Risultati per: Quotidianosanita.it

Circulation, Volume 149, Issue 2, Page 160-163, January 9, 2024.

Pancreatic cancer still carries the worst survival rate among all solid tumours, mostly due to the absence of early symptoms and a lack of satisfying treatment options, leading to an appalling 5-year survival rate of less than 12%. The only potentially curative treatment option is surgical resection followed by adjuvant chemotherapy. Since pancreatic cancer is usually diagnosed at advanced stage, treatment with curative intent can be provided to only 15–20% of patients. However, even after surgical resection, most patients develop local or systemic recurrence. During recent years, neoadjuvant chemotherapeutic regimens have been introduced for locally advanced or borderline resectable cancers to improve the chances for secondary resection (eg, CONKO007,1 PREOPANC,2 NEOLAP3). However, even after this sequential approach, only for a minority of patients long-term survival can be achieved. In the resectable situation, the role of neoadjuvant therapy remains to be determined, with conflicting…

Background
The Improving the Wellbeing of people with Opioid Treated CHronic pain (I-WOTCH) randomised controlled trial found that a group-based educational intervention to support people using strong opioids for chronic non-malignant pain helped a significant proportion of people to stop or decrease opioid use with no increase in pain-related disability. We report a linked process evaluation of the group-based intervention evaluated in comparison to a usual-care control group that received a self-help booklet and relaxation CD.

Methods
We interviewed 18 intervention facilitators, and 20 intervention and 20 control participants who had chronic non-malignant pain and were recruited from general (family) practices in the UK. Quantitative data included change mechanism questions on the trial questionnaires which explored motivation, expectations and self-efficacy. Fidelity was assessed by listening to a sample of audio-recorded group sessions and nurse consultations. Quantitative and qualitative data were integrated using ‘follow a thread’ and a mixed-methods matrix.

Findings
Four overarching themes emerged: (1) the right time to taper, (2) the backdrop of a life with chronic pain, (3) needing support and (4) the benefits of being in a group. Delivery fidelity was good, adherence (83%) and competence (79%) across a range of intervention groups. Staff delivering the intervention found three typical responses to the intervention: resistance, open to trying and feeling it was not the right time. The group experience was important to those in the intervention arm. It provided people with a forum in which to learn about the current thinking about opioid usage and its effects. It also gave them examples of how feasible or personally relevant coming off opioids might be.

Conclusion
The process evaluation data showed that the I-WOTCH intervention was well delivered, well received and useful for most interviewees. Being ‘the right time’ to taper and having support throughout tapering, emerged as important factors within the context of living with chronic pain.

Trial registration number
ISRCTN49470934.

In Reply We appreciate the letters from Kawji and Chang et al regarding our report of migrating localized ST-segment elevation in the setting of acute pericarditis. In response to Kawji’s comments, we agree that the ST-segment dynamic change in this case was fast. This was seen on the repeated electrocardiogram (ECG) in the emergency department (Figure, B), obtained 25 minutes after the first ECG by emergency medical services (Figure, A). It continued to evolve with migrating ST-segment elevation in localization as seen on the third ECG (Figure, C) obtained 88 minutes after the first ECG, and was followed by diffuse ST-segment elevation in all the leads except aVR and V1. The lack of coronary obstruction on coronary angiogram in the setting of ongoing chest pain along with other findings, including normal ventricular wall motion, normal cardiac troponin level, trivial pericardial effusion on transthoracic echocardiography, and significantly elevated C-reactive protein levels, established the diagnosis of acute pericarditis. We do not doubt that the ECG dynamic changes are due to acute pericarditis.

To the Editor We read with interest the case report by Xiao and Zhou. This article is very valuable. We wish to highlight 2 salient key points.

To the Editor I read the interesting case report by Xiao and Zhou. It is very unusual for the intense inflammation of acute pericarditis to resolve in 1 area in a few minutes, contrary to what is suggested by Xiao and Zhou. Rather, the inflammation may spread to other areas as mentioned in the case report. As correctly reported by the authors, stage 1 of ST-segment elevation in acute pericarditis persists for at least a few hours.

