Risultati per: Low Back Pain: raccomandazioni

Stroke, Volume 56, Issue Suppl_1, Page ATP237-ATP237, February 1, 2025. Introduction:Acute ischemic stroke (AIS) from distal medium vessel occlusion (DMVO) presents unique treatment challenges. Mechanical thrombectomy (MT) is emerging as a viable option for these patients, yet the role of pre-stroke aspirin treatment is unclear. This study evaluates the impact of pre-stroke low-dose aspirin on outcomes in DMVO patients undergoing MT.Methods:We conducted a multinational, multicenter, propensity score-weighted analysis within the Multicenter Analysis of primary Distal medium vessel occlusions: effect of Mechanical Thrombectomy (MAD-MT) registry. Patients with AIS due to DMVO, treated with MT, were included. We compared outcomes between patients on pre-stroke low-dose aspirin (75-100 mg) and those not on antiplatelet therapy. The primary outcome was functional independence at 90 days (mRS 0-2). Secondary outcomes included excellent functional outcome at 90 days (mRS 0-1), mortality, and day-one post-MT NIHSS score. Safety outcomes focused on hemorrhagic complications, including symptomatic intracerebral hemorrhage (sICH).Results:Among 1,354 patients, 150 were on pre-stroke low-dose aspirin. Aspirin use was associated with significantly better functional outcomes (mRS 0-2: OR = 2.12, 95% CI, 1.29 to 3.49; mRS 0-1: OR = 1.87, 95% CI, 1.12 to 3.14;) and lower 90-day mortality (OR = 0.53, 95% CI, 0.30 to 0.95). The aspirin group had lower NIHSS scores on day one (β = -2.0, 95% CI, -3.3 to -0.70). The rate of sICH was not significantly different between the groups (OR = 0.98, 95% CI, 0.56 to 1.72).Conclusions:Pre-stroke low-dose aspirin was associated with improved functional outcomes and reduced mortality in patients with DMVO undergoing MT, without a significant increase in sICH. These findings suggest that low-dose aspirin may be safe and associated with more frequent excellent outcomes for this patient population. Further prospective studies are needed to validate these results and assess long-term outcomes.

Stroke, Volume 56, Issue Suppl_1, Page ADP35-ADP35, February 1, 2025. Introduction:Portable, low-field (LF) magnetic resonance imaging (MRI) has the potential to improve access to brain imaging and facilitate diagnosis of acute ischemic stroke (AIS). However, due to longer acquisition time, diffusion-weighted imaging (DWI) at LF is often restricted to a single diffusion direction, which may reduce sensitivity of detection. We developed a multi-direction DWI sequence and evaluated its ability to detect stroke lesions compared with a single-direction sequence.Methods:Patients with a suspected diagnosis of AIS were prospectively enrolled at three US centers and underwent single-directionb0 andb900 s/mm2DWI and generation of corresponding apparent diffusion coefficient (ADC) maps on a 0.064 T MRI (Hyperfine Inc.). A subset of patients underwent additional multi-direction DWI (3 diffusion directions in x, y, and z planes) and generation of trace and ADC maps. Two independent assessors evaluated DWI and ADC scans and recorded the presence or absence of stroke lesions and their location (left/right hemisphere). The agreement, positive predictive value (PPV), negative predictive value (NPV), sensitivity, and specificity were calculated for both single- and multi-directional images as compared to the ground-truth clinical diagnosis.Results:A total of N=66 patients were included, with N=18 undergoing additional multi-directional acquisition. Of these patients, N=36 had a confirmed ischemic stroke, and N=29 had a stroke mimic with no evidence of infarction or diffusion restriction abnormality on conventional high-field imaging. Agreement between assessors regarding lesion detection on single-direction DWI was κ=0.88 and κ=0.84 on ADC, with a κ=0.92 agreement on lesion location. On multi-directional LF-MRI, agreement increased to κ=1.0 for DWI, ADC, and lesion location. Predictive values for detecting AIS on single-direction DWI revealed a PPV of 83.9% and NPV of 71.4% which was associated with a 72.2% sensitivity and 83.3% specificity. NPV, PPV, sensitivity and specificity all increased to 100% when multi-directional DWI was assessed.Conclusion:LF single-direction diffusion is sensitive and specific for the detection of acute ischemic infarcts, except for small lesions residing in white matter tracts that align with diffusion gradient direction. A novel LF multi-directional DWI sequence can overcome this limitation and potentially improve qualitative lesion conspicuity. Validation in a larger cohort is warranted.

