Impact of atrial fibrillation in critically ill patients admitted to a stepdown unit

Background: Limited data are available on the clinical course of patients with history of atrial fibrillation (AF) when admitted in an intensive care environment. We aimed to describe the occurrence of major adverse events in AF patients admitted to a stepdown care unit (SDU) and to analyse clinical factors associated with outcomes, impact of dicumarolic oral anticoagulant (OAC) therapy impact and performance of clinical risk scores in this setting. Materials and methods: Single-centre, observational retrospective analysis on a population of subjects with AF history admitted to a SDU. Therapeutic failure (composite of transfer to ICU or death) was considered the main study outcome. Occurrence of stroke and major bleeding (MH) was considered as secondary outcomes. The performance of clinical risk scores was evaluated. Results: A total of 1430 consecutive patients were enrolled. 194 (13.6%) reported the main outcome. Using multivariate logistic regression, age (odds ratio [OR]: 1.03, 95% confidence interval [CI]: 1.01-1.05), acute coronary syndrome (OR:3.10, 95% CI: 1.88-5.12), cardiogenic shock (OR:10.06, 95% CI: 5.37-18.84), septic shock (OR:5.19,95%CI:3.29-18.84), acute respiratory failure (OR:2.49, 95% CI: 1.67-3.64) and OAC use (OR: 1.61, 95% CI: 1.02-2.55) were independently associated with main outcome. OAC prescription was associated with stroke risk reduction and to both MH and main outcome risk increase. CHA2 DS2 -VASc (c-index: 0.545, P = .117 for stroke) and HAS-BLED (c-index:0.503, P = .900 for MH) did not significantly predict events occurrence. Conclusions: In critically ill AF patients admitted to a SDU, adverse outcomes are highly prevalent. OAC use is associated to an increased risk of therapeutic failure, clinical scores seem unhelpful in predicting stroke and MH, suggesting a highly individualized approach in AF management in this setting

Validation of a self-reported instrument to assess work-related difficulties in patients with migraine: the HEADWORK questionnaire

Background: The degree to which work-related difficulties are recognized in headache research is poor and often carried out with inadequate information such as "reduced ability to work as usual", which do not capture at all the variety of difficulties and the factors that impact over them. The aim of this paper is to present the validation of the HEADWORK questionnaire, which addresses the amount and severity of difficulties in work-related tasks and the factors that impact over them.Methods: We developed a set of items based on a previous literature review and patients' focus groups and tested it on a wide set of patients with episodic and chronic migraine attending eight different Italian headache centers. HEADWORK factor structure was assessed with exploratory and confirmatory factor analysis; internal consistency and construct validity were addressed as well.Results: The validation sample (N= 373) was mostly composed of patients with episodic migraine without aura (64.3%) and of females (81%). Factor analysis retrieved two different scales: "Work-related difficulties", composed of eleven items which explain 67.1% of the total variance, and "Factors contributing to work difficulties", composed of six items which explain 52.1% of the total variance. Both HEADWORK subscales have good measurement properties, with higher scores being associated to higher disability, lower quality of life, lower productivity, higher headache frequency and pain intensity.Conclusions: HEADWORK is a 17-item, two-scale questionnaire addressing the impact of migraine on work-related difficulties in terms of difficulties in general or specific skills, and the factors contributing to these difficulties, defined as negative impact on work tasks. It can be used to address disability weights for the purpose of calculating the burden of migraine, and to assess the balance between therapeutic and side effects of medication on productivity

Cerebral vascular reactivity and cognitive performance in patients with extracranial asymptomatic carotid stenosis