Objectives
The inadequate provision of language interpretation for people with limited English proficiency (LEP) is a determinant of poor health, yet interpreters are underused. This research explores the experiences of National Health Service (NHS) staff providing primary care for people seeking asylum, housed in contingency accommodation during COVID-19. This group often have LEP and face multiple additional barriers to healthcare access. Language discrimination is used as a theoretical framework. The potential utility of this concept is explored as a way of understanding and addressing inequities in care.

Design
Qualitative research using semistructured interviews and inductive thematic analysis.

Setting
An NHS primary care service for people seeking asylum based in contingency accommodation during COVID-19 housing superdiverse residents speaking a wide spectrum of languages.

Participants
Ten staff including doctors, nurses, mental health practitioners, healthcare assistants and students participated in semistructured online interviews. Some staff were redeployed to this work due to the pandemic.

Results
All interviewees described patients’ LEP as significant. Inadequate provision of interpretation services impacted the staff’s ability to provide care and compromised patient safety. Discrimination, such as that based on migration status, was recognised and challenged by staff. However, inequity based on language was not articulated as discrimination. Instead, insufficient and substandard interpretation was accepted as the status quo and workarounds used, such as gesticulating or translation phone apps. The theoretical lens of language discrimination shows how this propagates existing social hierarchies and further disadvantages those with LEP.

Conclusions
This research provides empirical evidence of how the inadequate provision of interpreters forces the hand of healthcare staff to use shortcuts. Although this innovative ‘tinkering’ allows staff to get the job done, it risks normalising structural gaps in care provision for people with LEP. Policy-makers must rethink their approach to interpretation provision which prioritises costs over quality. We assert that the concept of language discrimination is a valuable framework for clinicians to better identify and articulate unfair treatment on the grounds of LEP.

Objectives
The COVID-19 pandemic prompted planning for clinical surges and associated resource shortages, particularly of equipment such as ventilators. We sought to examine the experience of the healthcare professionals who created policies for crisis standards of care, and allocation of ventilators in the event of shortage.

Design
To that end, we conducted semistructured interviews with healthcare professionals in the USA involved in institutional planning for resource shortages in the setting of the COVID-19 pandemic.

Setting
USA.

Participants
We conducted 25 interviews between May and July 2021. Half of the respondents were female (48%), many from Northeastern institutions (52%), and most practised in academic institutions (92%).

Results
Many (64%) respondents reported that their institution had an approved policy to guide ventilator allocation in the event of a shortage. We identified one overarching theme: the work of planning for resource shortages imposed a psychological burden on many planners. We identified four subthemes that influenced that burden: impact of leadership, institutional variation in process and policies, faith in the policies and future directions.

Conclusions
Improved leadership strategies and cross-institutional collaboration can reduce the psychological burden of planning and facilitate updating plans in anticipation of future shortages.

Introduction
Physical inactivity is a risk factor for repeat cardiac events and all-cause mortality in coronary heart disease (CHD). Cardiac rehabilitation, a secondary prevention programme, aims to increase physical activity levels in this population from a reported low baseline. This trial will investigate the effectiveness and implementation of a very brief physical activity intervention, comparing different frequencies of physical activity measurement by cardiac rehabilitation clinicians. The Measure It! intervention (

Circulation, Volume 148, Issue Suppl_1, Page A12542-A12542, November 6, 2023. Introduction:The Metabolic Syndrome (MetSyn) is associated with persistently high risk of cardiovascular (CV) events despite statin treatment.Methods:REDUCE-IT was a multinational, double-blind trial that randomized 8179 high CV risk statin-treated patients with controlled low density lipoprotein cholesterol, and elevated triglycerides, to icosapent ethyl (IPE) 4 grams/day or placebo. In the overall trial, IPE reduced the risk of the primary composite endpoint (CV death, nonfatal myocardial infarction, nonfatal stroke, coronary revascularization or hospitalization for unstable angina) and the key secondary composite endpoint (CV death, nonfatal myocardial infarction or nonfatal stroke). Here we examine the prespecified patient subgroup with a history of MetSyn, but without diabetes at baseline.Results:Compared with placebo, IPE use in patients with MetSyn at baseline (n=2866) was associated with a 29% relative risk reduction for the primary composite endpoint (hazard ratio [HR], 0.71 [95% CI, 0.59-0.84]; P

