Antithrombotic therapy in patients treated with oral anticoagulation undergoing coronary artery stenting. An expert consensus document with focus on atrial fibrillation

Dual antiplatelet treatment with aspirin and clopidogrel is recommended after coronary stenting (PCI-S). There is scant evidence defining optimal post-PCI-S antithrombotic therapy in patients with atrial fibrillation (AF) in whom oral anticoagulation (OAC) is mandated. To evaluate the safety and efficacy of the antithrombotic strategies for this population, we conducted a systematic review of the available evidence in patients treated with OAC undergoing PCI-S. AF was the most frequent indication for OAC. Post-PCI-S management was highly variable, and triple therapy with warfarin, aspirin, and clopidogrel was the most frequent and effective combination. Warfarin plus aspirin alone was not sufficiently effective in the early period after PCI-S and should not be prescribed. While acknowledging that the optimal antithrombotic treatment for patients with AF at medium or high thromboembolic risk undergoing PCI-S is currently undefined, triple therapy of warfarin, aspirin, and clopidogrel is currently recommended, although associated with an increased risk of major bleeding. Restrictive use of drug-eluting stent is also recommended, due to the need for prolonged multiple-drug antithrombotic therapy which may increase the bleeding risk. Whether the combination of warfarin and clopidogrel (without aspirin) will preserve efficacy and produce less bleeding is an important issue still needing to be addressed.     

Prognosis of 5-year radiographic erosions of the wrist according to early, late, and persistent wrist swelling or tenderness in patients with early rheumatoid arthritis

OBJECTIVE: To determine whether early inflammatory activity in the first year of disease compared to persistent or later occurrence of swelling or tenderness in the wrist joints is associated with 5-year erosions in the same joint in patients with early rheumatoid arthritis (RA). METHODS: A cohort of 195 patients with early active RA was enrolled in the Finnish RA Combination Trial. Swelling and tenderness of wrists were assessed at baseline and at 3, 6, 12, 24, 36, and 48 months. Radiographs of the wrists were taken at the baseline and at 5 years. The 237 wrist joints of 125 patients without erosions at baseline were classified according to wrist swelling, i.e., I: never swollen; II: swollen during first year only; III: swollen during the second to fourth year only; and IV: swollen during the first year and followup, and similarly according to tenderness. RESULTS: Thirty percent of the wrists were never swollen in all clinical examinations; 43% were swollen only during the first year; 11% were not swollen in the first year, but were swollen at some time during 24-48 months; and 16% of wrists were swollen during the first year and at some time during 24-48 months. At 5 years, 64% of 237 wrists remained free of erosions. Erosions developed in 82% of wrists that were swollen during both the first year and 24-48 months, versus 56% of wrists that were not swollen at first year but were swollen during 24-48 months, 31% of wrists that were swollen during the first year only, and 11% of wrists that were never swollen. Similar results were seen for joint tenderness. CONCLUSION: Wrist swelling during the first year only is associated with less future wrist radiographic damage than persistent swelling or swelling only during the followup. Our results emphasize the value of early and continuous suppression of inflammatory activity in early RA.     

The OMERACT Ultrasound Group: status of current activities and research directions

Ultrasound (US) is a relatively new imaging modality in rheumatology that offers great potential as a diagnostic and management tool. In 2004, an OMERACT Ultrasound Special Interest Group was formed to address the metric qualities of US as a potential outcome measure. A preliminary systematic review highlighted the deficiencies in the literature, particularly with regard to the reliability of interpreting and acquiring images; as a consequence, a number of exercises were proposed to address these issues. This report describes a series of iterative studies that have resulted in improved intra- and inter-reader reliability for detecting and scoring synovitis from both static and real-time images of the hand joints of patients with rheumatoid arthritis. The reliability of acquiring images was also enhanced using standardized positions. Future studies will assess the value of US in clinical trials.     

Transplantation of human embryonic stem cell-derived neural precursor cells and enriched environment after cortical stroke in rats: cell survival and functional recovery

Cortical stem cell transplantation may help replace lost brain cells after stroke and improve the functional outcome. In this study, we transplanted human embryonic stem cell (hESC)-derived neural precursor cells (hNPCs) or vehicle into the cortex of rats after permanent distal middle cerebral artery occlusion (dMCAO) or sham-operation, and followed functional recovery in the cylinder and staircase tests. The hNPCs were examined prior to transplantation, and they expressed neuroectodermal markers but not markers for undifferentiated hESCs or non-neural cells. The rats were housed in either enriched environment or standard cages to examine the effects of additive rehabilitative therapy. In the behavioral tests dMCAO groups showed significant impairments compared with sham group before transplantation. Vehicle groups remained significantly impaired in the cylinder test 1 and 2 months after vehicle injection, whereas hNPC transplanted groups did not differ from the sham group. Rehabilitation or hNPC transplantation had no effect on reaching ability measured in the staircase test, and no differences were found in the cortical infarct volumes. After 2 months we measured cell survival and differentiation in vivo using stereology and confocal microscopy. Housing had no effect on cell survival or differentiation. The majority of the transplanted hNPCs were positive for the neural precursor marker nestin. A portion of transplanted cells expressed neuronal markers 2 months after transplantation, whereas only a few cells co-localized with astroglial or oligodendrocyte markers. In conclusion, hESC-derived neural precursor transplants provided some improvement in sensorimotor function after dMCAO, but did not restore more complicated sensorimotor functions.     

