Why selective screening for asymptomatic carotid stenosis is currently appropriate: a special report.

INTRODUCTION: Two of the main reasons recent guidelines do not recommend routine population-wide screening programs for asymptomatic carotid artery stenosis (AsxCS) is that screening could lead to an increase of carotid revascularization procedures and that such mass screening programs may not be cost-effective. Nevertheless, selective screening for AsxCS could have several benefits. This article presents the rationale for such a program. AREAS COVERED: The benefits of selective screening for AsxCS include early recognition of AsxCS allowing timely initiation of preventive measures to reduce future myocardial infarction (MI), stroke, cardiac death and cardiovascular (CV) event rates. EXPERT OPINION: Mass screening programs for AsxCS are neither clinically effective nor cost-effective. Nevertheless, targeted screening of populations at high risk for AsxCS provides an opportunity to identify these individuals earlier rather than later and to initiate a number of lifestyle measures, risk factor modifications, and intensive medical therapy in order to prevent future strokes and CV events. For patients at 'higher risk of stroke' on best medical treatment, a prophylactic carotid intervention may be considered.

Quality of life assessment in adult spinal muscular atrophy patients treated with nusinersen.

OBJECTIVE: To retrospectively evaluate quality of life (QoL) in a large multicenter cohort of adult patients affected by spinal muscular atrophy (SMA) during nusinersen treatment. METHODS: We included adult (≥ 18 years) patients clinically and genetically defined as SMA2, SMA3 and SMA4, who started nusinersen treatment in adulthood. QoL was rated by the Individualized Neuromuscular Quality of Life (INQoL) questionnaire. Concurrent motor function evaluation included the Hammersmith Functional Motor Scale Expanded (HFMSE), the Revised Upper Limb Module (RULM), the 6 min walking test (6MWT). RESULTS: 189 completed questionnaires were collected during a 14 months' treatment period. 78 patients were included (7 SMA2 and 69 SMA3 and 2 SMA4) with mean disease duration at first nusinersen administration of 33.2 years (± 12.5 years). All the scores for each INQoL domain (weakness, fatigue, activities, independence, social relationship, emotions, body images) and the derived QoL total score, significantly improved during the observation period, except the muscle locking and pain items. Exploratory analyses suggested that emotions and social relationships were more relevant issues for females compared to males. Social relationships were affected also by a longer disease duration (> 30 years). In SMA3 non-walker patients, activities ameliorate better compared to walkers. The HFMSE and RULM significantly improved from baseline; however, no associations with QoL total score and weakness, activities or independence were demonstrated. CONCLUSION: In our cohort, adult SMA patients showed a global improvement at the INQoL assessment over 14 months of nusinersen treatment. QoL assessment is relevant to SMA multidisciplinary evaluation.

CHA2DS2-VASc in the prediction of early atrial fibrillation relapses after electrical or pharmacological cardioversion.

BACKGROUND: In hemodynamically stable patients, mortality and morbidity related to atrial fibrillation are mainly due to cardioembolic disorder. No difference in the survival rate and incidence of embolic events has been described in patients undergoing rhythm or rate control if the latter is combined with an appropriate anticoagulant therapy. CHA2DS2-VASc is a score that allows clinicians to stratify embolic risk in patients affected by nonvalvular atrial fibrillation. Each item can be involved in triggering and maintaining atrial fibrillation. Thus, we hypothesized that CHA2DS2-VASc may help to predict early recurrences after cardioversion. METHODS: A total of 319 consecutive patients, admitted to our emergency department or hemodynamically stable persistent atrial fibrillation, were enrolled and treated with electrical or pharmacological sinus rhythm restoration. Outcome was defined as recurrence of atrial fibrillation 5 days after cardioversion. Predicted probability of sinus rhythm stability was assessed with an ordinal regression model using CHA2DS2-VASc as an independent variable. RESULTS: The model showed a progressive decrease in the predicted probability of sinus rhythm stability after electrical or pharmacological cardioversion along with an increase in the CHA2DS2-VASc score. A logarithmic relationship was the best-fit trend among CHA2DS2-VASc ranks and the predicted probability of sinus rhythm stability in patients undergoing both electrical and pharmacological cardioversion (r(2) = 0.98, P < 0.05 for electrical cardioversion; r(2) = 0.91, P < 0.05 for pharmacological cardioversion). CONCLUSION: Our preliminary results suggest that CHA2DS2-VASc score could be useful in evaluating the risk of early recurrence of atrial fibrillation after cardioversion. This information may have implications for disease monitoring and treatment strategies in clinical practice.

A non-comparative assessment of tolerability and efficacy of duloxetine in the treatment of depressed patients with Parkinson's disease.

OBJECTIVE: Depression is a comorbidity affecting quality of life (QoL) in patients with Parkinson's disease (PD) and requires appropriate treatment. This study evaluated the tolerability, safety, and efficacy of duloxetine 60 mg once daily for 12 weeks in PD patients with major depressive disorder (MDD). RESEARCH AND DESIGN METHODS: Non-comparative, open-label, multi-center study. MAIN OUTCOME MEASURES: Tolerability was evaluated by discontinuation rate (acceptable if ≤ 19%) due to treatment-emergent adverse events (TEAEs) and motor symptoms (UPDRS). Safety measures were TEAEs, the UKU side effect rating scale, vital signs, weight, laboratory tests, and ECG. Efficacy measures included HAMD-17, BDI, CGI-S, PGI-I, and pain VAS. QoL was measured by PDQ-39. RESULTS: Of the 151 patients enrolled, 8.6% (95% upper CI: 13.3%) discontinued the study due to TEAEs. Worsening in PD-related tremor and rigidity was not observed, activities of daily living significantly improved and UKU subscales progressively decreased. Clinically significant abnormalities in laboratory findings were limited to four cases of hypercholesterolemia and one increase of total bilirubin, CPK, and fasting glucose. Blood pressure, weight, and ECG did not change from baseline. HAMD-17 and PDQ-39 total score and individual domains, BDI, CGI-S, and PGI-I total scores significantly improved. CONCLUSIONS: Duloxetine seems well tolerated and likely effective in the treatment of depression associated with PD, with no detrimental effects in PD signs and symptoms.

Cerebrovascular assessment for the risk prediction of Alzheimer's disease.

Increasing evidence is emerging that vascular disease and its risk factors play a role in the development of Alzheimer's disease (AD) and affect the probability of an adverse outcome. The aims of this review are to explore the relationship between vascular risk factors and AD and to discuss the potential use of vascular markers in the clinical approach to cognitive impairment. Moreover, we present evidence about the potential use of ultrasonographic and neuroradiologic markers of cognitive impairment in order to establish possible treatment strategies in subjects with a clinical profile at risk of developing AD.