Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre, randomised controlled trial

BACKGROUND

Deep vein thrombosis (DVT) and pulmonary embolism are common after stroke. In small trials of patients undergoing surgery, graduated compression stockings (GCS) reduce the risk of DVT. National stroke guidelines extrapolating from these trials recommend their use in patients with stroke despite insufficient evidence. We assessed the effectiveness of thigh-length GCS to reduce DVT after stroke.

METHODS

In this outcome-blinded, randomised controlled trial, 2518 patients who were admitted to hospital within 1 week of an acute stroke and who were immobile were enrolled from 64 centres in the UK, Italy, and Australia. Patients were allocated via a central randomisation system to routine care plus thigh-length GCS (n=1256) or to routine care plus avoidance of GCS (n=1262). A technician who was blinded to treatment allocation undertook compression Doppler ultrasound of both legs at about 7-10 days and, when practical, again at 25-30 days after enrolment. The primary outcome was the occurrence of symptomatic or asymptomatic DVT in the popliteal or femoral veins. Analyses were by intention to treat. This study is registered, number ISRCTN28163533.

FINDINGS

All patients were included in the analyses. The primary outcome occurred in 126 (10.0%) patients allocated to thigh-length GCS and in 133 (10.5%) allocated to avoid GCS, resulting in a non-significant absolute reduction in risk of 0.5% (95% CI -1.9% to 2.9%). Skin breaks, ulcers, blisters, and skin necrosis were significantly more common in patients allocated to GCS than in those allocated to avoid their use (64 [5%] vs 16 [1%]; odds ratio 4.18, 95% CI 2.40-7.27).

INTERPRETATION

These data do not lend support to the use of thigh-length GCS in patients admitted to hospital with acute stroke. National guidelines for stroke might need to be revised on the basis of these results.

FUNDING

Medical Research Council (UK), Chief Scientist Office of Scottish Government, Chest Heart and Stroke Scotland, Tyco Healthcare (Covidien) USA, and UK Stroke Research Network.

Retinopathy of prematurity in small-for-gestational age infants compared with those of appropriate size for gestational age

AIM

To compare the incidence of retinopathy of prematurity (ROP) in small-for-gestational age (SGA) infants compared with appropriate-for-gestational age (AGA) infants undergoing eye screening in the Lothian region of south east Scotland 1990-2004.

METHODS

All infants in Lothian born with birth weight <1500 g and/or gestational age <32 weeks underwent eye screening by two experienced paediatric ophthalmologists. The presence of any stage of ROP (1-5), severe (stage 3 or greater) ROP and treated ROP was compared between the SGA and AGA infants using chi(2) or Fisher exact tests. SGA was defined as birth weight below the 10th centile for gestational age.

RESULTS

A total of 1413 babies with birth weights <1500 g and/or gestational age <32 weeks underwent eye screening; 329 (23%) were SGA. SGA infants born at gestational ages 26-31 weeks were more likely to develop any stage of ROP (p<0.01) than their AGA peers. SGA infants were also more likely to develop severe ROP (gestational age 26-27 weeks, p<0.01; 28-29 weeks, p = 0.01; 30-31 weeks, p = 0.01).

CONCLUSIONS

SGA infants who underwent eye screening in the Lothian region of south east Scotland from 1990 to 2004 were significantly more likely to develop ROP and more severe disease than AGA infants.

Bevacizumab and chemotherapy for recurrent glioblastoma: a single-institution experience

OBJECTIVE

Bevacizumab has been shown to be effective in the treatment of recurrent glioblastoma in combination with chemotherapy compared with historic controls but not in randomized trials.

METHODS

We conducted a retrospective analysis of patients treated for recurrent glioblastoma with bevacizumab vs a control group of patients, comparing progression-free survival (PFS) and overall survival (OS) between the two groups, and performed subgroup analysis based on age and performance status. Expression of vascular endothelial growth factor (VEGF) based on age was examined using DNA microarray analysis. We also evaluated the impact of bevacizumab on quality of life.

