Risultati per: Le campagne di screening come strumento di prevenzione oncologica tra dubbi e certezze

Comunicato del 22/02/2022 n°9

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 AWP117-AWP117, February 1, 2022. Introduction:Hyperfibrinolysis is associated with intracerebral hemorrhage (ICH) after the use of tPA for acute ischemic stroke (AIS). Point-of-care Rotational ThromboElastoMetry (ROTEM) testing may rapidly detect hyperfibrinolysis and identify AIS patients at high risk for hemorrhage.Hypothesis:Evidence of fibrinogen depletion on ROTEM will accurately predict bleeding following revascularization therapy for AIS.Methods:We reviewed medical records of AIS patients who underwent revascularization therapy between 2019-2020. All patients underwent ROTEM testing post-procedure to facilitate targeted blood product transfusion should hemorrhage occur. However, transfusion was not performed prophylactically. Repeat imaging with dual-energy CT was performed within 24 hours. A quality control registry of all AIS patients who undergo revascularization is maintained for purposes of Joint Commission certification. All variables, including ROTEM values and occurrence of intra- and extracranial hemorrhage, were entered prospectively. We examined the predictive value of a FIBTEM-A10

Stroke, Volume 53, Issue Suppl_1, Page A117-A117, February 1, 2022. Introduction:Right-to-left (RtL) intracardiac and intrapulmonary shunts are associated with embolic stroke. Although contrast-enhanced transcranial doppler ultrasonography (ceTCD) and transesophageal echocardiography (TEE) are used in embolic stroke work up, there are no standardized guidelines as to which test should be considered as ‘gold standard’. Our objective is to evaluate the sensitivity of contrast-enhanced TCD and TEE in detecting right-to-left shunt to determine respective utilities as screening tools.Methods:Electronic medical records of subjects presenting with acute neurological symptoms who had ceTCD and TEE were evaluated. Sensitivity and specificity were calculated. Based on the respective prevalence of intracardiac and intrapulmonary shunts, positive predictive value, negative predictive value, and test accuracy were determined for ceTCD and TEE. Social Science Statistics was used for data analysis.Results:From June 2016 to August 2021, of 7,498 ischemic stroke patients, 260 patients were suspected of having strokes related to right to left shunts and underwent ceTCD and TEE for detection of cardioembolic sources for stroke. A positive right-to-left shunt was detected in 83 subjects. Detection by ceTCD was confirmed by the operator for 81 patients while 2 were considered false positive results (delayed sporadic High Intensity Transient Signals (HITS)). Sensitivity of ceTCD was 97.65% (95% CI [91.76%, 99.71%]). No safety concerns were identified in patients undergoing ceTCD. Of those with positive ceTCD (68.57%, n=35) were detected by Valsalva, and all of those 35 patients had negative TEE. TEE had sensitivity of 70.34% (95% CI [61.23%, 78.39%]).Conclusion:Contrast-enhanced TCD has superior sensitivity, is cost-effective, practical, and a safe alternative to TEE in identifying intracardiac or intrapulmonary shunts. Screening superiority of ceTCD may lie in ability to elicit shunts during Valsalva maneuvers. To our knowledge this is the largest single center series confirming ceTCD as a gold standard tool for screening of right to left shunts.

Stroke, Volume 53, Issue Suppl_1, Page AWP66-AWP66, February 1, 2022. Introduction:As stroke survivors transition from acute to post-acute care, and finally to community settings, the Centers for Disease Control reports ~65% receive NO rehabilitation. Even more receive rehabilitation too late, after critical brain changes for recovery are complete. Stroke survivors with invisible disabilities of cognition and depression are especially vulnerable to experience poor recovery. We launched a dedicated process to identify invisible disabilities. Our long-term objective is to make acute and post-acute, evidence-based intervention accessible.Hypothesis: >50% of acute stroke patients have cognitive deficits, or depression.Methods:Our comprehensive stroke center completes bedside psychometric assessment with standardized instruments for aphasia (Language Screening Test, LAST), spatial neglect (Catherine Bergego Scale, CBS), memory/global cognition (Montreal Cognitive Assessment, MoCA), delirium (3-Minute Diagnostic Interview for the Confusion Assessment Method, 3D-CAM) and depression (Patient health questionnaire, PHQ-8). Patients unable to respond to questions are assessed for spatial neglect and delirium (standardized observations).Results:105 ischemic stroke survivors were assessed in the first quarter of program launch (April-July, 2021). Of that group, patients met screening criteria for spatial neglect (47%), aphasia (40%), delirium (19%) and depression (31%). Over 90% had memory / global cognitive impairment (MoCA

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.

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 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 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 2, Page 355-361, February 1, 2022. Background and Purpose:The CREST-2 (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial) consists of 2 parallel randomized stroke prevention trials in patients with asymptomatic high-grade stenosis of the cervical carotid artery. The purpose of this report is to detail the outcomes of a health screening effort to increase trial enrollment of women and minorities.Methods:Life Line screening (LLS) conducts nationwide screening for vascular disease. Screenings within a 50-mile radius of each CREST-2 center were identified for participation in a joint CREST-LLS program over the course of one year (November 2018 to October 2019) whereby patients with an abnormal carotid ultrasound were referred to the local CREST-2 center for further workup, management, and potential consideration for trial enrollment.Results:LLS completed the screening of 588 198 individuals in 29 732 zip codes across the United States. Of those, 230 021 individuals were screened at events occurring near a CREST-2 clinical center and 646 (0.3%) were found to have abnormal carotid ultrasound findings. Each of the 646 individuals was contacted by CREST-LLS program staff for permission to be referred to their local CREST-2 center; 200 (31%) consented to be contacted by CREST-2. Of those, 39 (19.5%) agreed to be, and were, evaluated at their local CREST-2 center. High-grade stenosis was confirmed in 27 patients. A total of 3 patients were eligible for the trial and were enrolled, one woman but no racial/ethnic minorities.Conclusions:The LLS program appears to identify community-living individuals with high-grade carotid stenosis through ultrasonography. However, the prevalence of abnormal carotid findings was low. In addition, screening and offering participation into the CREST-2 trial had no substantial impact on the proportion of women and minorities enrolled in the trial. Additional innovative strategies are needed to promote enrollment of diverse patients with carotid stenosis into stroke prevention trials.

Comunicato del 16/12/2021 n°78