Protect, promote and support: a warm chain of breastfeeding for oncological women\u2014results from a survey of young Italian cancer mothers

The objective of this article was to analyse the experience of breastfeeding in new mothers with a history of cancer compared to women without a cancer diagnosis. First, we explored the impact of the cancer diagnosis on the breastfeeding choice. Second, we evaluated the relationship between different feeding methods and the mother\u2019s mood states in women with and without a history of cancer. The sample was composed of 74 mothers divided into two groups: 34 with a cancer history (clinical sample) and 40 without a cancer diagnosis (control group). Participants were requested to complete a questionnaire three months after childbirth which assessed: socio-demographic and clinical data, feeding modes (breastfeeding, formula and mixed feeding) and the profile of mood states (POMS). Results showed that women in the clinical group breastfeed significantly less and use formula more than those in the control group. Moreover, in the clinical group, women who breastfeed feel reported higher levels of confusion (according to POMS) than mothers who bottle-feed or use a mixed feeding method. On the contrary, in the control sample, women who breastfeed feel significantly more vigorous than puerperae who bottle-feed or use mixed methods according to POMS. Our findings suggest the need for a specific warm chain of support and the development of guidelines with clear and specific information for women with a cancer diagnosis in order to reduce their confusion around breastfeeding

Prediction of early recurrent thromboembolic event and major bleeding in patients with acute stroke and atrial fibrillation by a risk stratification schema: the ALESSA score study

Background and Purposes—This study was designed to derive and validate a score to predict early ischemic events and major bleedings after an acute ischemic stroke in patients with atrial fibrillation. Methods—The derivation cohort consisted of 854 patients with acute ischemic stroke and atrial fibrillation included in prospective series between January 2012 and March 2014. Older age (hazard ratio 1.06 for each additional year; 95% confidence interval, 1.00–1.11) and severe atrial enlargement (hazard ratio, 2.05; 95% confidence interval, 1.08–2.87) were predictors for ischemic outcome events (stroke, transient ischemic attack, and systemic embolism) at 90 days from acute stroke. Small lesions (≤1.5 cm) were inversely correlated with both major bleeding (hazard ratio, 0.39; P=0.03) and ischemic outcome events (hazard ratio, 0.55; 95% confidence interval, 0.30–1.00). We assigned to age ≥80 years 2 points and between 70 and 79 years 1 point; ischemic index lesion >1.5 cm, 1 point; severe atrial enlargement, 1 point (ALESSA score). A logistic regression with the receiver-operating characteristic graph procedure (C statistic) showed an area under the curve of 0.697 (0.632–0.763; P=0.0001) for ischemic outcome events and 0.585 (0.493–0.678; P=0.10) for major bleedings. Results—The validation cohort consisted of 994 patients included in prospective series between April 2014 and June 2016. Logistic regression with the receiver-operating characteristic graph procedure showed an area under the curve of 0.646 (0.529–0.763; P=0.009) for ischemic outcome events and 0.407 (0.275–0.540; P=0.14) for hemorrhagic outcome events. Conclusions—In acute stroke patients with atrial fibrillation, high ALESSA scores were associated with a high risk of ischemic events but not of major bleedings

Timing of initiation of oral anticoagulants in patients with acute ischemic stroke and atrial fibrillation comparing posterior and anterior circulation strokes

Background: The aim of this study in patients with acute posterior ischemic stroke (PS) and atrial fibrillation (AF) were to evaluate the risks of recurrent ischemic event and severe bleeding and these risks in relation with oral anticoagulant therapy (OAT) and its timing. Methods: Patients with PS were prospectively included; the outcome events of these patients were compared with those of patients with anterior stroke (AS) which were taken from previous registries. The primary outcome was the composite of: stroke recurrence, TIA, symptomatic systemic embolism, symptomatic cerebral bleeding and major extracranial bleeding occurring within 90 days from acute stroke. Results: A total of 2,470 patients were available for the analysis: 473 (19.1%) with PS and 1,997 (80.9%) AS. Over 90 days, 213 (8.6%) primary outcome events were recorded: 175 (8.7%) in patients with AS and 38 (8.0%) in those with PS. In patients who initiated OAT within 2 days, the primary outcome occurred in 5 out of 95 patients (5.3%) with PS compared to 21 out of 373 patients (4.3%) with AS (OR 1.07; 95% CI 0.39-2.94). In patients who initiated OAT between days 3 and 7, the primary outcome occurred in 3 out of 103 patients (2.9%) with PS compared to 26 out of 490 patients (5.3%) with AS (OR 0.54; 95% CI 0.16-1.80). Conclusions: Patients with posterior or anterior stroke and AF appear to have similar risks of ischemic or hemorrhagic events at 90 days with no difference concerning the timing of initiation of OAT

