Patients with acute coronary syndrome (ACS) and nonobstructive coronary artery disease (CAD) have a substantial risk of subsequent coronary events within 1 year. The aim of the present study was to ...evaluate the prevalence, long-term outcomes, and adherence to oral antiplatelet therapy in patients with ACS and nonobstructive CAD compared with patients with ACS and obstructive CAD who had undergone percutaneous coronary intervention. Nonobstructive CAD was defined as an angiographic finding of <50% diameter stenosis in any major epicardial artery. These patients were further stratified into 2 groups: those with normal coronary arteries (0% angiographic stenosis) and those with mild CAD (0% to 50% angiographic stenosis). Major adverse cardiac events, defined as death, myocardial infarction, ACS leading to hospitalization, and nonfatal stroke, were recorded and compared with a historical control group of patients with ACS and obstructive CAD who had undergone percutaneous coronary intervention. Of 2,438 consecutive patients with ACS undergoing coronary angiography, 318 (13%) had nonobstructive CAD. Of the 318 with nonobstructive CAD, 160 had normal coronary arteries and 158 had mild CAD. Patients with obstructive CAD had experienced greater rates of major adverse cardiac events at 26 ± 16 months (16.6% vs 9.1%, p = 0.001), driven by a greater rate of myocardial infarction compared with those without (5.3% vs 0%, p <0.001). However, the rate of death, ACS leading to hospitalization, and stroke was similar. After adjusting for baseline characteristics, no difference was found in the risk of major adverse cardiac events across the groups. Only 50% of patients with nonobstructive CAD were prescribed dual antiplatelet therapy. In conclusion, patients with ACS and nonobstructive CAD remain at high risk of long-term recurrent ischemic events.
Pulmonary embolism can be a catastrophic event that can result in early death or serious hemodynamic dysfunction. The dehydration, immobility, and infections occurring in acute stroke patients puts ...these patients at risk of developing deep vein thrombosis and pulmonary embolism. Recombinant tissue-type plasminogen activator (rt-PA) is the established therapy for acute ischemic stroke, and its prompt administration results in a better outcome in stroke patients. We describe a 73-year-old man who arrived at the emergency room within 2 hours of acute onset of left hemiparesis who was treated with rt-PA and suffered a pulmonary embolism 3 days after acute stroke therapy. rt-PA is also a current therapy for pulmonary embolism, but an ischemic stroke in the previous 3 months is an absolute contraindication to thrombolysis because of the high risk of intracranial hemorrhage. We discuss clinical and therapeutic decisions and review the current literature.
The risk of disease transmission from nonstandard risk donors (NSRDs) is low, and outcomes are similar or better relative to transplants performed with standard criteria donors. However, NSRDs have ...posed new ethical challenges to the informed consent (IC) process. Based on the shared decision-making model, coinciding with the 3 main timings of the IC process (1 pretransplant assessments and waiting list registration, 2 time on the waiting list, and 3 time of the organ offer), we put forward a model (3-T Model) to summarize the knowledge on IC for NSRDs and to deliver conceptual and practical support to transplant providers on this emergent issue.
We searched
and analyzed data from our area to provide evidence and ethical arguments to promote standardization of the timing of patient information, degree of patient participation, and disclosure of donor risk factors throughout the 3 stages of the time continuum leading to the potential acceptance of NSRDs.
Each of the 3 timings carries special ethical significance and entails well-defined duties for transplant providers relative to patient involvement and information of the benefits and risks associated with NSRDs. Based on our framework, experience, and interpretation of the literature, we put forward a list of recommendations to combine standardization (ie, timing, content, and degree of patient participation) and individualization of IC.
The 3-T Model may enable the prevention of physicians' arbitrariness and the promotion of patient-centered care. Future studies will assess the effectiveness of the 3-T Model in transplant clinical practice.
Objective Results of recent studies suggest a link between neuronal excitatory or inhibitory unbalance and depression. To investigate this relation, we studied the rest activity and the cortical ...excitability of the cerebral areas dedicated to hand control in 12 patients with depression. Methods Brain activity was recorded from the Rolandic region in both hemispheres of 12 depression patients and 11 control subjects by means of magnetoencephalography. We studied cortical excitability by focusing on the M20 and M30 components of the magnetic fields evoked by a stimulation of the median nerve. Results Parietal rest rhythms showed greater total power in patients than in control subjects. In particular, the patient's parietal alpha was higher in the right than in the left hemisphere. Primary sensory cortex excitability, expressed by the M20, appeared significantly reduced in patients with depression, but was still higher in the right than in the left hemisphere. The M30 also appeared reduced, and this reduction was significantly correlated with both depression severity and global illness. Conclusions The patients studied were not completely drug free. For this reason, it is impossible to rule out the possibility that our results are an effect of drug assumption. Nevertheless, since all patients were well below the drugs' steady state levels when the data were recorded, the behaviour of M20 and M30 and their relation with the patients' clinical pictures suggest that an unbalance of the excitatory or inhibitory cortical activity, and especially a potentiation of the parietal afferent to the motor cortex, may be significant hallmarks of depression.
