Dynamic measurement of near-field radiative heat transfer

Super-Planckian near-field radiative heat transfer allows effective heat transfer between a hot and a cold body to increase beyond the limits long known for black bodies. Until present, experimental techniques to measure the radiative heat flow relied on steady-state systems. Here, we present a dynamic measurement approach based on the transient plane source technique, which extracts thermal properties from a temperature transient caused by a step input power function. Using this versatile method, that requires only single sided contact, we measure enhanced radiative conduction up to 16 times higher than the blackbody limit on centimeter sized glass samples without any specialized sample preparation or nanofabrication.

Single-center ventral hernia repair with porcine dermis collagen implant

INTRODUCTION

This study aims to evaluate the outcomes and utilization of porcine acellular dermal collagen implant (PADCI) during VHR at a large tertiary referral center.

METHODS

Records of 5485 patients who underwent VIHR from June 1995 to August 2014 were retrospectively reviewed to identify patients >18 years of age who had VIHR with PADCI reinforcement. Use of multiple mesh reinforcement products, inguinal hernias, and hiatal hernias were exclusion criteria. The primary outcome was hernia recurrence, and secondary outcomes were early complications and surgical site occurrences (SSOs). Uni- and multivariate analyses assessed risk factors for recurrence after PADCI reinforced VIHR.

RESULTS

There were 361 patients identified (54.5% female, mean age of 56.7 ± 12.5 years, and mean body mass index (BMI) of 33.0 ± 9.9 kg/m²). Hypertension (49.5%), diabetes (24.3%), and coronary artery disease (14.4%) were the most common comorbidities, as was active smoking (20.7%). Most were classified as American Association of Anesthesiologists (ASA) Class 3 (61.7%). Hernias were distributed across all grades of the ventral hernia working group (VHWG) grading system: grade I 93 (25.7%), grade II 51 (14.1%), grade III 113 (31.3%), and grade IV 6 (1.6%). Most VIHR were performed from an open approach (96.1%), and were frequently combined with concomitant surgical procedures (47.9%). Early postoperative complications (first 30 days) were reported in 39.0%, with 71 being SSO. Of the 19.7% of patients with SSO, there were 31 who required procedural intervention. After a mean follow-up of 71.5 ± 20.5 months, hernia recurrence was documented in 34.9% of patients. Age and male gender were predictors of recurrence on multivariate analysis.

CONCLUSION

To the best of our knowledge, this is the largest retrospective single institutional study evaluating PADCI to date. Hernias repaired with PADCI were frequently in patients undergoing concomitant operations. Reinforcement with PADCI may be considered a temporary closure, with a relatively high recurrence rate, especially among patients who are older, male, and undergo multiple explorations in a short perioperative period.

Persistent Hyperglycemia Is Associated With Increased Mortality After Intracerebral Hemorrhage

BACKGROUND

Hyperglycemia may be associated with worse outcome after intracerebral hemorrhage (ICH). We assessed the association of early glycemic trajectory on ICH mortality and edema growth.

METHODS AND RESULTS

We included patients from the Helsinki ICH study with glucose measurements at least once between both 0 to 24 and 24 to 72 hours from onset. Hyperglycemia was defined as blood glucose ≥8 mmol/L (144 mg/dL) based on the local threshold for treatment. Glycemic trajectory was defined on maximum values 0 to 24 and 24 to 72 hours after ICH: (1) persistent normoglycemia in both epochs; (2) late hyperglycemia (only between 24 and 72 hours); (3) early hyperglycemia (only before 24 hours); and (4) persistent hyperglycemia in both epochs. Logistic regression with known predictors of outcome estimated the association of glycemic trajectory and 6-month mortality. A generalized linear model assessed the association of glycemic trajectory and interpolated 72-hour edema extension distance. A total of 576 patients met eligibility criteria, of whom 214 (37.2%) had persistent normoglycemia, 44 (7.6%) late hyperglycemia, 151 (26.2%) early hyperglycemia, and 167 (29.0%) persistent hyperglycemia. Six-month mortality was higher in the persistent (51.1%) and early (26.3%) hyperglycemia groups than the normoglycemia (19.0%) and late hyperglycemia (3.6%) groups. Persistent hyperglycemia was associated with 6-month mortality (odds ratio 3.675, 95% CI 1.989-6.792; P<0.001). Both univariate (P=0.426) and multivariable (P=0.493) generalized linear model analyses showed no association between glycemic trajectory and 72-hour edema extension distance.

