Seroprevalence of trypanosomosis and associated risk factors in cattle from coast and amazonian provinces of Ecuador

Trypanosomosis is a tropical disease caused by various protozoan haemoparasites, which affects wild and domestic animals, the latter ones related to worldwide livestock production systems. Species such as Trypanosoma vivax and Trypanosoma evansi have been described using serological and molecular tools in several countries from South and Central America. However, Ecuador presents a relevant knowledge gap in the associated general epidemiology and risk factors of the disease. Therefore, the objective of this study was to determine the seroprevalence of trypanosomosis in cattle from different regions of Ecuador. 745 serum samples from 7 Coastal and 3 Amazon provinces were screened for IgG anti-Trypanosoma spp. antibodies, using an in-house indirect ELISA. The seropositivity was explored and associated with several variables such as sex, age, breed, region, management, and province, using statistical tools. The general seroprevalence of trypanosomosis was 19.1% (95% CI: 16.30-22.1%). The Amazonian provinces of Sucumbíos and Napo and the Coastal province of Esmeraldas presented the highest seroprevalence values of 36.7% (95% CI: 27.67-46.47%), 23.64% (95% CI: 16.06-32.68%) and 25% (95% CI: 15.99-35.94%), respectively. Statistical significance was found for the region, province, and management variables, indicating as relevant risk factors the extensive management and Amazon location of the cattle analyzed. Specific actions should be taken to identify the exact species on reservoirs and susceptible hosts, evaluate the implication of farm management and cattle movement as risk factors, and implement surveillance and treatment plans for affected herds.

A systematic-search-and-review of registered pharmacological therapies investigated to improve neuro-recovery after a stroke

Background

Stroke burden is largely due to long-term impairments requiring prolonged care with loss of productivity. We aimed to identify and assess studies of different registered pharmacological therapies as treatments to improve post-stroke impairments and/or disabilities.

Methods

We performed a systematic-search-and-review of treatments that have been investigated as recovery-enhancing or recovery-promoting therapies in adult patients with stroke. The treatment must have received registration or market authorization in any country regardless of primary indication. Outcomes included in the review were neurological impairments and functional/disability assessments. "The best available studies" based on study design, study size, and/or date of publication were selected and graded for level of evidence (LOE) by consensus.

Results

Our systematic search yielded 7,801 citations, and we reviewed 665 full-text papers. Fifty-eight publications were selected as "the best studies" across 25 pharmacological classes: 31 on ischemic stroke, 21 on ischemic or hemorrhagic stroke, 4 on intracerebral hemorrhage, and 2 on subarachnoid hemorrhage (SAH). Twenty-six were systematic reviews/meta-analyses, 29 were randomized clinical trials (RCTs), and three were cohort studies. Only nimodipine for SAH had LOE A of benefit (systematic review and network meta-analysis). Many studies, some of which showed treatment effects, were assessed as LOE C-LD, mainly due to small sample sizes or poor quality. Seven interventions had LOE B-R (systematic review/meta-analysis or RCT) of treatment effects.

Conclusion

Only one commercially available treatment has LOE A for routine use in stroke. Further studies of putative neuroprotective drugs as adjunctive treatment to revascularization procedures and more confirmatory trials on recovery-promoting therapies will enhance the certainty of their benefit. The decision on their use must be guided by the clinical profile, neurological impairments, and target outcomes based on the available evidence.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=376973, PROSPERO, CRD42022376973.

Transcranial Doppler ultrasonography in bacterial meningitis: A systematic review

PURPOSE

Bacterial meningitis remains a global threat due to its high mortality. It is estimated that >1.2 million cases of bacterial meningitis are reported annually. Intracranial vasculopathy is an important, under-documented complication, easily detected by transcranial Doppler (TCD) ultrasonography. Following the PRISMA Guidelines, we reviewed the utility of TCD in bacterial meningitis.

METHODS

This is a systematic review of observational studies on the use of TCD in patients with CSF-proven bacterial meningitis. Characteristic changes in TCD parameters along the course of the disease, correlation of TCD findings with neuroimaging, and functional outcomes were evaluated.

RESULTS

Nine studies were included with a total of 492 participants (mean age of 42). The most common TCD finding was intracranial arterial stenosis of the MCA (50%-82%) and ischemia (33%) was the predominant neuroimaging finding. The presence of an abnormal TCD finding increased the risk of poor outcomes as high as 70%.

CONCLUSIONS

Patients diagnosed with bacterial meningitis who underwent TCD show alterations in cerebral blood flow, correlating with imaging findings and poor outcomes. It aids in the diagnosis of its sequelae and can predict the prognosis of its outcome. TCD is a cost-effective, reliable modality for diagnosing vasculopathy associated with bacterial meningitis. It may prove useful in our armamentarium of management. Large prospective studies with long-term follow-up data may help establish the use of TCD in bacterial meningitis.

Predictive factors for clinical outcomes in Filipino patients with watershed infarction: A single center study

Background and purpose

Watershed infarcts denote ischemic lesions involving the distal territories of two major arteries. For years, hypotheses on its pathophysiological mechanisms have been proposed. Yet, the cause is still widely debated. This study aimed to determine the mechanism of watershed strokes and compare their clinical outcomes to acute ischemic stroke from other causes and predict the factors affecting clinical outcomes in patients with watershed infarcts.

Methods

This single-center, comparative, six-years retrospective cohort study included patients with a diagnosis of Acute Ischemic Stroke. Patients were classified under watershed group or acute ischemic stroke based on their neuroimaging findings. Stroke mechanisms were determined between groups as well as the factors associated with clinical outcomes in watershed strokes.

Results

Among the 424 patients included in the study, large artery atherosclerosis was seen in greater frequency in patients with watershed infarcts regardless of the type (EWIs: n = 68, 73% vs IWIs: n = 89, 75%). No differences observed in the clinical outcomes between groups. Multiple variable analysis showed that age, female sex, high NIHSS score and presence of underlying malignancy were associated with clinical outcomes.

Conclusion

Clinical outcomes between watershed infarcts and acute ischemic strokes were similar. Hemodynamic compromise in the setting of severe stenosis is the underlying mechanism for both types of watershed strokes thus, the goal of treatment is to maintain adequate perfusion. High baseline NIHSS score, increased age, female gender and underlying malignancy were all poor predictors of clinical outcomes in patients with watershed strokes.

Transcranial Doppler ultrasonography in tuberculous meningitis: A systematic review

BACKGROUND AND PURPOSE

Tuberculous (TB) meningitis is a common type of central nervous system infection, and may cause multifocal cerebral infarctions due to the involvement of cerebral vasculature. This systematic review aims to review and synthesize the utility of transcranial Doppler (TCD) in TB meningitis.

METHODS

This is a systematic review of observational studies on the use of TCD in patients diagnosed to have TB meningitis. Study outcomes included changes in TCD parameters during stages of TB meningitis, frequency of neurologic complications (such as hydrocephalus, vasculopathy, and cerebral infarction), correlation of TCD findings with neuroimaging, and functional outcomes.

RESULTS

Five studies were included with a total of 141 participants, with ages from 4 months to 75 years. The most common neurologic complication was hydrocephalus (87.1%), cerebral infarction (29.2%), and arterial stenosis (26.3%). There was increased mean flow velocity (MFV) most commonly in the middle cerebral artery in the early stage of TB meningitis, and decreased MFV in the advanced disease stage. TCD findings of stenosis were well correlated with CT or MR angiogram. Among patients with hydrocephalus, pulsatility indices were significantly decreased after ventriculoperitoneal shunting.

CONCLUSIONS

A considerable proportion of patients with TB meningitis develop cerebral hemodynamic disturbances which lead to cerebral ischemia and affect clinical outcomes. TCD is a reliable tool for the diagnosis of vasculopathy and increased intracranial pressure and can thus help monitor disease progression and treatment response. Future studies with larger populations and longer follow-ups are recommended to determine the association of TCD findings with functional outcomes.