RESULTS

We identified 44 patients who received bevacizumab and 79 patients who had not been treated with bevacizumab. There was a significant improvement in PFS and OS in the bevacizumab-treated group. Patients of older age (> or =55 years) and poor performance status (Karnofsky Performance Status < or =80) had significantly better PFS when treated with bevacizumab, and bevacizumab-treated older patients had significantly increased OS. VEGF expression was significantly higher in older glioblastoma patients (aged > or =55 years). Patients treated with bevacizumab also required less dexamethasone use and maintained their functional status longer than the control group.

CONCLUSIONS

Bevacizumab in combination with chemotherapy may be a more effective treatment for recurrent glioblastoma and warrants further randomized prospective studies to determine its effect on survival. Bevacizumab also has more effect in those with older age and might reflect biologic differences in glioblastoma in different age groups as seen with the expression of vascular endothelial growth factor.

A prevalence screen of MRSA nasal colonisation amongst UK doctors in a non-clinical environment

Screening for methicillin-resistant Staphylococcus aureus (MRSA) carriage in healthcare workers (HCWs) is both contentious and confounded by a lack of knowledge of background prevalence rates. This study examines prevalence of nasal MRSA carriage amongst a spectrum of medical professionals in a non-clinical environment. Medical conference attendees volunteered for screening for nasal MRSA carriage, and anonymised demographic data and attitudes towards screening were recorded. Two hundred sixty volunteers participated. One hundred seventy-three participants (67%) were from the British Medical Association's Annual Representatives Meeting, and 87 participants (33%) were attending the Association of Surgeons in Training conference. Six (2%) participants were positive for MRSA nasal carriage (BMA = 1%, ASIT = 5%; p = 0.099). Participants from a surgical specialty (4.8%) were more likely to be MRSA positive (p = 0.039). All positive samples came from male participants (p = 0.182). However, there was no significant association with gender, seniority or country of employment and MRSA status. Routine screening for MRSA was supported by 63% of participants in HCWs; 36% had previously undergone such screening. MRSA nasal carriage rates within this cross-sectional study are lower than studies reporting carriage rates in HCWs within the clinical environment. Further research is required to examine the relationship between MRSA nasal colonisation status of a HCW and subsequent MRSA infection in patients.

500. THE MANIPULATION OF THE EPIGENETIC MARK HISTONE 3 LYSINE 9 TRIMETHYLATION IN DONOR CELLS AND ITS EFFECTS ON THE DEVELOPMENT OF CLONED MOUSE EMBRYOS

To produce live cloned mammals from adult somatic cells the nuclei of these cells must be first reprogrammed from a very restricted, cell lineage-specific gene expression profile to an embryo-like expression pattern, compatible with embryonic development. Although this has been achieved in a number of species the efficiency of cloning remains very low. Inadequate reprogramming of epigenetic marks in the donor cells correlated with aberrant embryonic gene expression profiles has been identified as a key cause of this inefficiency. Some of the most common epigenetic marks are chemical modifications of histones, the main structural proteins of chromatin. A range of different histone modifications, including acetylation and methylation, exists and can be attributed to either repression or activation of genes. One epigenetic mark which is known to be very stable and difficult to remove during reprogramming is the trimethylation of lysine 9 in histone H3 (H3K9Me3). To test the hypothesis that H3K9Me3 marks are a major stumbling block for successful cloning we are attempting to remove these marks by overexpression of the H3K9Me3 specific histone demethylase, jmjd2b, in donor cells, prior to their use for nuclear transfer. We have engineered mouse embryonic stem (ES) cells for the tet inducible expression of a fusion protein with a functional jmjd2b or non-functional mutant jmjd2b histone demethylase. Approximately 94% and 88% of the cells can be induced for the expression of functional and mutant jmjd2b-EGFP in the respective ES cell lines. Immunofluorescence analyses have shown that induction of functional jmjd2b-EGFP results in an approximately 50% reduction of H3K9Me3 levels compared to non-induced cells and induced mutant jmjd2b-EGFP cells. The comparison of the in-vitro embryo development following nuclear transfer with induced and non-induced donor cells show significantly better overall development to blastocysts and morulae from induced donor cells with reduced H3K9Me3 levels.