CONCLUSION

Early hyperglycemia after ICH is harmful if it is persistent. Strategies to achieve glycemic control after ICH may influence patient outcome and need to be assessed in clinical trials.

Simultaneous Multiple Intracerebral Hemorrhages (SMICH)

BACKGROUND AND PURPOSE

Simultaneous multiple intracerebral hemorrhages (SMICHs) are uncommon. Few single-center studies have analyzed characteristics and outcome of SMICH. We analyzed clinical characteristics and outcome of SMICH patients from 2 comprehensive stroke centers.

METHODS

Baseline imaging from consecutive intracerebral hemorrhage (ICH) patients (n=1552) from Helsinki ICH study and Royal Melbourne Hospital ICH study was screened for SMICH. ICH pathogenesis was classified according to the structural lesion, medication, amyloid angiopathy, systemic/other disease, hypertension, undetermined classification system (SMASH-U). ICH caused by trauma, tumor, and aneurysmal rupture was excluded. Baseline clinical and radiological characteristics and 90-day mortality were compared between SMICH and single ICH patients. Association of SMICH with 90-day mortality was assessed in multivariable logistic regression models adjusted for predictors of ICH outcome.

RESULTS

Of 1452 patients, 85 (5.9%) were classified as SMICH. SMICH were more often female (58% versus 42%; P=0.004), had lower baseline Glasgow Coma Scale (12 versus 14; P=0.008), and more frequent lobar location (59% versus 34%; P<0.001) compared with single ICH. The SMASH-U pathogenesis of SMICH patients was less often hypertensive (20% versus 37%; P=0.001), more often systemic coagulopathy (12% versus 3%; P<0.001), and trended toward more cerebral amyloid angiopathy (32% versus 23%; P=0.071). SMICH was not associated with 90-day mortality on univariate (37% versus 35%; P=0.610), multivariable (odds ratio, 0.783; 95% confidence interval, 0.401-1.529; P=0.473), or propensity score-matched analyses (odds ratio, 0.760; 95% confidence interval, 0.352-1.638; P=0.484).

CONCLUSIONS

SMICH occurs in ≈1 in 20 ICH, more commonly with lobar located hematomas and systemic coagulopathy with less hypertensive angiopathy. The associated mortality is similar to single ICH. Given varied etiologies, SMICH management should target the underlying pathology.

Seroprevalence of hepatitis B virus and hepatitis C virus co-infection among people living with HIV/AIDS visiting antiretroviral therapy centres in Nepal: a first nationally representative study

OBJECTIVES

To assess the prevalence of human immunodeficiency virus (HIV), hepatitis C virus (HCV), and hepatitis B virus (HBV) co-infections among people living with HIV (PLHIV) in Nepal.

METHODS

A sample of 677 PLHIV representing key affected populations (KAP) in Nepal, who were undergoing antiretroviral (ART) therapy in ART clinics around the country, were voluntarily enrolled in the study. Rapid kit-based testing followed by ELISA for validation was performed, focusing on HBV surface antigen (HBsAg) and antibodies against HCV (anti-HCV). A multivariate logistic regression model was used to identify factors associated with HBV and HCV co-infection.

RESULTS

HCV and HBV co-infection among the 677 PLHIV was found to be 19% (95% confidence interval (CI) 16.6-22.7%) and 4.4% (95% CI 3.1-6.6%), respectively. The Eastern Region had the highest percentage of HCV infection (48%). The age group with the highest rates of co-infection was 30-39 years (58% and 70%, respectively, for HCV and HBV co-infection). After adjusting for confounding, males were more likely to have HBV co-infection than females (adjusted odds ratio (AOR) 4.61, 95% CI 1.42-14.98). Similarly, PLHIV who were male (AOR 5.7, 95% CI 2.06-15.98), had a secondary level of education (AOR 3.04, 95% CI 1.06-8.70), or who were drug users (AOR 28.7, 95% CI 14.9-55.22) were significantly more likely to have HCV co-infection.

