In this phase 2B trial involving 75 patients with acute ischemic stroke, tenecteplase was more effective than alteplase in achieving reperfusion and clinical improvement at 24 hours. Bleeding ...complications were similar in the two groups.
Thrombolytic treatment with alteplase, a recombinant tissue plasminogen activator, for acute ischemic stroke is of proven benefit.
1
However, alteplase is far from ideal, with incomplete and often delayed reperfusion in many patients.
2
Tenecteplase, a genetically engineered mutant tissue plasminogen activator, has some pharmacokinetic advantages over alteplase.
3
A balance between efficacy and risk of bleeding in the treatment of stroke appears to be achieved at a lower dose of tenecteplase than the dose used for myocardial infarction.
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A recent dose-ranging study of tenecteplase involving patients with acute ischemic stroke, which used standard clinical selection criteria, showed that a dose of 0.4 . . .
OBJECTIVE:To compare the accuracy of Alberta Stroke Program Early Computed Tomography Score (ASPECTS) and CT perfusion to detect established infarction in acute anterior circulation stroke.
...METHODS:We performed an observational study in 59 acute anterior circulation ischemic stroke patients who underwent brain noncontrast CT, CT perfusion, and MRI within 100 minutes from CT imaging. ASPECTS scores were calculated by 4 blinded vascular neurologists. The accuracy of ASPECTS and CT perfusion core volume to detect an acute MRI diffusion lesion of ≥70 mL was evaluated using receiver operating characteristics analysis and optimum cutoff values were calculated using Youden J.
RESULTS:Median ASPECTS score was 8 (interquartile range IQR 5–9). Median CT perfusion core volume was 22 mL (IQR 10.4–71.9). Median MRI diffusion lesion volume was 24.5 mL (IQR 10–63.9). No significant difference was found between the accuracy of CT perfusion and ASPECTS (c statistic 0.95 vs 0.87, p value for difference = 0.17). The optimum ASPECTS cutoff score to detect a diffusion-weighted imaging lesion ≥70 mL was <7 (sensitivity 0.74, specificity 0.86, Youden J = 0.60) and the optimum CT perfusion core volume cutoff was ≥50 mL (sensitivity 0.86, specificity 0.97, Youden J = 0.84). The CT perfusion core lesion covered a median of 100% (IQR 86%–100%) of the acute MRI lesion volume (Pearson R = 0.88; R = 0.77).
CONCLUSIONS:We found no significant difference between the accuracy of CT perfusion and ASPECTS to predict hyperacute MRI lesion volume in ischemic stroke.
It is unknown whether collateral vessel status, as seen on computed tomography angiography, can predict the fate of penumbral tissue identified on perfusion computed tomography and thereby influence ...clinical outcome. We tested this hypothesis in consecutive patients who underwent perfusion computed tomography/computed tomography angiography within 6 h of anterior circulation stroke, who also had repeat perfusion/infarct volume imaging at 24 h, and modified Rankin Scale at 3 months. Collateral status was graded as good or reduced depending on the extent of contrast visualized distal to the occlusion on computed tomography angiography. ‘Perfusion computed tomography mismatch’ ratio was calculated from the ratio of the mean transit time lesion/cerebral blood volume lesion. Of 92 patients with proximal intracranial vessel occlusion, good collateral status (51/92) was significantly associated with reduced infarct expansion and more favourable functional outcomes (modified Rankin Scale 0–2). Significant univariate predictors of favourable outcome were good collateral status, major reperfusion at 24 h, presence of perfusion computed tomography mismatch (for a range of ratios: ≥1.2, ≥2, ≥3, ≥3.5) and baseline National Institutes of Health Stroke Scale score. Notably, none of the 37 patients with a perfusion computed tomography mismatch ratio < 3.0 had a favourable outcome. In patients with perfusion computed tomography mismatch, significant independent predictors of favourable outcome were good collateral status, major reperfusion and baseline National Institutes of Health Stroke Scale score. There was also a strong interaction between major reperfusion and good collateral status in the regression models. In patients with proximal vessel occlusion, perfusion computed tomography mismatch is a prerequisite for a favourable clinical response, but good collateral status appears a critical determinant of ultimate outcome, particularly if major reperfusion occurs.
Few studies explored the effects of nutritional changes on body mass index (BMI), weight (Wt), waist circumference (WC) and hypertension, especially for the older Chinese population.
By using China ...Health and Nutrition Survey 2004-2011 waves, a total of 6348 observations aged ≥ 60 were involved in the study. The number of participants dropped from 2197 in 2004, to 1763 in 2006, 1303 in 2009, and 1085 in 2011. Dietary information was obtained from participants using 24 hour-recall over three consecutive days. Height, Wt, WC, systolic and diastolic blood pressure were also measured in each survey year. The dietary pattern was derived by exploratory factor analysis using principal component analysis methods. Linear Mixed Models were used to investigate associations of dietary patterns with BMI, Wt and WC. Generalized Estimating Equation models were used to assess the associations between dietary patterns and hypertension.
