Modulation of Stretch Reflexes of the Finger Flexors by Sensory Feedback from the Proximal Upper Limb Poststroke

Neural coupling of proximal and distal upper limb segments may have functional implications in the recovery of hemiparesis after stroke. The goal of the present study was to investigate whether the stretch reflex response magnitude of spastic finger flexor muscles poststroke is influenced by sensory input from the shoulder and the elbow and whether reflex coupling of muscles throughout the upper limb is altered in spastic stroke survivors. Through imposed extension of the metacarpophalangeal (MCP) joints, stretch of the relaxed finger flexors of the four fingers was imposed in 10 relaxed stroke subjects under different conditions of proximal sensory input, namely static arm posture (3 different shoulder/elbow postures) and electrical stimulation (surface stimulation of biceps brachii or triceps brachii, or none). Fast (300°/s) imposed stretch elicited stretch reflex flexion torque at the MCP joints and reflex electromyographic (EMG) activity in flexor digitorum superficialis. Both measures were greatest in an arm posture of 90° of elbow flexion and neutral shoulder position. Biceps stimulation resulted in greater MCP stretch reflex flexion torque. Fast imposed stretch also elicited reflex EMG activity in nonstretched heteronymous upper limb muscles, both proximal and distal. These results suggest that in the spastic hemiparetic upper limb poststroke, sensorimotor coupling of proximal and distal upper limb segments is involved in both the increased stretch reflex response of the finger flexors and an increased reflex coupling of heteronymous muscles. Both phenomena may be mediated through changes poststroke in the spinal reflex circuits and/or in the descending influence of supraspinal pathways

Interactions between imagined movement and the initiation of voluntary movement: A TMS study

Objective: The purpose was to examine motor imagery-induced enhancement in corticospinal excitability during a reaction time (RT) task. Methods: Nine young and healthy Subjects performed an isometric finger flexion tasks in response to a visual imperative cue. In the pre-cue period, they were instructed to: (I) rest; (2) imagine flexing their fingers isometrically (ImFlex): or (3) imagine extending their fingers isometrically (ImExt). Surface EMGs from the finger flexors and extensors were monitored to ensure EMG silence before movement onset. Transcranial magnetic stimulation (TMS) was used to evaluate changes in motor-evoked potentials (MEP) in the finger flexor and extensor muscles during the response phase. TMS was delivered either with the imperative cue, or 120 ms before and after the imperative cue. Results: RT was slower when they were imagining finger extension prior to the visual imperative cue. MEPs were significantly increased for the finger flexors during imagined finger flexion and for the finger extensors during imagined finger extension at both TMS delivery time points, reflecting movement specific enhancement in corticospinal excitability during motor imagery. When TMS was delivered 120 ms after the cue, finger flexor MEN were further facilitated under the Rest and ImFlex conditions, but not under the ImExt condition, suggesting additive interactions between imagery-induced enhancement and early rise in corticospinal excitability during the initiation of a reaction time response. Conclusions: Our results provide neurophysiological evidence mediating dynamic interactions between imagined movement and the initiation of voluntary movement. Significance: Motor imagery can be integrated into a rehabilitation protocol to facilitate motor recovery. (C) 2009 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd. All rights reserved

A new classification of cardio-oncology syndromes

Abstract Increasing evidence suggests a multifaceted relationship exists between cancer and cardiovascular disease (CVD). Here, we introduce a 5-tier classification system to categorize cardio-oncology syndromes (COS) that represent the aspects of the relationship between cancer and CVD. COS Type I is characterized by mechanisms whereby the abrupt onset or progression of cancer can lead to cardiovascular dysfunction. COS Type II includes the mechanisms by which cancer therapies can result in acute or chronic CVD. COS Type III is characterized by the pro-oncogenic environment created by the release of cardiokines and high oxidative stress in patients with cardiovascular dysfunction. COS Type IV is comprised of CVD therapies and diagnostic procedures which have been associated with promoting or unmasking cancer. COS Type V is characterized by factors causing systemic and genetic predisposition to both CVD and cancer. The development of this framework may allow for an increased facilitation of cancer care while optimizing cardiovascular health through focused treatment targeting the COS type

CRT-100.12 Risk of Bleeding Among Cangrelor-Treated Patients Administered Upstream P2Y12 Inhibitor Therapy