CONCLUSION

This first ever national assessment of HIV, HBV, and HCV co-infection performed among PLHIV in Nepal demonstrates that HCV and HBV infections are a health threat to this population and that interventions are required to mitigate the effects of co-infection and to prevent further morbidity and mortality.

Identifying substance misuse in primary care: TAPS Tool compared to the WHO ASSIST

BACKGROUND

There is a need for screening and brief assessment instruments to identify primary care patients with substance use problems. This study's aim was to examine the performance of a two-step screening and brief assessment instrument, the TAPS Tool, compared to the WHO ASSIST.

METHODS

Two thousand adult primary care patients recruited from five primary care clinics in four Eastern US states completed the TAPS Tool followed by the ASSIST. The ability of the TAPS Tool to identify moderate- and high-risk use scores on the ASSIST was examined using sensitivity and specificity analyses.

RESULTS

The interviewer and self-administered computer tablet versions of the TAPS Tool generated similar results. The interviewer-administered version (at cut-off of 2), had acceptable sensitivity and specificity for high-risk tobacco (0.90 and 0.77) and alcohol (0.87 and 0.80) use. For illicit drugs, sensitivities were >0.82 and specificities >0.92. The TAPS (at a cut-off of 1) had good sensitivity and specificity for moderate-risk tobacco use (0.83 and 0.97) and alcohol (0.83 and 0.74). Among illicit drugs, sensitivity was acceptable for moderate-risk of marijuana (0.71), while it was low for all other illicit drugs and non-medical use of prescription medications. Specificities were 0.97 or higher for all illicit drugs and prescription medications.

CONCLUSIONS

The TAPS Tool identified adult primary care patients with high-risk ASSIST scores for all substances as well moderate-risk users of tobacco, alcohol, and marijuana, although it did not perform well in identifying patients with moderate-risk use of other drugs or non-medical use of prescription medications. The advantages of the TAPS Tool over the ASSIST are its more limited number of items and focus solely on substance use in the past 3months.

Natural History of Perihematomal Edema and Impact on Outcome After Intracerebral Hemorrhage

BACKGROUND AND PURPOSE

Edema may worsen outcome after intracerebral hemorrhage (ICH). We assessed its natural history, factors influencing growth, and association with outcome.

METHODS

We estimated edema volumes in ICH patients from the Helsinki ICH study using semiautomated planimetry. We assessed the correlation between edema extension distance (EED) and time from ICH onset, creating an edema growth trajectory model up to 3 weeks. We interpolated expected EED at 72 hours and identified clinical and imaging characteristics associated with faster edema growth. Association of EED and mortality was assessed using logistic regression adjusting for predictors of ICH outcome.

RESULTS

From 1013 consecutive patients, 861 were included. There was a strong inverse correlation between EED growth rate (cm/d) and time from onset (days): EED growth=0.162*days exp(-0.927), R²=0.82. Baseline factors associated with larger than expected EED were older age (71 versus 68; P=0.002), higher National Institutes of Health Stroke Scale score (14 versus 8; P<0.001), and lower Glasgow Coma scale score (13 versus 15; P<0.001), larger ICH volume (19.7 versus 12.7 mL; P<0.001), larger initial EED (0.42 versus 0.30; P<0.001), irregularly shaped hematoma (55% versus 42%; P<0.001), and higher glucose (7.6 versus 6.9 mmol/L; P=0.001). Patients with faster edema growth had more midline shift (50% versus 31%; P<0.001), herniation (12% versus 4%; P<0.001), and higher 6-month (46% versus 26%; P<0.001) mortality. In the logistic regression model, higher-than-expected EED was associated with 6-month mortality (odds ratio, 1.60; 95% confidence interval, 1.04-2.46; P=0.032).

