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1.
Nat Ecol Evol ; 3(10): 1409-1414, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31558829

RESUMO

Microscopic analysis of backed lithic pieces from the Uluzzian technocomplex (45-40 thousand yr ago) at Grotta del Cavallo (southern Italy) reveals their use as mechanically delivered projectile weapons, attributed to anatomically modern humans. Use-wear and residue analyses indicate that the lithics were hunting armatures hafted with complex adhesives, while experimental and ethnographic comparisons support their use as projectiles. The use of projectiles conferred a hunting strategy with a higher impact energy and a potential subsistence advantage over other populations and species.

2.
Stroke ; 50(9): 2555-2557, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31284848

RESUMO

Background and Purpose- Transient global amnesia (TGA) is known as a benign syndrome, but recent data from neuroradiological studies support an ischemic cause in some cases, which might suggest an increased susceptibility to cerebrovascular events. We determined the long-term risk of stroke after a first TGA in 2 independent prospective cohorts. Methods- In 2 independent prospective cohorts of patients with TGA (OXVASC [Oxford Vascular Study], population-based; NU (Northern Umbria) cohort, TGA registry), cardiovascular risk factors and long-term outcomes, including stroke and major cardiovascular events, were identified on follow-up. Cardiovascular risk factors were treated according to primary prevention guidelines. In OXVASC, the age-/sex-adjusted risk of stroke during follow-up was compared with that expected from the rate in the underlying study population. Results- Among 525 patients with TGA (425 NU and 100 OXVASC), mean (SD) age was 65.1 (9.5) years and 42.5% male. Hypertension (58.1%), dyslipidemia (40.4%), and smoking (36.4%) were the most frequent cardiovascular risk factors. The risk of stroke was similar in the 2 cohorts, with a pooled annual risk of 0.6% (95% CI, 0.4-0.9) and a 5-year cumulative risk of 2.7% (1.1-4.3). Moreover, the stroke risk in OXVASC cases was no greater than that expected in the underlying study population (adjusted relative risk=0.73; 0.12-4.54; P=0.74). Conclusions- TGA does not carry an increased risk of stroke, at least when cardiovascular risk factors are treated according to primary prevention guidelines.

3.
Nat Ecol Evol ; 3(6): 905-911, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31086279

RESUMO

Understanding the reason(s) behind changes in human mobility strategies through space and time is a major challenge in palaeoanthropology. Most of the time this is due to the lack of suitable temporal sequences of human skeletal specimens during critical climatic or cultural shifts. Here, we present temporal variations in the Sr isotope composition of 14 human deciduous teeth and the N and C stable isotope ratios of four human remains from the Grotta Paglicci site (Apulia, southern Italy). The specimens were recovered from the Gravettian and Epigravettian layers, across the Last Glacial Maximum, and dated between 31210-33103 and 18334-19860 yr cal BP (2σ). The two groups of individuals exhibit different 87Sr/86Sr ratios and, while the Gravettians are similar to the local macro-fauna in terms of Sr isotopic signal, the Epigravettians are shifted towards higher radiogenic Sr ratios. These data, together with stable isotopes, can be explained by the adoption of different mobility strategies between the two groups, with the Gravettians exploiting logistical mobility strategies and the Epigravettians applying residential mobility.


Assuntos
Isótopos de Estrôncio , Estrôncio , Humanos , Isótopos , Itália , Dinâmica Populacional
4.
Int J Stroke ; 14(7): 678-685, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-30961463

