Statins in acute coronary syndrome: very early initiation and benefits.

The use of 3-hydroxy-3-methylglutaryl coenzyme A reductase (statins) is associated with a marked reduction in morbidity and mortality in patients at high cardiovascular risk or with established cardiovascular disease. In the last decade, several randomized controlled studies have demonstrated the benefit of statins in patients with acute coronary syndrome (ACS). These studies showed that use of statins in patients with ACS is associated with a significant reduction of the risk of recurrent cardiovascular events. Current American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend (Level of Evidence 1A) the use of statin therapy before hospital discharge for all patients with ACS regardless of the baseline low-density lipoprotein. Although there is no consensus on the preferable time of administration of statins during ACS, some clinical trials and pooled analyses provided substantial support for the institution of an early initiation to improve strategies that target the pathophysiologic mechanism operating during myocardial infarction. In particular, recent findings suggested that the earlier the treatment is started after the diagnosis of ACS the greater the expected benefit. Experimental studies with statins in ACS have shown several other effects that could extend the clinical benefit beyond the lipid profile modification itself. In particular, statins demonstrated the ability to induce anti-inflammatory effects, modulate endothelium and inhibit the thrombotic signaling cascade. Given these recognized potential benefit, statins should conceivably modulate the pathophysiological processes involved in the very early phase of plaque rupture and coronary thrombosis

A Rare Case of Severe Diarrhea: Gastrocolic Fistula Caused by Migration of Percutaneous Endoscopic Gastrostomy Tube

Gastrocolic fistula is a rare complication of the percutaneous endoscopic gastrostomy (PEG) placement procedure. This complication occurs due to penetration of interposed colon when a PEG tube is placed into the stomach. It can go unrecognized, becoming evident only when a tube replacement is performed or tube migration occurs. We report a case of severe, intractable diarrhea occurring about one month after the PEG procedure in a patient with severe traumatic brain injury. We present our case and discuss its significance with the aim of raising clinicians’ awareness of this rare condition

Iliacus Muscle Hematoma an Uncommon Complication in a Rehabilitation Unit: A Case Report Study

Iliacus muscle hematoma is a very rare condition in rehabilitation wards. A 35-year-old pregnant woman at seven months with cerebellar hematoma with signs of compression underwent a cesarean procedure together with neurosurgical decompression of the posterior cranial fossa procedure. After a period in an intensive unit without any complications, she was admitted to our neurorehabilitation ward and treated with antihypertensive therapy, heparin, and anti-seizure drugs. During a rehabilitation session, after a bed–wheelchair transfer, she was feeling very unwell suffering from severe right leg pain radiating to the mid-face leg. Despite unremarkable physical evidence (skin appearance, temperature, and peripheral arterial pulse in both legs), imaging data (ultrasound, CT, and MRI) confirmed the presence of a right iliac muscle hematoma (IMH). Enoxaparin was immediately stopped, and bed rest was prescribed in an antalgic position with tramadole acetaminophen for pain control. After a few days, the patient felt well and was discharged without any additional symptoms. Our study demonstrates that, when a sudden severe leg pain develops, IMH should be considered in the differential diagnosis. This finding suggests further research and tailored protocols for rehabilitation in patients at high risk for iliacus muscle hematoma

The Reliability of the Progression of Autonomies Scale Applied on Acquired Brain Injured Patients

The Progression of Autonomies Scale (PAS) is a behavioral scale useful to assess the autonomy levels in acquired brain-injured patients. It provides a broad profile, assessing different domains of human activities ranging from personal, domestic, and extradomestic autonomies. This cross-sectional study is aimed at evaluating the reliability of this scale on a large cohort of acquired brain injury (ABI) patients. Fifty-one ABI patients (49% traumatic, 33.3% hemorrhagic, 17.7% other etiologies), hospitalized in the S. Anna Institute of Crotone, Italy (mean age male 46.08 ± 14.53 and mean age female patients 43.2 ± 11.3) were recruited. We found a high level of reliability of the scale, with a coefficient at the inter-rater agreement between substantial (0.61 ≤ k ≤ 0.8) and almost perfect (0.81 ≤ k ≤ 1), and almost perfect at the test-retest (intra-rater). We confirm that the PAS is a well-structured tool for the assessment of the autonomy levels in brain-injured patients. These findings encourage the application of this scale in the clinical practice of rehabilitation unit to design a tailored rehabilitation treatment on real goals and to monitor the generalization of the recovered abilities to the daily routine activities

Predicting Outcome of Traumatic Brain Injury: Is Machine Learning the Best Way?

One of the main challenges in traumatic brain injury (TBI) patients is to achieve an early and definite prognosis. Despite the recent development of algorithms based on artificial intelligence for the identification of these prognostic factors relevant for clinical practice, the literature lacks a rigorous comparison among classical regression and machine learning (ML) models. This study aims at providing this comparison on a sample of TBI patients evaluated at baseline (T0), after 3 months from the event (T1), and at discharge (T2). A Classical Linear Regression Model (LM) was compared with independent performances of Support Vector Machine (SVM), k-Nearest Neighbors (k-NN), Naïve Bayes (NB) and Decision Tree (DT) algorithms, together with an ensemble ML approach. The accuracy was similar among LM and ML algorithms on the analyzed sample when two classes of outcome (Positive vs. Negative) approach was used, whereas the NB algorithm showed the worst performance. This study highlights the utility of comparing traditional regression modeling to ML, particularly when using a small number of reliable predictor variables after TBI. The dataset of clinical data used to train ML algorithms will be publicly available to other researchers for future comparisons