Molecular identification of Trypanosoma theileri in cattle from the Ecuadorian Amazon

Trypanosoma theileri is a cosmopolitan opportunistic haemoparasite described in wild and domestic ruminants, and also in arthropod vectors. The presence of this parasite has been reported in several South American countries, including Amazonian regions. Despite the importance of livestock production, Ecuador possesses scarce studies about trypanosomosis and no T. theileri reports in its territory. Here, we showed molecular evidences of the presence of T. theileri in cattle from a province located in the Ecuadorian Amazon. Bovine blood samples were collected from 2014 to 2019, during campaigns to detect haemoparasites in the Ecuadorian provinces of Orellana and Sucumbíos. DNA was extracted from the buffy coat and used in PCR assays with three different molecular markers, ITS1, 18S and Cathepsin L-like. T. theileri was detected only in the Sucumbíos province, with a specific molecular prevalence of 8.6% (3/35) using the three primers and an additional animal detected as positive (11.4% prevalence) only by the ITS1 marker. DNA sequences derived from the generated amplicons were subjected to phylogenetics maximum parsimony and maximum likelihood analysis, which indicate the presence of TthI and TthII genotypes circulating in the evaluated animals. Molecular surveillance should be continually implemented in Ecuador in order to deepen the epidemiological and evolutionary knowledge about T. theileri as well other haemoparasites in the amazon parts of the country.

A Case of Reversible Cerebral Vasoconstriction Syndrome: Postpartum Cerebral Angiopathy in a 32-Year-Old Primigravid Treated with Intravenous Immunoglobulin

This is a case of a 32-year-old primigravid who developed sudden severe headache on the 7th day postpartum associated with focal neurologic deficits and altered sensorium. She had a GCS score of 6, anisocoric pupils and an NIHSS score of 31. Cranial MRI with MRA showed multifocal hyperacute to acute infarcts on the left occipital lobe, left thalamus, and midbrain which was more prominent on the right. Due to clinical deterioration, a repeat Cranial MRI with MRA was done and showed progression of infarcts involving both thalami and right pons with interval appearance of contour irregularities in the proximal anterior cerebral, posterior cerebral, basilar and internal carotid arteries. Serial transcranial Doppler showed significant distal right middle cerebral artery vasospasm. She was managed as a case of reversible cerebral vasoconstriction syndrome, associated with postpartum cerebral angiopathy. Intravenous pulse methylprednisolone was started subsequently IVIG was initiated. Intravenous immunoglobulin was given for 5 days. The patient gradually improved, underwent rehabilitation therapy, and was discharged stable after 6 weeks.

Serine-Threonine Kinase TAO3-Mediated Trafficking of Endosomes Containing the Invadopodia Scaffold TKS5α Promotes Cancer Invasion and Tumor Growth

Invadopodia are actin-based proteolytic membrane protrusions required for invasive behavior and tumor growth. In this study, we used our high-content screening assay to identify kinases whose activity affects invadopodia formation. Among the top hits selected for further analysis was TAO3, an STE20-like kinase of the GCK subfamily. TAO3 was overexpressed in many human cancers and regulated invadopodia formation in melanoma, breast, and bladder cancers. Furthermore, TAO3 catalytic activity facilitated melanoma growth in three-dimensional matrices and in vivo. A novel, potent catalytic inhibitor of TAO3 was developed that inhibited invadopodia formation and function as well as tumor cell extravasation and growth. Treatment with this inhibitor demonstrated that TAO3 activity is required for endosomal trafficking of TKS5α, an obligate invadopodia scaffold protein. A phosphoproteomics screen for TAO3 substrates revealed the dynein subunit protein LIC2 as a relevant substrate. Knockdown of LIC2 or expression of a phosphomimetic form promoted invadopodia formation. Thus, TAO3 is a new therapeutic target with a distinct mechanism of action. SIGNIFICANCE: An unbiased screening approach identifies TAO3 as a regulator of invadopodia formation and function, supporting clinical development of this class of target.

Worse prognosis in women, compared with men, after thrombolysis: An individual patient data pooling study of Asian acute stroke registries

BACKGROUND AND PURPOSE

To examine sex differences in disease profiles and short-term outcomes after acute ischemic stroke treated with recombinant tissue plasminogen activator.

METHODS

Eight national and regional stroke registries contributed individual participant data from mainland China, Japan, Philippines, Singapore, South Korea and Taiwan in 2005-2018. The primary outcome was ordinal-modified Rankin scale at 90 days. Key safety outcome was symptomatic intracerebral hemorrhage (sICH).

RESULTS

Of 4453 patients included in the analyses, 1692 (36.3%) were women who were older, more likely to have a more severe neurological deficit, history of hypertension and atrial fibrillation, and a cardioembolic stroke compared to men. Women were more likely than men to have unfavorable shift of modified Rankin scale (fully adjusted odds ratio) (women vs. men) 1.14, 95% confidence interval 1.02-1.28). There was no significant sex difference for death 1.05 (0.84-1.31) or sICH (1.17, 0.89-1.54). Women were more likely to have unfavorable functional outcome with increasing age (P = 0.022 for interaction). In the age groups 70-80 and ≥80 years, women had a worse functional outcome compared to men (1.22, 1.02-1.47 and 1.43, and 1.06-1.92, respectively).

CONCLUSION

In this pooled data from Asian acute stroke registries, women had poorer prognosis than men after receiving recombinant tissue plasminogen activator for acute ischemic stroke, which worsened with age. Women older than 70 appear to have a worse outcome than men which could be explained by greater stroke severity, more AF, and cardioembolic stroke.

Cilostazol Versus Aspirin in Ischemic Stroke Patients With High-Risk Cerebral Hemorrhage: Subgroup Analysis of the PICASSO Trial

Background and Purpose- Although cilostazol has shown less hemorrhagic events than aspirin, only marginal difference was observed in hemorrhagic stroke events among patients at high risk for cerebral hemorrhage. To identify patients who would most benefit from cilostazol, this study analyzed interactions between treatment and subgroups of the PICASSO trial (Prevention of Cardiovascular Events in Asian Ischemic Stroke Patients With High Risk of Cerebral Hemorrhage). Methods- Ischemic stroke patients with a previous intracerebral hemorrhage or multiple microbleeds were randomized to treatment with cilostazol or aspirin and followed up for a mean 1.8 years. Efficacy, defined as the composite of any stroke, myocardial infarction, and vascular death, and safety, defined as the incidence of hemorrhagic stroke, were analyzed in the 2 groups. Interactions between treatment and age, sex, presence of hypertension and diabetes mellitus, index of high-risk cerebral hemorrhage, and white matter lesion burden were analyzed for primary and key secondary outcomes. Changes in vital signs and laboratory results were compared in the 2 groups. Results- Among all 1534 patients enrolled, a significant interaction between treatment group and index of high risk for cerebral hemorrhage on hemorrhagic stroke (P for interaction, 0.03) was observed. Hemorrhagic stroke was less frequent in the cilostazol than in the aspirin group in patients with multiple microbleeds (1 versus 13 events; hazard ratio, 0.08 [95% CI, 0.01-0.61]; P=0.01). A marginal interaction between treatment group and white matter change on any stroke (P for interaction, 0.08) was observed. Cilostazol reduced any stroke significantly in patients with mild (5 versus 16 events; hazard ratio, 0.36 [95% CI, 0.13-0.97]; P=0.04)-to-moderate (16 versus 32 events; hazard ratio, 0.50 [95% CI, 0.29-0.92]; P=0.03) white matter changes. Heart rate and HDL (high-density lipoprotein) cholesterol level were significantly higher in the cilostazol group than in the aspirin group at follow-up. Conclusions- Cilostazol may be more beneficial for ischemic stroke patients with multiple cerebral microbleeds and before white matter changes are extensive. Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT01013532.

Low-dose versus standard-dose alteplase in acute ischemic stroke in Asian stroke registries: an individual patient data pooling study

OBJECTIVE

To investigate the comparative efficacy and safety of the low-dose versus standard-dose alteplase using real-world acute stroke registry data from Asian countries.

METHODS

Individual participant data were obtained from nine acute stroke registries from China, Japan, Philippines, Singapore, South Korea, and Taiwan between 2005 and 2018. Inverse probability of treatment weight was used to remove baseline imbalances between those receiving low-dose versus standard-dose alteplase. The primary outcome was death or disability defined by modified Rankin Scale scores of 2 to 6 at 90 days. Secondary outcomes were symptomatic intracerebral hemorrhage and death. Generalized linear mixed models with the individual registry as a random intercept were performed to determine associations of treatment with low-dose alteplase and outcomes.

RESULTS

Of the 6250 patients (mean age 66 years, 36% women) included in these analyses, 1610 (24%) were treated with low-dose intravenous alteplase. Clinical outcomes for low-dose alteplase were not significantly different to those for standard-dose alteplase, adjusted odds ratios for death or disability: 1.00 (0.85-1.19) and symptomatic intracerebral hemorrhage 0.87 (0.63-1.19), except for lower death with borderline significance, 0.77 (0.59-1.01).