Hemorrhagic transformation in acute ischemic stroke patients and atrial fibrillation: time to initiation of anticoagulants and outcome

Background: In patients with acute ischemic stroke and atrial fibrillation, early anticoagulation prevents ischemic recurrence but with the risk of hemorrhagic transformation (HT). The aims of this study were to evaluate in consecutive patients with acute stroke and atrial fibrillation (1) the incidence of early HT, (2) the time to initiation of anticoagulation in patients with HT, (3) the association of HT with ischemic recurrences, and (4) the association of HT with clinical outcome at 90 days. Methods and Results: HT was diagnosed by a second brain computed tomographic scan performed 24 to 72 hours after stroke onset. The incidence of ischemic recurrences as well as mortality or disability (modified Rankin Scale scores >2) were evaluated at 90 days. Ischemic recurrences were the composite of ischemic stroke, transient ischemic attack, or systemic embolism. Among the 2183 patients included in the study, 241 (11.0%) had HT. Patients with and without HT initiated anticoagulant therapy after a mean 23.3 and 11.6 days, respectively, from index stroke. At 90 days, 4.6% (95% confidence interval, 2.3–8.0) of the patients with HT had ischemic recurrences compared with 4.9% (95% confidence interval, 4.0–6.0) of those without HT; 53.1% of patients with HT were deceased or disabled compared with 35.8% of those without HT. On multivariable analysis, HT was associated with mortality or disability (odds ratio, 1.71; 95% confidence interval, 1.24–2.35). Conclusions: In patients with HT, anticoagulation was initiated about 12 days later than patients without HT. This delay was not associated with increased detection of ischemic recurrence. HT was associated with increased mortality or disability

Anticoagulation After Stroke in Patients With Atrial Fibrillation : To Bridge or Not With Low-Molecular-Weight Heparin?

Background and Purpose- Bridging therapy with low-molecular-weight heparin reportedly leads to a worse outcome for acute cardioembolic stroke patients because of a higher incidence of intracerebral bleeding. However, this practice is common in clinical settings. This observational study aimed to compare (1) the clinical profiles of patients receiving and not receiving bridging therapy, (2) overall group outcomes, and (3) outcomes according to the type of anticoagulant prescribed. Methods- We analyzed data of patients from the prospective RAF and RAF-NOACs studies. The primary outcome was defined as the composite of ischemic stroke, transient ischemic attack, systemic embolism, symptomatic cerebral bleeding, and major extracerebral bleeding observed at 90 days after the acute stroke. Results- Of 1810 patients who initiated oral anticoagulant therapy, 371 (20%) underwent bridging therapy with full-dose low-molecular-weight heparin. Older age and the presence of leukoaraiosis were inversely correlated with the use of bridging therapy. Forty-two bridged patients (11.3%) reached the combined outcome versus 72 (5.0%) of the nonbridged patients (P=0.0001). At multivariable analysis, bridging therapy was associated with the composite end point (odds ratio, 2.3; 95% CI, 1.4-3.7; P Conclusions- Our findings suggest that patients receiving low-molecular-weight heparin have a higher risk of early ischemic recurrence and hemorrhagic transformation compared with nonbridged patients.Peer reviewe

CORRELATI CLINICI E DI IMAGING MOLECOLARE NELLA DISFUNZIONE COGNITIVA DELLA MALATTIA DI PARKINSON: RISULTATI DI UNO STUDIO SU UN’AMPIA COORTE DI PAZIENTI DE NOVO