RESUMO

BACKGROUND: Randomized controlled trials provide high-level evidence, but the necessity to include selected patients may limit the generalisability of their results. METHODS: Comparisons were made of baseline and outcome data between patients with acute ischemic stroke (AIS) recruited into the alteplase-dose arm of the international, multi-center, Enhanced Control of Hypertension and Thrombolysis Stroke study (ENCHANTED) in the United Kingdom (UK), and alteplase-treated AIS patients registered in the UK Sentinel Stroke National Audit Programme (SSNAP) registry, over the study period June 2012 to October 2015. RESULTS: There were 770 AIS patients (41.2% female; mean age 72 years) included in ENCHANTED at sites in England and Wales, which was 19.5% of alteplase-treated AIS patients registered in the SSNAP registry. Trial participants were significantly older, had lower baseline neurological severity, less likely Asian, and had more premorbid symptoms, hypertension and atrial fibrillation. Although ENCHANTED participants had higher rates of symptomatic intracerebral hemorrhage than those in SSNAP, there were no differences in onset-to-treatment time, levels of disability (assessed by the modified Rankin scale) at hospital discharge, and mortality over 90 days between groups. CONCLUSIONS: Despite the high level of participation, equipoise over the dose of alteplase among UK clinician investigators favored the inclusion of older, frailer, milder AIS patients in the ENCHANTED trial. CLINICAL TRIAL REGISTRATION: Clinical Trial Registration-URL: http://www.clinicaltrials.gov . Unique identifier: NCT01422616.

5.
Neurol Sci ; 40(8): 1619-1626, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31004231

RESUMO

PURPOSE: We performed an evaluation of dysphagia in an unselected series of strokes to identify factors causing persisting dysphagia at 1 month after onset and to formulate a predictive score. METHODS: We evaluated the association between dysphagia and clinical aspects (univariate analysis) at the 7th and 30th days after admission. We performed a multivariate logistic regression at the 30th day on the factors that were significant. We computed a simple score for predicting persistent dysphagia. RESULTS: We recruited 249 patients. At the 7th day, 94 patients were dysphagic (37.75%). Factors associated with dysphagia included TACI (OR 3.85), mRS ≥ 3 (OR 4.45), malnutrition (OR 2.69), and BMI ≥ 20 (OR 0.52). At the 30th day, 217 patients remained in the study, and dysphagia persisted in 75 (36.76%). The factors that were associated with dysphagia were age > 74 years (OR 1.99), TACI (OR 5.82), mRS score ≥ 3 (OR 4.31), malnutrition (OR 3.27), and BMI ≥ 20 (OR 0.45). The multivariate analysis indicated that mRS ≥ 3 (OR 1.80) and BMI ≥ 20 (OR 0.45) remained significantly associated with dysphagia. The best correlation with dysphagia was the sum of mRS and the reciprocal of the BMI multiplied by 100 ((mRS + 1 ∕ BMI) × 100). We named this score PreDyScore that ranged between 3.7 and 10.47. Using < 6 and > 8 as cutoffs, the sensitivity was 67.03%, and the specificity 95.65%. CONCLUSION: BMI < 20 and mRS ≥ 3 are easily measurable bedside predictive factors of persistent dysphagia. PreDyScore showed good sensitivity and very good specificity and enables the prediction of persistent dysphagia with great accuracy in any clinical setting.