Stroke, Volume 56, Issue Suppl_1, Page AWP201-AWP201, February 1, 2025. Introduction:The use of ultra low-field portable Magnetic Resonance Imaging (pMRI) in acute ischemic stroke (AIS) is gaining interest, as pMRI is FDA approved and has practical advantages over high-field MRI brain (hMRI). The ACTION PMR study is a prospective cohort study enrolling AIS and perform pMRI within 24 hours of last known normal (LKN). We sought to report patients enrolled in the study from our institution to evaluate the performance of pMRI compared to hMRI.Methods:Among the 10 patients enrolled in our center, 1 was excluded for technically nondiagnostic imaging and 1 was excluded due to no infarct visible on hMRI, leaving 8 AIS patients in the cohort for analysis. All 8 patients had both pMRI and hMRI during their hospitalization. Our institutional pMRI (Hyperfine Inc. Swoop®) is a 0.064 Tesla MRI machine, and the protocol includes diffusion-weighted imaging, apparent diffusion coefficient, and fluid-attenuated inversion recovery (scan time 18 minutes) sequences. Infarct size was measured based upon maximum longitudinal axis on DWI.Results:Among the 8 AIS patients with radiographic infarcts on hMRI, the mean age was 61.0 years (range, 47.2 to 76.2) and 2 were female. Thrombolysis was administered in 7 (87.5%) patients, and the mean NIHSS on presentation was 3.8 (range, 2 to 7). The mean time from LKN to pMRI was 15.9 hours (range, 10.9 to 20.3) and from pMRI to hMRI was 7.3 hours (range 1.2 to 17.6). All 8 AIS patients had infarcts visible on pMRI. On the 8 hMRI scans, 10 infarct lesions were demonstrated. Infarct distribution was as follows: subcortical (6), cerebellar (1), and cortical MCA/PCA (3). Among 10 infarct lesions measured, mean size was 15.2 mm (range 3.6 to 37.6), and 9 (90%) of hMRI infarcts were visible on pMRI, with the smallest infarct visible on pMRI being 4.5 mm. In contrast, the hMRI visible infarct that was not visible on pMRI measured 3.6 mm. Case 1 (Figure 1) demonstrated DWI-FLAIR mismatch of a right subcortical infarct on hMRI and on pMRI as well.Conclusions:In our series, pMRI performed reasonably well on AIS patients and was able to detect the majority (90%) of acute infarcts seen on hMRI. pMRI was able to detect infarcts above 4.5 mm and was also able to demonstrate DWI-FLAIR mismatch. Clinicians need to be aware of the strengths and limitations of pMRI to maximize patient selection for use in the AIS population. Future improvements in DWI imaging at low field may improve sensitivity for small infarcts in the future.

Stroke, Volume 56, Issue Suppl_1, Page AWP271-AWP271, February 1, 2025. Introduction:Patients with single subcortical infarction (SSI) have relatively favorable prognosis, but they often experience early neurological deterioration (END) in a clinical course. Endothelial shear stress (ESS) applied to the vascular wall may also be one of the causes.Hypothesis:We would like to analyze the association between ESS and occurrence of END in SSI patients.Methods:We included consecutive patients with SSI within 72 hours of symptom onset between 2010 and 2020. END was defined as an increase of ≥ 2 in the total NIHSS score or ≥ 1 in the motor NIHSS score within the first 72 hours of admission. As a parameter for ESS, the signal intensity gradient (SIG) value was obtained at the vessel boundary in time-of-flight image in initial brain magnetic resonance angiography. The maximum, minimum, mean, and standard deviation of SIG were obtained from all intracranial vessels. Among them, the SIG value of the relevant vessel that caused SSI was taken as the main independent variable.Results:A total of 495 patients with SSI were evaluated (median age: 67 years, END prevalence: 17.2%). In multivariable analysis, the mean SIG value of relevant vessels was significantly associated with END (adjusted odds ratio = 0.81, 95% confidence interval: 0.68-0.97). However, maximum, minimum, or standard deviation SIG value of relevant vessel was not associated with END. Additionally, the mean SIG value of the whole intracranial vessel also showed no correlation with the occurrence of END. The statistical correlation between the average SIG value of relative vessels and END was clearly evident in distal SSI, but the correlation was lost in proximal SSI. Age or proximal type SSI also showed an association with END regardless of SIG value.Conclusions:In patients with acute SSI, the mean SIG value of relevant vessels showed a negative association with the occurrence of END. In other words, if the ESS applied to the relevant vessel where the index stroke occurred is weak, END may occur relatively easily. This tendency was more evident in patients with distal SSI lesions.