La malattia di Parkinson (MP) è una sindrome neurodegenerativa il cui quadro clinico è primariamente caratterizzato da un disordine del movimento. Tuttavia, ormai da molti anni essa non viene più considerata esclusivamente come una malattia motoria. La neurodegenerazione che coinvolge i sistemi extrapiramidali, infatti, si accompagna ad un ampio corollario di sintomi non motori quali il disturbo del sonno REM, la modificazione del profilo psicologico, la facile faticabilità e la compromissione cognitiva, la gestione dei quali rappresenta per il medico un vero e proprio target importante tanto quanto il controllo motorio. Al fine di migliorare la comprensione del disturbo cognitivo e nella ricerca della sua genesi, si è concentrato negli ultimi anni lo sforzo di numerosi lavori, sia clinici che di imaging molecolare, volti a definire i fattori di rischio e i sistemi biochimici coinvolti nello sviluppo di compromissione cognitiva in corso di MP. Tali studi hanno permesso di aprire una nuova e ampia finestra conoscitiva sui disturbi neuropsicologici che possono presentarsi in questa popolazione di pazienti. Un largo consenso è infatti presente in letteratura sulla considerazione che, al di là del rischio di demenza, deficit cognitivi lievi e selettivi accompagnino il paziente sin dalle fasi iniziali e acquisiscano maggiore gravità con il progredire della malattia. L’impiego di strumenti sempre più raffinati per l’indagine neuropsicologica e di neuroimaging ha inoltre consentito da un lato, di condurre analisi qualitative approfondite dei profili cognitivi di questi pazienti e dall’altro lato, di formulare coerenti modelli di interpretazione neurobiologica. Col tempo si è compreso come la compromissione cognitiva nella MP differisca da quella tipica della Malattia di Alzheimer (AD), sia in termini di profilo cognitivo coinvolto, che di andamento e risposta alla terapia, sia per quanto riguarda la presenza di marcatori bioumorali. Pertanto, recentemente definizioni cliniche appartenenti esclusivamente all’AD, come il Mild Cognitive Impairment, sono state riviste ed adattate alla MP con la produzione di criteri diagnostici specifici. Risulta tuttavia molto complesso capire i meccanismi alla base di questa disfunzione, essendo essa strettamente legata in questi pazienti a deficit motori e alterazioni psicologiche che possono in gran parte alterarne la comprensione. Scopo di questo studio è stato quello di valutare, in un’ampia coorte di pazienti con recente diagnosi di MP e non ancora in terapia farmacologica, le caratteristiche cliniche e il profilo cognitivo all’esordio di malattia. Ulteriore scopo dello studio è stato quello di cercare una possibile correlazione tra la presenza di una precoce disfunzione cognitiva e il depauperamento dei neuroni dopaminergici striatali, classicamente coinvolto nella genesi del disturbo motorio. A questo scopo, 135 pazienti de novo sono stati sottoposti ad un’ampia batteria di test neuropsicologici (MMSE, FAB, TMT, Stroop test, CMP47, WCST, digit span, test di Corsi, test di fluenza verbale fonemica, test della figura complessa di Rey-Osterrieth e Rey Auditory Verbal Learning Test), ad una valutazione del profilo psicologico mediante le scale HAM-D, HAM-A e Beck e ad una valutazione clinica mediante esame obiettivo neurologico e scale motorie specifiche per la malattia, che hanno permesso di calcolare punteggi di rigidità, bradicinesia, tremore e assiali all’esordio di malattia. I pazienti, inoltre, sono stati sottoposti ad un’indagine funzionale di imaging molecolare per valutare il grado di degenerazione delle vie nigrostriatali mediante scintigrafia cerebrale con DaT-SCAN. L’informazione quantitativa del legame è stata ottenuta in 94 pazienti mediante il valore dello Specific Binding Ratio (SBR) definito mediante il software BasGan. Questo studio ha permesso di confermare come una parte di pazienti con MP (20,7%) presenti una compromissione cognitiva lieve (MCI) già in fase precoce di malattia, la quale si associa ad una scolarità più bassa ed un’età d’esordio di malattia più alta. La presenza di compromissione cognitiva iniziale si associa inoltre a punteggi motori più elevati, specie quelli di rigidità e assiali. Precedenti studi inoltre suggeriscono una correlazione tra performance cognitive frontali e disfunzione striatale nei pazienti con MP avanzato. I nostri dati, ottenuti su un campione molto ampio di pazienti in fase precoce di malattia e non ancora trattati farmacologicamente, hanno permesso di associare la degenerazione dopaminergica del caudato alla compromissione di prove cognitive che indagano funzioni di pianificazione e memoria di lavoro, confermando l’importanza delle strette connessioni cortico striatali di questa regione anatomica nel mantenimento dell’integrità delle prestazioni cognitive, specie esecutive, di questi pazienti

Imaging in Glucocerebrosidase-Associated Parkinsonism: Current Status and Implications for Pathophysiology.