Over time, older people's diets were shifting towards a modern dietary pattern (high intake of dairy, fruit, cakes and fast food). Traditional and modern dietary patterns had distinct associations with BMI, Wt and WC. Participants with a diet in the highest quartile for traditional composition had a β (difference in mean) of -0.23 (95 % CI: -0.44; -0.02) for BMI decrease, β of -0.90 (95 % CI: -1.42; -0.37) for Wt decrease; and β of -1.57 (95 % CI: -2.32; -0.83) for WC decrease. However, participants with a diet in the highest quartile for modern diet had a β of 0.29 (95 % CI: 0.12; 0.47) for BMI increase; β of 1.02 (95 % CI: 0.58; 1.46) for Wt increase; and β of 1.44 (95 % CI: 0.78; 2.10) for Wt increase. No significant associations were found between dietary patterns and hypertension.
We elucidate the associations between dietary pattern and change in BMI, Wt, WC and hypertension in a 7-year follow-up study. The strong association between favourable body composition and traditional diet, compared with an increase in BMI, WC and Wt with modern diet suggests that there is an urgent need to develop age-specific dietary guideline for older Chinese people.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Summary Background We assessed patient outcomes 90 days after hospital admission for stroke following a multidisciplinary intervention targeting evidence-based management of fever, hyperglycaemia, ...and swallowing dysfunction in acute stroke units (ASUs). Methods In the Quality in Acute Stroke Care (QASC) study, a single-blind cluster randomised controlled trial, we randomised ASUs (clusters) in New South Wales, Australia, with immediate access to CT and on-site high dependency units, to intervention or control group. Patients were eligible if they spoke English, were aged 18 years or older, had had an ischaemic stroke or intracerebral haemorrhage, and presented within 48 h of onset of symptoms. Intervention ASUs received treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction with multidisciplinary team building workshops to address implementation barriers. Control ASUs received only an abridged version of existing guidelines. We recruited pre-intervention and post-intervention patient cohorts to compare 90-day death or dependency (modified Rankin scale mRS ≥2), functional dependency (Barthel index), and SF-36 physical and mental component summary scores. Research assistants, the statistician, and patients were masked to trial groups. All analyses were done by intention to treat. This trial is registered at the Australia New Zealand Clinical Trial Registry (ANZCTR), number ACTRN12608000563369. Findings 19 ASUs were randomly assigned to intervention (n=10) or control (n=9). Of 6564 assessed for eligibility, 1696 patients' data were obtained (687 pre-intervention; 1009 post-intervention). Results showed that, irrespective of stroke severity, intervention ASU patients were significantly less likely to be dead or dependent (mRS ≥2) at 90 days than control ASU patients (236 42% of 558 patients in the intervention group vs 259 58% of 449 in the control group, p=0·002; number needed to treat 6·4; adjusted absolute difference 15·7% 95% CI 5·8–25·4). They also had a better SF-36 mean physical component summary score (45·6 SD 10·2 in the intervention group vs 42·5 10·5 in the control group, p=0·002; adjusted absolute difference 3·4 95% CI 1·2–5·5) but no improvement was recorded in mortality (21 4% of 558 in intervention group and 24 5% of 451 in the control group, p=0·36), SF-36 mean mental component summary score (49·5 10·9 in the intervention group vs 49·4 10·6 in the control group, p=0·69) or functional dependency (Barthel Index ≥60: 487 92% of 532 patients vs 380 90% of 423 patients; p=0·44). Interpretation Implementation of multidisciplinary supported evidence-based protocols initiated by nurses for the management of fever, hyperglycaemia, and swallowing dysfunction delivers better patient outcomes after discharge from stroke units. Our findings show the possibility to augment stroke unit care. Funding National Health & Medical Research Council ID 353803, St Vincent's Clinic Foundation, the Curran Foundation, Australian Diabetes Society-Servier, the College of Nursing, and Australian Catholic University.
