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The efficacy and safety of direct oral anticoagulants (DOAC) in patients with embolic stroke of undetermined source (ESUS) remains unclear. We systematically searched PubMed, Embase, and Cochrane Library for randomized controlled trials (RCT) comparing DOACs versus aspirin in patients with ESUS. Risk ratios (RR) and 95% confidence intervals (CI) were computed for binary endpoints. Four RCTs comprising 13,970 patients were included. Compared with aspirin, DOACs showed no significant reduction of recurrent stroke (RR 0.95; 95% CI 0.84–1.09; p = 0.50; I2 = 0%), ischemic stroke or systemic embolism (RR 0.97; 95% CI 0.80–1.17; p = 0.72; I2 = 0%), ischemic stroke (RR 0.92; 95% CI 0.79–1.06; p = 0.23; I2 = 0%), and all-cause mortality (RR 1.11; 95% CI 0.87–1.42; p = 0.39; I2 = 0%). DOACs increased the risk of clinically relevant non-major bleeding (CRNB) (RR 1.52; 95% CI 1.20–1.93; p < 0.01; I2 = 7%) compared with aspirin, while no significant difference was observed in major bleeding between groups (RR 1.57; 95% CI 0.87–2.83; p = 0.14; I2 = 63%). In a subanalysis of patients with non-major risk factors for cardioembolism, there is no difference in recurrent stroke (RR 0.98; 95% CI 0.67–1.42; p = 0.90; I2 = 0%), all-cause mortality (RR 1.24; 95% CI 0.58–2.66; p = 0.57; I2 = 0%), and major bleeding (RR 1.00, 95% CI 0.32–3.08; p = 1.00; I2 = 0%) between groups. In patients with ESUS, DOACs did not reduce the risk of recurrent stroke, ischemic stroke or systemic embolism, or all-cause mortality. Although there was a significant increase in clinically relevant non-major bleeding, major bleeding was similar between DOACs and aspirin.

Background Dual antiplatelet therapy (DAPT) with clopidogrel plus aspirin is a well-established practice after a minor stroke or transient ischemic attack (TIA). However, ticagrelor plus aspirin may be an alternative. Aims We systematically searched PubMed, Embase, and Cochrane Central from inception to January 2024. We included randomized controlled trials (RCTs) enrolling adults with acute minor stroke or TIA within 72 hours of the onset of the symptoms. Results A total of 8 RCTs were included in our meta-analysis. Ticagrelor plus aspirin (RR, 0.70; 95% CrI 0.52, 0.91) and clopidogrel plus aspirin (RR, 0.79; 95% CrI 0.64, 0.98) were superior to aspirin in preventing stroke recurrence in overall analysis. Excluding studies with dual antiplatelet up to 90 days, ticagrelor plus aspirin was the only strategy that maintained superiority compared with aspirin regarding stroke recurrence (RR, 0.70; 95% CrI 0.51, 0.95) and ischemic stroke (RR, 0.68; 95% CrI 0.47, 0.94). There was no significant difference between treatment groups regarding hemorrhagic stroke, functional disability, and mortality. Conclusions DAPTs were superior to aspirin in preventing recurrence or ischemic stroke. Although no significant difference was observed between DAPTs, ticagrelor plus aspirin may be related to worse major bleeding results, including intracranial bleeding. Ticagrelor plus aspirin is a considerable option for patients after a minor stroke or TIA.

ObjectiveTo measure the impact of the covid-19 pandemic on admissions to hospital and interventions for acute ischemic stroke and acute myocardial infarction.DesignA retrospective analysis.Setting746 qualifying hospitals in the USA from the Premier Healthcare Database.ParticipantsPatients aged 18 years and older who were admitted to hospital with a primary diagnosis of acute ischemic stroke or acute myocardial infarction between 1 March 2019 and 28 February 2021.Main outcome measuresRelative changes in volumes were assessed for acute ischemic stroke and acute myocardial infarction hospital admissions as well as intravenous thrombolysis, mechanical thrombectomy, and percutaneous coronary intervention (overall and for acute myocardial infarction only) across the first year of the pandemic versus the prior year. Mortality in hospital and length of stay in hospital were also compared across the first year of the pandemic versus the corresponding period the year prior. These metrics were explored across the different pandemic waves.ResultsAmong 746 qualifying hospitals, admissions to hospital were significantly reduced after the covid-19 pandemic compared with before the pandemic for acute ischemic stroke (−13.59% (95% confidence interval−13.77% to −13.41%) and acute myocardial infarction (−17.20% (−17.39% to −17.01%)), as well as intravenous thrombolysis (−9.47% (−9.99% to −9.02%)), any percutaneous coronary intervention (−17.89% (−18.06% to −17.71%)), and percutaneous coronary intervention for acute myocardial infarction (−14.36% (−14.59% to −14.12%)). During the first year of the pandemic versus the previous year, the odds of mortality in hospital for acute ischemic stroke were 9.00% higher (3.51% v 3.16%; ratio of the means 1.09 (95% confidence interval (1.03 to 1.15); P=0.0013) and for acute myocardial infarction were 18.00% higher (4.81% v 4.29%; ratio of the means 1.18 (1.13 to 1.23); P<0.0001).ConclusionsWe observed substantial decreases in admissions to hospital with acute ischemic stroke and acute myocardial infarction, but an increase in mortality in hospital throughout the first year of the pandemic. Public health interventions are needed to prevent these reductions in future pandemics.