CONCLUSIONS

The present analyses of real-world Asian acute stroke registry data suggest that low-dose intravenous alteplase has overall comparable efficacy for functional recovery and greater potential safety in terms of reduced mortality, to standard-dose alteplase for the treatment of acute ischemic stroke.

Effect of Combined Treatment with MLC601 (NeuroAiDTM) and Rehabilitation on Post-Stroke Recovery: The CHIMES and CHIMES-E Studies

BACKGROUND AND PURPOSE

MLC601 has been shown in preclinical studies to enhance neurorestorative mechanisms after stroke. The aim of this post hoc analysis was to assess whether combining MLC601 and rehabilitation has an effect on improving functional outcomes after stroke.

METHODS

Data from the CHInese Medicine NeuroAiD Efficacy on Stroke (CHIMES) and CHIMES-Extension (CHIMES-E) studies were analyzed. CHIMES-E was a 24-month follow-up study of subjects included in CHIMES, a multi-centre, double-blind placebo-controlled trial which randomized subjects with acute ischemic stroke, to either MLC601 or placebo for 3 months in addition to standard stroke treatment and rehabilitation. Subjects were stratified according to whether they received or did not receive persistent rehabilitation up to month (M)3 (non- randomized allocation) and by treatment group. The modified Rankin Scale (mRS) and Barthel Index were assessed at month (M) 3, M6, M12, M18, and M24.

RESULTS

Of 880 subjects in CHIMES-E, data on rehabilitation at M3 were available in 807 (91.7%, mean age 61.8 ± 11.3 years, 36% female). After adjusting for prognostic factors of poor outcome (age, sex, pre-stroke mRS, baseline National Institute of Health Stroke Scale, and stroke onset-to-study-treatment time), subjects who received persistent rehabilitation showed consistently higher treatment effect in favor of MLC601 for all time points on mRS 0-1 dichotomy analysis (ORs 1.85 at M3, 2.18 at M6, 2.42 at M12, 1.94 at M18, 1.87 at M24), mRS ordinal analysis (ORs 1.37 at M3, 1.40 at M6, 1.53 at M12, 1.50 at M18, 1.38 at M24), and BI ≥95 dichotomy analysis (ORs 1.39 at M3, 1.95 at M6, 1.56 at M12, 1.56 at M18, 1.46 at M24) compared to those who did not receive persistent rehabilitation.

CONCLUSIONS

More subjects on MLC601 improved to functional independence compared to placebo among subjects receiving persistent rehabilitation up to M3. The larger treatment effect of MLC601 was sustained over 2 years which supports the hypothesis that MLC601 combined with rehabilitation might have beneficial and sustained effects on neuro-repair processes after stroke. There is a need for more data on the effect of combining rehabilitation programs with stroke recovery treatments.

Effects of ibuprofen and carbamazepine on the ion transport system and fatty acid metabolism of temperature conditioned juveniles of Solea senegalensis

The increasing presence of pharmaceuticals in aquatic environments in the last decades, derived from human and veterinary use, has become an important environmental problem. Previous studies have shown that ibuprofen (IB) and carbamazepine (CBZ) modify physiological and biochemical processes in Senegalese sole (Solea senegalensis) in a temperature-dependent manner. In other vertebrates, there is evidence that both of these pharmaceuticals interfere with the 'arachidonic acid (AA) cascade', which is responsible for the biosynthesis of numerous enzymes that are involved in the osmoregulatory process. The present work aims to study the temperature-dependent effects of these two pharmaceuticals on several biochemical and molecular parameters in Senegalese sole. Regarding osmoregulation, Na⁺, K⁺ -ATPase enzyme activity was determined in the gills, kidney and intestine, and the expressions of both Na⁺, K⁺ -ATPase 1α-subunit isoforms (ATP1A1a and ATP1A1b) were quantified in gills. Gill prostaglandin-endoperoxide synthase-2 (PTGS2) gene expression and fatty acid composition were selected to determine the interference of both pharmaceuticals with the AA cascade. Senegalese sole juveniles, acclimatised at 15°C or 20°C, were exposed through intraperitoneal injection to IB (10mg/kg) and CBZ (1mg/kg) for 48h. Non-injected fish (Control) and those injected with the carrier (sunflower oil; S.O.), acclimated at each of the two temperatures, were used for comparison. The results show that IB directly affected the osmoregulatory mechanisms that alter gill and intestine Na⁺, K⁺ -ATPase activities. In addition, the copy number of ATP1A1a was higher at 20°C than at 15°C, which could be a direct response to the temperature variation. The gene expression of PTGS2 was affected by neither drug administration nor acclimation temperature. Nevertheless, detailed analysis of AA and eicosapentaenoic acid (EPA) percentages revealed a CBZ-derived effect in the fatty acid composition of the gills.

Erratum: Stroke Epidemiology in South, East, and South-East Asia: A Review

[This corrects the article on p. 286 in vol. 19.].

Blood Feeding Status, Gonotrophic Cycle and Survivorship of Aedes (Stegomyia) aegypti (L.) (Diptera: Culicidae) Caught in Churches from Merida, Yucatan, Mexico

Blood-feeding status, gonotrophic cycle, and survival rates of Aedes (Stegmyia) aegypti (L.) was investigated in catholic churches from Merida, Yucatan. Female Ae. aegypti were caught using backpack aspirator during 25 consecutive days in rainy (2015) and dry season (2016). Blood-feeding status was determined by external examination of the abdomen and classified as unfed, fed, and gravid. Daily changes in the parous-nulliparous ratio were recorded, and the gonotrophic cycle length was estimated by a time series analysis. Also, was observed the vitellogenesis to monitoring egg maturity. In total, 408 females Ae. aegypti were caught, and there was a significant difference in the number of females collected per season (Z = -6.729, P ≤ 0.05). A great number was caught in the rainy season (n = 329). In the dry season, 79 females were caught, which the fed females were twice greatest than the unfed. The length of gonotrophic cycle was estimated on the base of a high correlation coefficient value appearing every 4 days in rainy at 26.7 ± 1.22°C, and 3 days in dry season at 29.8 ± 1.47°C. The daily survival rate of the Ae. aegypti population was higher in both seasons, 0.94 and 0.93 for the rainy and dry season, respectively. The minimum time estimated for developing mature eggs after blood feeding was similar in both seasons (3.5 days in rainy versus 3.25 days in dry). The measurement of the vectorial capacity of Ae. aegypti in catholic churches could help to understand the dynamics of transmission of arboviruses in sites with high human aggregation.

Stroke Epidemiology in South, East, and South-East Asia: A Review

Asia, which holds 60% of the world’s population, comprises some developing countries which are in economic transition. This paper reviews the epidemiology of stroke in South, East and South-East Asia. Data on the epidemiology of stroke in South, East, and South-East Asia were derived from the Global Burden of Disease study (mortality, disability-adjusted life-years [DALYs] lost because of stroke), World Health Organization (vascular risk factors in the community), and publications in PubMed (incidence, prevalence, subtypes, vascular risk factors among hospitalized stroke patients). Age- and sex-standardized mortality is the lowest in Japan, and highest in Mongolia. Community-based incidence data of only a few countries are available, with the lowest rates being observed in Malaysia, and the highest in Japan and Taiwan. The availability of prevalence data is higher than incidence data, but different study methods were used for case-finding, with different age bands. For DALYs, Japan has the lowest rates, and Mongolia the highest. For community, a high prevalence of hypertension is seen in Mongolia and Pakistan; diabetes mellitus in Papua New Guinea, Pakistan, and Mongolia; hypercholesterolemia in Japan, Singapore, and Brunei; inactivity in Malaysia; obesity in Brunei, Papua New Guinea, and Mongolia; tobacco smoking in Indonesia. Hypertension is the most frequent risk factor, followed by diabetes mellitus and smoking. Ischemic stroke occurs more frequently than hemorrhagic stroke, and subarachnoid hemorrhages are uncommon. There are variations in the stroke epidemiology between countries in South, East, and South-East Asia. Further research on stroke burden is required.