The effects of heat stress on physical functioning in persons with multiple sclerosis

While motor and cognitive impairments are common in Multiple Sclerosis (MS) patients, research concerning their relationship in this population has been limited. We aimed to evaluate cross-sectional associations between cognitive functions, walking speed, and falls in patients with MS. Through a retrospective chart review of 81 patients with MS, we examined whether measures of cognitive function predicted walking speed on the Timed 25-Foot Walk and self-reported fall frequency. Hierarchical linear regressions showed that after controlling for age, gender, and disease severity, slower processing speed and IQ predicted slower gait speed, while poorer verbal memory predicted increased frequency of falls. Moreover, a binary logistic regression showed that poorer verbal memory also predicted increased risk of multiple falls. Thus, specific cognitive functions are meaningfully related to mobility limitations in patients with MS. These findings suggest that risk assessment for gait decline and falls should include cognitive assessment in patients with MS.     

Respective prevalence of the different carpentier classes of mitral regurgitation: a stepping stone for future therapeutic research and development

Abstract Objectives: To determine the prevalence of mitral regurgitation (MR) in the U.S. adult population by classifying its mechanisms according to Carpentier's functional class. Background: MR is the most common clinically recognizable valvular heart condition in the U.S. affecting 2 to 2.5 million people in 2000. A true estimate of the prevalence of MR in accordance to the functional class and etiology is unavailable. Methods: We conducted a Medline search regarding prevalence and etiologies of MR. Etiologies were grouped by Carpentier's functional classification, and estimated prevalence numbers were projected to U.S. adult population of 200 million. Moderate‐to‐severe grades of MR were included. Results: Carpentier type I, including congenital MR and endocarditis, has a prevalence of less than 20 per million. Myxomatous infiltration leading to mitral valve prolapse is the largest group associated with a type II mechanism with 15,000 per million prevalence. Type IIIa includes rheumatic heart disease, systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), and rare infiltrative and tropical disorders. SLE and APS have a mean prevalence of 10,520 per million. Carpentier IIIb is the largest group leading to MR, which is mostly functional, and includes ischemic cardiomyopathy, left ventricular (LV) dysfunction, and dilated cardiomyopathies. The estimated prevalence of MR in ischemic cardiomyopathy is 7500 to 9000 per million, and in LV dysfunction, 16,250 per million. Conclusions: The largest number of people with MR is in type IIIb. Certain etiologies show overlap within functional classes due to multiple mechanisms of MR. We attempted to classify etiologies of MR by a functional class to determine the disease burden. (J Card Surg 2011;26:385‐392)     

Thermal responses to whole‐body cooling in air with special reference to arteriovenous anastomoses in fingers

The arteriovenous anastomoses (AVAs) in the distal parts of the extremities play a significant role in the heat exchange with the environment. The aim of the study was to examine the thermal responses to whole‐body cooling in air, and especially the behaviour of finger skin temperature (T_f, rich in AVAs). Eight young men sat in minimal clothing at 32°C air temperature (T_a), which was then lowered gradually to 13°C in 100 min. In the beginning of cooling, T_f was high and fluctuating, and then suddenly exhibited a rapid fall, while temperatures in other skin sites fell fairly linearly along decreasing T_a to the end of cooling. During the period from start to the rapid fall in T_f, rectal temperature decreased from 37·4°C (SD 0·2) to 37·2°C (0·2), mean skin temperature (T_sk) from 34·6°C (0·5) to 31·2°C (2·0) and whole‐body thermal sensation from ‘slightly warm/warm’ to ‘slightly cool/cold’. The start of the steep fall in T_f varied considerably between individuals in terms of time (2–75 min), T_a (16·7–32·0°C) and T_sk (28·8–34·7°C). On the other hand, the range of T_f at that point was narrower (32·1–35·8°C). The findings stress the importance of taking into account the distal skin temperatures in thermoregulatory studies in addition to the ordinarily used more proximal and central skin sites. Also, it might be advisable to start such experiments with relatively high and fluctuating T_f to guarantee that the thermal state of the subject is well defined.