Advancements in understanding the mechanisms of symptomatic lacunar ischemic stroke: translation of knowledge to prevention strategies.

Symptomatic lacunar ischemic stroke (25% of all brain infarctions) results from occlusion of a single penetrating artery by microatheromas or lipohyalinosis and rarely from an intracranial atheromatous branch disease. Recurrent lacunar stroke may be associated with more severe clinical features and has been involved in producing lacunar state and vascular subcortical dementia. In the first multicenter randomized clinical trial (SPS3) focused on stroke prevention among patients with recent lacunar stroke, the addition of clopidogrel to aspirin not only did not reduced significantly the risk of recurrent stroke, but also increased significantly the likelihood of hemorrhage and fatal outcome. If lacunar stroke is primarily non-atherothromboembolic, secondary prevention aimed at preventing atheroma progression may not be very effective. The efficacy of drugs that improve endothelial function in lacunar stroke patients remains to be studied in the future.

Clinical characteristics of acute lacunar stroke in women: emphasis on gender differences.

There are few studies analyzing features of ischemic stroke subtypes in women. We assessed gender differences in lacunar stroke subtype based on data collected from a prospective stroke registry in Barcelona, Spain. Lacunar ischemic stroke was diagnosed in 310 (8.1 %) women and 423 (11.1 %) men of a total of 3,808 consecutive stroke patients included in a prospective hospital-based stroke registry, in Barcelona, Catalonia (Spain), over a period of 19 years. Independent factors for lacunar stroke in women were assessed by multivariate analysis. Women accounted for 42 % of all lacunar stroke patients (n = 733) in the registry and 11.4 % of all patients with ischemic stroke (n = 2,704). Very old age (85 years or older) was found in 20.3 % in women versus 11.1 % in men (P < 0.0001). In the logistic regression analysis, obesity [odds ratio (OR) = 4.24], prolonged hospital stay (>12 days) (OR = 1.59), arterial hypertension (OR = 1.50), and age (OR = 1.06) were significant variables independently associated with lacunar stoke in women, whereas peripheral vascular disease (OR = 0.51), chronic obstructive pulmonary disease (OR = 0.46), renal dysfunction (OR = 0.13), and heavy smoking (OR = 0.04) were independent variables for lacunar stroke in men. Women with lacunar stroke were remarkably older and presented with obesity and hypertension more frequently than did men. Lacunar stroke severity was similar in men and women. These findings in lacunar stroke patients could be explained by differences in gender for ischemic stroke in general.

Cognitive profile in patients with a first-ever lacunar infarct with and without silent lacunes: a comparative study.

BACKGROUND: The detection of early neuropsychological abnormalities as precursors of cognitive decline of vascular origin in patients with lacunar stroke is a subject of increasing interest. The objective of this study was to assess whether there were differences in the performance of a battery of neuropsychological tests in first-ever lacunar stroke patients with and without associated silent multiple lacunar infarctions found incidentally on the brain magnetic resonance imaging (MRI) scan. METHODS: A total of 72 consecutive patients with first-ever lacunar infarction were studied 1 month after stroke. All patients underwent a comprehensive neuropsychological evaluation, which included the California Verbal Learning Test (CVLT), Phonetic Verbal Fluency Test (PMR), Semantic Verbal Fluency Test (category "animals"), Digit Span Forward and Backward from the Wechsler Adult Intelligence Scale (WAIS-III), and Mini-Mental State Examination (MMSE). RESULTS: A total of 38 patients (52.7%) had silent multiple lacunar infarcts, with corona radiata as the most frequent topography (P < 0.023). White matter hyperintensities (leukoaraiosis) were observed in 81.1% of patients with silent multiple lacunar infarcts and in 50% with a single lacunar infarction (P < 0.007). Patients in both groups showed similar scores in the MMSE, but those with associated silent lacunar infarctions showed a poorer performance in the semantic fluency test (P < 0.008) and in short delayed verbal memory (P < 0.001). In both cases, however, leukoaraiosis was not statistically significant in multivariate linear regression models adjusted by confounding covariates. In these models, multiple silent lacunar infarctions and education were independent predictors of poor performance in the semantic fluency test and in short delayed verbal memory. CONCLUSIONS: The presence of silent multiple lacunar infarctions documented on brain MRI scans in patients with first-ever lacunar stroke was associated with mild neuropsychological abnormalities, particularly in the performance of executive functions (semantic fluency) and short delayed verbal memory. According to these findings, in the initial stages of small vessel disease, mild neuropsychological abnormalities appear to be related to lacunes rather than to leukoaraiosis or perivascular hyperintensities of vascular cause.