Prognostic Factors and Pattern of Long-Term Recovery with MLC601 (NeuroAiD™) in the Chinese Medicine NeuroAiD Efficacy on Stroke Recovery - Extension Study

BACKGROUND

The Chinese Medicine NeuroAiD Efficacy on Stroke recovery - Extension (CHIMES-E) study is among the few acute stroke trials with long-term outcome data. We aimed to evaluate the recovery pattern and the influence of prognostic factors on treatment effect of MLC601 over 2 years.

METHODS

The CHIMES-E study evaluated the 2 years outcome of subjects aged ≥18 years with acute ischemic stroke, National Institutes of Health Stroke Scale (NIHSS) score 6-14, pre-stroke modified Rankin Scale (mRS) score ≤1 included in a multicenter, randomized, double-blind, placebo-controlled trial of MLC601 for 3 months. Standard stroke care and rehabilitation were allowed during follow-up with mRS score being assessed in-person at month (M) 3 and by telephone at M1, M6, M12, M18 and M24.

RESULTS

Data from 880 subjects were analyzed. There was no difference in baseline characteristics between treatment groups. The proportion of subjects with mRS score 0-1 increased over time in favor of MLC601 most notably from M3 to M6, thereafter remaining stable up to M24, while the proportion deteriorating to mRS score ≥2 remained low at all time points. Older age (p < 0.01), female sex (p = 0.06), higher baseline NIHSS score (p < 0.01) and longer onset to treatment time (OTT; p < 0.01) were found to be predictors of poorer outcome at M3. Greater treatment effect, with more subjects improving on MLC601 than placebo, was seen among subjects with 2 or more prognostic factors (OR 1.65 at M3, 1.78 at M6, 1.90 at M12, 1.65 at M18, 1.39 at M24), especially in subjects with more severe stroke or longer OTT.

CONCLUSIONS

The sustained benefits of MLC601 over 2 years were due to more subjects improving to functional independence at M6 and beyond compared to placebo. Selection of subjects with poorer prognosis, particularly those with more severe NIHSS score and longer OTT delay, as well as a long follow-up period, may improve the power of future trials investigating the treatment effect of neuroprotective or neurorestorative therapies.

Durability of the beneficial effect of MLC601 (NeuroAiD™) on functional recovery among stroke patients from the Philippines in the CHIMES and CHIMES-E studies

Background and Aim A pre-specified country analysis of subjects from the Philippines in the CHInese Medicine NeuroAiD Efficacy on Stroke recovery (CHIMES) Study showed significantly improved functional and neurological outcomes on MLC601 at month (M) 3. We aimed to assess these effects on long-term functional recovery in the Filipino cohort. Methods The CHIMES-E (extension) Study evaluated subjects who completed three months of randomized placebo-controlled treatment in CHIMES up to two years. Blinding of treatment allocation was maintained and all subjects received standard stroke care and rehabilitation. Modified Rankin Score (mRS) and Barthel Index (BI) were assessed in-person at M3 and by telephone at M6, M12, M18, M24. Odds ratios (OR) with corresponding 95% confidence intervals (CI) for functional recovery using ordinal analysis of mRS and for achieving functional independence (mRS 0-1 or BI ≥ 95) at each time point were calculated, adjusting for age, sex, baseline National Institute of Health Stroke Scale (NIHSS), onset-to-treatment time (OTT) and pre-stroke mRS. Results The 378 subjects (MLC601 192, placebo 186) included in CHIMES-E from the Philippines (mean age 60.2 ± 11.1) had more women ( p < 0.001), worse baseline NIHSS ( p < 0.001) and longer onset to treatment time ( p = 0.002) compared to other countries. Baseline characteristics were similar between treatment groups. The treatment effect of MLC601 seen at M3 peaked at M6 with OR for mRS shift of 1.53 (95% CI 1.05-2.22), mRS dichotomy 0-1 of 1.77 (95% CI 1.10-2.83), and BI ≥ 95 of 1.87 (95% CI 1.16-3.02). The beneficial effect persisted up to M24. Conclusion The beneficial effect of MLC601 seen at M3 in the Filipino cohort is durable up to two years after stroke.

CHInese Medicine NeuroAiD Efficacy on Stroke Recovery - Extension Study (CHIMES-E): A Multicenter Study of Long-Term Efficacy

BACKGROUND

The CHInese Medicine NeuroAiD Efficacy on Stroke recovery (CHIMES) study was an international randomized double-blind placebo-controlled trial of MLC601 (NeuroAiD) in subjects with cerebral infarction of intermediate severity within 72 h. CHIMES-E (Extension) aimed at evaluating the effects of the initial 3-month treatment with MLC601 on long-term outcome for up to 2 years.

METHODS

All subjects randomized in CHIMES were eligible for CHIMES-E. Inclusion criteria for CHIMES were age ≥18, baseline National Institute of Health Stroke Scale of 6-14, and pre-stroke modified Rankin Scale (mRS) ≤1. Initial CHIMES treatment allocation blinding was maintained, although no further study treatment was provided in CHIMES-E. Subjects received standard care and rehabilitation as prescribed by the treating physician. mRS, Barthel Index (BI), and occurrence of medical events were ascertained at months 6, 12, 18, and 24. The primary outcome was mRS at 24 months. Secondary outcomes were mRS and BI at other time points.

RESULTS

CHIMES-E included 880 subjects (mean age 61.8 ± 11.3; 36% women). Adjusted OR for mRS ordinal analysis was 1.08 (95% CI 0.85-1.37, p = 0.543) and mRS dichotomy ≤1 was 1.29 (95% CI 0.96-1.74, p = 0.093) at 24 months. However, the treatment effect was significantly in favor of MLC601 for mRS dichotomy ≤1 at 6 months (OR 1.49, 95% CI 1.11-2.01, p = 0.008), 12 months (OR 1.41, 95% CI 1.05-1.90, p = 0.023), and 18 months (OR 1.36, 95% CI 1.01-1.83, p = 0.045), and for BI dichotomy ≥95 at 6 months (OR 1.55, 95% CI 1.14-2.10, p = 0.005) but not at other time points. Subgroup analyses showed no treatment heterogeneity. Rates of death and occurrence of vascular and other medical events were similar between groups.

CONCLUSIONS

While the benefits of a 3-month treatment with MLC601 did not reach statistical significance for the primary endpoint at 2 years, the odds of functional independence defined as mRS ≤1 was significantly increased at 6 months and persisted up to 18 months after a stroke.

Aquatic pollution may favor the success of the invasive species A. franciscana

The genus Artemia consists of several bisexual and parthenogenetic sibling species. One of them, A. franciscana, originally restricted to the New World, becomes invasive when introduced into ecosystems out of its natural range of distribution. Invasiveness is anthropically favored by the use of cryptobiotic eggs in the aquaculture and pet trade. The mechanisms of out-competition of the autochthonous Artemia by the invader are still poorly understood. Ecological fitness may play a pivotal role, but other underlying biotic and abiotic factors may contribute. Since the presence of toxicants in hypersaline aquatic ecosystems has been documented, our aim here is to study the potential role of an organophosphate pesticide, chlorpyrifos, in a congeneric mechanism of competition between the bisexual A. franciscana (AF), and one of the Old World parthenogenetic siblings, A. parthenogenetica (PD). For this purpose we carried out life table experiments with both species, under different concentrations of the toxicant (0.1, 1 and 5μg/l), and analyzed the cholinesterase inhibition at different developmental stages. The results evidence that both, AF and PD, showed an elevated tolerance to high ranges of chlorpyrifos, but AF survived better and its fecundity was less affected by the exposure to the pesticide than that of PD. The higher fecundity of AF is a selective advantage in colonization processes leading to its establishment as NIS. Besides, under the potential selective pressure of abiotic factors, such as the presence of toxicants, its higher resistance in terms of survival and biological fitness also indicates out-competitive advantages.

Prognostic factors and treatment effect in the CHIMES study

BACKGROUND

Stroke trials often analyze patients with heterogeneous prognoses using a single definition of outcome, which may not be applicable to all subgroups. We aimed to evaluate the treatment effects of MCL601 among patients stratified by prognosis in the Chinese Medicine Neuroaid Efficacy on Stroke Recovery (CHIMES) study.

METHODS

Analyses were performed using data from the CHIMES study, an international, randomized, placebo-controlled, double-blind trial comparing MLC601 with placebo in patients with ischemic stroke of intermediate severity in the preceding 72 hours. All subjects with baseline data and the modified Rankin Scale (mRS) score at 3 months were included.