Introduction
The results of open defecation-free (ODF) programmes vary greatly, especially in low- and middle-income countries (LMICs). This study will systematically investigate available qualitative research to identify the elements contributing to open defecation programmes’ effectiveness in various situations across LMICs. Furthermore, this review seeks to identify gaps in the available literature and areas that require additional investigation and action.

Methods and analysis
Inclusion criteria were developed considering issues related to open defecation in LMICs, sanitation interventions and behavioural change. Research examining sanitation interventions in schools, shelters, disability communities and virtual communities was excluded, as the review focused exclusively on community-based interventions. Studies published in English and Indonesian were included without limitation of the initial year until 31 January 2025. Systematic research will be carried out using ScienceDirect, PubMed, ProQuest and Scopus databases. Information from grey literature, including conference proceedings and reports from relevant organisations, will be systematically searched using Google Scholar and the websites of leading institutions, such as the WHO, UNICEF and WaterAid. This systematic review did not impose any restrictions on the place and date of publication. Two reviewers followed Joanna Briggs Institute guidelines in selecting studies, conducting critical appraisal using confidential tools and extracting data using a structured approach. Data synthesis will be performed using meta-aggregate methods to identify the themes. A ConQual Summary will be used to assess confidence in the findings.

Ethics and dissemination
The findings of the systematic review will be disseminated through a publication in a peer-reviewed journal and presented at a relevant conference. Since the data used will not contain individual patient information, ethical approval is unnecessary.

PROSPERO registration number
CRD42023408851.

Objectives
Neonatal pain prevention is not only a humanistic but also an ethical imperative. Fitting with the principles of family-centred care, parental involvement in neonatal pain management plays an active role in infant development and parental well-being. However, the process of parental involvement faces constant challenges. To help structure and implement a family engagement programme in neonatal pain management in the neonatal intensive care unit (NICU), we conducted a scoping review to identify facilitators and barriers to parental involvement in neonatal pain management.

Methods
We conducted the scoping review using the Arksey and O’Malley framework. PubMed, Cochrane Library, Web of Science, CINAHL, Scopus, Wanfang database (Chinese), CNKI (Chinese), VIP database(Chinese) and SinoMed (Chinese) were searched systematically for relevant studies published in English and Chinese from inception up to October 2023. We categorised the facilitators and barriers based on the socioecological model and analysed the results thematically in each category.

Results
Ten English qualitative studies were included in the final analysis. The 34 facilitators and 41 barriers extracted were grouped into 4 domains of the socioecological model framework. Of the 10 facilitator themes, the most critical theme was informational and emotional support. Of the 10 barrier themes, the most frequently reported theme was restricted policies and resources.

Conclusions
Our review highlights the essential roles of intrapersonal and interpersonal factors in parental involvement in pain management while suggesting the interconnectedness of factors in various domains within the context of the socioecological model. It implies that most interventions require development and administration at both intrapersonal and interpersonal levels. Regarding the macrolevel, a broad programme with clear regulatory approaches and targeted guidelines could be developed in the future to drive innovations in NICU pain management mode.

Introduction
Heart failure with preserved ejection fraction (HFpEF) is characterised by severe exercise intolerance, particularly in those living with obesity. Low-energy meal-replacement plans (MRPs) have shown significant weight loss and potential cardiac remodelling benefits. This pragmatic randomised trial aims to evaluate the efficacy of MRP-directed weight loss on exercise intolerance, symptoms, quality of life and cardiovascular remodelling in a multiethnic cohort with obesity and HFpEF.

