Risultati per: Artrite psoriasica e altre comorbilità in pazienti con psoriasi nel setting della medicina generale

Morto a 92 anni per i postumi di un incidente a Forlì

Il 21 febbraio, un convegno online insieme a OMaR e Orphanet

Si occuperà dei piani di indirizzo e gestione dell’associazione

Il cardiochirurgo Gerosa, prototipo più piccolo e meno rumoroso

Objective
Management of chronic obstructive pulmonary disease (COPD) with inhaled corticosteroid/long-acting β2-agonist (ICS/LABA) improves lung function and health status and reduces COPD exacerbation risk versus monotherapy. This study described treatment use, healthcare resource utilisation (HCRU), healthcare costs and outcomes following initiation of single-device ICS/LABA as initial maintenance therapy (IMT).

Design
Retrospective cohort study.

Setting
Primary care, England.

Data sources
Linked data from the Clinical Practice Research Datalink Aurum and Hospital Episode Statistics datasets.

Participants
Patients with COPD and ≥1 single-device ICS/LABA prescription between July 2015 and December 2018 were included.

Primary and secondary outcome measures
Treatment pathways, COPD-related HCRU and healthcare costs, COPD exacerbations, time to triple therapy, medication adherence (proportion of days covered ≥80%) and indexed treatment time to discontinuation. Data for patients without prior maintenance therapy history (IMT users) and non-triple users were assessed over a 12-month follow-up period.

Results
Of 13 451 new ICS/LABA users, 5162 were IMT users (budesonide/formoterol, n=1056; beclomethasone dipropionate/formoterol, n=2427; other ICS/LABA, n=1679), for whom at 3 and 12 months post-index, 45.6% and 39.4% were still receiving any ICS/LABA. At >6 to ≤12 months, the proportion of IMT users with ≥1 outpatient visit (10.1%) and proportion with ≥1 inpatient stay (12.6%) had increased from those at 3 months (9.0% and 7.4%, respectively). Inpatient stays contributed most to total COPD-related healthcare costs. For non-triple IMT users, at 3 and 12 months post-index, 4.5% and 13.7% had ≥1 moderate-to-severe COPD exacerbation. Time to triple therapy initiation and time to discontinuation of index medication ranged from 45.9 to 50.2 months and 2.3 to 2.8 months between treatments. Adherence was low across all time points (21.5–27.6%). Results were similar across indexed therapies.

Conclusions
In the year following treatment initiation, ICS/LABA adherence was poor and many patients discontinued or switched therapies, suggesting that more consideration and optimisation of treatment is required in England for patients initiating single-device ICS/LABA therapy.

Introduction
Previous studies suggested that electrical impedance tomography (EIT) has the potential to guide positive end-expiratory pressure (PEEP) titration via quantifying the alveolar collapse and overdistension. The aim of this trial is to compare the effect of EIT-guided PEEP and acute respiratory distress syndrome (ARDS) network low PEEP/fraction of inspired oxygen (FiO2) table strategy on mortality and other clinical outcomes in patients with ARDS.

Methods
This is a parallel, two-arm, multicentre, randomised, controlled trial, conducted in China. All patients with ARDS under mechanical ventilation admitted to the intensive care unit will be screened for eligibility. The enrolled patients are stratified by the aetiology (pulmonary/extrapulmonary) and partial pressure of arterial oxygen/FiO2 (≥150 mm Hg or

Stroke, Volume 55, Issue Suppl_1, Page A137-A137, February 1, 2024. Introduction:Within 5 years of a stroke, approximately 25% of patients will have a recurrent event. Blood pressure (BP) reduction can reduce this risk; every 10 mmHg decrease in systolic BP is associated with a 20% risk reduction. Despite this benefit, 50% of patients with hypertension remain uncontrolled after a stroke. Reasons for poor control may be related to poor post-stroke follow up care. We aim to quantify post-stroke BP control and follow up in a large health system.Methods:We performed a retrospective analysis of patients with stroke admitted to Yale New Haven Health System (YNHHS) between 2013-2021. YNHHS has 5 hospitals and a large outpatient network. Eligible patients included those who received primary care within YNHHS, were discharged alive, and not on dialysis. We analyzed patient features, time to outpatient encounter, and vital signs. The primary outcome was uncontrolled BP ( >140/90) obtained during the office visit closest to and before 6 months from the date of discharge.Results:During the study period 12,561 patients were admitted with stroke to YNHHS. After exclusions, the final cohort was 2,867 patients. Among these patients, 48 % were male, 65% non-Hispanic White, 22% non-Hispanic Black, 9% Hispanic, and 4% other. Mean (standard deviation) age was 68 (12) years. Approximately 25% of patients had uncontrolled BP. When the updated ACC/AHA (2017) BP goal (2 follow up visits. The median (interquartile range [IQR]) number of days to first visit with a PCP or neurologist was 30 (10-97) days and 45 (27-99) days, respectively. The median (IQR) number of visits with either a PCP or neurologist was 0 (0-2).Conclusion:Among patients with recent stroke, more than half do not achieve BP control per current guidelines. The majority of patients do not engage with a PCP or neurologist within 6 months following a stroke, even though they have an established provider within the system. Gaps in follow up represents a notable opportunity for improving post-stroke care.

