Risultati per: Screening della retinopatia diabetica

Objective
To estimate the budget impact of portable wide-field digital imaging incorporation on screening neonatal causes of childhood blindness and visual impairment in Rio de Janeiro, Brazil.

Design
Budget impact analysis.

Setting
Rio de Janeiro, Brazil.

Primary and secondary outcome measures
The primary outcome was the direct cost of indirect binocular ophthalmoscopy, red reflex test and portable wide-field digital image screening comprising all babies born in Rio de Janeiro’s government maternity wards. The secondary outcome was the budget impact of implementing portable wide-field digital image screening in Rio de Janeiro, Brazil.

Results
Considering 100% coverage of maternity wards, the total budget impact between 2020 and 2024 would be US$3 820 706.04, ranging from US$3 139 844.34 to US$6 099 510.35. The additional cost would be US$3 124 457.28, ranging from US$2 714 492.26 to US$4 880 608.63.

Conclusion
The cost of universal digital imaging screening corresponds to less than 1% of the government health budget of the city of Rio de Janeiro. The information provided in this study may help government decision-makers evaluate the feasibility of implementing this new strategy in the municipal setting. Further health economic evaluations should be performed to verify the affordability of the implementation of this screening strategy in the Brazilian scenario, taking into account scarce human resources.

Objective
To assess the effect of adding an oral glucose tolerance test (OGTT) to fasting plasma glucose (FPG) in terms of detection of type 2 diabetes (T2D) and impaired glucose tolerance (IGT).

Design
Retrospective analysis of serial cross-sectional screening study.

Setting
Population-based health examinations within primary care in Västerbotten County, Sweden.

Participants
Individuals aged 40- 50 and 60 years with participation from 1985 to 2017. Those with previously diagnosed diabetes and FPG≥7 mmol/L were excluded.

Primary and secondary outcome measures
Prevalence of hyperglycaemia on the OGTT (IGT and T2D defined as 2-hour postload capillary plasma glucose of 8.9–12.1 mmol/L and ≥12.2 mmol/L, respectively). Analyses were further stratified by age, sex and risk factor burden to identify groups at high or low risk of IGT and T2D on testing. The numbers needed to screen (NNS) to prevent one case of T2D through detection and treatment of IGT was estimated, combining prevalence numbers with average progression rates and intervention effects from previous meta-analyses.

Results
The prevalence of IGT ranged from 0.9% (95% CI 0.7% to 1.1%) to 29.6% (95% CI 27.4% to 31.7%), and the prevalence of T2D ranged from 0.06% (95% CI 0.02% to 0.11%) to 7.0% (95% CI 5.9% to 8.3%), depending strongly on age, sex and risk factor burden. The estimated NNS to prevent one case of T2D through detection and lifestyle treatment of IGT ranged from 1332 among 40-year-old men without risk factors, to 39 among 60-year-old women with all risk factors combined.

Conclusions
The prevalence of hyperglycaemia on OGTT is highly dependent on age, sex and risk factor burden; OGTT should be applied selectively to high-risk groups to avoid unnecessary testing in the general population.

Introduction
Point-of-care dual tests (POCTs) for simultaneously detecting antibodies to HIV and syphilis (dual HIV-syphilis POCTs) have been developed recently and show encouraging performance compared with the reference tests in laboratory-based studies. As community-based voluntary, counselling and testing (CBVCT) services are effective providers of HIV and syphilis testing and counselling with high acceptability among men who have sex with men (MSM), the evaluation of the utility of these dual tests in CBVCT services is a high priority. This prospective cross-sectional study will conduct a clinical utility evaluation of two dual POCTs in non-clinical settings for the screening of HIV and syphilis in MSM. This master protocol outlines the overall research approach that will be used in four countries.

Methods and analysis
MSM presenting at CBVCT services participating in the study for HIV/STI screening will be enrolled. The (WHO preapproved) dual POCTs to be evaluated will be SD Bioline HIV/Syphilis Duo (Abbot) and Dual Path Platform HIV-Syphilis Assay (Chembio). Trained staff will collect a capillary blood sample using finger prick blood to perform both POCTs according the manufacturers’ instructions. An analysis of the feasibility of introducing the dual POCT for the screening of HIV and syphilis in MSM at CBVCT services will be performed, by assessing its acceptability and usability at CBVCT service among MSM users and providers.

Ethics and dissemination
This core protocol was independently peer reviewed and approved by the Research Project Review Panel (RP2) of the WHO Department of Sexual and Reproductive Health and Research and by the WHO Ethics Review Committee (ERC). The protocol has been adapted to individual countries and approved by RP2, ERC and institutional review boards at each site. Results will be disseminated through peer-reviewed journals and relevant conferences.

