Impact on Prehospital Delay of a Stroke Preparedness Campaign: A SW-RCT (Stepped-Wedge Cluster Randomized Controlled Trial)

Background and Purpose—Public campaigns to increase stroke preparedness have been tested in different contexts, showing contradictory results. We evaluated the effectiveness of a stroke campaign, designed specifically for the Italian population in reducing prehospital delay. Methods—According to an SW-RCT (Stepped-Wedge Cluster Randomized Controlled Trial) design, the campaign was launched in 4 provinces in the northern part of the region Emilia Romagna at 3-month intervals in randomized sequence. The units of analysis were the patients admitted to hospital, with stroke and transient ischemic attack, over a time period of 15 months, beginning 3 months before the intervention was launched in the first province to allow for baseline data collection. The proportion of early arrivals (within 2 hours of symptom onset) was the primary outcome. Thrombolysis rate and some behavioral end points were the secondary outcomes. Data were analyzed using a fixed-effect model, adjusting for cluster and time trends. Results—We enrolled 1622 patients, 912 exposed and 710 nonexposed to the campaign. The proportion of early access was nonsignificantly lower in exposed patients (354 [38.8%] versus 315 [44.4%]; adjusted odds ratio, 0.81; 95% confidence interval, 0.60–1.08; P=0.15). As for secondary end points, an increase was found for stroke recognition, which approximated but did not reach statistical significance (P=0.07). Conclusions—Our campaign was not effective in reducing prehospital delay. Even if some limitations of the intervention, mainly in terms of duration, are taken into account, our study demonstrates that new communication strategies should be tested before large-scale implementation. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT01881152

Acquired uterine arteriovenous malformation: Management and treatment

Uterine arteriovenous malformations are rare causes of abnormal uterine bleeding during the midlife. They are congenite or acquired, characterized by an abnormal connection between arteries and veins, without an interconnecting capillary bed. A correct and prompt diagnosis is important. We present a case of acquired uterine arteriovenous malformation after a medical termination of pregnancy, successfully resolved with uterine artery embolization with multiple platinum coils. In literature this condition is a relatively rare disorder, limited to a few case reports and a small number of series, so we conduct a brief review of literature. All studies presented university setting and were performed in single institutions. All patients were symptomatic and presented with acute abnormal vaginal bleeding. Ten women had elective termination of pregnancy, 22 had a spontaneous/ missed/incomplete recent abortion. Ultrasound is the fi rst-line diagnostic method, completed by Doppler interrogation. Hysteroscopy, computed tomography and magnetic resonance imaging are useful for diagnosis. Angiographic embolization is considered the gold standard to preserve reproductive ability in younger women. Our case is characterized by a punctual diagnosis and a successful treatment in few hours, the patients was dismissed from hospital after four days

Complete work-up for the management of retained products of conception

Retained products of conception represent an uncommon complication after miscarriage, planned termination of pregnancy, term spontaneous vaginal delivery or caesarean section. The aim of this study was to review the diagnostic and therapeutic management of this condition, according to the current literature, in order to assess patients correctly and reduce the number of unnecessary procedures with all their consequences. This updated review of the literature explores the pathophysiology, clinical features, diagnostic investigations, and treatment options for this complex condition. Laboratory tests are normal in most cases and have limited utility. Gray scale and Color Doppler ultrasound are the first line modality for the diagnosis of RPOC, even if ultrasound features alone should not be considered as conclusive, having an overall reported sensitivity of 44-85% and a specificity of 88-94%. Hysteroscopic resection of placental remnants, in absence of electricity use, seems to be the best treatment option with low risks and less complications related to fertility. Diagnosis and correct management of RPOC remain a major clinical challenge, since no clearly defined diagnostic criteria and treatment guidelines still exist. Hysteroscopic resection seems to be a good option, but well-designed randomized controlled trials are needed to define the best treatment modality

Supplementary Material for: Parenchyma, Pipes, Perfusion and Penumbra Imaging: The Multimodal CT in Wake-Up Stroke Basilar Thrombosis

Medicin

Development of an education campaign to reduce delays in pre-hospital response to stroke

Background: Systematic reviews call for well-designed trials with clearly described intervention components to support the effectiveness of educational campaigns to reduce patient delay in stroke presentation. We herein describe the systematic development process of a campaign aimed to increase stroke awareness and preparedness. Methods: Campaign development followed Intervention Mapping (IM), a theory- and evidence-based tool, and was articulated in two phases: needs assessment and intervention development. In phase 1, two cross-sectional surveys were performed, one aiming to measure stroke awareness in the target population and the other to analyze the behavioral determinants of prehospital delay. In phase 2, a matrix of proximal program objectives was developed, theory-based intervention methods and practical strategies were selected and program components and materials produced. Results: In phase 1, the survey on 202 citizens highlighted underestimation of symptom severity, as in only 44% of stroke situations respondents would choose to call the emergency service (EMS). In the survey on 393 consecutive patients, 55% presented over 2 hours after symptom onset; major determinants were deciding to call the general practitioner first and the reaction of the first person the patient called. In phase 2, adult individuals were identified as the target of the intervention, both as potential “patients” and witnesses of stroke. The low educational level found in the patient survey called for a narrative approach in cartoon form. The family setting was chosen for the message because 42% of patients who presented within 2 hours had been advised by a family member to call EMS. To act on people’s tendency to view stroke as an untreatable disease, it was decided to avoid fear-arousal appeals and use a positive message providing instructions and hope. Focus groups were used to test educational products and identify the most suitable sites for message dissemination. Conclusions: The IM approach allowed to develop a stroke campaign integrating theories, scientific evidence and information collected from the target population, and enabled to provide clear explanations for the reasons behind key decisions during the intervention development process. Trial registration: NCT01881152. Retrospectively registered June 7 2013 Keywords: Stroke, Public campaign, Pre-hospital delay, Media, Cartoon, Intervention mappin