Evolution in Cardiovascular Care for Elderly Patients With Non–ST-Segment Elevation Acute Coronary Syndromes: Results From the CRUSADE National Quality Improvement Initiative

OBJECTIVES This study evaluated the impact of age on care and outcomes for non-ST-segment elevation acute coronary syndromes (NSTE ACS). BACKGROUND Recent clinical trials have expanded treatment options for NSTE ACS, now reflected in guidelines. Elderly patients are at highest risk, yet have previously been shown to receive less care than younger patients. METHODS In 56,963 patients with NSTE ACS at 443 U.S. hospitals participating in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) National Quality Improvement Initiative from January 2001 to June 2003, we compared use of guidelines-recommended care across four age groups: <65, 65 to 74, 75 to 84, and ≥85 years. A multivariate model tested for age-related differences in treatments and outcomes after adjusting for patient, provider, and hospital factors. RESULTS Of the study population, 35% were ≥75 years old, and 11% were ≥85 years old. Use of acute anti-platelet and anti-thrombin therapy within the first 24 h decreased with age. Elderly patients were also less likely to undergo early catheterization or revascularization. Whereas use of many discharge medications was similar in young and old patients, clopidogrel and lipid-lowering therapy remained less commonly prescribed in elderly patients. In-hospital mortality and complication rates increased with advancing age, but those receiving more recommended therapies had lower mortality even after adjustment than those who did not. CONCLUSIONS Age impacts use of guidelines-recommended care for newer agents and early in-hospital care. Further improvements in outcomes for elderly patients by optimizing the safe and early use of therapies are likely

Homotopic contralesional excitation suppresses spontaneous circuit repair and global network reconnections following ischemic stroke

Understanding circuit-level manipulations that affect the brain\u27s capacity for plasticity will inform the design of targeted interventions that enhance recovery after stroke. Following stroke, increased contralesional activity (e.g. use of the unaffected limb) can negatively influence recovery, but it is unknown which specific neural connections exert this influence, and to what extent increased contralesional activity affects systems- and molecular-level biomarkers of recovery. Here, we combine optogenetic photostimulation with optical intrinsic signal imaging to examine how contralesional excitatory activity affects cortical remodeling after stroke in mice. Following photothrombosis of left primary somatosensory forepaw (S1FP) cortex, mice either recovered spontaneously or received chronic optogenetic excitation of right S1FP over the course of 4 weeks. Contralesional excitation suppressed perilesional S1FP remapping and was associated with abnormal patterns of stimulus-evoked activity in the unaffected limb. This maneuver also prevented the restoration of resting-state functional connectivity (RSFC) within the S1FP network, RSFC in several networks functionally distinct from somatomotor regions, and resulted in persistent limb-use asymmetry. In stimulated mice, perilesional tissue exhibited transcriptional changes in several genes relevant for recovery. Our results suggest that contralesional excitation impedes local and global circuit reconnection through suppression of cortical activity and several neuroplasticity-related genes after stroke, and highlight the importance of site selection for targeted therapeutic interventions after focal ischemia

Ice Lines, Planetesimal Composition and Solid Surface Density in the Solar Nebula

To date, there is no core accretion simulation that can successfully account for the formation of Uranus or Neptune within the observed 2-3 Myr lifetimes of protoplanetary disks. Since solid accretion rate is directly proportional to the available planetesimal surface density, one way to speed up planet formation is to take a full accounting of all the planetesimal-forming solids present in the solar nebula. By combining a viscously evolving protostellar disk with a kinetic model of ice formation, we calculate the solid surface density in the solar nebula as a function of heliocentric distance and time. We find three effects that strongly favor giant planet formation: (1) a decretion flow that brings mass from the inner solar nebula to the giant planet-forming region, (2) recent lab results (Collings et al. 2004) showing that the ammonia and water ice lines should coincide, and (3) the presence of a substantial amount of methane ice in the trans-Saturnian region. Our results show higher solid surface densities than assumed in the core accretion models of Pollack et al. (1996) by a factor of 3 to 4 throughout the trans-Saturnian region. We also discuss the location of ice lines and their movement through the solar nebula, and provide new constraints on the possible initial disk configurations from gravitational stability arguments.Comment: Version 2: reflects lead author's name and affiliation change, contains minor changes to text from version 1. 12 figures, 7 tables, accepted for publication in Icaru