Wide-field digital retinal imaging versus binocular indirect ophthalmoscopy for retinopathy of prematurity screening: a two-observer prospective, randomised comparison

AIM

To compare the diagnostic accuracy of wide-field digital retinal imaging (WFDRI) with the current "gold standard" of binocular indirect ophthalmoscopy (BIO) for retinopathy of prematurity (ROP) screening examinations.

METHODS

A consecutive series of premature infants undergoing ROP screening at Edinburgh Royal Infirmary were eligible for recruitment into this prospective, randomised, comparative study. Infants were screened using both WFDRI (Retcam II with neonatal lens) and BIO by two paediatric ophthalmologists who were randomised to the examination technique. Both examiners documented their clinical findings and management plans in a masked fashion. WFDRI eye findings were compared with those of BIO.

RESULTS

A total of 81 infants were recruited, and information from 245 eye examinations was analysed. The sensitivity of WFDRI in detecting any stage of ROP, stage 3 ROP and "plus" disease was 60%, 57% and 80%, respectively, and specificity 91%, 98% and 98%, respectively. The proportional agreement between WFDRI and BIO was 0.96 for detecting stage 3 disease and 0.97 for detecting "plus" disease. There was very good agreement on management decisions (kappa 0.85).

CONCLUSION

When used in a routine ROP screening setting, a randomised comparison of WFDRI and BIO, WFDRI showed relatively poor sensitivity in detecting mild forms of ROP in the retinal periphery. This resulted in difficulty in making decisions to discharge infants from the screening programme. Sensitivity was better for more severe forms of ROP, but at present WFDRI should be regarded as an adjunct to, rather than a replacement for, BIO in routine ROP screening.

Incidence of retinopathy of prematurity in Lothian, Scotland, from 1990 to 2004

BACKGROUND

To report the trends in incidence of retinopathy of prematurity (ROP) within Lothian, a geographically defined region in southeast Scotland over a 15-year period from 1990 to 2004.

METHODS

This was a prospective observational study of all infants born with gestational age <32 weeks and/or birth weight <1500 g who were born to mothers resident in Lothian between 1 January 1990 and 31 December 2004. Eligible infants underwent eye screening by two experienced paediatric ophthalmologists (BF and EW). Lothian population data were obtained from the Scottish Health Service. The trends in survival rates, incidence and treatment of ROP were analysed from 1990 to 1994, 1995 to 1999 and 2000 to 2004.

RESULTS

Lothian population data showed a steady decline in the number of live births from 1990 to 2004. The proportion of babies born with birth weight <1500 g and/or gestational age <32 weeks remained constant (p = 0.271 using chi(2) test), although the proportion of these babies surviving to 42 weeks corrected gestation increased from 1990 to 2004 (p<0.001 using chi(2) test for trend). There was a statistically significant linear trend towards a reduction in the number of babies undergoing treatment for ROP throughout the study period (p<0.01 using chi(2) test for trend). A reduction in the incidence of any degree of ROP and severe (stage 3 or greater) ROP was also observed although this did not reach statistical significance.

CONCLUSIONS

There was a significant increase in survival of infants with birth weight <1500 g and/or gestational age <32 weeks together with a significant reduction in the number of infants treated for ROP in the Lothian region of southeast Scotland from 1990 to 2004.

P3b versus P3a: an event-related potential investigation of the glucose facilitation effect

The ingestion of a glucose containing drink has been shown to improve performance on a variety of cognitive tasks. There is debate, however, as to whether glucose especially benefits hippocampal memory functioning or whether it has a more global effect on attentional systems. The present study used event related potential methodology (ERPs) to investigate further glucose-mediated cognitive processes. Each participant acted as his/her own control in a repeated measures design, receiving one of two possible treatments (25 g glucose vs. placebo) in a counterbalanced order. After a two hour fasting period participants completed a visual three-stimulus oddball task. This paradigm involves an individual detecting an infrequent target stimulus randomly embedded in a train of repetitive background or standard stimuli. Detection of the target results in a large P3b ERP component (memory updating effect). The infrequent presentation of a novel and irrelevant stimulus, randomly interspersed with the target and standard stimuli, generates a P3a response (orientation of attention effect). These components were used as markers to establish whether the glucose enhancement effect was restricted to the neuro-cognitive processes related to memory. Consistent with behavioural work, glucose moderated the magnitude and latency of the P3b ERP component. However, glucose also interacted with attentional systems (P3a and an earlier P2), although this effect was non-significant. This work converges with recent fMRI findings indicating the sensitivity of the medial-temporal lobes and the pre-frontal cortex to glucose administration.