CONCLUSIONS

Edema growth can be readily monitored and is an independent determinant of mortality after ICH, providing an important treatment target for strategies to improve patient outcome.

Abstract WP53: The prognostic value of Posterior Circulation Acute Stroke Prognosis Early Ct Score (pcaspects) on CT perfusion in patients with basilar artery occlusion

Background: CT perfusion (CTP) increases diagnostic confidence in ischaemic stroke. Despite bone-related artefacts, CTP has been shown to improve diagnostic sensitivity compared to non contrast-CT (NCCT) and Computed Tomography Angiography source images (CTA-SI) in posterior circulation strokes. The posterior circulation Acute Stroke Prognosis Early CT score (pcASPECTS) on CTA-SI predicts clinical outcome in patients with basilar artery occlusion (BAO). We assessed the prognostic value of pcASPECTS on CTP in BAO patients.

Methods: A retrospective analysis of consecutive patients with BAO diagnosed on CT angiography was performed. pcASPECTS was assessed as evident hypoattenuation on CTA-SI, focally reduced cerebral blood flow (CBF) or cerebral blood volume (CBV), focally increased time to peak of the residue function (Tmax) or mean transit time (MTT). Two investigators independently reviewed the images blinded to clinical outcome. Reliability was assessed with intraclass correlation coefficient (ICC). Good outcome was defined as modified Rankin Scale≤3 at 3 months.

Results: We included 43 BAO patients with whole-brain CTP images. In receiver-operating-characteristic (ROC) analysis, the area-under-curve (AUC) was 0.79 (95% CI 0.6-0.9) for pcASPECTS on CBF, 0.77 (95% CI 0.6-0.9) on Tmax, 0.73 (95% CI 0.6-0.9) on MTT, 0.72 (95% CI 0.6-0.9) on CBV, 0.67 (95% CI 0.5-0.8) on CTA-SI. In logistic regression adjusted for age and clinical severity, pcASPECTS<8 was associated with poor outcome on Tmax (OR 14.6, 95% CI 2.3-115; p=0.007) and CBF (OR 15.1, 95% CI 1.3-121; p=0.02). Although CTP AUC did not show higher accuracy in comparison with CTA-SI AUC (p=0.2), in logistic regression, CTA-SI pcASPECTS was not significantly associated with clinical outcome (OR 6.9, 95% CI 0.7-70; p=0.1, adjusted for age, NHSS). Higher pcASPECTS on CBF (OR 0.5 95%CI 0.2-0.9, p=0.04) and Tmax (OR 0.5 95% 0.3-0.9; p=0.02) were associated with lower mortality. Interrater reliability was good for CTP maps (ICC between 0.74 and 0.86 95% CI

0.6-0.9 versus 0.66 for CTA-SI 95% CI 0.4-0.8).

Conclusions: The CTP pcASPECTS may identify BAO patients at higher risk of disability and mortality.

Abstract WMP20: The Basilar Artery on Computed Tomography Angiography (batman) Prognostic Score for Basilar Artery Occlusion

Background: Basilar artery occlusion (BAO) is associated with high risk of disability and mortality. This study aimed to assess the prognostic value of a new radiological score: the “Basilar Artery on Computed Tomography Angiography score (BATMANs)”.

Methods: A retrospective analysis of consecutive stroke patients with a diagnosis of BAO on CT angiography (CTA) was performed. BATMANs is a 10 point CTA-based grading system. We allocated 1 point for each patent segment (proximal, middle and distal) of the basilar artery, 1 point for any patent intracranial vertebral arteries (VA), 1 point for each posterior cerebral artery (PCA) and 2 points for each posterior communicating artery (PcoM) or 1 point for hypoplastic PcoM (<1 mm diameter). Two investigators reviewed the CTA images blinded to clinical outcome. Reliability was assessed with intraclass coefficient correlation (ICC). Good outcome was defined as modified Rankin Scale≤3 at 3 months; successful reperfusion as thrombolysis in cerebral infarction 2b-3. BATMANs was externally validated and compared with the Posterior Circulation Collateral score (PC-CS).