Stroke, Volume 55, Issue Suppl_1, Page AWP95-AWP95, February 1, 2024. Background:Informed consent is an essential part of current medical practice which protects the patient’s right to make an informed decision with sufficient understanding of the risks and the benefits of any medical intervention. Because of the need to provide care quickly, consent is often obtained remotely in acute ischemic stroke. Currently, to our knowledge, no study has provided a direct measurement of effectiveness of remote consent compared to in-person consent. In this study, we surveyed those providing consent for thrombolysis and thrombectomy for satisfaction with the consent process. We also compared in person and remote consent for effectiveness in understanding of the intervention.Methods:We conducted post-consent surveys of the person consenting to either thrombolysis or thrombectomy (patient or their legally authorized representative). Surveys assessed satisfaction with the consent process including if the explanation of the procedure was clear and if they had comfortable level of understanding. Survey also included self- and objective assessments of the information provided. Patients who received thrombolysis via wake-up protocol, or as part of another research study, were excluded.Results:A total of 86 surveys assessing 61 remote and 25 in-person consents were analyzed. The in person consents were 56% thrombectomy, while remote consents were 97% thrombectomy. Both in-person and remote groups had high satisfaction rate (9.72/10 vs 9.44/10, P = 0.301) and high self-assessment of understanding (2.56/3 vs 2.74/3, P = 0.11). Objective assessment testing consenter’s knowledge of the procedure showed slightly lower performance for in-person consent, although this was statistically not significant (91% vs 93%, P= 0.17). Further analysis excluding self-consents showed no difference in the two groups (92% vs 94%, P = 0.77).Conclusion:Our observational study showed that patient and legal authorized representatives had a similarly satisfactory experience and understanding when consenting to thrombolysis/thrombectomy when consented in person compared to remote consent.

Stroke, Volume 55, Issue Suppl_1, Page AWMP7-AWMP7, February 1, 2024. Background:Despite decades long adoption as the standard-of-care for ischemic stroke, the majority of eligible patients do not receive intravenous thrombolysis (IVT), with underutilization especially pronounced in rural areas. Telestroke, however, may help alleviate this geographical healthcare disparity. The current study aims to identify the impact of implementing a mature telestroke network within a rural setting.Methods:Retrospective review of a prospectively maintained telestroke database from a large rural tertiary care comprehensive stroke center covering 31 spoke hospitals spanning critical access hospitals to primary stroke centers between 10/2021-02/2023. Data was compared to a previous review period (01/2016-12/2018; comprised of 8 spokes) and the statewide IVT rates recorded in GWTG. Data analysis conducted via descriptive statistics and Fisher’s (two-tailed) exact test.Results:1801 telestroke consults were performed; 41.4% (746/1801) were ineligible for acute stroke intervention. 39% (410/1055) of eligible patients were treated with IVT (vs. 33% [317/959] previously, p = 0.068), representing 58% (410/708; vs 24% [107/448] previously, p < 0.001) of statewide total IVT administration. Symptomatic hemorrhage (sICH) was 3.0%, overall 30-day mortality was 5.6%, and sICH mortality was 1.0%. IVT deferred most commonly: low NIH (44%), mimics (21%), coagulopathy (8%), followed by other. 22% (396/1801) of total consults were transferred from the originating site (vs. 34% [305/890] previously, p < 0.0001) of which 10% (42/396) underwent EVT.Discussion:The impact of expanding a rural telestroke network continued to produce high IVT rates (nearly double the national average) with safety outcomes (sICH, mortality) at or below national standards. Additionally, a large network has significantly increased the proportion of patients remaining at originating sites, optimizing both tertiary and local centers’ resources. The value of a regional telestroke hub is further underscored by the significant increase in statewide IVT attributed to network consults. However, further strategies are needed to better educate rural providers on acute stroke to reduce the rate of ineligible consults and streamline use of telestroke services.