Maternal obesity, length of gestation, risk of postdates pregnancy and spontaneous onset of labour at term

OBJECTIVE

To investigate the effect of maternal body mass index (BMI) on postdates pregnancy, length of gestation and likelihood of spontaneous onset of labour at term.

DESIGN

Retrospective cohort study.

SETTING

Swedish Medical Birth Register.

POPULATION

A total of 186 087 primiparous women (of whom 143 519 had spontaneous onset of labour at term) who gave birth between 1998 and 2002.

METHODS

Mann-Whitney test, one-way analysis of variance, linear regression and single variable logistic regression.

MAIN OUTCOME MEASURES

Postdates pregnancy (>/=294 days or 42(+0) weeks), length of gestation and likelihood of spontaneous onset of labour at term.

RESULTS

About 6.8% of pregnancies delivered postdates. Higher maternal BMI (kg/m(2)) during the first trimester was associated with longer gestation (P < 0.001) as was a greater change in BMI between the first and third trimesters (BMI measured on admission prior to delivery) with mean (SD) gestation at delivery of 280.7 (8.6) and 283.2 (8.6) days for increases in BMI of <2 and >/=10 kg/m(2), respectively. Higher BMI during the first trimester was associated with a lower chance of spontaneous onset of labour at term. Compared with BMI 20 to <25 kg/m(2), the odds ratios (95% CI) for spontaneous onset of labour at term were 1.21 (1.15-1.27) for BMI of <20 kg/m(2), 0.71 (0.69-0.74) for BMI of 25 to <30 kg/m(2), 0.57 (0.54-0.60) for BMI of 30 to <35 kg/m(2) and 0.43 (0.40-0.47) for BMI of >/=35 kg/m(2). Higher BMI during the first trimester (BMI of >/=35 kg/m(2) compared with BMI of 20 to <25 kg/m(2)) was also associated with an increased risk of complications including stillbirth (OR 3.90, 95% CI 2.44-6.22), gestational diabetes (OR 5.61, 95% CI 4.61-6.83) and caesarean section (OR 2.39; 95% CI 2.20-2.59).

CONCLUSIONS

Higher maternal BMI in the first trimester and a greater change in BMI during pregnancy were associated with longer gestation and an increased risk of postdates pregnancy. Higher maternal BMI during the first trimester was also associated with decreased likelihood of spontaneous onset of labour at term and increased likelihood of complications.

Fractal analysis of the retinal vascular network in fundus images

Complexity of the retinal vascular network is quantified through the measurement of fractal dimension. A computerized approach enhances and segments the retinal vasculature in digital fundus images with an accuracy of 94% in comparison to the gold standard of manual tracing. Fractal analysis was performed on skeletonized versions of the network in 40 images from a study of stroke. Mean fractal dimension was found to be 1.398 (with standard deviation 0.024) from 20 images of the hypertensives sub-group and 1.408 (with standard deviation 0.025) from 18 images of the non-hypertensives subgroup. No evidence of a significant difference in the results was found for this sample size. However, statistical analysis showed that to detect a significant difference at the level seen in the data would require a larger sample size of 88 per group.

Prediction of antibiotic resistance using Neisseria gonorrhoeae multi-antigen sequence typing

OBJECTIVES

To establish whether antibiotic resistance in Neisseria gonorrhoeae is uniform within a given sequence type as determined by N gonorrhoeae multi-antigen sequence typing (NG-MAST).

METHODS

Antibiotic susceptibility testing and typing was performed on all N gonorrhoeae isolated in Scotland over a 2-year period. Antibiotic susceptibility to seven antibiotics was determined using the agar dilution method and NG-MAST was performed.