The use of perfusion imaging to guide selection of patients for stroke thrombolysis remains controversial because of lack of supportive phase three clinical trial evidence. We aimed to measure the ...outcomes for patients treated with intravenous recombinant tissue plasminogen activator (rtPA) at a comprehensive stroke care facility where perfusion computed tomography was routinely used for thrombolysis eligibility decision assistance. Our overall hypothesis was that patients with 'target' mismatch on perfusion computed tomography would have improved outcomes with rtPA. This was a prospective cohort study of consecutive ischaemic stroke patients who fulfilled standard clinical/non-contrast computed tomography eligibility criteria for treatment with intravenous rtPA, but for whom perfusion computed tomography was used to guide the final treatment decision. The 'real-time' perfusion computed tomography assessments were qualitative; a large perfusion computed tomography ischaemic core, or lack of significant perfusion lesion-core mismatch were considered relative exclusion criteria for thrombolysis. Specific volumetric perfusion computed tomography criteria were not used for the treatment decision. The primary analysis compared 3-month modified Rankin Scale in treated versus untreated patients after 'off-line' (post-treatment) quantitative volumetric perfusion computed tomography eligibility assessment based on presence or absence of 'target' perfusion lesion-core mismatch (mismatch ratio >1.8 and volume >15 ml, core <70 ml). In a second analysis, we compared outcomes of the perfusion computed tomography-selected rtPA-treated patients to an Australian historical cohort of non-contrast computed tomography-selected rtPA-treated patients. Of 635 patients with acute ischaemic stroke eligible for rtPA by standard criteria, thrombolysis was given to 366 patients, with 269 excluded based on visual real-time perfusion computed tomography assessment. After off-line quantitative perfusion computed tomography classification: 253 treated patients and 83 untreated patients had 'target' mismatch, 56 treated and 31 untreated patients had a large ischaemic core, and 57 treated and 155 untreated patients had no target mismatch. In the primary analysis, only in the target mismatch subgroup did rtPA-treated patients have significantly better outcomes (odds ratio for 3-month, modified Rankin Scale 0-2 = 13.8, P < 0.001). With respect to the perfusion computed tomography selected rtPA-treated patients (n = 366) versus the clinical/non-contrast computed tomography selected rtPA-treated patients (n = 396), the perfusion computed tomography selected group had higher adjusted odds of excellent outcome (modified Rankin Scale 0-1 odds ratio 1.59, P = 0.009) and lower mortality (odds ratio 0.56, P = 0.021). Although based on observational data sets, our analyses provide support for the hypothesis that perfusion computed tomography improves the identification of patients likely to respond to thrombolysis, and also those in whom natural history may be difficult to modify with treatment.
Multiple Sclerosis is more common in women than men and females have more relapses than men. In a large international cohort we have evaluated the effect of gender on disability accumulation and ...disease progression to determine if male MS patients have a worse clinical outcome than females.
Using the MSBase Registry, data from 15,826 MS patients from 25 countries was analysed. Changes in the severity of MS (EDSS) were compared between sexes using a repeated measures analysis in generalised linear mixed models. Kaplan-Meier analysis was used to test for sex difference in the time to reach EDSS milestones 3 and 6 and the secondary progressive MS.
In relapse onset MS patients (n = 14,453), males progressed significantly faster in their EDSS than females (0.133 vs 0.112 per year, P<0.001,). Females had a reduced risk of secondary progressive MS (HR (95% CI) = 0.77 (0.67 to 0.90) P = 0.001). In primary progressive MS (n = 1,373), there was a significant increase in EDSS over time in males and females (P<0.001) but there was no significant sex effect on the annualized rate of EDSS change.
Among registrants of MSBase, male relapse-onset patients accumulate disability faster than female patients. In contrast, the rate of disability accumulation between male and female patients with primary progressive MS is similar.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Demand for higher education in Australia has doubled since 1989, increasing the number of students from diverse social, economic and academic backgrounds. Equity targets have seen a proliferation of ...programs and interventions aimed at encouraging school students, particularly those from low socio-economic status backgrounds, to participate in higher education. However, little is known about the specific occupational interests of school students upon which targeted strategies might effectively be designed and implemented. This paper examines school students' aspirations for specific careers that require a university education, in relation to student background and school-related variables. The analysis draws from a study of 6492 students from Years 3 to 12 in 64 New South Wales public schools. We found a complex array of factors relating to interest in different careers. Year level at school, gender and prior achievement were stronger predictors across many careers than factors such as SES, Indigenous status and school location. We argue that rather than taking a one-size-fits-all approach to encouraging participation in higher education, outreach activities should be targeted to take account of student diversity and inequalities that foster differing aspirations.
Objective:
To determine physical, cognitive and social activity levels of stroke patients undergoing rehabilitation, and whether these changed over time.
Design:
Observational study using behavioural ...mapping techniques to record patient activity over 12 hours on one weekday and one weekend day at baseline (week 1) and again two weeks later (week 2).
Setting:
A 20-bed mixed rehabilitation unit.
Subjects:
Fourteen stroke patients.
Interventions:
None.
Main measures:
Percentage of day spent in any activity or physical, cognitive and social activities. Level of independence using the Functional Independence Measure (FIM) and mood using the Patient Health Questionniare-9 (PHQ-9).
Results:
The stroke patients performed any activity for 49%, social activity for 32%, physical activity for 23% and cognitive activity for 4% of the day. Two weeks later, physical activity levels had increased by 4% (95% confidence interval (CI) 1 to 8), but levels of any activity or social and cognitive activities had not changed significantly. There was a significant: (i) positive correlation between change in physical activity and change in FIM score (r = 0.80), and (ii) negative correlation between change in social activity and change in PHQ-9 score (r = −0.72). The majority of activity was performed by the bedside (37%), and most physical (47%) and cognitive (54%) activities performed when alone. Patients undertook 5% (95% CI 2 to 9) less physical activity on the weekends compared with the weekdays.
Conclusions:
Levels of physical, cognitive and social activity of stroke patients were low and remained so even though level of independence and mood improved. These findings suggest the need to explore strategies to stimulate activity within rehabilitation environments.
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