Circulation, Volume 148, Issue Suppl_1, Page A16924-A16924, November 6, 2023. Introduction:Cardiac screening is mandated by most sporting organisations. A resting 12-lead ECG may identify individuals who harbour cardiac disorders who may be at risk of sudden cardiac death (SCD). Lateral wave inversion (TWI) may identify subjects with cardiac phenotypes that are linked to SCD.Aim:The aim of this study was to ascertain the prevalence of lateral TWI in adolescent individuals as part of a systematic nationwide cardiac screening. The yield of family screening in these probands was also evaluated.Methodology:A national cardiac screening program (BEAT-IT) was set up in the 2017/2018 scholastic year for students attending year 11 classes. 2672 students (14-17 years) and their legal guardians gave consent. Screening protocol consisted of a questionnaire/ECG at school. ECGs were reported as per the ‘International Recommendations for ECG interpretation’ (2017). Those with contiguous TWI in ≥2 lateral leads were evaluated. An athlete was defined as an individual who participated in organized sport and/or engaged in >4 hours of physical activity weekly.Results:2672 adolescents gave consent (mean age 15 years, 50.4% female, 95.8% Caucasian, 39.0% athletes). 6 (0.22%) had lateral TWI, extending into the inferior (n=4, 0.15%) or anterior (n=2 (0.07%) leads. The prevalence was the same in both genders (p=0.477) and athletic status (p=0.580). 2 (0.07%) had symptoms, 4 (0.15%) were female, all were Caucasian, 3 (0.11%) were athletes. 4 (0.15%) had borderline or other pathological ECG changes (n=2 LAE, n=1 RAE, n=1 ST depression). 4 (0.15%) had deep TWI (≥2mm). One patient was diagnosed with HCM (0.04%). All subjects are under surveillance. Family screening in relatives (n=27) identified two (7.4%) with cardiomyopathy (n=1 HCM, n=1 DCM). Another 5 (18.5%) had an abnormal ECG requiring surveillance. These findings suggest that some of the participants identified at screening may harbour pre-clinical phenotypes.Conclusion:Lateral TWI is an infrequent finding in young individuals and requires surveillance as it may be a manifestation of heart disease. Family screening may help increase the degree of suspicion of pre-clinical disease in peripubertal individuals.

Circulation, Volume 148, Issue Suppl_1, Page A13909-A13909, November 6, 2023. Introduction:Metabolically obese normal weight (MONW) refers to metabolic abnormalities despite normal body mass index (BMI).Hypothesis:Because obesity is generally defined by BMI, it is assumed that people with MONW do not have excessive adiposity but still have the metabolic dysregulation associated with adiposity.Methods:We included participants aged 20-65 of the National Health and Nutrition Examination Surveys from 1999-2006 and 2011-2018 with normal BMI (18.5-25 kg/m2), fasting blood samples, and DEXA data. According to the AHA criteria, MONW was defined having ≥3 of the following criteria, besides a normal BMI: Hypertriglyceridemia (≥ 150 mg/dL) or treatment for elevated triglycerides; HDL cholesterol level < 40 mg/dL in men or