Results: The derivation cohort (DC) included 83 patients with 41 in the validation cohort (VC). In receiver-operating-characteristic (ROC) analysis, BATMANs had an area-under-curve (AUC) of 0.81 (95%CI 0.7-0.9) in DC and an AUC of 0.74 (95%CI 0.6-0.9) in VC. BATMANs<7 was the optimal threshold for poor outcome in DC (sensitivity=84%, specificity=76%). In logistic regression adjusted for age and clinical severity, BATMANs<7 was associated with poor outcome in DC (OR 5.5, 95% CI 1.4 -21; p=0.01), in VC (OR 6.9, 95% CI 1.4-33; p=0.01) and among endovascular patients (OR 3.8, 95%CI 1.0-14; p=0.05). BATMANs was independently associated with functional outcome after adjustment for revascularization and time to treatment (OR 4.8, 95%CI 1-18; p=0.01); however, it was not associated with recanalization. Inter-rater agreement was excellent (ICC 0.85, 95% CI 0.76-0.89). BATMANs showed higher accuracy in comparison with PC-CS (p=0.03).

Conclusions: The addition of collateral quality to clot burden in BATMANs appears to improve prognostic accuracy in BAO patients.

Abstract TP339: Simultaneous Multiple Intracerebral Hemorrhages (SMICH)

Background and Purpose: Simultaneous multiple intracerebral hemorrhages (SMICH) are uncommon. Few single center studies have analyzed characteristics and outcome of SMICH. We analyzed clinical characteristics and outcome of SMICH patients from two comprehensive stroke centers.

Methods: Baseline imaging from consecutive intracerebral hemorrhage (ICH) patients (n=1552) from Helsinki ICH study and Royal Melbourne Hospital ICH study were screened for SMICH. ICH etiology was classified according to the SMASH-U classification system. ICH due to trauma, tumor and aneurysmal rupture were excluded. Baseline clinical and radiological characteristics and 90-day mortality were compared between SMICH and single ICH patients. Association of SMICH with 90-day mortality was assessed in multivariable logistic regression models adjusted for predictors of ICH outcome.

Results: 1452 patients were included in the analysis and 85 (5.9%) were classified as SMICH. SMICH were more often female (58% vs 42%;p=0.004), had lower baseline Glasgow Coma Scale (12 vs 14;p=0.008), and more frequent lobar location (59% v 34%;p<0.001) compared to single ICH. The SMASH-U etiology of SMICH patients was less often hypertensive (20% vs 37%;p=0.001), more other systemic coagulopathy (12% vs 3%;p<0.001) and trended towards more cerebral amyloid angiopathy (32% vs 23%;p=0.071). SMICH was not associated with 90-day mortality on univariate (37% vs 35%;p=0.635), multivariable (OR 0.783 95%CI 0.401-1.529;p=0.473), or propensity score matched analyses (OR 0.817 95% CI 0.400-1.668,p=0.578).

Conclusion: SMICH occurs in approximately 1 in 20 ICH with more often lobar located hematomas, less often hypertensive and associated with more systemic coagulopathy. The mortality is similar to single ICH. Given varied etiologies, SMICH management should target the underlying pathology.

Abstract 31: The Association Between Baseline Ischemic Core Volume and Benefit of Endovascular Thrombectomy in Pooled Data from Six Randomized Trials

Background and purpose: Patients estimated to have a large irreversibly injured ischemic core are sometimes excluded from reperfusion therapies. We examined the association between estimated core volume and thrombectomy outcomes.

Methods: Patient-level CT perfusion (CTP) and clinical data were pooled from trials comparing endovascular thrombectomy with standard care in anterior circulation ischemic stroke: MR CLEAN, EXTEND IA, ESCAPE, SWIFT PRIME, REVASCAT and PISTE. Ischemic core volume was estimated using relative cerebral blood flow <30% of normal brain (RAPID automated software, IschemaView). The primary outcome was the 90 day modified Rankin scale (mRS), adjusted for baseline prognostic variables. To account for between-trial variance we used mixed-effects modeling with a random effect for trial incorporated in all models.