Background and purposeLarge vessel occlusion (LVO) accounts for a third of all ischemic strokes. Artificial intelligence (AI) has shown good accuracy in identifying LVOs on computed tomography angiograms (CTA). We sought to analyze whether AI-adjudicated CTA improves workflow times and clinical outcomes in patients with confirmed LVOs.Materials and methodsWe systematically searched PubMed, Embase, and Web of Science for studies comparing initial radiological assessment assisted by AI softwares versus standard assessment of patients with acute LVO strokes. Results were pooled using a random-effects model as mean differences for continuous outcomes or odds ratio (OR) for dichotomous outcomes, along with 95% confidence intervals (CI).ResultsWe included 9 studies comprising 1,270 patients, of whom 671 (52.8%) had AI-assisted radiological assessment. AI consistently improved treatment times when compared to standard assessment, as evidenced by a mean reduction of 20.55 minutes in door-to-groin time (95% CI -36.69 to -4.42 minutes; p<0.01) and a reduction of 14.99 minutes in CTA to reperfusion (95% CI -28.45 to -1.53 minutes; p=0.03). Functional independence, defined as a modified Rankin scale 0-2, occurred at similar rates in the AI-supported group and with the standard workflow (OR 1.27; 95% CI 0.92 to 1.76; p=0.14), as did mortality (OR 0.71; 95% CI 0.27 to 1.88; p=0.49).ConclusionsThe incorporation of AI softwares for LVO detection in acute ischemic stroke enhanced workflow efficiency and was associated with decreased time to treatment. However, AI did not improve clinical outcomes as compared with standard assessment.Key messagesArtificial intelligence (AI) tools to identify large vessel occlusion (LVO) strokes have been increasingly present in stroke centers around the world. Despite widespread use, there is still no proof these tools increase efficacy workflow or clinical outcomes.Adding AI tools to initial radiological assessment reduced treatment times, such as door to groin, imaging to groin, and imaging to recanalization. Despite time optimization, there was no difference in clinical outcomes after the implementation of AI softwares.AI tools like Viz.ai and RAPID seem to improve important metrics in stroke care for patients with LVO. Additional studies are needed to elucidate in which scenarios this intervention can provide optimal benefit.

BackgroundMechanical thrombectomy (MT) has become standard for large vessel occlusions, but rates of complete recanalization are suboptimal. Previous reports correlated radiographic signs with clot composition and a better response to specific techniques. Therefore, understanding clot composition may allow improved outcomes.MethodsClinical, imaging, and clot data from patients enrolled in the STRIP Registry from September 2016 to September 2020 were analyzed. Samples were fixed in 10% phosphate-buffered formalin and stained with hematoxylin-eosin and Martius Scarlett Blue. Percent composition, richness, and gross appearance were evaluated. Outcome measures included the rate of first-pass effect (FPE, modified Thrombolysis in Cerebral Infarction 2c/3) and the number of passes.ResultsA total of 1430 patients of mean±SD age 68.4±13.5 years (median (IQR) baseline National Institutes of Health Stroke Scale score 17.2 (10.5–23), IV-tPA use 36%, stent-retrievers (SR) 27%, contact aspiration (CA) 27%, combined SR+CA 43%) were included. The median (IQR) number of passes was 1 (1–2). FPE was achieved in 39.3% of the cases. There was no association between percent histological composition or clot richness and FPE in the overall population. However, the combined technique resulted in lower FPE rates for red blood cell (RBC)-rich (P<0.0001), platelet-rich (P=0.003), and mixed (P<0.0001) clots. Fibrin-rich and platelet-rich clots required a higher number of passes than RBC-rich and mixed clots (median 2 and 1.5 vs 1, respectively; P=0.02). CA showed a trend towards a higher number of passes with fibrin-rich clots (2 vs 1; P=0.12). By gross appearance, mixed/heterogeneous clots had lower FPE rates than red and white clots.ConclusionsDespite the lack of correlation between clot histology and FPE, our study adds to the growing evidence supporting the notion that clot composition influences recanalization treatment strategy outcomes.

O presente estudo teve como objectivo analisar a influência da comunicação interna na satisfação dos trabalhadores das Pequenas e Médias Empresas (PME), dos concelhos de Santa Maria da Feira, S. João da Madeira, Oliveira de Azeméis e Vale de Cambra.Para auxílio de investigação usou-se, como instrumento de recolha de dados, um questionário contendo questões relacionadas com os 3 tipos de comunicação interna: (1) oral, (2) escrita e (3) as novas tecnologias de informação. No final obteve-se uma amostra composta por 91 questionários.A interpretação e análise dos dados recolhidos, com recurso ao programa informático “Microsoft Office Excel 2007”, permitem-nos concluir que a influência da comunicação interna na satisfação dos trabalhadores é real e atinge indicadores bem expressivos em algumas variáveis.No final, efectuámos algumas recomendações consideradas pertinentes, no sentido de alargar o campo de investigação e retirar daí ensinamentos importantes para a estratégia e a gestão das Pequenas e Médias Empresas.