RESULTS

Isolates from 1762 episodes of infection were tested, of which 8.0% were penicillinase-producing N gonorrhoeae, 8.4% were tetracycline-resistant N gonorrhoeae, 2.7% had chromosomal penicillin resistance, 30.5% had chromosomal tetracycline resistance, 2.0% had decreased susceptibility to azithromycin and 25.3% were ciprofloxacin resistant (including 1.7% with intermediate resistance). Resistance to spectinomycin or decreased susceptibility to ceftriaxone or cefixime was not observed. Of 405 sequence types, 169 contained two to 85 isolates accounting for 1526 isolates. The overall concordance between sequence type and antibiotic susceptibility category was 98.1% (95% CI 97.8 to 98.3). The concordance for penicillin (chromosomal and plasmid-mediated resistance) was 97.1% (95% CI 96.1 to 97.8), for ciprofloxacin it was 99.5% (95% CI 99.1 to 99.8), for azithromycin it was 97.8% (95% CI 96.9 to 98.5) and for tetracycline (chromosomal and plasmid-mediated resistance) it was 92.0% (95% CI 90.5 to 93.3).

CONCLUSIONS

Antibiotic resistance in N gonorrhoeae was usually uniform within a given sequence type. Therefore the sequence type of an isolate allows the presence of antibiotic resistance to be predicted with a high degree of accuracy. Further studies on the geographical variation and temporal stability of antibiotic susceptibility patterns within sequence types are required.

A phase II, multicenter trial of weekly topotecan in patients with recurrent platinum-sensitive epithelial cancers of the ovary and peritoneum

The purpose of this study was to evaluate the response rate and toxicity of weekly topotecan in patients with recurrent platinum-sensitive epithelial cancers of the ovary and peritoneum. Thirty-nine platinum-sensitive recurrent ovarian cancer patients received topotecan (4 mg/m2) intravenously day 1, day 8, day 15, every 28 days. Colony-stimulating factors were excluded from the study. Clinical response was assessed by clinical, serologic, and radiographic measures at the conclusion of cycle four. Patients received 136 cycles of topotecan (median = 3; range 1–6) and were evaluated for response and toxicity. Median number of prior regimens was one. Grade 3/4 neutropenia developed in 3 (7.7%) patients. Grade 3 thrombocytopenia was seen in one (2.6%) patient, with no incidence of grade 4 thrombocytopenia. There was no evidence of grade 3 anemia, but one patient (2.6%) was associated with grade 4 anemia. There was no grade 3 or 4 neuropathy. We encountered 18 dose reductions following less than or equal to grade 2 myelosuppression, necessitating the removal of eight (20.5%) patients prior to cycle four. Twenty-one (53.8%) patients were removed from the study due to disease progression. Following the completion of cycle four, four (10.3%) patients demonstrated stable disease and four (10.3%) patients exhibited a partial response. There were no complete responses. Median disease-free survival was 12 weeks. Weekly topotecan (4 mg/m2) demonstrated modest activity and was moderately well tolerated. However, the significant number of dose reductions and high incidence of patients who demonstrated disease progression suggests additional modifications with this specific regimen are necessary.

Spinocerebellar ataxia type 8 in Scotland: frequency, neurological, neuropsychological and neuropsychiatric findings

OBJECTIVES

The objectives of this study were to: (i) establish whether the spinocerebellar ataxia type 8 (SCA 8) expansion is associated with ataxia in Scotland; (ii) test the hypothesis that SCA 8 is associated with neuropsychological impairment; and (iii) review neuroradiological findings in SCA 8.

METHODS

The methods included: (i) measurement of SCA 8 expansion frequencies in ataxic patients and healthy controls; (ii) comprehensive neuropsychological assessment of patients with SCA 8 and matched controls, neuropsychiatric interview; and (iii) comparison of patient and matched control magnetic resonance imaging (MRI) scans.

RESULTS

(i) 10/694 (1.4%) unrelated individuals with ataxia had combined CTA/CTG repeat expansions >100 compared to 1/1190 (0.08%) healthy controls (P < 0.0005); (ii) neuropsychological assessment revealed a dysexecutive syndrome among SCA 8 patients, not readily explained by motor or mood disturbance; neuropsychiatric symptoms occurred commonly; (iii) cerebellar atrophy was the only salient MRI abnormality in the patient group.