Circulation, Volume 148, Issue Suppl_1, Page A17715-A17715, November 6, 2023. In a 2-center trial (PulseReductiononBeta-Blocker andIvabradineTherapy (PROBE-IT)) we tested the hypothesis that failure to adequately reduce heart rate (HR) contributes to non-response to beta-blockers. Twenty-two dilated cardiomyopathy patients (DCM) with a sinus rhythm (SR) heart rate (HR) ≥70 bpm without reverse remodeling after target doses of beta-blockers were randomized 2:1 to 5±2.5 mg b.i.d of ivabradine (IVB) or matching placebo, and treated for 24 weeks with continuation of beta-blockers. Echocardiograms for LVEF measurements and endomyocardial biopsies for measurement of global gene expression by RNA-Sequencing were performed at baseline and end of study. The protocol design aimed for approximately equal numbers of patients with a HR reduction (HRι) and a control group with no change in HR (HRν), with the predefined statistical analysis plan comparing subjects above and below the median HR change. Characteristics and changes from baseline in the 17 patients who completed the trial were (*P

Circulation, Volume 148, Issue Suppl_1, Page A18034-A18034, November 6, 2023. Background:Gunshot wounds cause catastrophic injuries. When bullets embolize to heart, without penetrating cardiac injury, optimal management remains unclear.Case:25 year old male, presented after multiple gunshot wounds (GSW). On exam, perirectal GSW, 3 GSWs to right thigh and 2 GSW to left thigh noted. Lungs CTA bilaterally, CVS normal S1, S2. CTA chest showed Infra renal IVC injury and large retroperitoneal hematoma. (1,2). ECHO revealed a bullet in the dependent part of right atrium, abutting the tricuspid valve (3). No chest injury noted, suggesting migration of bullet from IVC, following the trajectory of venous return to right atrium. He underwent IVC patch repair. Percutaneous approach was unsuccessful to snare the bullet using 8-mm and 14-mm triloop snare, 15-mm gooseneck snare (4), bronchial forceps (5) and balloon. Multidisciplinary team decided to abandon further percutaneous or surgical extraction attempts as the bullet firmly lodged in sub-tricuspid chordo papillary apparatus with no valvular dysfunction.Discussion:In hemodynamically stable patient with intracardiac bullet, there is no standard treatment approach. 65% of bullets entering vena cava, migrate and lodge in chordo papillary apparatus or trabeculations. Low risk percutaneous extraction approaches have gained popularity, with about 50% success. When percutaneous extraction fails, clinicians face a critical decision to observe or perform open sternotomy extraction. Numerous case reports support observation only approach. This patient has done well with observation, suggesting non-operative initial management is reasonable in hemodynamically stable patient with intracardiac bullet.

Circulation, Volume 148, Issue Suppl_1, Page A15076-A15076, November 6, 2023. Introduction:Cryoballon (CB)-guided pulmonary vein isolation (PVI) is an accepted treatment option for atrial fibrillation (AF). The cardiac autonomic nervous system (ANS) plays a crucial role in the regulation of AF.Hypothesis:ANS modulation has an impact on patients’ AF free survival following CB-ablation. The aim of this observational clinical trial was to analyze the impact of vagal reactions (VRs), as a surrogate parameter for ANS modulation, on the long-term outcome of CB-ablation in patients with persistent AF (PERS AF).Methods:Data from consecutive PERS AF patients treated with a CB-guided PVI for symptomatic drug refractory AF between 2013-2023 were analyzed. VRs were defined as bradycardia < 40 beats/min, asystole or higher-degree atrioventricular block. All patients were continuously followed up in our outpatient clinic. AF-recurrence was defined as AF lasting > 30 seconds beyond a 3-month blanking period.Results:A total of 250 consecutive patients (mean age 63.9 ± 10.0 years, 70% male) were included. VRs were recorded in 61 patients (24%). The mean follow-up duration amounted to 84±14 months. Within this observation period 101 patients (40%) developed AF recurrence a mean of 1.75 ± 0.80 times. Re-ablation procedures were performed in 61 patients (60%) a mean of 1.28 ± 0.55 times. Reconnected PVs were documented in 41 cases (67%). An additional substrate modification was performed in 34 procedures (42%). Patients with procedure associated VRs presented with a significantly higher estimated AF-free survival rate compared to those without (log-rank p-value=0.016) (Figure1). Multivariate analyses revealed the days to first AF recurrence following primary CB-ablation as an independent predictor for AF-free survival (CI 0.841-0.928, HR, 0.883, p