RESULTS

Data from 1006 subjects were analyzed. The predictive variables for mRS score greater than 1 at month 3 were age older than 60 years (P < .001), baseline National Institutes of Health Stroke Scale score 10-14 (P < .001), stroke onset to initiation of study treatment of more than 48 hours (P < .001), and female sex (P = .026). A higher number of predictors was associated with poorer mRS score at month 3 for both placebo (P < .001) and treatment (P < .001) groups. The odds ratio (OR) for achieving a good outcome increased with the number of predictors and reached statistical significance in favor of MLC601 among patients with 2 to 4 predictors combined (unadjusted OR = 1.44, 95% confidence interval, 1.02-2.03; adjusted OR = 1.60, 95% confidence interval, 1.10-2.34).

CONCLUSIONS

Age, sex, baseline National Institutes of Health Stroke Scale score, and time to first dose are predictors of functional outcome in the CHIMES study. Stratification by prognosis showed that patients with 2 or more predictors of poorer outcome have better treatment effect with MLC601 than patients with single or no prognostic factor. These results have implications on designing future stroke trials.

Abstract W MP60: Prevalence Of Post Stroke Daytime Sleepiness

Background of the study: In patients with stroke, the most common Sleep Disorder are sleep apnea, insomia (30%), and excessive daytime sleepiness. Ischemic stroke patients had 76.8% sleep disorder and hemorrhagic stroke patients had 82.5% sleep disorder. There were several postulated mechanisms on the pathophysiologic effects of sleep disorders on stroke which includes: acute hemodynamic changes during episodes of apnea, decreased cerebral blood flow, and paradoxical embolization, hypercoagulability, hypoxia-related cerebral ischemia, and atherosclerosis. With these several mechanisms, post stroke recovery among patients with post stroke sleep disorder can be altered.

Methodology: A cross sectional study was conducted in Jose Reyes Memorial Medical Center from July 2013 to June 2014. All Medical records and neuroimaging of post stroke patients (≥ 6 months) were reviewed. Those patients with cognitive dysfunction, unable to give consent or unable to understand the study protocol and whose neuroimaging cannot be retrieved were excluded in the study. The interviewer assisted Epworth Sleepiness Scale (ESS) was used in this study to determine daytime sleep propensity.

Results: A total of 130 subjects were included. There were 82 (63%) male and 48(37%) female. The mean age is 58. The variables shown to be significantly associated with ESS were duration of stroke, number of risk factor and type of stroke. The more recent the stroke (specifically shorter than 2.7 years which is the mean), the higher the ESS score. A patient with two risk factors was 4.6x more likely to have an ESS of 10-14 compared to one who has only 1 risk factor. Those who had intracranial bleeding were 2.5 times more likely to have an ESS of 10-14.

Conclusion: Among post stroke patients, the more recent the stroke, the more risk factors present, and those who had intracerebral hemorrhage have higher propensity for daytime sleepiness.

Baseline characteristics and treatment response of patients from the Philippines in the CHIMES study

BACKGROUND

The CHIMES Study compared MLC601 with placebo in patients with ischemic stroke of intermediate severity in the preceding 72 h. Sites from the Philippines randomized 504 of 1099 (46%) patients in the study. We aimed to define the patient characteristics and treatment responses in this subgroup to better plan future trials.

METHODS

The CHIMES dataset was used to compare the baseline characteristics, time from stroke onset to study treatment initiation, and treatment responses to MLC601 between patients recruited from Philippines and the rest of the cohort. Treatment effect was analyzed using end-points at month 3 as described in the primary publication, that is, modified Rankin Score, National Institutes of Health Stroke Scale, and Barthel Index.

RESULTS

The Philippine cohort was younger, had more women, worse baseline National Institutes of Health Stroke Scale, and longer time delay from stroke onset to study treatment compared with the rest of the cohort. Age (P = 0·003), baseline National Institutes of Health Stroke Scale (P < 0·001), and stroke onset to study treatment initiation (P = 0·016) were predictors of modified Rankin Score at three-months. Primary analysis of modified Rankin Score shift was in favor of MLC601 (adjusted odds ratio 1·41, 95% confidence interval 1·01-1·96). Secondary analyses were likewise in favor of MLC601 for modified Rankin Score dichotomy 0-1, improvement in National Institutes of Health Stroke Scale (total and motor scores), and Barthel Index.

CONCLUSIONS

The treatment effects in the Philippine cohort were in favor of MLC601. This may be due to inclusion of more patients with predictors of poorer outcome.

The real stroke burden in the Philippines

Stroke is the Philippines' second leading cause of death. It has a prevalence of 0·9%; ischemic stroke comprises 70% while hemorrhagic stroke comprises 30%. Age-adjusted hypertension prevalence is 20·6%, diabetes 6·0%, dyslipidemia 72·0%, smoking 31%, and obesity 4·9%. The neurologist-to-patient ratio is 1:330·000, with 67% of neurologists practicing in urban centers. Health care is largely private and the cost is borne out-of-pocket by patients and their families. Challenges include delivering adequate support to the rural communities and to the underprivileged sectors.

Chinese medicine neuroaid efficacy on stroke recovery: a double-blind, placebo-controlled, randomized study

BACKGROUND AND PURPOSE

Previous clinical studies suggested benefit for poststroke recovery when MLC601 was administered between 2 weeks and 6 months of stroke onset. The Chinese Medicine Neuroaid Efficacy on Stroke recovery (CHIMES) study tested the hypothesis that MLC601 is superior to placebo in acute, moderately severe ischemic stroke within a 72-hour time window.

METHODS

This multicenter, double-blind, placebo-controlled trial randomized 1100 patients with a National Institutes of Health Stroke Scale score 6 to 14, within 72 hours of onset, to trial medications for 3 months. The primary outcome was a shift in the modified Rankin Scale. Secondary outcomes were modified Rankin Scale dichotomy, National Institutes of Health Stroke Scale improvement, difference in National Institutes of Health Stroke Scale total and motor scores, Barthel index, and mini-mental state examination. Planned subgroup analyses were performed according to age, sex, time to first dose, baseline National Institutes of Health Stroke Scale, presence of cortical signs, and antiplatelet use.

RESULTS

The modified Rankin Scale shift analysis-adjusted odds ratio was 1.09 (95% confidence interval, 0.86-1.32). Statistical difference was not detected between the treatment groups for any of the secondary outcomes. Subgroup analyses showed no statistical heterogeneity for the primary outcome; however, a trend toward benefit in the subgroup receiving treatment beyond 48 hours from stroke onset was noted. Serious and nonserious adverse events rates were similar between the 2 groups.

CONCLUSIONS

MLC601 is statistically no better than placebo in improving outcomes at 3 months when used among patients with acute ischemic stroke of intermediate severity. Longer treatment duration and follow-up of participants with treatment initiated after 48 hours may be considered in future studies.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00554723.

Stroke education in the Philippines

Education is paramount in effectively reducing the significant burden of stroke in the Philippines. Dedicated academic institutions and dynamic professional organizations in the Philippines have collaborated to involve themselves in the plight against stroke through systematic curriculum development for undergraduates, continuous regulation of quality residency and fellowship training program, hosting up-to-date Continuing Medical Education (CME) activities for local and international audience, and active participation in clinical stroke trials. Most recently, the University of Santo Tomas Faculty of Medicine & Surgery and the Department of Neurology & Psychiatry offered a 72-hour Certification Course in Stroke Medicine that commenced in 2011 in anticipation of the Master on Health Sciences in Stroke Medicine course being prepared for 2013.

CHIMES-I: sub-group analyzes of the effects of NeuroAiD according to baseline brain imaging characteristics among patients randomized in the CHIMES study

RATIONALE

The clinical effects of neuroprotective and/or neurorestorative therapies may vary according to location and size of the ischemic injury. Imaging techniques can be useful in stratifying patients for trials that may be beneficial against particular ischemic lesion characteristics.

AIM

To test the hypothesis that the efficacy of NeuroAiD compared with placebo in improving functional outcome and reducing neurological deficit in patients with cerebral infarction of intermediate severity varies between sub-groups of patients randomized in the main Chinese Medicine Neuroaid Efficacy on Stroke study when categorized according to baseline imaging characteristics.

DESIGN

This is a retrospective cohort sub-group analysis of patients who participated in the main Chinese Medicine Neuroaid Efficacy on Stroke study, a multicenter, double-blind, placebo-controlled trial that recruited 1100 patients within 72 h of ischemic stroke onset with National Institutes of Health Stroke Scale 6-14 and were randomized to either NeuroAiD or placebo taken four capsules three times daily for three months. Review of the baseline images to classify the acute stroke lesions in terms of size, location, and extent of involvement will be performed retrospectively by two readers who will remain blinded as to treatment allocation and outcomes of the subjects.