MTB-3, a microtubule plus-end tracking protein (+TIP) of Neurospora crassa.

The microtubule (MT) "plus end" constitutes the platform for the accumulation of a structurally and functionally diverse group of proteins, collectively called "MT plus-end tracking proteins" (+TIPs). +TIPs control MT dynamics and link MTs to diverse sub-cellular structures. Neurospora crassaMicroTubule Binding protein-3 (MTB-3) is the homolog of yeast EB1, a highly conserved +TIP. To address the function of MTB-3, we examined strains with mtb-3 deletions, and we tagged MTB-3 with GFP to assess its dynamic behavior. MTB-3-GFP was present as comet-like structures distributed more or less homogeneously within the hyphal cytoplasm, and moving mainly towards the apex at speeds up to 4× faster than the normal hyphal elongation rates. MTB-3-GFP comets were present in all developmental stages, but were most abundant in mature hyphae. MTB-3-GFP comets were observed moving in anterograde and retrograde direction along the hypha. Retrograde movement was also observed as originating from the apical dome. The integrity of the microtubular cytoskeleton affects the presence and dynamics of MTB-3-GFP comets, while actin does not seem to play a role. The size of MTB-3-GFP comets is affected by the absence of dynactin and conventional kinesin. We detected no obvious morphological phenotypes in Δmtb-3 mutants but there were fewer MTs in Δmtb-3, MTs were less bundled and less organized. Compared to WT, both MT polymerization and depolymerization rates were significantly decreased in Δmtb-3. In summary, the lack of MTB-3 affects overall growth and morphological phenotypes of N. crassa only slightly, but deletion of mtb-3 has strong effect on MT dynamics.

Effects of the implementation of a preventive interventions program on the reduction of medication errors in critically ill adult patients.

PURPOSE: Medication errors (MEs) are a major factor limiting the effectiveness and safety of pharmacological therapies in critically ill patients. The purpose was to determine if a preventive interventions program (PIP) is associated with a significant reduction on prevalence of patients with MEs in intensive care unit (ICU). METHODS: A prospective before-after study was conducted in a random sample of adult patients in a medical-surgical ICU. Between 2 observational phases, a PIP (bundle of interventions to reduce MEs) was implemented by a multidisciplinary team. Direct observation was used to detect MEs at baseline and postintervention. Each medication process, that is, prescription, transcription, dispensing, preparation, and administration, was compared with what the prescriber ordered; if there was a difference, the error was described and categorized. Medication errors were defined according to the National Coordinating Council for Medication Error Reporting and Prevention. RESULTS: A total of 410 medications for 278 patients were evaluated. A 31.7% decrease on the prevalence of patients with MEs (41.9%-28.6%; P < .05) was seen. Main variations occurred in anti-infectives for systemic use and prescription and administration stage. CONCLUSIONS: The implementation of PIP by a multidisciplinary team resulted in a significant reduction on the prevalence of patients with ME at an adult ICU.

Impacto del cuidado multidisciplinario en los desenlaces clínicos de los pacientes críticos / Impact of multidisciplinary teams on clinical outcomes of critically ill patients

La seguridad de los pacientes críticos en la Unidad de Cuidados Intensivos (UCI), ha sido progresivamente reconocida como un componente esencial de la práctica de la medicina intensiva moderna. La creación y promoción de equipos multidisciplinarios liderados por un intensivista ha demostrado mejorar la seguridad de la atención de salud. La incorporación de un farmacéutico con entrenamiento especializado a la UCI, ha generado un impacto positivo en los desenlaces clínicos y económicos. El fomento de la cultura de la seguridad en la UCI y el rediseño de los procesos defectuosos pueden mejorar significativamente la seguridad y calidad de la atención de los pacientes críticos.

The safety of critically ill patients in Intensive Care Unit (ICU) has been increasingly recognized as an essential component of the practice of modern intensive care. The creation and promotion of intensivist-led multidisciplinary teams has shown to improve the safety of health care. The addition in the ICU of a pharmacist with specialized training has generated a positive impact on clinical and economic outcomes. The promotion of safety culture in the ICU and the redesign of faulty processes can significantly improve the safety and quality of care of critically ill patients.