6.
Lancet ; 393(10174): 877-888, 2019 03 02.
Artigo em Inglês | MEDLINE | ID: mdl-30739745

RESUMO

BACKGROUND: Systolic blood pressure of more than 185 mm Hg is a contraindication to thrombolytic treatment with intravenous alteplase in patients with acute ischaemic stroke, but the target systolic blood pressure for optimal outcome is uncertain. We assessed intensive blood pressure lowering compared with guideline-recommended blood pressure lowering in patients treated with alteplase for acute ischaemic stroke. METHODS: We did an international, partial-factorial, open-label, blinded-endpoint trial of thrombolysis-eligible patients (age ≥18 years) with acute ischaemic stroke and systolic blood pressure 150 mm Hg or more, who were screened at 110 sites in 15 countries. Eligible patients were randomly assigned (1:1, by means of a central, web-based program) within 6 h of stroke onset to receive intensive (target systolic blood pressure 130-140 mm Hg within 1 h) or guideline (target systolic blood pressure <180 mm Hg) blood pressure lowering treatment over 72 h. The primary outcome was functional status at 90 days measured by shift in modified Rankin scale scores, analysed with unadjusted ordinal logistic regression. The key safety outcome was any intracranial haemorrhage. Primary and safety outcome assessments were done in a blinded manner. Analyses were done on intention-to-treat basis. This trial is registered with ClinicalTrials.gov, number NCT01422616. FINDINGS: Between March 3, 2012, and April 30, 2018, 2227 patients were randomly allocated to treatment groups. After exclusion of 31 patients because of missing consent or mistaken or duplicate randomisation, 2196 alteplase-eligible patients with acute ischaemic stroke were included: 1081 in the intensive group and 1115 in the guideline group, with 1466 (67·4%) administered a standard dose among the 2175 actually given intravenous alteplase. Median time from stroke onset to randomisation was 3·3 h (IQR 2·6-4·1). Mean systolic blood pressure over 24 h was 144·3 mm Hg (SD 10·2) in the intensive group and 149·8 mm Hg (12·0) in the guideline group (p<0·0001). Primary outcome data were available for 1072 patients in the intensive group and 1108 in the guideline group. Functional status (mRS score distribution) at 90 days did not differ between groups (unadjusted odds ratio [OR] 1·01, 95% CI 0·87-1·17, p=0·8702). Fewer patients in the intensive group (160 [14·8%] of 1081) than in the guideline group (209 [18·7%] of 1115) had any intracranial haemorrhage (OR 0·75, 0·60-0·94, p=0·0137). The number of patients with any serious adverse event did not differ significantly between the intensive group (210 [19·4%] of 1081) and the guideline group (245 [22·0%] of 1115; OR 0·86, 0·70-1·05, p=0·1412). There was no evidence of an interaction of intensive blood pressure lowering with dose (low vs standard) of alteplase with regard to the primary outcome. INTERPRETATION: Although intensive blood pressure lowering is safe, the observed reduction in intracranial haemorrhage did not lead to improved clinical outcome compared with guideline treatment. These results might not support a major shift towards this treatment being applied in those receiving alteplase for mild-to-moderate acute ischaemic stroke. Further research is required to define the underlying mechanisms of benefit and harm resulting from early intensive blood pressure lowering in this patient group. FUNDING: National Health and Medical Research Council of Australia; UK Stroke Association; Ministry of Health and the National Council for Scientific and Technological Development of Brazil; Ministry for Health, Welfare, and Family Affairs of South Korea; Takeda.


Assuntos
Pressão Sanguínea/efeitos dos fármacos , Isquemia Encefálica/tratamento farmacológico , Fibrinolíticos/administração & dosagem , Acidente Vascular Cerebral/tratamento farmacológico , Ativador de Plasminogênio Tecidual/administração & dosagem , Administração Intravenosa , Idoso , Austrália/epidemiologia , Pressão Sanguínea/fisiologia , Isquemia Encefálica/patologia , Brasil/epidemiologia , Feminino , Fibrinolíticos/uso terapêutico , Humanos , Hemorragias Intracranianas/epidemiologia , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Estudos Prospectivos , República da Coreia/epidemiologia , Ativador de Plasminogênio Tecidual/uso terapêutico , Resultado do Tratamento
7.
Lancet Neurol ; 18(3): 231, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30784551
9.
J Anthropol Sci ; 962018 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-30036183

RESUMO

The Uluzzian techno-complex is commonly considered to be a "transitional industry" mostly on the basis of some inferred characteristics such as a chiefly flake-based production, a small amount of Upper Palaeolithic-like tools and a combination of Middle and Upper Palaeolithic elements both in the toolkit and in the technical systems. Following its discovery, the Uluzzian was identified as the Italian counterpart of the French Châtelperronian and attributed to Neandertals. However, a study issued in 2011 has established the modern character of the two deciduous teeth found in 1964 in the Uluzzian deposit of Grotta del Cavallo, fostering renewed interests to the Uluzzian culture, which real nature is almost unknown to the international scientific community. Here we provide preliminary results of the study on the lithic assemblage from the earliest Uluzzian layer and on backed pieces from the whole Uluzzian sequence of Grotta del Cavallo (Apulia, Italy), the type site of the Uluzzian. Moreover, besides a thorough review on the stratigraphy of Grotta del Cavallo (Supplementary Materials), we provide updated information on the human remains by presenting two unpublished teeth from the reworked deposit of the same cave. We conclude that the early Uluzzians demonstrate original technological behavior and innovations devoid of any features deriving or directly linked with the late Mousterian of Southern Italy. Therefore, the novelty nature of the Uluzzian techno-complex (with respect to the preceding Mousterian) complies with the recent reassessment of the two deciduous teeth from Grotta del Cavallo in suggesting an earliest migration of modern humans in southern Europe around 45,000 years ago.