Background: Preliminary studies have reported cognitive dysfunction in unilateral asymptomatic carotid stenosis (ACS). Impaired cerebral hemodynamic status measured by cerebrovascular reactivity has been associated with cognitive dysfunction in unilateral ACS. Aims: (1) To evaluate cognitive performance in bilateral ACS compared to unilateral ACS and healthy subjects and (2) to explore the relationship between cognitive performance and cerebral hemodynamic status in bilateral ACS. Methods: Asymptomatic patients with ultrasound evidence of bilateral or unilateral ACS (60 %-99 % diameter reduction) were prospectively collected. Healthy subjects (HS) comparable for demographics and vascular risk profile served as controls. A neuropsychological investigation included phonemic and categorical Verbal Fluency (VF) tests to explore the left hemisphere and Colored Progressive Matrices (CPM), and Complex Figure Test Copy (CFTC) tests to explore the right hemisphere. Cerebrovascular reactivity (CVR) to hypercapnia using the transcranial Doppler (TCD) based breath-holding index (BHI) test was performed in each subject. Impaired CVR was defined as a BHI\0.69. Generalized linear multivariate and univariate models were employed to evaluate the mean difference on left and right cognitive test abilities in bilateral ACS patients with left and right preserved or impaired CVR. Vascular risk factors, education years, mini-mental status examination (MMSE), and current medications were included as covariates. Results: 333 consecutive subjects were included: 126 bilateral ACS; 73/75 left/right unilateral ACS; 56 HS; mean age: 70 \ub1 3.78 years; males: 65 %; education years: 10.3 \ub1 3.7; MMSE score: 26.7 \ub1 1.27. Bilateral and unilateral ACS patients showed significantly lower scores in all cognitive tests compared to HS (p\0.05). In the multivariate analysis, among bilateral ACS an impaired CVR in the right side was associated with a significantly reduced CPM score: from an estimated mean of 32.6 [95 % Confidence Interval (CI): 29.8\u201335.4) to 23.0 (95 % CI: 20.2\u201325.8) and the CFTC score from 34.7 (95 % CI: 32.0\u201337.4) to 26.0 (95 % CI: 23.3\u201328.7). Similarly, an impaired CVR on the left side was associated with a reduced phonemic VF score: 13.5 (95 % CI: 11.2\u201315.8) to 7.5 (95 % CI: 5.4\u20139.7) and categorical VF score from 21.1 (95 % CI: 18.1\u201324.1) to 12.3 (95 % CI: 9.5\u201315.1). All comparisons were statistically significant (p\0.05). Conclusions: Patients with unilateral or bilateral ACS are more likely to suffer cognitive dysfunction compared to healthy controls. Impaired CVR predicts the development of cognitive dysfunction in bilateral ACS. A non-invasive assessment of CVR using the TCDbased BHI test may contribute to a more comprehensive risk stratification in these patients

Cerebral hemodynamics and cognitive performances in bilateral asymptomatic carotid stenosis.

Cerebral hemodynamics and cognitive performance in bilateral asymptomatic carotid stenosis. Balucani C, Viticchi G, Falsetti L, Silvestrini M. From the Department of Neurology (C.B.), University of Perugia, Perugia, Italy; Department of Neurology and Stroke Center (C.B.), SUNY Downstate Medical Center, Brooklyn, NY; Neurological Clinic (G.V., M.S.), Marche Polytechnic University, Ancona; and Internal and Subintensive Medicine (L.F.), Ospedali Riuniti, Ancona, Italy. OBJECTIVES: To evaluate cognitive performance in subjects with bilateral asymptomatic carotid stenosis (B-ACS) compared to subjects with unilateral ACS and to subjects with no carotid stenosis (CS) and to explore the relationship between cognitive performance and cerebral hemodynamics status in B-ACS. METHODS: The neuropsychological investigation included phonemic (ph) and categorical (ca) Verbal Fluency (VF) tests for exploring the left brain functions and Colored Progressive Matrices (CPM) and Complex Figure Copy Test (CFCT) for the right brain. Cerebral hemodynamics status was assessed using the transcranial Doppler-based breath-holding index test. RESULTS: A total of 333 subjects were included: 127 B-ACS, 73/77 left/right unilateral ACS, 56 no CS, mean age 70 ± 3.78 years, 65% male. Subjects with B-ACS and subjects with unilateral ACS showed significantly lower scores in all cognitive tests compared to subjects with no CS (p < 0.05). Subjects with B-ACS with left impaired hemodynamics status showed a significantly reduced ph-VF score, from 13.4 (95% confidence interval [CI] 11.2-15.8) to 7.5 (95% CI 5.4-9.7), and a reduced ca-VF score, from 19.7 (95% CI 18.1-24.1) to 10.8 (95% CI 9.5-15.1), compared to subjects with no CS. Similarly, impaired cerebral hemodynamics in the right side was associated with a significantly reduced CPM score, from an estimated mean of 34.2 (95% CI 29.8-35.4) to 24.6 (95% CI 20.2-25.8), and CFCT score from 37.0 (95% CI 32.0-37.4) to 27.1 (95% CI 23.3-28.7). All comparisons were p < 0.05. CONCLUSION: Subjects with B-ACS and subjects with unilateral ACS are more likely to have cognitive dysfunction compared to subjects with no CS. There appears to be a link between cognitive dysfunction and hemodynamics impairment due to carotid stenosis

Cerebrovascular assessment for the risk prediction of Alzheimer’s disease.

Cerebrovascular Assessment for the Risk Prediction of Alzheimer's Disease. Silvestrini M, Viticchi G, Altamura C, Luzzi S, Balucani C, Vernieri F. Neurological Clinic, Marche Polytechnic University, Ancona, Italy. Increasing evidence is emerging that vascular disease and its risk factors play a role in the development of Alzheimer's disease (AD) and affect the probability of an adverse outcome. The aims of this review are to explore the relationship between vascular risk factors and AD and to discuss the potential use of vascular markers in the clinical approach to cognitive impairment. Moreover, we present evidence about the potential use of ultrasonographic and neuroradiologic markers of cognitive impairment in order to establish possible treatment strategies in subjects with a clinical profile at risk of developing AD