Introduction: Little is known about the use of cangrelor in patients with MI who are treated with an oral P2Y12 inhibitor upstream prior to cardiac catheterization. Methods: CAMEO (Cangrelor in Acute MI: Effectiveness and Outcomes) is a 12-hospital observational registry studying platelet inhibition for MI patients undergoing cardiac cath. Upstream oral P2Y12 inhibition was defined as receipt of an oral P2Y12 inhibitor within 24 hours prior to hospitalization or in-hospital prior to cath. Among cangrelor-treated patients, we compared bleeding after cangrelor use through 7 days post-discharge between patients with and w/o upstream oral P2Y12 inhibitor exposure using logistic regression. We examined rates of bleeding among patients with a shorter (\u3c1 hour) vs. longer (1-3 hours or \u3e3 hours) duration between the last oral dose and cangrelor start. Results: Among 1,775 cangrelor-treated MI patients, 433 (24.4%) had upstream oral P2Y12 inhibitor treatment prior to cath. Of these, 165 patients (38%) started cangrelor within 1 hour, 109 (25%) between 1-3 hours, and 134 (31%) \u3e 3 hours after the in-hospital oral P2Y12 inhibitor dose. Cangrelor-treated patients who received upstream treatment were more likely to have a history of prior PCI, MI, PAD, and diabetes and to be clopidogrel-treated (all p\u3c0.01) compared w/o upstream treatment. There was no significant difference in risk of bleeding among cangrelor-treated patients with and w/o upstream oral P2Y12 inhibitor exposure (Table). While bleeding events were higher in patients with longer delays to cangrelor initiation, bleeding risk was not significant after adjustment (Table). Conclusions: Bleeding risk was not observed to be higher in cangrelor-treated patients after upstream oral P2Y12 inhibitor exposure compared with patients treated with cangrelor w/o upstream oral P2Y12 inhibitor exposure

Adjuvant Chemoradiation Therapy for Pancreatic Adenocarcinoma: Who Really Benefits?

The role of adjuvant chemoradiation therapy (CRT) in pancreatic cancer remains controversial. The primary aim of this study was to determine if CRT improved survival in patients with resected pancreatic cancer in a large, multiinstitutional cohort of patients

The Current State of Transradial Access: A Perspective on Transradial Outcomes, Learning Curves, and Same-Day Discharge

The adoption of transradial access in the United States and internationally has been growing over the past few years. In the population of patients presenting with acute coronary syndromes, particularly ST-elevation myocardial infarction, transradial access has the benefit of fewer vascular and bleeding complications and lower mortality rates over transfemoral access. We will examine the current evidence supporting transradial access for several patient populations, including those patients presenting with acute coronary syndromes. We will review the literature regarding the learning curve for transradial access with new operators, as well as experienced transfemoral operators new to transradial access. Finally, we will investigate the role of transradial access in same-day discharge for stable patients undergoing percutaneous coronary intervention

Failure to Launch

The importance of inflammation and inflammatory pathways in atherosclerotic disease and acute coronary syndromes (ACS) is well established. The success of statin therapy rests not only on potently reducing levels of low-density lipoprotein cholesterol, but also on the many beneficial, pleiotropic effects statin therapy has on various inflammatory mechanisms in atherosclerotic disease, from reducing endothelial dysfunction to attenuating levels of serum C-reactive protein. Due to the growing awareness of the importance of inflammation in ACS, investigators have attempted to develop novel therapies against known markers of inflammation for several decades. Targeted pathways have ranged from inhibiting C5 cleavage with a high-affinity monoclonal antibody against C5 to inhibiting the activation of the p38 mitogen-activated protein kinase signaling cascades. In each of these instances, despite promising early preclinical and mechanistic studies and phase 2 trials suggesting a potential benefit in reducing post-MI complications or restenosis, these novel therapies have failed to show benefits during large, phase 3 clinical outcomes trials. This review discusses several examples of novel anti-inflammatory therapies that failed to show significant improvement on clinical outcomes when tested in large, randomized trials and highlights potential explanations for why targeted therapies against known markers of inflammation in ACS have failed to launch

Remote Stab Wound Resulting in AV Fistula and High-Output Heart Failure

A 54-year-old African American male with no medical history presented to an urgent care clinic with signs and symptoms of new-onset congestive heart failure. There was an initial concern for congestive heart failure secondary to an ischemic etiology as an echocardiogram revealed a depressed ejection fraction. However, a left heart cardiac catheterization did not demonstrate any significant coronary disease. As a loud bruit was auscultated over the right base of the patient’s neck, he underwent a carotid duplex ultrasound revealing a fistula between the right common carotid artery (CCA) and the right internal jugular vein (IJV). A diagnosis of high-output heart failure secondary to a large arteriovenous (AV) fistula was made, and the patient underwent ligation and repair of the fistula with resolution of symptoms of congestive heart failure