Background: Glucocerebrosidase (GBA) mutations have been described as the most prevalent in Parkinson’s disease (PD) and in Lewy body dementia, accounting for up to 7 and 13.8% of cases, respectively. To elucidate the pathophysiology of idiopathic Parkinson’s disease (iPD), the pathogenic mechanisms leading to Lewy body accumulation in GBA-associated parkinsonism (GBA-PD) are a matter of current research. However, only few imaging studies, conducted on small GBA-PD patient cohorts, exist. Methods: We provide an overview of current structural and functional imaging studies in patients with Gaucher’s disease and parkinsonism and in GBA-PD patients, underlining the main differences compared to iPD. Results: A limited number of PET studies have been conducted in GBA-PD, exploring brain metabolism and dopaminergic presynaptic and postsynaptic function. Moreover, structural MRI and spectroscopy studies recently evidenced the differences with iPD, aiding to understand of some peculiar aspects of iPD. Finally, new evidence from transcranial sonography confirms the technique’s role in the study of GBA-PD and highlights the additional involvement of the raphe nucleus. Conclusions: Further imaging studies conducted in a broader population of early GBA-P

Migraine features in migraineurs with and without anxiety-depression symptoms: A hospital-based study

BACKGROUND: Migraine, anxiety and depression often coexist. A "neurolimbic" model of migraine has been recently proposed accounting for a dynamic influence of pain, mood and anxiety on the migraine disease. However, very few data exist concerning clinical migraine features in patients reporting anxiety-depression symptoms. OBJECTIVE: Aim of our study was to test differences in clinical migraine features between migraineurs with anxiety-depression symptoms and migraineurs without ones. MATERIALS AND METHODS: We recruited 200 consecutive migraineurs. Other primary headaches comorbidity and migraine prophylaxis were exclusion criteria. Each patient was interviewed following a structured questionnaire including general features about migraine, triggers, allodynia. Anxiety and depression symptoms were evaluated in each patient by two brief self-reported scales: the generalized anxiety disorder 7-item scale (GAD-7) and the Patient Health Questionnaire 9-item scale (PHQ-9). A cut-off of 5 in both the GAD-7 and the PHQ-9 was considered positive for the presence of anxiety-depressive symptoms. RESULTS: One hundred and one patients (51.5%) had anxiety-depression symptoms (GAD-7 and PHQ-9 ≥ 5). They reported a more headaches/month (p = 0.004), higher number of triggers (p < 0.001), and were more allodynic (p = 0.005). In a binary logistic regression model triggers and allodynia made a unique statistical contribution on reporting anxiety-depression symptoms. CONCLUSION: Our results showed that the presence of anxiety-depression symptoms affects migraine clinical presentation. They are associated with enhanced migraine triggers susceptibility, more ictal allodynic symptoms as well as more headaches/month. An altered sensation in migraineurs with anxiety-depression symptoms could be a result of a lower pain threshold and an increased cortical excitability in a broader context of a neurolimbic dysfunction

From Pregnancy to Lactation: When the Pathway is Complicated by Cancer

Background: Women with a cancer history report high distress during pregnancy and infant feeding. Despite the clear advantages of breastfeeding, little is known about factors influencing infant feeding behavior in women with cancer history. Research aim: This three-time point longitudinal study aimed to explore the centrality of pregnancy and infant feeding experiences in 17 pregnant women with a cancer history (cases) compared to 17 pregnant women without cancer history (controls). Methods: During pregnancy, participants filled out the Centrality of Events Scale and an ad hoc questionnaire about specific emotions, concerns, and expectations about infant feeding (T1), and their childbirth and infant feeding experiences during hospitalization (T2), and at 3-months postpartum (T3). Results: Results at T1 demonstrated that participants with a history of cancer reported a higher perception of negative judgment and moral choice about breastfeeding than participants without a history of cancer. At T2 they reported a more positive childbirth experience than controls. From T2 to T3 participants with a history of cancer breastfed at a higher percentage than controls, and at T3 they reported higher levels of emotional and physical pleasure about the infant feeding experiences. Conclusions: Women with cancer history may experience a higher emotional and physical pleasure with infant feeding. Despite initial difficulties, a greater prevalence of breastfeeding was present for women with a history of cancer. Although this is a small sample, this research suggests that support and promotion of breastfeeding might be very effective after a serious medical diagnosis