10.
Cerebrovasc Dis ; 45(5-6): 213-220, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29705803

RESUMO

BACKGROUND: Debate exists as to whether statin pretreatment confers an increased risk of 90-day mortality and symptomatic intracranial haemorrhage (sICH) in acute ischaemic stroke (AIS) patients treated with intravenous thrombolysis. We assessed the effects of undifferentiated lipid-lowering pretreatment on outcomes and interaction with low-dose versus standard-dose alteplase in a post hoc subgroup -analysis of the Enhanced Control of Hypertension and Thrombolysis Stroke Study. METHODS: In all, 3,284 thrombolysis-eligible AIS patients (mean age 66.6 years; 38% women), with information on lipid-lowering pretreatment, were randomly assigned to low-dose (0.6 mg/kg) or standard-dose (0.9 mg/kg) intravenous alteplase within 4.5 h of symptom onset. Of the total number of patients, 615 (19%) received statin or other lipid-lowering pretreatment. The primary clinical outcome was combined endpoint of death or disability (modified Rankin Scale scores 2-6) at 90 days. RESULTS: Compared with patients with no lipid-lowering pretreatment, those with lipid-lowering pretreatment were significantly older, more likely to be non-Asian and more likely to have a medical history including vascular co-morbidity. After propensity analysis assessment and adjustment for important baseline variables at the time of randomisation, as well as imbalances in management during the first 7 days of hospital admission, there were no significant differences in mortality (OR 0.85; 95% CI 0.58-1.25, p = 0.42), or in overall -90-day death and disability (OR 0.85, 95% CI 0.67-1.09, p = 0.19), despite a significant decrease in sICH among those with -lipid-lowering pretreatment according to the European Co-operative Acute Stroke Study 2 definition (OR 0.49, 95% CI 0.28-0.83, p = 0.009). No differences in key efficacy or safety outcomes were seen in patients with and without lipid-lowering pretreatment between low- and standard-dose alteplase arms. CONCLUSIONS: Lipid-lowering pretreatment is not associated with adverse outcome in AIS patients treated with intravenous alteplase, whether assessed by 90-day death and disability or death alone.

11.
Artigo em Inglês | MEDLINE | ID: mdl-29389652

RESUMO

Quantitative blood velocity measurements, as currently implemented in commercial ultrasound scanners, are based on pulsed-wave (PW) spectral Doppler and are limited to detect the axial component of the velocity in a single sample volume. On the other hand, vector Doppler methods produce angle-independent estimates by, e.g., combining the frequency shifts measured from different directions. Moreover, thanks to the transmission of plane waves, the investigation of a 2-D region is possible with high temporal resolution, but, unfortunately, the clinical use of these methods is hampered by the massive calculation power required for their real-time execution. In this paper, we present a novel approach based on the transmission of plane waves and the simultaneous reception of echoes from 16 distinct subapertures of a linear array probe, which produces eight lines distributed over a 2-D region. The method was implemented on the ULAO-OP 256 research scanner and tested both in phantom and in vivo. A continuous real-time refresh rate of 36 Hz was achieved in duplex combination with a standard B-mode at pulse repetition frequency of 8 kHz. Accuracies of -11% on velocity and of 2°on angle measurements have been obtained in phantom experiments. Accompanying movies show how the method improves the quantitative measurements of blood velocities and details the flow configurations in the carotid artery of a volunteer.

12.
Aging Clin Exp Res ; 30(2): 205-207, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-28584901

RESUMO

BACKGROUND: Peripheral arterial disease (PAD) is frequent among older diabetic patients, but the evidence about endovascular revascularization is very limited. METHOD: We retrospectively analyzed data collected from 120 diabetic patients consecutively admitted to a Diabetic Foot Clinic, including 64 patients aged 65-79 years and 56 patients aged 80 or more. RESULTS: Percutaneous transluminal angioplasty (PTA) was followed by technical success in 82.5% of older patients and 62.5% of oldest old ones (p = 0.05). No significant difference was observed in regards to complete re-epithelization (76.6 vs 76.8%, p = 0.820), recurrent stenosis (26.6 vs 19.6%, p = 0.371), intra- or post-procedure complications (21.9 vs 10.7%, p = 0.102), and amputations (12.5 vs 5.4%, p = 0.176). DISCUSSION: Our findings suggest that older and oldest old patients with diabetic foot and critical ischemia could be effectively and safely treated with PTA.