CONCLUSIONS

The SCA 8 expansion is associated with ataxia in Scotland. The disorder is associated with a dysexecutive syndrome.

A phase II study of outpatient first-line paclitaxel, carboplatin, and bevacizumab for advanced-stage epithelial ovarian, peritoneal, and fallopian tube cancer

The purpose of this study was to assess the response rate and toxicity of paclitaxel, carboplatin, and bevacizumab (PCB) primary induction therapy for the treatment of advanced-stage ovarian carcinoma. Twenty patients were treated with paclitaxel (175 mg/m(2)), carboplatin (AUC of 5 IV), and bevacizumab (15 mg/kg) of body weight; q21 days for six cycles. Bevacizumab was administered at cycles two through six. Patients received 116 cycles of PCB chemotherapy (median = 6, range 2-6) and were evaluable for toxicity assessment. Grade 3 and 4 neutropenia developed in 23.3% and 25% of cycles, with no incidence of grades 3/4 thrombocytopenia or anemia. Prior to cycle six, one patient was removed from the study due to grade 3 neuropathy and another patient was excluded due to clinical deterioration. There was no incidence of gastrointestinal perforations, and only two patients demonstrated grade 3 hypertension (HTN). No grade 4 HTN was observed. Eighteen patients were evaluated for response following induction therapy. Six demonstrated a complete response (30%) and ten exhibited a partial response (50%), resulting in a total response rate of 80%. One patient exhibited stable disease (5%), and one demonstrated disease progression (5%). The lack of bowel perforations and wound complications should mitigate some concerns regarding these side effects. This study suggests that first-line treatment with PCB can be safely administered to previously untreated advanced-stage ovarian carcinoma patients. The favorable toxicity results and reasonable response rate warrant additional study in a larger patient population.

A phase II randomized, placebo-controlled, double-blind study of the efficacy and safety of RC-1291 (RC) for the treatment of cancer cachexia

9133

Background: Cancer cachexia is closely correlated with poor outcome and poor survival. RC is an oral ghrelin mimetic with orexigenic and anabolic activity. Methods: A phase II trial enrolled 81 patients with cancer, performance scores of 0–2, and weight loss of 5% or more within 6 months prior to enrollment at 17 sites in the US. Patients were randomized to treatment with two placebo (PL) or two 25 mg RC capsules taken once daily for 12 weeks. Outcome measures included lean body mass (LBM), total body mass (TBM) by DEXA (central reading), scale weight, handgrip strength (HS) and QOL measures. Biochemical markers included IGF-1 and IGFBP-3. In the per protocol analysis (32 RC, 28 PL) more than 20 cancer types were represented; the most common were lung (n=13) and colorectal cancer (n=15). The two treatment groups were balanced at baseline except for (RC vs PL, respectively): gender (66 % male vs 57 %), TBM (60.9 kg vs 65.3 kg), and HS (53.8 kg vs 56.6 kg). The analyses (repeated measures ANOVA without imputation) included all available data from the patients. Results: TBM and LBM (primary endpoint at 8 wks) were significantly increased vs. PL at wks 4 and 8 and at wks 4, respectively. The magnitude of the increase vs. baseline was stable from wk 4 through wk 12 during RC treatment for both TBM and LBM. HS was increased at significantly at wk 8. IGF-1 and IGFBP-3 significantly increased at wks 4, 8, and 12. No significant differences were found on the QOL or scale weight measures. RC was well tolerated. Patients having any AEs were 96% vs 87% and SAEs were 32% and 26% for RC and PL, respectively. The percent of patients and types of AEs were similar; possible exceptions included cardiac events and infections (11% vs 3% and 30% vs 42%, RC vs PL, respectively). Conclusions: In this randomized, double-blind, placebo-controlled trial, RC treatment led to improvements in LBM, TBM and HS. RC-1291 is a promising potential therapeutic agent for the treatment of cancer cachexia.

No significant financial relationships to disclose.