Results: Of 1352 patients, pre-treatment CTP was assessable in 539 after exclusion of 27 patients (12 severe motion, 2 no lesion within coverage, 2 contrast bolus failure, 11 data corruption during transfer from site). There were 264 allocated to endovascular thrombectomy and 275 to control. Baseline characteristics were similar between endovascular and control patients with CTP, median core 9.6 mL (IQR 2.4-26 mL) and with the overall trial demographics. Larger estimated core volume was associated with lower probability of independent outcome (mRS 0-2) in endovascular (OR 0.87 95%CI 0.80-0.95) and control patients (OR 0.85 95%CI 0.77-0.93, core*treatment interaction p=0.62) and increased disability: utility scores derived from mRS reduced by 2% (95%CI 1-4%) per 10mL increase in core volume for both endovascular and control patients (core*treatment interaction p=0.79). However, patients with >70mL core (median 100 mL, IQR 82-144mL) still benefitted from thrombectomy: ordinal mRS cOR 7.0 (2.6 -18.9) and the number needed to treat (NNT) remained stable across the spectrum of core volumes (point estimate NNT<10 for mRS 0-2 and NNT<3 for improvement in at least 1 mRS level).

Conclusions: Increasing estimated core volume was independently associated with worse outcome but endovascular thrombectomy remained effective versus standard care even in patients with large core who otherwise met eligibility for these trials.

Abstract WP346: Persistent Hyperglycemia is Independently Associated With Increased Mortality After Intracerebral Hemorrhage

Background and purpose: Hyperglycemia may be associated with worse outcome after intracerebral hemorrhage (ICH). We assessed the association of early glycemic trajectory on ICH mortality.

Methods: We included patients from the Helsinki ICH study with glucose measurements at least once between both 0-24 hours and 24-72 hours from ICH onset. Hyperglycemia was defined as blood glucose ≥8 mMol/L (144 mg/dL) based on the local threshold for treatment. Glucose trajectory was defined on maximum values 0-24 hours and 24-72 hours after ICH; 1) persistent normoglycemia in both epochs, 2) late hyperglycemia (only between 24-72 hours), 3) early hyperglycemia (only prior to 24 hours), 4) persistent hyperglycemia in both epochs. Logistic regression adjusted for factors associated with 6-month mortality estimated the association of glycemic trajectory with mortality.

Results: There were 576 patients meeting eligibility criteria, of whom 214 (37.2%) had persistent normoglycemia, 44 (7.6%) late hyperglycemia, 151 (26.2%) early hyperglycemia, and 167 (29%) persistent hyperglycemia. Six-month mortality was higher in the persistent (51.1%) and early (26.3%) hyperglycemia groups than the normoglycemia (19.0%) and late hyperglycemia (3.6%) groups. Persistent hyperglycemia was independently associated with 6-month mortality (OR 3.453; 95% CI 1.863-6.400;p<0.001) adjusted for baseline ICH and oedema volume, age, warfarin use, anti-hypertensive use, baseline Glasgow Coma Scale, National Institutes of Health Stroke Scale and ventricular extension.

Conclusion: Early persistent hyperglycemia is associated with markedly higher risk of mortality after ICH. Strategies to achieve glycemic control after ICH may improve patient outcome and need to be assessed in clinical trials.

Galectin-3-Binding Glycomimetics that Strongly Reduce Bleomycin-Induced Lung Fibrosis and Modulate Intracellular Glycan Recognition

