Antonio Muscari

Changes of liver enzymes and bilirubin during ischemic stroke: mechanisms and possible significance

BackgroundSmall changes of bilirubin and liver enzymes are often detected during the acute phase of stroke, but their origin and significance are still poorly understood.MethodsOn days 0, 3, 7, and 14 after admission, 180 patients with ischemic stroke underwent serial determinations of bilirubin, GOT, GPT, γGT, alkaline phosphatase, C-reactive protein (CRP) and complete blood count. On days 0 and 7 common bile duct diameter was measured by ultrasound, and on day 3 cerebral infarct volume (IV) was calculated from CT scan slices.ResultsDuring the first week GOT, GPT, γGT (Pu2009<u20090.001) and CRP (Pu2009=u20090.03) increased with subsequent plateau, while significant decrements (Pu2009<u20090.001) concerned unconjugated bilirubin, erythrocytes and haemoglobin. Alkaline phosphatase, direct bilirubin and common bile duct diameter remained stable. IV correlated with CRP, leukocytes, GOT, γGT (ru2009>u20090.3, Pu2009<u20090.001 for all) and direct bilirubin (ru2009=u20090.23, Pu2009=u20090.008). In multivariate analysis only CRP and GOT remained independently associated with IV (Pu2009<u2009=0.001). The correlation of IV with GOT increased progressively from admission to day 14. GOT independently correlated with GPT which, in turn, correlated with γGT. γGT was also highly correlated with leukocytes. Unconjugated bilirubin correlated with haemoglobin, which was inversely correlated with CRP.ConclusionsThe changes of bilirubin and liver enzymes during ischemic stroke reflect two phenomena, which are both related to IV: 1) inflammation, with consequent increment of CRP, leukocytes and γGT, and decrease of haemoglobin and unconjugated bilirubin and 2) an unknown signal, independent from inflammation, leading to increasing GOT and GPT levels.

No Direct Survival Effect of Light to Moderate Alcohol Drinking in Community‐Dwelling Older Adults

To assess the relationship between light to moderate alcohol consumption and mortality, particularly accounting for baseline health status and physical activity.

Short- and Long-Term Stroke Risk after Urgent Management of Transient Ischaemic Attack: The Bologna TIA Clinical Pathway

Background: Rapid management can reduce the short stroke risk after transient ischaemic attack (TIA), but the long-term effect is still little known. We evaluated 3-year vascular outcomes in patients with TIA after urgent care. Methods: We prospectively enrolled all consecutive patients with TIA diagnosed by a vascular neurologist and referred to our emergency department (ED). Expedited assessment and best secondary prevention was within 24 h. Endpoints were stroke within 90 days, and stroke, myocardial infarction, and vascular death at 12, 24 and 36 months. Results: Between August 2010 and July 2013, we evaluated 686 patients with suspected TIA; 433 (63%) patients had confirmed TIA. Stroke at 90 days was 2.07% (95% confidence interval (CI), 1.1-3.9) compared with the ABCD2-predicted risk of 9.1%. The long-term stroke risk was 2.6% (95% CI, 1.1-4.2), 3.7% (95% CI, 1.6-5.9) and 4.4% (95% CI, 1.9-6.8) at 12, 24 and 36 months, respectively. The composite outcome of stroke, myocardial infarction, and vascular death was 3.5% (95% CI, 1.7-5.1), 4.9% (95% CI, 2.5-7.4), and 5.6% (95% CI, 2.8-8.3) at 12, 24, and 36 months, respectively. Conclusions: TIA expedited management driven by vascular neurologists was associated with a marked reduction in the expected early stroke risk and low long-term risk of stroke and other vascular events.

A comparison of risk factors as predictors of cardiovascular and non-cardiovascular mortality in the elderly people--relevance of N-terminal pro-B-type natriuretic peptide and low systolic blood pressure.

Many risk factors are known to predict ischaemic events and mortality in the elderly people, but their ranking of importance remains uncertain. This study was designed to identify and compare the main predictors of total mortality (TM), cardiovascular mortality (CVM) and non‐cardiovascular mortality (NCVM) in older adults.

Stroke/Thromboembolism and Intracranial Hemorrhage in a Real-world Atrial Fibrillation Population: The Complications of Atrial Fibrillation in the Bologna Area (CAFBO) Study

BACKGROUNDnIschemic events (IEs) and intracranial hemorrhages (ICHs) are feared complications of atrial fibrillation (AF) and of antithrombotic treatment in patients with these conditions.nnnMETHODSnPatients with AF admitted to the EDs of the Bologna, Italy, area with acute IE or ICH were prospectively recorded over 6 months.nnnRESULTSnA total of 178 patients (60 male patients; median age: 85 years) presented with acute IE. Antithrombotic therapy was as follows: (1) vitamin K antagonists (VKAs) in 31 patients (17.4%), with international normalized ratio (INR) at admission of < 2.0 in 16 patients, 2.0 to 3.0 in 13 patients, and > 3.0 in two patients; (2) aspirin (acetylsalicylic acid) (ASA) in 107 patients (60.1%); and (3) no treatment in 40 patients (22.5%), mainly because AF was not diagnosed. Twenty patients (eight male patients; median age: 82 years) presented with acute ICH: 13 (65%) received VKAs (INR, 2.0-3.0 in 11 patients and > 3.0 in two patients), while six (30%) received ASA. Most IEs (88%) and ICHs (95%) occurred in patients aged > 70 years. A modeling analysis of patients aged > 70 years was used to estimate annual incidence in subjects anticoagulated with VKAs in our Network of Anticoagulation Centers (NACs), or those expected to have AF but not included in NACs. The expected incidence of IE was 12.0%/y (95% CI, 10.7-13.3) in non-NACs and 0.57%/y (95% CI, 0.42-0.76) in NACs (absolute risk reduction [ARR], 11.4%/y; relative risk reduction [RRR], 95%; P < .0001). The incidence of ICH was 0.63%/y (95% CI, 0.34-1.04) and 0.30%/y (95% CI, 0.19-0.44), respectively (ARR, 0.33%/y; RRR, 52.4%/y; P = .04).nnnCONCLUSIONSnIEs occurred mainly in elderly patients who received ASA or no treatment. One-half of patients with IEs receiving anticoagulant treatment had subtherapeutic INRs. Therapeutic approaches to elderly subjects with AF require an effective anticoagulant treatment strategy.