Assuntos
Angioplastia/estatística & dados numéricos , Pé Diabético/cirurgia , Pé/irrigação sanguínea , Doença Arterial Periférica/cirurgia , Idoso , Idoso de 80 Anos ou mais , Amputação/estatística & dados numéricos , Feminino , Humanos , Isquemia/fisiopatologia , Masculino , Estudos Retrospectivos , Resultado do Tratamento
13.
Phlebology ; 33(2): 75-83, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-28081660

RESUMO

Forced expiration against an airway obstruction was originally described as a method for inflating the Eustachian tubes and is accredited to Antonio Maria Valsalva (1666-1723). The Valsalva maneuver is commonly applied for different diagnostic purposes. Its use for phlebologic diagnosis is the object this review. Venous reflux is the most frequent pathophysiologic mechanism in chronic venous disease. Reflux is easily visualized by duplex ultrasound when properly elicited, in standing position. A simple way to elicit reflux is the so-called "compression-release maneuver": by emptying the muscle reservoir, it determines a centrifugal gradient, dependent on hydrostatic pressure, creating an aspiration system from the superficial to the deep system. The same results are obtained with dynamics tests activating calf muscles. The Valsalva maneuver elicits reflux by a different mechanism, increasing the downstream pressure and, thus, highlighting any connection between the source of reflux and the refluxing vessel. The Valsalva maneuver is typically used to investigate the saphenofemoral junction. When the maneuver is performed correctly, it is very useful to analyse several conditions and different hemodynamic behaviours of the valvular system at the saphenofemoral junction. Negative Valsalva maneuver always indicates valvular competence at the saphenofemoral junction. Reverse flow lasting during the whole strain (positive Valsalva maneuver) indicates incompetence or absence of proximal valves. Coupling Valsalva maneuver to compression-release maneuver, with the sample volume in different saphenofemoral junction sections, may reveal different hemodynamic situations at the saphenofemoral junction, which can be analysed in detail.


Assuntos
Veia Femoral/diagnóstico por imagem , Veia Safena/diagnóstico por imagem , Manobra de Valsalva , Doenças Vasculares/diagnóstico por imagem , Insuficiência Venosa/fisiopatologia , Velocidade do Fluxo Sanguíneo , Cardiologia , Doença Crônica , Hemodinâmica , Humanos , Músculo Esquelético/patologia , Postura , Escleroterapia , Ultrassonografia Doppler Dupla
14.
JAMA Neurol ; 74(11): 1328-1335, 2017 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-28973174

RESUMO

Importance: A lower dose of intravenous alteplase appears to be a safer treatment option than the standard dose, reducing the risk of symptomatic intracerebral hemorrhage. There is uncertainty, however, over how this effect translates into an overall clinical benefit for patients with acute ischemic stroke (AIS). Objective: To assess whether older, Asian, or severely affected patients with AIS who are considered at high risk of thrombolysis may benefit more from low-dose rather than standard-dose alteplase treatment. Design, Setting, and Participants: This study is a prespecified secondary analysis of the Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED), an international, randomized, open-label, blinded, end-point clinical trial of low-dose vs standard-dose intravenous alteplase for patients with AIS. From March 1, 2012, to August 31, 2015, a total of 3310 patients who had a clinical diagnosis of AIS as confirmed by brain imaging and who fulfilled the local criteria for thrombolysis treatment were included in the alteplase-dose arms. Patients were randomly assigned to receive low-dose (0.6 mg/kg; 15% as bolus and 85% as infusion over 1 hour) or standard-dose (0.9 mg/kg; 10% as bolus and 90% as infusion over 1 hour) alteplase. Of the 3310 randomized patients, 13 patients were excluded for missing consent, mistaken randomization, and duplicate randomization numbers. This secondary analysis was conducted between May 1, 2016, and April 28, 2017. Main Outcomes and Measures: The primary end point was a poor outcome defined by the combination of death and any disability as scored by the modified Rankin Scale (scores range from 2 to 6, with the highest score indicating death) at 90 days. Results: Of the 3297 patients included in the analysis, 1248 (37.9%) were women, and the mean (SD) age was 67 (13) years. No significant differences in the treatment effects were observed between low- and standard-dose alteplase for poor outcomes (death or disability) by age, ethnicity, or severity (all P > .37 for interaction). Similarly, the treatment effects of low- vs standard-dose alteplase on function outcome (ordinal shift of the modified Rankin Scale) in Asians (odds ratio, 1.05; 95% CI, 0.90-1.22) was consistent with non-Asians (odds ratio, 0.93; 95% CI, 0.76-1.14) (P = .32 for interaction). There were generally consistent reductions in rates of symptomatic intracerebral hemorrhage with low-dose alteplase, although this reduction was not statistically significant by age, ethnicity, or severity. Conclusions and Relevance: This analysis found that the effects of low-dose alteplase were not clearly superior to the effects of standard-dose alteplase on death or disability in key demographic subgroups of patients with AIS. Further investigation is required to identify patients with AIS who may benefit from low-dose alteplase. Trial Registration: clinicaltrials.gov Identifier: NCT01422616.