Stroke, Volume 55, Issue Suppl_1, Page ATP109-ATP109, February 1, 2024. Introduction:The Hyperfine portable low-field Magnetic Resonance Imaging (MRI) scanner (0.064 Tesla) was FDA approved in 2020. The use of portable low-field MRI (pMRI) has been best studied in ICU settings, although there has been interest in expanding this technology in floor level status stroke patients.Methods:We report our experience launching pMRI in our academic comprehensive stroke program in the non-ICU setting. From September 2021 to March 2022, 24 pMRI scans were performed (2 volunteers, 22 floor-status stroke patients). Our institutional pMRI protocol includes localizer, DWI, ADC, and FLAIR (24 minutes scan time). Good head position (GHP) was defined as the vertex of the head abutting the top of the helmet insert. Complete scans were defined as including all sequences and Partial scan included DWI/ADC.Results:Among 24 scans, most 17/24 (70.8%) were Complete and 2 scans were aborted after only localizer images. Six scans were Partial, due to patient discomfort in 4 (“feeling hot” [2], neck/back pain [2]), and technical issues with machine in 2. Among 22 scans that were Partial or Complete, 6 scans had poor head positioning. We noted that although there was initial GHP, the head could shift out due to gravity or patient self-adjustment due to discomfort. To combat the shift issue, the bed was placed in slight reverse Trendelenburg. We also implemented wedge padding for the lower back that improved comfort. After scan # 11, re-training was performed to include GHP updates. Before re-training, 6/11 (45.5%) had GHP, and afterwards, 11/11 (100%) had GHP. Our quality review also noted that artifact on the DWI/ADC mimicking restricted diffusion could be seen in the internal capsule and corpus callosum, and clinical teams were educated on this.Conclusions:The use of low-field pMRI in non-ICU settings is feasible. Our institutional QI experience suggests that patient selection and technical skill in GHP is a consideration. After adjusting our protocol, the rate of GHP increased from 45% to 100%. Clinical teams also need to be aware of artifact mimicking restricted diffusion in areas of tightly bound white matter tracks. Further studies are warranted to better maximize pMRI and understand the logistical barriers to successful implementation.

Stroke, Volume 55, Issue Suppl_1, Page ATP99-ATP99, February 1, 2024. Background:Inpatient telestroke programs have emerged as a solution to provide timely stroke care in underserved areas, but their successful implementation and factors influencing their effectiveness remain underexplored. This study aimed to qualitatively evaluate the perspectives of inpatient clinicians located at the spoke hospital who were participating in a newly established inpatient telestroke program in order to identify implementation barriers and facilitators.Methods:This was a formative evaluation relying on semi-structured qualitative interviews with sixteen inpatient providers (physicians and nurse practitioners) that have utilized inpatient telestroke services. Interviews were conducted with providers at spoke sites of a hub-and-spoke inpatient telestroke program. The Integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework guided data analysis, focusing on the innovation, recipients, context, and facilitation aspects of implementation. Interviews were transcribed and coded using thematic analysis.Results:Fifteen themes were identified in the data and mapped to the i-PARIHS framework. Themes related to the innovation (telestroke program) included easy access to stroke specialists, the benefits of limiting patient transfers, concerns about duplicating tests, and challenges of timing inpatient telestroke visits and notes to align with discharge workflow. Themes pertaining to recipients (care team members and patients) were communication gaps between teams, concern about the supervision of advanced practice providers, and challenges with nurse empowerment. With regards to the context (hospital and system factors), providers highlighted familiarity with telehealth technologies as a facilitator to implementing inpatient telestroke, yet highlighted resource limitations in smaller facilities. Facilitation (program implementation) was recognized as crucial for education, standardization, and buy-in.Conclusion:This study identified barriers and facilitators in launching an inpatient telestroke program within a health system, highlighting the importance of leveraging facilitators and addressing barriers for effective implementation and continuity.

Comunicato del 29/01/2024 n°5

In video-collegamento dalla Stazione Spaziale Internazionale

Le tre richieste della medicina generale alla politica

Objectives
The objective of this study is to report the prevalence, clinical characteristics and healthcare utilisation of patients with type 2 diabetes (T2DM) and previously undiagnosed cognitive impairment who were identified as having a low Montreal Cognitive Assessment (MoCA) score.

Design
A population-based cohort study comparing clinical characteristics, medications, outpatient and inpatient care of patients with a MoCA score 26 using descriptive statistics, linear regression and multivariate logistic regression.

Setting
Electronic medical records of a large health maintenance organisation in Israel.

Participants
350 patients, age >65 with T2DM who participated in a cognitive function screening initiative using MoCA, and had a follow-up visit during the 12 months after screening.

Results
130 (37.1%) had a MoCA score >26 and 68 (19.4%)