacy or safety outcomes between patients treated using Telestroke vs. in-person assessments.Methods:A retrospective chart review identified acute ischemic stroke patients who presented to our center in 2021, who were assessed and treated using either Telestroke or an in-person assessment. The primary outcomes for efficacy were door-to-needle (DTN) time for alteplase administration and door to puncture (DTP) time for endovascular thrombectomy. The primary safety outcomes were 3-month mortality and symptomatic intracranial hemorrhage rates (sICH).Results:We treated 302 acute stroke patients in 2021, with 18.2% (n=55/302) of patients treated using Telestroke. There were no differences in clinical outcomes between patients treated using Telestroke vs. in-person assessments: median DTN (35.5min (n=42) vs. 33min (n=182), p

To the Editor We read with interest the editorial interpretation by Ahn et al of the A021501 trial but disagree with the authors’ conclusions. Radiation therapy has been a central component of neoadjuvant trials for pancreatic cancer (PC) for more than a decade; however, the duration of neoadjuvant chemotherapy and optimal radiation dose remain unanswered. Randomized clinical trials must be adequately powered to compare treatment interventions. Unfortunately, about 75% of participants in the A021501 trial did not complete the assigned intervention, limiting the interpretation about the role of radiation therapy. Despite that important detail, the Editorial’s interpretation that neoadjuvant radiation therapy (in any form) is questionable for patients with operable PC is not a conclusion supported by A021501. To make that conclusion would require typically more than 500 patients randomized (eg, RTOG 0848 and CONKO-007). In addition, A021501 did not address more established neoadjuvant hypofractionated or conventionally fractionated radiation therapy standards.

This randomized clinical trial examines quality of life in patients with resected melanoma at high risk for relapse who were treated with adjuvant pembrolizumab vs standard of care with either ipilimumab or high-dose interferon α 2b.

To the Editor We congratulate Katz et al on their ambitious phase 2 randomized clinical trial designed to prospectively compare modified FOLFIRINOX (mFOLFIRINOX) alone vs sequential mFOLFIRINOX and hypofractionated radiotherapy for patients with borderline resectable pancreatic cancer (BRPC). Much commentary, including the accompanying Editorial, has characterized the A021501 trial as a failure of radiotherapy to improve outcomes in BRPC, in contrast with prior randomized clinical trials demonstrating improved rates of R0 resection and overall survival for patients treated with neoadjuvant chemoradiotherapy. We contend that this characterization is unfounded due to intrinsic methodological limitations of the study, including (1) timing of randomization, (2) potential cohort imbalances, and (3) power limitations resulting from the early closure of the radiotherapy arm. These limitations, in our view, render the A021501 trial unable to generate definitive conclusions regarding the utility of radiotherapy in BRPC, and we caution against overgeneralization of this trial’s results.

In Reply We appreciate—and are not surprised by—the robust response to the A021501 phase 2 randomized clinical trial and its accompanying Editorial, particularly from the radiation oncology community. As Hall and colleagues observe, radiation therapy (RT) has been a central component of neoadjuvant trials for pancreatic cancer (PC) for years. But should it remain so? Our study was a further attempt to help answer this question. It was designed specifically to determine whether either systemic chemotherapy with mFOLFIRINOX or mFOLFIRINOX followed by hypofractionated RT would improve the 18-month overall survival rate of patients with borderline resectable PC relative to a historic control rate of 50%. However, it was not designed nor powered to definitively address the value of RT in the neoadjuvant setting.

This subgroup analysis of a randomized clinical trial investigates whether tucatinib in combination with trastuzumab and capecitabine provides survival and intracranial benefits for patients with ERBB2-positive metastatic breast cancer and brain metastases.

To the Editor We read with interest the recent A021501 phase 2 randomized clinical trial and the accompanying Editorial. The trial investigates the individual contributions of neoadjuvant chemotherapy and chemoradiotherapy in patients with borderline resectable pancreatic ductal adenocarcinoma (PDAC). Patients received either stereotactic body radiotherapy (SBRT; 33-40 Gy in 5 fractions) or hypofractionated image-guided radiotherapy (25 Gy in 5 fractions). The median overall survival (OS) for the chemoradiotherapy and chemotherapy arms was 17.1 and 29.8 months, respectively. In the Discussion, the authors claimed that chemotherapy could be a new standard of neoadjuvant treatment. We believe that this study has the following limitations in reaching such a conclusion.

To the Editor The Alliance Group is to be commended for inserting Central Review at multiple critical steps in a patient’s passage through the A021501 protocol. The authors state that the “reasons why an insufficient number of patients in arm 2 [with radiotherapy (RT)] met the prespecified threshold for R0 resection is not immediately evident.” Beyond the small sample size and the heterogeneity of even radiographically similar borderline resectable cases, there may be some clues if one can explain the distribution differences displayed in eTable 2 in the Supplement. Specifically, arm 2 had more “advanced disease at surgery” and “metastases discovered at surgery”—and consequentially was noted to have a lower percentage undergoing pancreatectomy (35% vs 49% [arm 1, preoperative chemotherapy only]) as well as completing the entire protocol (18% vs 30%, respectively).

Results of a large clinical trial counter previous findings of benefit with torsemide.

Messa a punto all’IRCCS IRE, in laboratorio fa regredire malattia