STUDY OUTCOMES

The primary efficacy end-point in the main Chinese Medicine Neuroaid Efficacy on Stroke study is the modified Rankin Scale grades at three-months. Secondary efficacy end-points are the National Institutes of Health Stroke Scale score at three-months; difference of National Institutes of Health Stroke Scale scores between baseline and 10 days and between baseline and three-months; difference of National Institutes of Health Stroke Scale sub-scores between baseline and 10 days and between baseline and three-months; modified Rankin Scale at 10 days, one-month, and three-months; Barthel index at three-months; and Mini Mental State Examination at 10 days and three-months. Analysis of these primary and secondary end-points will be performed for sub-groups defined in this study after review of the baseline brain imaging: nonlacunar and lacunar, cortical and sub-cortical, hemispheric vs. brainstem, Alberta Stroke Program Early CT score <7 and 7-10, and score <8 and 8-10.

Antiplatelet therapy and the effects of B vitamins in patients with previous stroke or transient ischaemic attack: a post-hoc subanalysis of VITATOPS, a randomised, placebo-controlled trial

Background

Previous studies have suggested that any benefits of folic acid-based therapy to lower serum homocysteine in prevention of cardiovascular events might be offset by concomitant use of antiplatelet therapy. We aimed to establish whether there is an interaction between antiplatelet therapy and the effects of folic acid-based homocysteine-lowering therapy on major vascular events in patients with stroke or transient ischaemic attack enrolled in the vitamins to prevent stroke (VITATOPS) trial.

Methods

In the VITATOPS trial, 8164 patients with recent stroke or transient ischaemic attack were randomly allocated to double-blind treatment with one tablet daily of placebo or B vitamins (2 mg folic acid, 25 mg vitamin B₆, and 500 μg vitamin B₁₂) and followed up for a median 3·4 years (IQR 2·0–5·5) for the primary composite outcome of stroke, myocardial infarction, or death from vascular causes. In our post-hoc analysis of the interaction between antiplatelet therapy and the effects of treatment with B vitamins on the primary outcome, we used Cox proportional hazards regression before and after adjusting for imbalances in baseline prognostic factors in participants who were and were not taking antiplatelet drugs at baseline and in participants assigned to receive B vitamins or placebo. We also assessed the interaction in different subgroups of patients and different secondary outcomes. The VITATOPS trial is registered with ClinicalTrials.gov, number NCT00097669, and Current Controlled Trials, number ISRCTN74743444.

Findings

At baseline, 6609 patients were taking antiplatelet therapy and 1463 were not. Patients not receiving antiplatelet therapy were more likely to be younger, east Asian, and disabled, to have a haemorrhagic stroke or cardioembolic ischaemic stroke, and to have a history of hypertension or atrial fibrillation. They were less likely to be smokers and to have a history of peripheral artery disease, hypercholesterolaemia, diabetes, ischaemic heart disease, and a revascularisation procedure. Of the participants taking antiplatelet drugs at baseline, B vitamins had no significant effect on the primary outcome (488 patients in the B-vitamins group [15%] vs 519 in the placebo group [16%]; hazard ratio [HR] 0·94, 95% CI 0·83–1·07). By contrast, of the participants not taking antiplatelet drugs at baseline, B vitamins had a significant effect on the primary outcome (123 in the B-vitamins group [17%] vs 153 in the placebo group [21%]; HR 0·76, 0·60–0·96). The interaction between antiplatelet therapy and the effect of B vitamins on the primary outcome was significant after adjusting for imbalance in the baseline variables (adjusted p for interaction=0·0204).

Interpretation

Our findings support the hypothesis that antiplatelet therapy modifies the potential benefits of lowering homocysteine with B-vitamin supplementation in the secondary prevention of major vascular events. If validated, B vitamins might have a role in the prevention of ischaemic events in high-risk individuals with an allergy, intolerance, or lack of indication for antiplatelet therapy.

Funding

Australia National Health and Medical Research Council, UK Medical Research Council, Singapore Biomedical Research Council, and Singapore National Medical Research Council.

Effect of ivermectin on the liver of gilthead sea bream Sparus aurata: a proteomic approach

Gilthead sea bream Sparus aurata is the most commercialized Mediterranean aquacultured fish species. Ivermectin has recently (experimentally) started to be used to control ectoparasitic infestations in Mediterranean cultured marine fish. The potential hepatotoxicity of ivermectin was investigated in gilthead sea bream juveniles (35g) following oral administration at the recommended dose of 0.2 mgkg(-1) fish for 10d. Difference Gel Electrophoresis Technology (DIGE) was used to study the effect of this treatment in gilthead sea bream liver protein profile under routine culture conditions. The 2D-DIGE protein maps obtained were analyzed using the DeCyder 6.5 software. The results obtained showed significant changes in the expression of 36 proteins respect to the control group. Among these proteins, six increased in abundance, and 30 decreased. Spot showing differential expression respect to the control were analyzed by mass spectrometry and database search, which resulted in three positive identifications corresponding to hepatic proteins involved in lipid metabolism (apoA-I), oxidative stress responses and energy generation (beta-globin, ATP synthase subunit beta). These proteins have not been previously associated to invermectin effect.

Tissue-specific robustness of fatty acid signatures in cultured gilthead sea bream (Sparus aurata L.) fed practical diets with a combined high replacement of fish meal and fish oil

The present study aimed to determine the tissue-specific robustness of fatty acid (FA) signatures of gilthead sea bream (Sparus aurata L.) by analyzing the changes in lipid class and FA composition of skeletal muscle, brain, liver, and mesenteric adipose tissue. Triplicate groups of fish were fed to visual satiety over a 14-mo production cycle with 2 practical plant protein-based diets formulated with either fish oil or a blend of vegetable oils (66% of fish oil replacement) to contain 53% CP and 21% crude fat on a DM basis. Growth rates (P = 0.22) and tissue lipid class composition were not altered by the dietary treatment (P = 0.34 and 0.52 for neutral lipids and phospholipids, respectively). The FA signatures of neutral lipids reflected the composition of the diet, although the output of principal components analysis revealed a divergent FA profile for liver compared with skeletal muscle, brain, and mesenteric adipose tissue. Because the theoretical EFA needs were met by the 2 diets, the FA composition of phospholipids remained almost unaltered in all tissues. Interestingly, however, the brain showed the greatest robustness and regulatory capacity to preserve the phenotype of fish fed fish oil-based diets. The FA signatures of total lipids are a combinatory result of neutral and polar lipids, and the most relevant fat storage tissues (mesenteric adipose tissue and skeletal muscle) were more easily influenced by dietary FA composition. The present study provides new insights into fish tissue FA composition and reinforces the use of FA signatures as useful criteria in determining whether EFA requirements for a wide range of physiological processes, including those of neural tissues, can be met with practical fish feeds.

A double-blind, placebo-controlled, randomized, multicenter study to investigate CHInese Medicine Neuroaid Efficacy on Stroke recovery (CHIMES Study)

Rationale Traditional Chinese Medications(TCM) have been reported to have beneficial effects in stroke patients, but were not rigorously evaluated by GCP standards. Aim This study tests the hypothesis that Neuroaid, a TCM widely used in China post-stroke, is superior to placebo in reducing neurological deficit and improving functional outcome in patients with acute cerebral infarction of an intermediate severity. Design This is a multicenter, randomised, double-blind, placebo-controlled study of Neuroaid in ischemic stroke patients with National Institute of Health Stroke Scale(NIHSS) 6-14 treated within 48 h of stroke onset. Neuroaid or placebo is taken (4 capsules) 3 times daily for 3 months. Treatments are assigned using block randomization, stratified for centers, via a central web-randomization system. With a power of 90% and two-sided test of 5% type I error, a sample size is 874. Allowing for a drop-out rate of up to 20%, 1100 individuals should be enrolled in this study. Study Outcomes The primary efficacy endpoint is the modified Rankin Scale(mRS) grades at 3 months. Secondary efficacy endpoints are the NIHSS score at 3 months; difference of NIHSS scores between baseline and 10 days, and between baseline and 3 months; difference of NIHSS sub-scores between baseline and 10 days, and between baseline and 3 months; mRS at 10 days, 1 month, and 3 months; Barthel index at 3 months; Mini Mental State Examination at 10 days and 3 months. Safety outcomes include complete blood count, renal and liver panels, and electrocardiogram.