We read with the great interest the randomized controlled trial on gastric cancer prevention by active eradication of Helicobacter pylori in a high-risk area of southern China since 1994.1 During the long-term observation, the active eradication of H pylori significantly reduced gastric cancer incidence (adjusted hazard ratio, 0.57; 95% confidence interval, 0.33–0.98), compared to placebo. This experience might support the massive screening and eradication of H pylori in China, which has persistently high incidence and mortality of gastric cancer.

La campagna di prevenzione promossa dall’Istituto nazionale per le ricerche cardiovascolari

Stroke, Volume 53, Issue 5, Page e218-e218, May 1, 2022.

Stroke, Volume 53, Issue Suppl_1, Page ATP29-ATP29, February 1, 2022. Background:We implemented a multi-disciplinary process improvement (PI) intervention at a Comprehensive Stroke Center in cooperation with speech/language pathology in order to expedite oral medication delivery in patients with dysphagia. Following a failed nurse dysphagia screen, trained neurology providers were able to evaluate dysphagia further and approve the use of oral medications.Methods:We analyzed prospectively collected data from the PI intervention for timing of dysphagia screen, first oral antithrombotic, and aspiration pneumonia in ischemic stroke patients (9/2019-07/2021). Patients were included if they passed a dysphagia assessment by any provider, with comparisons made between patients who passed by physicians (Ph), nurses (RN) or speech/language pathologists (SLP).Results:Of the 789 included patients, 673 were passed by RN, 104 by SLP, and 12 by Ph. Compared to patients passed by SLP, those passed by Ph were younger and had less severe deficits (Table). Patients passed by Ph were screened more quickly than those screened by RN or SLP (median 38 vs. 182 vs. 1330 min after arrival, p=0.0001), and received first oral antithrombotic far more quickly (median 335 vs. 774 vs. 1409 min, p=0.0001). No patients passed by Ph experienced an aspiration pneumonia (0%), although there were non-significantly more pneumonias among patients passed by SLP (5%) and RN (2%, p=0.11).Conclusions:We safely conducted a physician-driven dysphagia screening paradigm which led to faster oral medication delivery, and no signal of patient harm.

Stroke, Volume 53, Issue Suppl_1, Page ATP75-ATP75, February 1, 2022. Background:Since publication of the landmark endovascular thrombectomy trials for large vessel occlusion (LVO) ischemic stroke patients, many clinical tools to identify these patients have been developed. In the real world, resource constraints may limit these early activation strategies. Definitive guidelines by the American Heart Association recommending LVO screening tools await studies proving their impact on outcome. We therefore aimed to evaluate the implementation of our LVO screening tool in our hospital on both time and clinical metrics.Methods:Our previously validated “SNO” scale (expressive aphasia/speech, neglect, ocular deviation), has acceptable balance of user ease, sensitivity and specificity. October 2020 we began an LVO alert for patients presenting with at least 1 of the 3 above signs, and collected their data including baseline National Institutes of Health Stroke scale scores (NIHSSS), time metrics, and mortality rates and compared them between LVO activation and non activation groups using t-test and chi square.Results:Since 10/2020, 93 (22 endovascularly treated) LVO alerts were called compared with 55 (23 treated) patients in the same time epoch who fulfilled criteria but not LVO activated (1219 stroke alerts called in 2020). Mean age was 71 vs 74 years and NIHSSS were 21 vs 18. There was a trend towards earlier minutes from door to puncture (94 vs 110), device placement (113 vs 129), and recanalization (146 vs 152) between them. The most significant difference was in door to thrombolysis times (33 vs 49 minutes, p0.05).Discussion:Although LVO activation using SNO criteria has shortened times to intervention in our hospital, clinical improvements may be dampened by ongoing issues limiting full adoption. But, those treatment modalities that require no additional resources, regardless of LVO (IV TPA) were expedited.Conclusion:LVO activation based on SNO criteria has shortened time to treatment. NIHSSS at discharge did not notably improve among the LVO activation group, but in house mortality was halved.

Stroke, Volume 53, Issue Suppl_1, Page ATMP93-ATMP93, February 1, 2022. Introduction:Congenital and acquired thrombophilias are associated with childhood arterial ischemic stroke (AIS), especially if multiple thrombophilias or other risk factors are present. The 2019 AHA guidelines recommend thrombophilia evaluation for all children with AIS, although the optimal extent of testing is unknown. The objective of this study was to determine the utility of routine thrombophilia screening in management of children following AIS.Methods:Thrombophilia screening sent as part of clinical care was collected from patients with childhood (1 month-18 years) AIS during an 11 year period at a single institution.Results:Factor V Leiden was sent on 56%, Prothrombin gene on 47%, homocysteine on 50%, lipoprotein a on 52%, antithrombin on 44%, protein C on 57%, protein S on 54%, and anticardiolipin antibodies on 51% of children. Five percent of patients were FVL heterogenous, and 1% were PT gene heterogenous. Three percent had mildly elevated homocysteine. Twenty percent had elevated lipoprotein a. Two patients had transiently low antithrombin, 4 had transiently low protein C activity, and one had transiently low protein S activity. One patient with sickle cell disease had persistently low protein S activity. One low protein S was not repeated. Ten patients had elevated ACLAs: 6 were transient, two had mildly elevated IgM that was not repeated, and 2 had known APLA syndrome. Two patients (cardioembolic stroke; moyamoya) had two thrombophilias.Conclusion:Rates of thrombophilias were consistent with expected incidence for the general population and did not predict stroke recurrence. Patients with elevated lipoprotein a and homocysteine were referred for treatment, otherwise results from the remainder of thrombophilia evaluation did not alter patient care in a population already known to be at risk for thrombosis.