Assuntos
Isquemia Encefálica/tratamento farmacológico , Fibrinolíticos/farmacologia , Avaliação de Resultados (Cuidados de Saúde) , Acidente Vascular Cerebral/tratamento farmacológico , Ativador de Plasminogênio Tecidual/farmacologia , Administração Intravenosa , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Grupo com Ancestrais do Continente Asiático/etnologia , Isquemia Encefálica/etnologia , Feminino , Fibrinolíticos/administração & dosagem , Humanos , Masculino , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Acidente Vascular Cerebral/etnologia , Ativador de Plasminogênio Tecidual/administração & dosagem
15.
Curr Neurol Neurosci Rep ; 17(8): 60, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28667504

RESUMO

PURPOSE OF REVIEW: The purpose of the review is to examine recent evidence on the effects of intravenous thrombolysis and identify the remaining uncertainties. RECENT FINDINGS: We review the results of two large trials (the third International Stroke Trial (IST-3) and The Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED)) and the publications from the individual patient data analyses of the trials of alteplase conducted by the Stroke Thrombolysis Trialists Collaboration. Despite about a 2% risk of fatal intracerebral haemorrhage, on average, adult patients of all ages treated with 0.9 mg/kg alteplase within 4.5 h will have better long-term functional outcome. The use of a lower dose of alteplase (0.6 mg/kg) is associated with a lower risk of haemorrhage but its effect on functional outcome has not been proven to be non-inferior to standard dose therapy. Some clinicians feel confident to treat selected patients who present beyond 4.5 h or have unknown time of onset, but many also agree that the current trials and other research is needed to reliably define the optimum imaging methods and treatment eligibility criteria.


Assuntos
Isquemia Encefálica/tratamento farmacológico , Fibrinolíticos/farmacologia , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/normas , Fibrinolíticos/administração & dosagem , Fibrinolíticos/efeitos adversos , Humanos
16.
Int J Stroke ; 12(5): 560-567, 2017 07.
Artigo em Inglês | MEDLINE | ID: mdl-28697713

RESUMO

Although proof-based medicine has generated much valid evidence for the drawing up of guidelines and recommendations for best clinical practice in symptomatic and asymptomatic carotid stenosis, whether and when it is better to employ endarterectomy or stenting as the intervention of choice still remain matters of debate. Moreover, guidelines have been targeted up to now to the 'representative' patient, as resulting from the statistical analyses of the studies conducted on the safety and efficacy of both interventions as well as on medical therapy alone. The Italian Stroke Organization (ISO) and Stroke Prevention and Awareness Diffusion (SPREAD) group has thus decided to update its statements for an 8th edition. To this end, a multidisciplinary team of authors representing Italian scientific societies in the neurology, neuroradiology, vascular and endovascular surgery, interventional cardiology, and general medicine fields re-examined the literature available on stroke. Analyses and considerations on patient subgroups have allowed to model the risks/benefits of endarterectomy and stenting in the individual. Accordingly, the guideline's original methodology has been revised to follow the new SIGN (Scottish Intercollegiate Guideline Network) Grade-like approach, integrating it with new considerations on Precision, or Personalized Medicine. Therefore, this guideline offers recommendations on precision medicine for the single patient, and can be followed in addition to the more standard guidelines.