STUDY REGISTRATION

ClinicalTrials.gov identifier: NCT00554723.

Acute toxicity of dichlorvos to Aphanius iberus (Cuvier & Valenciennes, 1846) and its anti-cholinesterase effects on this species

This study evaluates the toxic effects of the organophosphate pesticide (OP) dichlorvos to the endangered Iberian toothcarp (Aphanius iberus). To this end, the lethal toxicity of dichlorvos based on 96h-LC50 bioassays was determined in saline water (50g/L), and in vivo effects of dichlorvos on cholinesterase (ChE) activity were investigated in adult female and male specimens. The 96h-LC50 value determined by probit analysis was 3.17mg/L (95% confidence limits: 1.34-3.97). The characterisation of the ChE using different substrates and specific inhibitors was also carried out in head and muscle tissues. Acetylthiocholine was the substrate preferred by both head and muscle ChE in males and females. Eserine sulphate and BW284C51 significantly inhibited both head and muscle enzyme activity at low concentrations (muM range), and iso-OMPA had no significant effect. These results indicate that in the head and muscle the predominant ChE form is acetylcholinesterase (AChE) for both sexes. The kinetic parameters for ChE activity (Km and Vmax) were similar in both sexes. The 96h-LC50 value obtained for adult specimens of Iberian toothcarp was 3.17mg/L. ChE activity in head and body tissues of both sexes was significantly inhibited in all concentrations tested (0.5, 1, 2 and 4mg/L) after "in vivo" dichlorvos exposure. However, Iberian toothcarp was able to tolerate high concentrations of dichlorvos, and resist high levels of brain and muscle ChE inhibition without mortality. Both ChE inhibition and recovery followed a similar time-course pattern in response to sub-lethal exposure to dichlorvos (1mg/L), and the enzyme activity did not return to control levels after 96h in clean water. The results of this study show that ChE activity is a good biomarker of exposure to OP in the Iberian toothcarp adults.

The accuracy of transcranial Doppler in the diagnosis of middle cerebral artery stenosis

BACKGROUND AND PURPOSE

It was the aim of this study to systematically review available literature on the accuracy of transcranial Doppler (TCD) compared with angiography for the diagnosis of > or =50% middle cerebral artery stenosis in patients with transient ischemic attack or ischemic stroke.

METHODS

We performed a systematic review that included original articles published on TCD accuracy from 1982 until the end of December 2005 using angiography as the gold standard. The following measures of diagnostic accuracy were obtained from each primary study: sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Weighted mean averages were then calculated from individual results for different velocity cutoffs.

RESULTS

Six papers met our selection criteria. Using laboratory-specific variable mean flow velocity cutoffs, self-reported best accuracy results yield a mean weighted average sensitivity of 92%, specificity of 92%, PPV of 88% and NPV of 98% for 80 cm/s cutoff. For 100 cm/s cutoff, the sensitivities were 100%, specificity 97%, PPV 88% and NPV 100%.

CONCLUSIONS

Although limited to few reports, this analysis demonstrates fair TCD performance against angiography. Since increasing velocity cutoffs do not yield decreasing sensitivity and increasing specificity, further studies are required to determine optimal velocity values and possibly other criteria such as velocity ratios to develop a screening test with balanced performance parameters.

Grave prognosis on spontaneous intracerebral haemorrhage: GP on STAGE score

BACKGROUND AND OBJECTIVE

Spontaneous intracerebral haemorrhage (ICH) is more common in Asia than in western countries, and has a high mortality rate. A simple prognostic score for predicting grave prognosis of ICH is lacking. Our objective was to develop a simple and reliable score for most physicians.

MATERIAL AND METHOD

ICH patients from seven Asian countries were enrolled between May 2000 and April 2002 for a prospective study. Clinical features such as headache and vomiting, vascular risk factors, Glasgow coma scale (GCS), body temperature (BT), blood pressure on arrival, location and size of haematoma, intraventricular haemorrhage (IVH), hydrocephalus, need for surgical treatment, medical treatment, length of hospital stay and other complications were analyzed to determine the outcome using a modified Rankin scale (MRS). Grave prognosis (defined as MRS of 5-6) was judged on the discharge date.

RESULTS

995 patients, mean age 59.5 +/- 14.3 years were analyzed, after exclusion of incomplete data in 87 patients. 402 patients (40.4%) were in the grave prognosis group (MRS 5-6). Univariable analysis and then multivariable analysis showed only four statistically significant predictors for grave outcome of ICH. They were fever (BT > or = 37.8 degrees c), low GCS, large haematoma and IVH. The grave prognosis on spontaneous intracerebral haemorrhage (GP on STAGE) score was derived from these four factors using a multiple logistic model.

CONCLUSION

A simple and pragmatic prognostic score for ICH outcome has been developed with high sensitivity (82%) and specificity (82%). Furthermore, it can be administered by most general practitioners. Validation in other populations is now required.

Assessment of the efficacy of Artemia sp (Crustacea) cysts chorion as barrier to chlorpyrifos (organophosphorus pesticide) exposure. Effect on hatching and survival

In order to reveal the efficacy of the Artemia cysts chorion as barrier to the organophosphorus pesticide chlorpyrifos, whole and decapsulated cysts have been exposed to 10 mg L(-1) chlorpyrifos in sea water during hydration and hatching phase, separately. The concentration of chlorpyrifos in capsulated and decapsulated cysts after exposure has been determined in order to elucidate the efficacy of chorion as protection to the embryo. The results obtained demonstrate the ability of the cysts chorion to obstruct the pass of chlorpyrifos molecules through this protection structure. Thus, the concentration of chlorpyrifos in exposed decapsulated cysts is higher than in exposed whole cysts. Moreover, after removing the chorion of exposed cysts, the concentration of chlorpyrifos in the embryo was lower than that of cysts exposed, what would demonstrate the retention of chlorpyrifos molecules by the shell. Hatching was not severely affected by exposure to the insecticide whereas survival at 44 h of the nauplii exposed to chlorpyrifos was significantly different from the controls. Survival of nauplii hatched from exposed decapsulated cysts was higher than that from those hatched from exposed whole cysts, probably because of the lower vitality of the latter, due to depletion of energy reserves during hatching.

The accuracy of transcranial Doppler in the diagnosis of stenosis or occlusion of the terminal internal carotid artery

BACKGROUND AND PURPOSE

Transcranial Doppler (TCD) can detect intracranial stenoses and occlusions that can help in the diagnosis and management of ischemic stroke. The accuracy parameters for lesions located in the terminal internal carotid artery (TICA) are less known, unlike other basal cerebral vessels.

PATIENTS AND METHODS

The authors studied consecutive patients referred for TCD who underwent contrast angiography or magnetic resonance angiography. They calculated the sensitivity, specificity, positive and negative predictive values (PPV and NPV), and likelihood ratios.

RESULTS

Forty-three patients had TCD and angiography: mean age was 57 +/- 20 years, and 65% were men. Twenty-two patients were diagnosed with TICA stenosis or occlusion on TCD underwent angiography. Four patients had abnormal TCD findings that were not confirmed by angiography. Two of 21 patients with normal TCD showed moderate (< 50%) stenosis of the TICA and cavernous segment of the internal carotid artery at angiography. Accuracy parameters for TCD were as follows: sensitivity = 90% (confidence interval [CI], 63%-96%), specificity = 83% (CI, 61%-94%), PPV = 82%, NPV = 86%, positive likelihood ratio = 5, and negative likelihood ratio = 0.17.

CONCLUSIONS

TCD is a sensitive screening tool for the lesions in the TICA. Specificity is likely affected by a wide spectrum of the stenosis severity shown at angiography and time lags between the studies.