Diastolic dysfunction and cardiovascular risk in old subjects: Possible association with NAFLD?

Non-alcoholic fatty liver disease (NAFLD) is frequently associated with metabolic syndrome (MS) and may represent a cardiovascular (CV) risk factor. Functional cardiac abnormalities have been reported in patients with NAFLD. The aim of this paper is to investigate whether these findings are present also in elderly people. We tested 171 subjects aging more than 65 years, enrolled in a prospective study on CV risk reduction, for laboratory examination, abdominal ultrasound for evaluation of hepatic steatosis and standard echocardiography for determining morphological and functional cardiac parameters. Higher BMI, serum levels of glucose, triglycerides, cholesterol, insulin and visceral adipose tissue and lower serum levels of HDL-cholesterol were significantly associated with NAFLD. Furthermore, subjects with NAFLD had higher prevalence of diabetes, pathological waist-circumference, insulin-resistance and positive ATP-III criteria. While NAFLD had only a borderline significant association with higher end-diastolic thicknesses of left-ventricle posterior wall (edPW) and right-ventricle wall, higher values of edPW and end-diastolic thickness of interventricular septum were significantly correlated with glucose levels above 100mg/dl, hypertension, MS and insulin-resistance. Moreover, subjects with MS and/or pathological waist-circumference had a lower early-diastolic mitral annular motion, whereas those with insulin-resistance had lower E/A ratio and early-diastolic filling peak velocity. Regression analyses identify hypertension and pathological waist-circumference as factors independently associated to pathological edPW, and hypertriglyceridemia to pathological left-ventricle mass. In conclusion, an ultrasonographic diagnosis of NAFLD in old subjects may be an alert on the coexistence of multiple CV risk factors and on the presence of possible alterations of cardiac morphology and diastolic function.

Hypertension and Other Determinants of White Matter Lesions in Stroke Patients.

Hypertension is the main risk factor for both white matter lesions (WMLs) and stroke, but many stroke patients do not have WMLs. To find specific determinants of WMLs, the authors assessed 321 ischemic and hemorrhagic stroke patients who had undergone echocardiography. The patients with WMLs (n=160) were more often hypertensive and had a higher systolic blood pressure than the patients without WMLs. However, in a multivariate analysis, only the following variables remained associated with WMLs: (1) age: odds ratio [OR], 1.08 per year (95% confidence interval [CI], 1.06–1.11); (2) left ventricular relative wall thickness (RWT) ≥0.52: OR, 2.78 (95% CI, 1.59–4.88); (3) lacunar strokes: OR, 4.15 (95% CI, 1.83–9.44); (4) hemorrhagic strokes: OR, 5.36 (95% CI, 1.57–18.39); and (5) female: OR, 1.91 (95% CI, 1.12–3.27). Thus, the main modifiable risk factor for WMLs was RWT, which proved to be an even stronger risk factor than hypertension. This suggests that RWT might be a useful target in the treatment of hypertension to counteract the appearance of WMLs.

Factors predisposing to small lacunar versus large non-lacunar cerebral infarcts: is left ventricular mass involved?

Abstract Objectives: To find some specific determinants of lacunar strokes (LS), this study compared LS and non-LS patients using the size and location of cerebral lesions as discriminant between the two groups. Methods: The main cardiovascular risk factors and some echocardiographic parameters were assessed in 225 ischemic stroke patients aged 75·1±11·4 (SD) years, including 101 patients with symptoms and lesions of lacunar type (deep hypodensities with diameter ≤ 1·5 cm) and 124 patients with non-lacunar lesions. Results: LS patients tended to be younger and had a higher prevalence of smokers than non-LS patients. In a subgroup undergoing echocardiogram, those with LS had a higher left ventricular mass index (LVMI) than non-LS patients (141·6±44·9 vs. 115·1±31·8 g/m2, P u200a=u200a 0·005). The prevalence of hypertension, diabetes, and carotid stenoses > 50% was similar in the two groups. In multivariable analysis the ever-smoker status (OR u200a=u200a 1·9, P u200a=u200a 0·02), atrial fibrillation (inverse association, OR u200a=u200a 0·5, P u200a=u200a 0·03), LVMI ≧ 130 g/m2 (OR u200a=u200a 6·6, P u200a=u200a 0·001), and age ≤ 72 years (OR u200a=u200a 5·9, P u200a=u200a 0·003) remained independently associated with LS. Conclusions: The patients with lacunar cerebral lesions had a greater left ventricular mass than those with non-lacunar lesions, while blood pressure values did not differ. Lacunar lesions were also associated with smoking and a younger age.

Physical Activity and Other Determinants of Survival in the Oldest Adults

To determine the role of physical activity as a possible survival determinant in the oldest adults.

Clinical predictors of fever in stroke patients: relevance of nasogastric tube

Fever frequently occurs in stroke patients and worsens their prognosis. However, only few studies have assessed the determinants of fever in acute stroke, and no study has specifically addressed the possible prediction of the development of fever.