Outcome prediction in disorders of consciousness: the role of coma recovery scale revised

Abstract Background To evaluate the utility of the revised coma remission scale (CRS-r), together with other clinical variables, in predicting emergence from disorders of consciousness (DoC) during intensive rehabilitation care. Methods Data were retrospectively extracted from the medical records of patients enrolled in a specialized intensive rehabilitation unit. 123 patients in a vegetative state (VS) and 57 in a minimally conscious state (MCS) were included and followed for a period of 8 weeks. Demographical and clinical factors were used as outcome measures. Univariate and multivariate Cox regression models were employed for examining potential predictors for clinical outcome along the time. Results VS and MCS groups were matched for demographical and clinical variables (i.e., age, aetiology, tracheostomy and route of feeding). Within 2 months after admission in intensive neurorehabilitation unit, 3.9% were dead, 35.5% had a full recovery of consciousness and 66.7% remained in VS or MCS. Multivariate analysis demonstrated that the best predictor of functional improvement was the CRS-r scores. In particular, patients with values greater than 12 at admission were those with a favourable likelihood of emergence from DoC. Conclusions Our study highlights the role of the CRS-r scores for predicting a short-term favorable outcome

The Timecourse of Electrophysiological Brain–Heart Interaction in DoC Patients

Disorders of Consciousness (DOC) are a spectrum of pathologies affecting one’s ability to interact with the external world. Two possible conditions of patients with DOC are Unresponsive Wakefulness Syndrome/Vegetative State (UWS/VS) and Minimally Conscious State (MCS). Analysis of spontaneous EEG activity and the Heart Rate Variability (HRV) are effective techniques in exploring and evaluating patients with DOC. This study aims to observe fluctuations in EEG and HRV parameters in the morning/afternoon resting-state recording. The study enrolled 13 voluntary Healthy Control (HC) subjects and 12 DOC patients (7 MCS, 5 UWS/VS). EEG and EKG were recorded. PSDalpha, PSDtheta powerband, alpha-blocking, alpha/theta of the EEG, Complexity Index (CI) and SDNN of EKG were analyzed. Higher values of PSDalpha, alpha-blocking, alpha/theta and CI values and lower values of PSD theta characterized HC individuals in the morning with respect to DOC patients. In the afternoon, we detected a significant difference between groups in the CI, PSDalpha, PSDtheta, alpha/theta and SDNN, with lower PSDtheta value for HC. CRS-R scores showed a strong correlation with recorded parameters mainly during evaluations in the morning. Our finding put in evidence the importance of the assessment, as the stimulation of DOC patients in research for behavioural response, in the morning

External Validation and Calibration of the DecaPreT Prediction Model for Decannulation in Patients with Acquired Brain Injury

We propose a new set of clinical variables for a more accurate early prediction of safe decannulation in patients with severe acquired brain injury (ABI), during a post-acute rehabilitation course. Starting from the already validated DecaPreT scale, we tested the accuracy of new logistic regression models where the coefficients of the original predictors were reestimated. Patients with tracheostomy were retrospectively selected from the database of the neurorehabilitation unit at the S. Anna Institute of Crotone, Italy. New potential predictors of decannulation were screened from variables collected on admission during clinical examination, including (a) age at injury, (b) coma recovery scale-revised (CRS-r) scores, and c) length of ICU period. Of 273 patients with ABI (mean age 53.01 years; 34% female; median DecaPreT = 0.61), 61.5% were safely decannulated before discharge. In the validation phase, the linear logistic prediction model, created with the new multivariable predictors, obtained an area under the receiver operating characteristics curve of 0.901. Our model improves the reliability of simple clinical variables detected at the admission of the post-acute phase in predicting decannulation of ABI patients, thus helping clinicians to plan better rehabilitation

Influence of Oxidative Stress and Inflammation on Nutritional Status and Neural Plasticity: New Perspectives on Post-Stroke Neurorehabilitative Outcome

Beyond brain deficits caused by strokes, the effectiveness of neurorehabilitation is strongly influenced by the baseline clinical features of stroke patients, including a patient’s current nutritional status. Malnutrition, either as a pre-stroke existing condition or occurring because of ischemic injury, predisposes patients to poor rehabilitation outcomes. On the other hand, a proper nutritional status compliant with the specific needs required by the process of brain recovery plays a key role in post-stroke rehabilitative outcome favoring neuroplasticity mechanisms. Oxidative stress and inflammation play a role in stroke-associated malnutrition, as well as in the cascade of ischemic events in the brain area, where ischemic damage leads to neuronal death and brain infarction, and, via cell-to-cell signaling, the alteration of neuroplasticity processes underlying functional recovery induced by multidisciplinary rehabilitative treatment. Nutrition strategies based on food components with oxidative and anti-inflammatory properties may help to reverse or stop malnutrition and may be a prerequisite for supporting the ability of neuronal plasticity to result in satisfactory rehabilitative outcome in stroke patients. To expand nutritional recommendations for functional rehabilitation recovery, studies considering the evolution of nutritional status changes in post-stroke patients over time are required. The assessment of nutritional status must be included as a routine tool in rehabilitation settings for the integrated care of stroke-patients