Methods and analysis
Prospective multicentre, open-label, blinded endpoint randomised controlled trial comparing low-energy MRP with guideline-driven care plus health coaching. Participants (n=110, age ≥18 years) with HFpEF and clinical stability for at least 3 months will be randomised to receive either MRP (810 kcal/day) or guideline-driven care for 12 weeks. Randomisation is stratified by sex, ethnicity, and baseline Sodium Glucose Cotransporter-2 inhibitor (SGLT2-i) use, using the electronic database RedCap with allocation concealment. Key exclusion criteria include severe valvular, lung or renal disease, infiltrative cardiomyopathies, symptomatic biliary disease or history of an eating disorder. Participants will undergo glycometabolic profiling, echocardiography, MRI for cardiovascular structure and function, body composition analysis (including visceral and subcutaneous adiposity quantification), Kansas City Cardiomyopathy Questionnaire (KCCQ) and Six-Minute Walk Test (6MWT), at baseline and 12 weeks. An optional 24-week assessment will include non-contrast CMR, 6MWT, KCCQ score. Optional substudies include a qualitative study assessing participants’ experiences and barriers to adopting MRP, and skeletal muscle imaging and cardiac energetics using 31Phosphorus MR spectroscopy.

Statistical analysis
Complete case analysis will be conducted with adjustment for baseline randomisation factors including sex, ethnicity and baseline SGLT2-i use. The primary outcome is the change in distance walked during the 6MWT. The primary imaging endpoint is the change in left atrial volume indexed to height on cardiac MRI. Key secondary endpoints include symptoms and quality of life measured by the KCCQ score.

Ethics and dissemination
The Health Research Authority Ethics Committee (REC reference 22/EM/0215) has approved the study. The findings of this study will be published in peer-reviewed journals.

Trial registration number
NCT05887271.

An international panel of dermatologists released a consensus statement on the off-label use of low-dose oral minoxidil (LDOM) for patients with hair loss, creating a prescription framework for clinical practice.

Planned birth at 39+0–39+6 weeks in low-risk women was associated with lower odds of perinatal mortality and other adverse outcomes. Reductions in odds of adverse outcome were greater following scheduled caesarean section than induction of labour. Compared to expectant management, induction of labour was associated with lower odds of severe perineal trauma, shoulder dystocia, and caesarean birth. These findings generate further hypotheses that need to be tested in adequately powered randomised controlled trials.

Background
Worldwide, lung cancer (LC) is the second most frequent cancer and the leading cause of cancer related mortality. Low-dose CT (LDCT) screening reduced LC mortality by 20–24% in randomised trials of high-risk populations. A significant proportion of those screened have nodules detected that are found to be benign. Consequently, many individuals receive extra imaging and/or unnecessary procedures, which can have a negative physical and psychological impact, as well as placing a financial burden on health systems. Therefore, there is a need to identify individuals who need no interval CT between screening rounds.

Methods and analysis
The aim of this study is to identify risk factors predictive of LC, which are known at the time of the scan, in patients with LDCT screen-detected lung nodules. The MEDLINE and EMBASE databases will be searched and articles that are on cohorts or mention cohorts of screenees with nodules will be identified. A data extraction framework will ensure consistent extraction across studies. Individual participant data (IPD) will be collected to perform a one-stage IPD meta-analysis using hierarchical univariate models. Clustering will be accounted for by having separate intercept terms for each cohort. Where IPD is not available, the effects of risk factors will be extracted from publications, if possible. Effects from IPD cohorts and aggregate data will be reported and compared. The PROBAST (Prediction model Risk Of Bias ASsessment Tool) will be used for assessment of quality of the studies.

Ethics and dissemination
Ethical approval was not required as this study is a secondary analysis. The results will be disseminated through publication in peer-reviewed journals and presentations at relevant conferences.