Discovery of glycan-competitive galectin-3-binding compounds that attenuate lung fibrosis in a murine model and that block intracellular galectin-3 accumulation at damaged vesicles, hence revealing galectin-3-glycan interactions involved in fibrosis progression and in intracellular galectin-3 activities, is reported. 3,3'-Bis-(4-aryltriazol-1-yl)thiodigalactosides were synthesized and evaluated as antagonists of galectin-1, -2, -3, and -4 N-terminal, -4 C-terminal, -7 and -8 N-terminal, -9 N-terminal, and -9 C-terminal domains. Compounds displaying low-nanomolar affinities for galectins-1 and -3 were identified in a competitive fluorescence anisotropy assay. X-ray structural analysis of selected compounds in complex with galectin-3, together with galectin-3 mutant binding experiments, revealed that both the aryltriazolyl moieties and fluoro substituents on the compounds are involved in key interactions responsible for exceptional affinities towards galectin-3. The most potent galectin-3 antagonist was demonstrated to act in an assay monitoring galectin-3 accumulation upon amitriptyline-induced vesicle damage, visualizing a biochemically/medically relevant intracellular lectin-carbohydrate binding event and that it can be blocked by a small molecule. The same antagonist administered intratracheally attenuated bleomycin-induced pulmonary fibrosis in a mouse model with a dose/response profile comparing favorably with that of oral administration of the marketed antifibrotic compound pirfenidone.

Targeting human respiratory syncytial virus transcription anti-termination factor M2-1 to inhibit in vivo viral replication

Human respiratory syncytial virus (hRSV) is a leading cause of acute lower respiratory tract infection in infants, elderly and immunocompromised individuals. To date, no specific antiviral drug is available to treat or prevent this disease. Here, we report that the Smoothened receptor (Smo) antagonist cyclopamine acts as a potent and selective inhibitor of in vitro and in vivo hRSV replication. Cyclopamine inhibits hRSV through a novel, Smo-independent mechanism. It specifically impairs the function of the hRSV RNA-dependent RNA polymerase complex notably by reducing expression levels of the viral anti-termination factor M2-1. The relevance of these findings is corroborated by the demonstration that a single R151K mutation in M2-1 is sufficient to confer virus resistance to cyclopamine in vitro and that cyclopamine is able to reduce virus titers in a mouse model of hRSV infection. The results of our study open a novel avenue for the development of future therapies against hRSV infection.

Escherichia coli biofilm: development and therapeutic strategies

Escherichia coli biofilm consists of a bacterial colony embedded in a matrix of extracellular polymeric substances (EPS) which protects the microbes from adverse environmental conditions and results in infection. Besides being the major causative agent for recurrent urinary tract infections, E. coli biofilm is also responsible for indwelling medical device-related infectivity. The cell-to-cell communication within the biofilm occurs due to quorum sensors that can modulate the key biochemical players enabling the bacteria to proliferate and intensify the resultant infections. The diversity in structural components of biofilm gets compounded due to the development of antibiotic resistance, hampering its eradication. Conventionally used antimicrobial agents have a restricted range of cellular targets and limited efficacy on biofilms. This emphasizes the need to explore the alternate therapeuticals like anti-adhesion compounds, phytochemicals, nanomaterials for effective drug delivery to restrict the growth of biofilm. The current review focuses on various aspects of E. coli biofilm development and the possible therapeutic approaches for prevention and treatment of biofilm-related infections.

Abstract 62: Extending the Time for Thombolysis in Emergency Neurological Deficits (EXTEND) - Penumbral Patterns Among Patients 4.5-9 Hrs and Wake - Up Stroke

Background: EXTEND is a randomised, double-blind, placebo-controlled Phase III trial of intravenous alteplase vs. placebo among patients with ischemic stroke 4.5-9 hours from stroke onset or wake-up-stroke (WUS). There is uncertainty about the extent of salvageable tissue in this crucial time window for exploring therapeutic options. Whether WUS represents a plausible patient group for therapy is worthy exploring

Objective: To determine the penumbral mismatch and ischaemic core volumes in the EXTEND cohort and compare these characteristics between WUS and non-WUS subsets.

Methods: Patients with ischemic stroke within 4.5-9 hours from stroke onset and WUS patients (time of WUS onset defined as the midpoint between time to sleep and awakening with the stroke symptoms) are eligible for enrollment. Criteria for trial entry include perfusion-diffusion mismatch using a perfusion threshold of Tmax>6sec and a perfusion:diffusion lesion volume ratio of >1.2. Ischemic core must be <70mL based on assessment by automated RAPID software on MR or CT platforms (Stanford).