Assuntos
Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas , Medicina de Precisão , Stents , Acidente Vascular Cerebral/prevenção & controle , Humanos , Itália , Medicina de Precisão/métodos
17.
Artigo em Inglês | MEDLINE | ID: mdl-28742032

RESUMO

High frame rate (HFR) imaging methods based on the transmission of defocused or plane waves rather than focused beams are increasingly popular. However, the production of HFR images poses severe requirements both in the transmission and the reception sections of ultrasound scanners. In particular, major technical difficulties arise if the images must be continuously produced in real-time, i.e., without any acquisition interruption nor loss of data. This paper presents the implementation of the real-time HFR-compounded imaging application in the ULA-OP 256 research platform. The beamformer sustains an average output sample rate of 470 MSPS. This allows continuously producing coherently compounded images, each of 64 lines by 1280 depths (here corresponding to 15.7 mm width and 45 mm depth, respectively), at frame rates up to 5.3 kHz. Imaging tests addressed to evaluate the achievable speed and quality performance were conducted on phantom. Results obtained by real-time compounding frames obtained with different numbers of steering angles between +7.5° and -7.5° are presented.

18.
Stroke ; 48(9): 2605-2609, 2017 09.
Artigo em Inglês | MEDLINE | ID: mdl-28739832

RESUMO

BACKGROUND AND PURPOSE: Renal dysfunction (RD) is associated with poor prognosis after stroke. We assessed the effects of RD on outcomes and interaction with low- versus standard-dose alteplase in a post hoc subgroup analysis of the ENCHANTED (Enhanced Control of Hypertension and Thrombolysis Stroke Study). METHODS: A total of 3220 thrombolysis-eligible patients with acute ischemic stroke (mean age, 66.5 years; 37.8% women) were randomly assigned to low-dose (0.6 mg/kg) or standard-dose (0.9 mg/kg) intravenous alteplase within 4.5 hours of symptom onset. Six hundred and fifty-nine (19.8%) patients had moderate-to-severe RD (estimated glomerular filtration rate, <60 mL/min per 1.73 m2) at baseline. The impact of RD on death or disability (modified Rankin Scale scores, 2-6) at 90 days, and symptomatic intracerebral hemorrhage, was assessed in logistic regression models. RESULTS: Compared with patients with normal renal function (>90 mL/min per 1.73 m2), those with severe RD (<30 mL/min per 1.73 m2) had increased mortality (adjusted odds ratio, 2.07; 95% confidence interval, 0.89-4.82; P=0.04 for trend); every 10 mL/min per 1.73 m2 lower estimated glomerular filtration rate was associated with an adjusted 9% increased odds of death from thrombolysis-treated acute ischemic stroke. There was no significant association with modified Rankin Scale scores 2 to 6 (adjusted odds ratio, 1.03; 95% confidence interval, 0.62-1.70; P=0.81 for trend), modified Rankin Scale 3 to 6 (adjusted odds ratio, 1.20; 95% confidence interval, 0.72-2.01; P=0.44 for trend), or symptomatic intracerebral hemorrhage, or any heterogeneity in comparative treatment effects between low-dose and standard-dose alteplase by RD grades. CONCLUSIONS: RD is associated with increased mortality but not disability or symptomatic intracerebral hemorrhage in thrombolysis-eligible and treated acute ischemic stroke patients. Uncertainty persists as to whether low-dose alteplase confers benefits over standard-dose alteplase in acute ischemic stroke patients with RD. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01422616.