PROSPERO registration number
CRD42022309515

Introduction
Non-adherence to tuberculosis (TB) treatment poses a significant challenge to effective TB management globally and is a major contributor to the emergence of multidrug-resistant TB. Although adherence to TB treatment has been widely studied, a comprehensive evaluation of the comparative levels of adherence in high- versus low-TB burden settings remains lacking. The objective of this systematic review and meta-analysis is to assess the levels of adherence to TB treatment in high-TB burden countries compared to low-burden countries. Additionally, it seeks to identify the unique facilitators and barriers to treatment adherence in these distinct settings.

Methods and analysis
This systematic review and meta-analysis will be conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses Protocols Statement. Using key medical subject heading terms and free-text terms related to TB treatment adherence, a systematic search of the literature will be performed in Medline, Embase, CINAHL, Scopus, Global Health and the Cochrane Databases of Systematic Reviews. A medical librarian will assist with developing the search strategy. Two independent reviewers will independently screen studies against predefined inclusion and exclusion criteria at both the title/abstract and full-text stages. Working in duplicate, the same two reviewers will independently extract relevant study and outcomes data, including study descriptors, TB burden, adherence levels and adherence measures, from eligible studies. Countries will be classified according to TB burden based on the WHO’s high-burden country list from the post-2015 era (2015–2025). The quality of the included studies will be appraised using the Cochrane Risk of Bias tool and the Newcastle-Ottawa Scale. Qualitative data will be appraised using the Critical Appraisal Skills Programme tool. Studies will be pooled using the DerSimonian-Laird random-effects meta-analysis. Additionally, a meta-synthesis of the qualitative data from the included studies may be conducted to identify emergent themes related to facilitators and barriers of TB treatment adherence in high- vs low-TB burden countries.

Ethics and dissemination
Ethics approval is not required for this study as it does not involve the recruitment or collection of data from participants. The findings from this systematic review and meta-analysis will be disseminated through publication in peer-reviewed journals, presentations at scientific conferences, and via social media channels to enhance visibility, particularly within programmatic and policy spheres.

PROSPERO registration number
CRD42021273336

Objectives
To map the scope of available evidence on relationships between multimorbidity patterns and functioning among adults in low- and middle-income countries (LMICs), and describe methods used.

Design
Scoping review guided by a five-step methodological framework and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews reporting guidelines.

Data sources
PubMed/MEDLINE, Scopus, EBSCOhost (CINAHL) and Cochrane databases were searched from January 1976 to March 2023, plus reference lists of included studies.

Eligibility criteria for selecting studies
Peer-reviewed full-text articles or conference proceedings of any design, published in English or Afrikaans, involving adults ( >18 years) with multimorbidity living in LMICs. Studies had to refer to associations between multimorbid patterns of co-occurrence and functioning. Multimorbidity was defined as the coexistence of ≥2 diseases, including any combination of non-communicable, infectious and mental health conditions.

Data extraction and synthesis
Data were extracted independently by two reviewers using a piloted form. Findings were synthesised according to methodological approaches, multimorbidity-pattern epidemiology, evidence gaps/limitations and recommendations for future research. The International Classification of Functioning, Disability and Health framework was used to classify functional problems.

Results
Nine studies (total sample size: 62 003) were included, mainly from upper-middle-income Asian countries. Key methodological inconsistencies were identified in defining and operationalising multimorbidity, conditions included in determining patterns, statistical methods for pattern determination and functioning outcome measures. Five main multimorbidity pattern domains emerged: Cardio-Metabolic and Coronary Atherosclerotic, Musculoskeletal, Respiratory and Digestive/Visceral, Degenerative, and Mental Health-Related. Mobility limitations, instrumental activities of daily living, self-care and bowel/bladder problems were consistently linked to all pattern domains.

Conclusions
The limited and geographically skewed body of literature, along with methodological inconsistencies, hampers a comprehensive understanding of multimorbidity patterns and associations with functioning in LMICs. Future research should explore context-specific multimorbidity definitions, employ transparent methodologies, use standardised measures and incorporate diverse samples to inform tailored interventions and policies.

Objective
To study the behavioural factors associated with sustained cigarette smoking cessation, and those associated with a current smoker attempting to quit, among current and former cigarette smokers living in low-income South African communities.

Setting
Three low-income areas in South Africa.