Stroke, Volume 53, Issue Suppl_1, Page AWP228-AWP228, February 1, 2022. Background:Cardiac structure and function are important in determining ischemic stroke (IS) etiology, but whether there is an association with cognition post IS is unknown.Methods:IS patients admitted to Johns Hopkins Hospital (2017-2019) underwent transthoracic echocardiography. IS was classified (TOAST) by a masked reviewer. Parasternal short axis left atrial (LA) diameter was evaluated as a continuous variable with a spline at 4cm (normal ≤4cm versus enlarged >4cm); left ventricle ejection fraction (LVEF) was evaluated as a nonlinear continuous variable with two spline knots at 40% and 65%. Cognition was assessed by telephone using the Six Item Screener (SIS), which tests orientation (day, month, year) and recall (grass, paper, shoe) and was dichotomized into low (0-3, worse score) and high (4-6, better score), and conservatively imputing low category scores for non-answerers. Multivariable logistic regression determined the association of SIS category with LA or LVEF, each, adjusted for covariates.Results:Participants (N=119) were on average 60 (18-89) years, 60% male, and 59% Black. Mean LA diameter was 3.9cm (SD=0.8) and mean LVEF 61.4% (SD=10.5). For LA diameter ≤4cm, each 1cm increase was associated with 5.93 greater odds (95% CI=1.49-23.65) of scoring in the high SIS category, while for LA diameter >4cm each 1cm increase was associated with lower odds (OR=0.88, 95% CI=0.39-1.99) of scoring in the high SIS category (Figure 1). Decreased (OR=0.91, 95% CI=0.74-1.11), normal (OR=0.98, 95% CI=0.91-1.06) or hyperdynamic LVEF (OR=1.02, 95% CI=0.90-1.14) showed no relationship with SIS category.Conclusions:In this study, a 1cm change in LA diameter was significantly associated with a higher score on a telephone cognition screening test, if patients had a LA diameter within normal range, but without the same association with SIS if the LA diameter was >4cm. We cautiously suggest that LA function may be associated with cognition post-stroke.

Stroke, Volume 53, Issue Suppl_1, Page AWP116-AWP116, February 1, 2022. Background:Delirium occurs frequently in patients with stroke but is often underrecognized. We aimed to develop a novel delirium screening tool designed specifically for stroke patients, and to test its feasibility and accuracy in a pilot study.Methods:We designed an easy-to-use 5-point instrument called the Fluctuating Mental Status Evaluation (FMSE) and tested it in a cohort of patients with intracerebral hemorrhage (ICH) who had daily delirium assessments throughout their admission. Expert ratings were performed by an attending neurointensivist or behavioral neurologist each afternoon using DSM-5 criteria, and were derived from bedside assessments and clinical data from the preceding 24 hours. Paired FMSE assessments were performed by patients’ clinical nurses after brief training on the use of the tool. Nursing assessments were aggregated over 24-hour periods (including day and night shifts), and accuracy of the FMSE was analyzed on both a per-assessment day and per-patient basis.Results:Among the 40 enrolled patients (mean age 71.1±12.2, median initial NIHSS score 16.5 [IQR 12-20]), 34 experienced delirium during their hospitalization. There were 306 total coma-free days with paired assessments, of which 208 (68%) were rated as days with delirium. Compared to expert ratings, an FMSE score ≥1 had 86% sensitivity and 74% specificity on a per-day basis, while a score ≥2 had 68% sensitivity and 83% specificity. On a per-patient basis, a score ≥1 at any point during admission had 97% sensitivity and 67% specificity in identifying patients who experienced delirium, while a score ≥2 had 94% sensitivity and 67% specificity.Conclusion:The FMSE is a feasible delirium screening tool in ICH patients, with high real-world sensitivity and specificity. Based on these results, we plan to validate the tool in a larger, more diverse cohort of stroke patients, using score cutoffs of ≥1 as “possible” delirium and ≥2 as “probable” delirium.