Assuntos
Isquemia Encefálica/tratamento farmacológico , Fibrinolíticos/uso terapêutico , Insuficiência Renal Crônica/epidemiologia , Acidente Vascular Cerebral/tratamento farmacológico , Ativador de Plasminogênio Tecidual/uso terapêutico , Administração Intravenosa , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/epidemiologia , Isquemia Encefálica/mortalidade , Hemorragia Cerebral/induzido quimicamente , Comorbidade , Feminino , Taxa de Filtração Glomerular , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Prognóstico , Ensaios Clínicos Controlados Aleatórios como Assunto , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/mortalidade , Terapia Trombolítica , Resultado do Tratamento
19.
Stroke ; 48(7): 1877-1883, 2017 07.
Artigo em Inglês | MEDLINE | ID: mdl-28619989

RESUMO

BACKGROUND AND PURPOSE: Many patients receiving thrombolysis for acute ischemic stroke are on prior antiplatelet therapy (APT), which may increase symptomatic intracerebral hemorrhage risk. In a prespecified subgroup analysis, we report comparative effects of different doses of intravenous alteplase according to prior APT use among participants of the international multicenter ENCHANTED study (Enhanced Control of Hypertension and Thrombolysis Stroke Study). METHODS: Among 3285 alteplase-treated patients (mean age, 66.6 years; 38% women) randomly assigned to low-dose (0.6 mg/kg) or standard-dose (0.9 mg/kg) intravenous alteplase within 4.5 hours of symptom onset, 752 (22.9%) reported prior APT use. Primary outcome at 90 days was the combined end point of death or disability (modified Rankin Scale [mRS] scores, 2-6). Other outcomes included mRS scores 3 to 6, ordinal mRS shift, and symptomatic intracerebral hemorrhage by various standard criteria. RESULTS: There were no significant differences in outcome between patients with and without prior APT after adjustment for baseline characteristics and management factors during the first week; defined by mRS scores 2 to 6 (adjusted odds ratio [OR], 1.01; 95% confidence interval [CI], 0.81-1.26; P=0.953), 3 to 6 (OR, 0.95; 95% CI, 0.75-1.20; P=0.662), or ordinal mRS shift (OR, 1.03; 95% CI, 0.87-1.21; P=0.770). Alteplase-treated patients on prior APT had higher symptomatic intracerebral hemorrhage (OR, 1.82; 95% CI, 1.00-3.30; P=0.051) according to the safe implementation of thrombolysis in stroke-monitoring study definition. Although not significant (P-trend, 0.053), low-dose alteplase tended to have better outcomes than standard-dose alteplase in those on prior APT compared with those not using APT (mRS scores of 2-6; OR, 0.84; 95% CI, 0.62-1.12 versus OR, 1.16; 95% CI, 0.99-1.36). CONCLUSIONS: Low-dose alteplase may improve outcomes in thrombolysis-treated acute ischemic stroke patients on prior APT, but this requires further evaluation in a randomized controlled trial. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01422616.


Assuntos
Isquemia Encefálica/tratamento farmacológico , Hemorragia Cerebral/induzido quimicamente , Fibrinolíticos , Avaliação de Resultados (Cuidados de Saúde) , Inibidores da Agregação de Plaquetas/uso terapêutico , Índice de Gravidade de Doença , Acidente Vascular Cerebral/tratamento farmacológico , Ativador de Plasminogênio Tecidual , Idoso , Idoso de 80 Anos ou mais , Feminino , Fibrinolíticos/administração & dosagem , Fibrinolíticos/efeitos adversos , Fibrinolíticos/farmacologia , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/efeitos adversos , Método Simples-Cego , Ativador de Plasminogênio Tecidual/administração & dosagem , Ativador de Plasminogênio Tecidual/efeitos adversos , Ativador de Plasminogênio Tecidual/farmacologia
20.
Science ; 356(6338): 635-638, 2017 05 12.
Artigo em Inglês | MEDLINE | ID: mdl-28495750

RESUMO

Dryland biomes cover two-fifths of Earth's land surface, but their forest area is poorly known. Here, we report an estimate of global forest extent in dryland biomes, based on analyzing more than 210,000 0.5-hectare sample plots through a photo-interpretation approach using large databases of satellite imagery at (i) very high spatial resolution and (ii) very high temporal resolution, which are available through the Google Earth platform. We show that in 2015, 1327 million hectares of drylands had more than 10% tree-cover, and 1079 million hectares comprised forest. Our estimate is 40 to 47% higher than previous estimates, corresponding to 467 million hectares of forest that have never been reported before. This increases current estimates of global forest cover by at least 9%.


Assuntos
Florestas , Conservação dos Recursos Naturais , Terra (Planeta) , Ecossistema , Mapeamento Geográfico
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