Results: 105 patients have been randomised to date with median age of 78.0 (IQR 66.5, 82 yrs), median admission NIHSS of 14.0 (8.0, 18.0) and half being female. WUS patients (n=69, 66%) compared to non-WUS patients, WUS patients had comparable median NIHSS of 14 (8, 18) vs 14.5 (8.0, 14.3 p =0.5), larger ischemic core volume of 15.5 ml (7.0, 33ml) vs 4.0 ml (0, 24.0ml p =0.005), perfusion deficit volume of 86.0 ml (58.5, 121.8ml) vs 73.0 ml (48.0, 124.0 ml p=0.6), mismatch ratio of 4.4 ml (2.6, 8.6 ml) vs 5.9 ml (2.7, 24.4 p=0.8) and mismatch volume of 64.0 ml (38.5, 91.8ml) vs 62.0 ml (42.5ml, 103.5ml p=0.5).

Conclusion: Within the EXTEND cohort, there is a clinically significant amount of salvageable penumbral tissue within the 4.5-9 hr time window. Patients with WUS have larger ischemic core compared to those in the non-WUS group. However, comparable salvageable mismatch volumes and baseline NIHSS are noted between groups. Tissue salvage has the potential to lead to clinical improvement in both groups.

Abstract 59: Extending the Time for Thombolysis in Emergency Neurological Deficits (EXTEND) - High Prevalence of Intracranial Vessel Occlusion in Wake-up-stroke Patients

Background: EXTEND is an investigator-initiated, randomised, double-blind and placebo-controlled Phase III trial of intravenous alteplase vs placebo in patients with ischemic stroke 4.5-9 hours from stroke onset or wake-up-stroke (WUS). The prevalence of intra-cranial vessel occlusion in WUS patients remains to be determined and can guide the development of optimal therapy for this unique group of stroke patients.

Objective: To study the prevalence and characteristics of intra-cranial vessel occlusion in this WUS cohort.

Methods: Ischemic stroke patients within 4.5-9 hours from stroke onset or with WUS (time of WUS onset defined as the midpoint between time to sleep and awakening with the stroke symptoms) are eligible for enrollment. Criteria for entry into the trial include perfusion-diffusion mismatch using a perfusion threshold of Tmax>6sec and a perfusion:diffusion lesion volume ratio of >1.2. Diffusion lesion volume must be <70mL based on assessment by automated RAPID software. Intra-cranial vessel occlusion was assessed on MR or CT angiogram performed at randomisation and 24 later. Two expert readers assessed these images independently.

Results: 97 patients had images with adequate quality, including 63 (65%) in the WUS group with median age of 77.0 yrs (IQR 67.0, 81.0) and NIHSS of 14.0 (9.0, 19.0). 62 of 63 patients (98%) had vessel occlusion with 44.4% involving M1 of the middle cerebral artery, 17.5% M2, 4.8% M3, 25.4% both internal carotid artery (ICA) and M1, 4.8% ICA alone and 3.1% the posterior cerebral artery. The median ischemic core volume was 15.0 ml (6.5, 31.5), Tmax>6 volume 88.5ml (58.0, 122.0), mismatch volume 65.5ml (42.8, 92.0), and ratio of 4.8 (2.5, 8.7). 19 patients (30%) demonstrated recanalization on follow-up imaging.

Conclusion: In WUS patients there is a very high rate of intracranial vessel occlusion with relatively large volumes of salvageable penumbral tissue. Intravenous thrombolytic therapy followed by thrombectomy in selected cases may be an appropriate therapeutic option with safety and efficacy remaining to be established in randomized controlled trials.

Beyond the Rhetoric: Maternal, Newborn and Child Survival in Nepal

Nepal has performed exceptionally in improving reproductive, maternal and child health outcomes over the past two decades. In this article, we discuss these achievements and outline a vision for the future of maternal, newborn and child survival in Nepal after the era of the Millennium Development Goals. On the pathway towards quality universal health care services for all, we propose strengthening of health information systems, gradual health system reforms, improvement of existing facility based services, development of integrated service delivery models, improved technical and managerial capacity at district and facility levels. Elimination of all preventable causes of maternal, newborn and child deaths in Nepal should be our collective aspirational goal.