Do recency processes associated with repetitive sensorimotor events modulate the magnitude and functional coupling of brain rhythmicity in human temporal cortex? Intracranial stereo ...electroencephalographic activity (SEEG; 256 Hz sampling rate) was recorded from hippocampus, and inferior (BA20) and middle (BA21) temporal cortex in four epilepsy patients. The repetitive events were represented by predicted imperative somatosensory stimuli (CNV paradigm) triggering hand movements (‘repetitive visuomotor’) or counting (‘repetitive counting’). The non‐repetitive events were ‘rare’ (P3 paradigm) somatosensory stimuli triggering hand movements (‘non‐repetitive visuomotor’) or counting (‘non‐repetitive counting’). Brain rhythmicity was indexed by event‐related desynchronization/synchronization (ERD/ERS) of SEEG data, whereas the functional coupling was evaluated by spectral SEEG coherence between pairs of the mentioned areas. The frequency bands of interest were theta (4–8 Hz), alpha (8–12 Hz), beta (14–30 Hz), and gamma (32–46 Hz). Compared to the non‐repetitive events, the ‘repetitive visuomotor’ events showed a significant beta and gamma ERS in the hippocampus and a significant theta ERD in the inferior temporal cortex. Furthermore, the ‘repetitive visuomotor’ events induced a task‐specific significant gamma coherence among the examined areas. These results suggest that recency processes do modulate the magnitude and functional coupling of brain rhythmicity (especially gamma) in the human temporal cortex.
The 'excitability' and 'conductivity' of motor pathways during transcranial stimulation (TCS) have been investigated in 49 patients affected by multiple sclerosis (34), amyotrophic lateral sclerosis ...(7), spino-cerebellar ataxia (3), primary lateral sclerosis (4) and brain metastasis (1). Hyper-reflexia, spasticity and weakness were correlated with the central motor conduction time (CCT) and with the threshold intensity of TCS required to produce a motor evoked potential (MEP). MEPs to magnetic TCS were recorded from hand and foot muscles during relaxation, contraction and after tendon vibration. Thresholds and CCTs of the patients were compared with those of 30 healthy controls. Increased threshold was found in 37 out of 49 patients (75.5%). Prolongation of the CCT was found in 38 out of 63 clinically affected upper limbs (60.3%) and in 56 out of 77 clinically affected lower limbs (72.7%). Absent motor responses to maximal TCS were found in 20 out of 98 lower limbs (20.4%). Excluding ALS patients (in whom there was a lower threshold for MEP elicitation), a significant linear correlation was found between prolonged CCT and increased threshold. While MEPs with prolonged CCTs have elevated TCS threshold, it is important to note that an elevated threshold was found in 14 out of 49 patients (28.5%) despite unchanged CCT. Spasticity and/or hyper-reflexia were more frequently associated with increased threshold than with prolonged CCT, while weakness was correlated equally well with both these parameters. In this respect magnetic TCS proves to represent a new tool for the detection of abnormal 'excitability' of the central motor tracts.
Motor evoked potentials (MEPs) to transcranial stimulation (TCS) and somatosensory evoked potentials to median nerve stimulation (MN-SEPs) were examined in 74 patients affected by multiple sclerosis ...(MS = 49 cases), amyotrophic lateral sclerosis (ALS = 9 cases), cervical cord lesions (7 cases), Parkinson's disease (PD = 5 cases), Huntington's chorea (HC = 2 cases), Wilson's disease (WD = 1 case), subacute combined degeneration (SCD = 1 case). MN-SEPs were altered in 38% of arms in MS with a higher incidence in clinically affected than in clinically 'silent' arms (= 77.8% vs. 27.5%). MEP alterations were found in 54% of examined arms, mostly because of a prolongation of the motor CCT. This index was invariably altered in the affected arms, whilst it was involved in 40% of the 'silent' ones. Twelve out of 18 arms displayed abnormal MEPs in ALS. These were mainly due to an absent response, even if moderate motor CCT prolongation and 'giant' MEPs were also encountered. MN-SEPs were altered in 3/18 arms. By recording MEPs from proximal and distal upper limb muscles, cues on the level of abnormal propagation were obtained in patients suffering from 'focal' lesions of the spinal cord. Combining SEP records enhanced the diagnostic yield in this field. Both MEPs and SEPs were normal in patients with PD and HC, whilst abnormally prolonged CCTs were found in the case with WD. MEP and SEP recording revealed central propagation abnormalities coupled to a severe clinical picture of the peripheral nerve involvement (as in the case of SCD).