Nesta dissertação é apresentado o estudo e implementação de testes de software em desenvolvimento ágil.Os testes de software têm cada vez mais importância para as empresas que desenvolvem software, devido à natural evolução das exigências do cliente. Face à necessidade de cumprir as expetativas do cliente, a F3M Information Systems, SA sentiu que devia melhorar as suas práticas de testes.Com base na metodologia de desenvolvimento de software Scrum, foi realizada uma análise a três processos de testes identificados pelo International Software Testing Qualifications Board (ISTQB) como orientados a este tipo de desenvolvimento: Test-Driven Development (TDD), Acceptance Test-Driven Development (ATDD) e Behavior-Driven Development (BDD). A análise e comparação dos três processos ditou que o BDD era que se adequava à empresa, pois tem um grande enfoque no cliente e no comportamento final do software.O BDD foi implementado, de forma parcial, num dos projetos mais recentes da empresa desenvolvido em ASP.NET com arquitetura MVC. O processo revelou-se bastante efetivo sobretudo por permitir uma redução significativa do tempo despendido nos testes, devido à sua automatização, e por facilitar a interação entre todas as partes envolvidas desde o início do projeto.

A entrada no novo milénio, marcou o aprofundamento dos fenómenos globalizantes, fenómenos esses que tiveram um forte impacto na alteração dos padrões das diversas atividades económicas, e entre essas, as atividades ligadas à prestação de serviços.Do lado das empresas prestadoras de serviços, a globalização ao mesmo tempo que as aproximou de novos mercados e de potenciais novos clientes, também esbateu as fronteiras dos mercados económicos, colocando na mesma arena atores económicos que até então não concorriam entre si, o que conduziu a uma maior saturação dos mercados. Do lado dos clientes, a globalização conferiu ao cliente novas caraterísticas: maior educação e conhecimento, maior exigência e menor tolerância.Se as empresas de maior dimensão têm maior capacidade de fazer face a essa nova realidade ou paradigma, as empresas de menor dimensão, como as microempresas, não possuem os mesmos recursos para fazerem face a essas adversidades. Para estas, a principal estratégia deve ser a de satisfazer e fidelizar os clientes. Mas para tal, é fundamental dominar os conceitos, mecanismos, antecedentes e problemáticas da qualidade de serviço, da satisfação e da fidelização de clientes.Neste trabalho, pretende-se demonstrar a importância da qualidade de serviço, e a sua influência para a satisfação e posterior fidelização dos clientes de uma microempresa prestadora de serviços.Com a aplicação do modelo SERVQUAL ao estudo de caso foi possível identificar as dimensões da qualidade de serviço mais valorizadas pelos clientes que recorrem aos serviços deste tipo de empresas. Assim como permitiu concluir que a melhoria dos parâmetros mais deficitários terá uma influência direta na satisfação e consequente fidelização de clientes.

A entrada no novo milénio, marcou o aprofundamento dos fenómenos globalizantes, fenómenos esses que tiveram um forte impacto na alteração dos padrões das diversas atividades económicas, e entre essas, as atividades ligadas à prestação de serviços.Do lado das empresas prestadoras de serviços, a globalização ao mesmo tempo que as aproximou de novos mercados e de potenciais novos clientes, também esbateu as fronteiras dos mercados económicos, colocando na mesma arena atores económicos que até então não concorriam entre si, o que conduziu a uma maior saturação dos mercados. Do lado dos clientes, a globalização conferiu ao cliente novas caraterísticas: maior educação e conhecimento, maior exigência e menor tolerância.Se as empresas de maior dimensão têm maior capacidade de fazer face a essa nova realidade ou paradigma, as empresas de menor dimensão, como as microempresas, não possuem os mesmos recursos para fazerem face a essas adversidades. Para estas, a principal estratégia deve ser a de satisfazer e fidelizar os clientes. Mas para tal, é fundamental dominar os conceitos, mecanismos, antecedentes e problemáticas da qualidade de serviço, da satisfação e da fidelização de clientes.Neste trabalho, pretende-se demonstrar a importância da qualidade de serviço, e a sua influência para a satisfação e posterior fidelização dos clientes de uma microempresa prestadora de serviços.Com a aplicação do modelo SERVQUAL ao estudo de caso foi possível identificar as dimensões da qualidade de serviço mais valorizadas pelos clientes que recorrem aos serviços deste tipo de empresas. Assim como permitiu concluir que a melhoria dos parâmetros mais deficitários terá uma influência direta na satisfação e consequente fidelização de clientes.