Design
In-person surveys with structured questions that asked respondents about their cigarette smoking and quitting behaviour, sociodemographic information and behavioural attributes.

Participants
Current smokers were eligible to participate if they had smoked at least one cigarette in the week prior to the interview (n=569). Former smokers were eligible if they had ever smoked cigarettes regularly in the past and had abstained from smoking for at least 6 months (n=106).

Outcomes
(1) Abstinence from cigarette smoking for at least 6 months and (2) attempting to quit cigarette smoking in the past 12 months.

Results
Compared with low levels of self-control, high levels of self-control increase the odds of sustained cessation (OR=2.690, 95% CI: 2.480 to 2.917) and of making a quit attempt (OR=1.271, 95% CI: 1.254 to 1.288). Relative to low levels of stress, high levels of stress reduce the odds of sustained cessation (OR=0.938, 95% CI: 0.927 to 0.948) and of attempting to quit (OR=0.824, 95% CI: 0.666 to 1.019). Hyperbolic discounting reduces the odds of sustained cessation (OR=0.841, 95% CI: 0.822 to 0.862) while exhibiting more quitting self-efficacy increases these odds (OR=2.063, 95% CI: 1.745 to 2.439). Being impatient reduces the odds of making a quit attempt (OR=0.814, 95% CI: 0.702 to 0.943), as does a tendency to postpone important tasks (OR=0.784, 95% CI: 0.644 to 0.956).

Conclusions
Non-pharmacological cessation support to low-income smokers should challenge potential lifetime quitters to practice self-control, equip them with tools to manage stress, and tackle temptations to time-discounting. Existing healthcare infrastructure should be leveraged to question people who smoke about their behavioural attributes, and to use this information to deliver behavioural support that motivates and facilitates sustained smoking cessation.

New England Journal of Medicine, Volume 392, Issue 4, Page 383-394, January 23, 2025.

Objective
To evaluate the feasibility of implementing family-integrated newborn care (FINC) for hospitalised preterm and low birthweight infants in Ethiopia. Despite the WHO’s call for family engagement in newborn care, evidence of the feasibility of implementation remains scarce.

Design
An observational feasibility study employing a mixed-methods design comprising a quantitative cross-sectional survey among 157 healthcare providers (HCPs) and a qualitative Participatory Rural Appraisal.

Setting
The study was conducted in 30 neonatal care units (NCUs) of hospitals in Tigray, Northern Ethiopia.

Participants
HCPs who were on duty in NCUs during the data collection period were included in the study.

Analysis
Descriptive statistics were obtained for the quantitative data using STATA V.16, while qualitative data were coded and analysed using a framework analysis approach with qualitative data analysis software (Atlas.ti V.9).

Results
In total, 157 HCPs were enrolled with a mean (SD) age of 32 (±6.8) years. Participants scored a higher weighted mean score for implementability (0.75) and a lower mean score for adaptability (0.50). Out of the 157 HCPs, the majority perceived that FINC was technically implementable (96%), conceptually acceptable (74%) and ethically correct (88%). Furthermore, 49% perceived that integrating FINC into the existing system was technically manageable, while 52% agreed that it was expandable to other healthcare facilities. However, HCPs reported lower confidence regarding its practicality (32%), integration (31%) and adaptability (16%). NCU space (97%), number of NCU rooms (87%) and increased risk of infection (83%) were perceived as potential challenges to the feasibility of FINC. More importantly, only 33% of HCPs felt that there was an organisational demand to consider FINC in NCUs. Furthermore, there was a statistically significant variation in the mean score for acceptability and perception of additional burden between age groups (p=0.04).

Conclusions and recommendations
The current study shows that FINC is conceptually acceptable, technically implementable and expandable to other settings, with weighted mean scores of 0.75, 0.72 and 0.66, respectively. However, its practicality (0.53), integration (0.52) and adaptability (0.50) could be generally constrained mainly by the poor organisational infrastructure related to NCU space and infection prevention measures. Addressing motivational, attitudinal and competency gaps of NCU HCPs, along with organisational capacity, would be required.

In patients achieving a median LDL level of 35 mg/dL, neuropsychological testing found no change in cognitive function after 5 years of follow-up.