Characterization of enzootic foci of Venezuelan equine encephalitis virus in western Venezuela

The distribution of the sylvatic subtype ID Venezuelan equine encephalitis (VEE) viruses in the lowland tropical forests of western Venezuela was investigated using remote sensing and geographic information system technologies. Landsat 5 Thematic Mapper satellite imagery was used to study the reflectance patterns of VEE endemic foci and to identify other locations with similar reflectance patterns. Enzootic VEE virus variants isolated during this study are the closest genetic relatives of the epizootic viruses that emerged in western Venezuela during 1992-1993. VEE virus surveillance was conducted by exposing sentinel hamsters to mosquito bites and trapping wild vertebrates in seven forests identified and located by means of the satellite image. We isolated VEE viruses from 48 of a total of 1,363 sentinel hamsters in two of the forests on six occasions, in both dry and wet seasons. None of the 12 small vertebrates captured in 8,190 trap-nights showed signs of previous VEE virus infection. The satellite image was classified into 13 validated classes of land use/vegetation using unsupervised and supervised techniques. Data derived from the image consisted of the raw digital values of near- and mid-infrared bands 4, 5, and 7, derived Tasseled Cap indices of wetness, greenness, and brightness, and the Normalized Difference Vegetation Index. Digitized maps provided ancillary data of elevation and soil geomorphology. Image enhancement was applied using Principal Component Analysis. A digital layer of roads together with georeferenced images was used to locate the study sites. A cluster analysis using the above data revealed two main groups of dense forests separated by spectral properties, altitude, and soil geomorphology. Virus was isolated more frequently from the forest type identified on flat flood plains of main rivers rather than the forest type found on the rolling hills of the study area. The spatial analysis suggests that mosquitoes carrying the enzootic viruses would reach 82-97% of the total land area by flying only 1-3 km from forests. We hypothesize that humans within that area are at risk of severe disease caused by enzootic ID VEE viruses. By contrast, equines could actually become naturally vaccinated, thus preventing the local emergence of epizootic IC VEE virus strains and protecting humans indirectly.

Comparison of PCR mediated amplification of DNA and the classical methods for detection of Mycobacterium leprae in different types of clinical samples in leprosy patients and contacts

Traditional staining and microscopic examination techniques for the detection of Mycobacterium leprae, DNA amplification by polymerase chain reaction (PCR) of a 531-bp fragment of the M. leprae specific gene encoding the 36-kDa antigen, and serodiagnosis with M. leprae specific antigens (PGL-1 and D-BSA) were compared on different clinical specimens (serum samples, slit-skin smears, biopsies and swabs) from 60 leprosy patients attending the Sanatorium of Fontilles. Patients were divided into groups; (i) 20 multibacillary patients (MB) with positive bacteriological index (BI) by conventional methods and on WHO multidrug therapy (MDT); (ii) 30 MB patients with negative BI and completed minimum 2 years treatment MDT; (iii) 10 paucibacillary (PB) patients who had completed 6 months MDT at least 8 years ago. Control groups included four non-leprosy patients for PCR methods and 40 health control patients and 10 tuberculosis patients for serological methods. In the multibacillary BI positive group, there was a good correlation between all methods. All tests were negative in the paucibacillary group, although only a few patients were tested and all had been treated many years ago. One must be cautious concerning the diagnostic potential of these techniques in this type of leprosy. We also studied different combinations of leprosy diagnosis methods to determine the potential risk in a leprosy contact individuals group. The prevalence of antibodies to M. leprae antigens in serum was measured, together with the presence of M. leprae DNA in the nose and lepromin status in a group of 43 contacts of leprosy patients (12 household and 31 occupational) to evaluate the maintenance of infection reservoirs and transmission of the disease. Only two individuals were found to form a potential high risk group.

Characterisation of cholinesterases and evaluation of the inhibitory potential of chlorpyrifos and dichlorvos to Artemia salina and Artemia parthenogenetica

In this study, the acute toxicity of the organophosphorous pesticides dichlorvos and chlorpyrifos to two different species of Artemia (A. salina and A. parthenogenetica) was evaluated. In addition, the in vivo effect of these two pesticides on cholinesterase (ChE) activity of both A. salina and A. parthenogenetica was also determined. The characterisation of the ChE, using different substrates and specific inhibitors, and the normal range of activity in non-exposed individuals were previously investigated for both species. The results obtained indicate that the ChE of A. salina is different from that of A. parthenogenetica and that both enzymes cannot be classified neither as acetylcholinesterase nor as butyrylcholinesterase since they show intermediary characteristics between the two vertebrate forms. The range of normal ChE activity was 2.65+/-0.15 U/mg protein for A. salina, and 3.69+/-0.17 U/mg protein for A. parthenogenetica. Significant in vivo effects of both pesticides on Artemia ChE activity were found, at concentrations between 5.38 and 9.30 mg/l for dichlorvos and between 1.85 and 3.19 mg/l for chlorpyrifos. Both Artemia species are resistant to these pesticides and they are able to survive with more than 80% ChE inhibition. However, A. parthenogenetica is more resistant than A. salina, with about a 95% reduction in its ChE activity respect to the control for nauplii exposed to the median lethal concentrations (LC50), without lethal effects after 24 h of exposure.

Bioaccumulation of chlorpyrifos through an experimental food chain: study of protein HSP70 as biomarker of sublethal stress in fish

The accumulation and transfer of the organophosphorus pesticide chlorpyrifos has been studied in an experimental aquatic two-level food chain using two species of the crustacean Artemia (A. franciscana and A. parthenogenetica) and the small fish Aphanius iberus. Artemia adults contaminated by exposure to the pesticide in water were used as live prey for Aphanius, the next trophic level. During the experimental bioaccumulation phase, fish were fed chlorpyrifos-contaminated Artemia pools with concentrations between 6.5 and 14.5 ng/g fresh weight for 32 days. Both concentrations accumulated in fish, and biomagnification factor (BMF) values showed a continuous decrease during the bioaccumulation phase, probably due to the physicochemical characteristics of the organophosphorus pesticide, to the biotransformation ability of fish and to the progressive adaptation of fish metabolism to toxic exposure. The first day that fish were fed uncontaminated preys, the pesticide accumulated via food was rapidly eliminated and was not detected. The effect of chlorpyrifos exposure through the food chain on stress protein (HSP70) synthesis was measured as a general biochemical response of stress in the fish (A. iberus). The levels of HSP70 were significantly higher in fish fed on contaminated Artemia than in the control fish fed on uncontaminated Artemia. Results showed that the HSP70 induction in fish could be associated to exposure of chlorpyrifos via food.

Genetic diversity and relationships among Venezuelan equine encephalitis virus field isolates from Colombia and Venezuela

During field studies of enzootic Venezuelan equine encephalitis (VEE) viruses associated with epizootic emergence, a large number of virus isolates were made in sylvatic foci of Venezuela and Colombia. To rapidly characterize these isolates, antigenic subtypes were determined by means of immunofluorescence and by single-strand conformational polymorphism (SSCP) analysis by use of an 856-bp fragment from the P62 gene, which we used to distinguish genetic variants. Representative isolates were sequenced to assess the sensitivity of SSCP to detect genetic differences. The SSCP analysis distinguished isolates differing by as little as 1 nucleotide; overall, differences of > or = 1 nucleotide were recognized 89% of the time, and the sensitivity to distinguish strains that differed by only 1 or 4 nucleotides was 17 and 57%, respectively. Phylogenetic analyses of representative sequences showed that all recent isolates from the Catatumbo region of western Venezuela and the middle Magdalena Valley of Colombia were closely related to epizootic subtype IAB and IC strains; strains from Yaracuy and Miranda States were more distantly related. Cocirculation of the same virus genotype in both Colombian and Venezuelan foci indicated that these viruses are readily transported between enzootic regions separated by > 300 km. The SSCP analysis appears to be a simple, fast, and relatively efficient method of screening VEE virus isolates to identify meaningful genetic variants.

Spatial dispersion of adult mosquitoes (Diptera: Culicidae) in a sylvatic focus of Venezuelan equine encephalitis virus

We studied the spatial localization of mosquitoes in sylvatic focus of Venezuelan equine encephalitis virus in western Venezuela to identify mosquito species potentially involved in the hypothesized transport of viruses out of enzootic foci. The following criteria were used to identify species with potential for virus export: (1) common in the forest and surrounding area, (2) feeding on a wide range of vertebrates; (3) long dispersal capabilities, and (4) established vectorial competence for enzootic or epizootic VEE viruses. CDC traps baited with light/CO2 were operated for four and 12-h intervals to collect mosquitoes at four stations along two forest/open area transects from September to November 1997. We collected 60,444 mosquitoes belonging to 11 genera and 34 species. The most common species were Aedes serratus (Theobald), Ae. scapularis (Rondani), Ae. fulvus (Wiedmann), Culex nigripalus Theobald, Cx, (Culex) "sp", Cx. mollis Dyar & Knab, Cx. spissipes (Theobald), Cx. pedroi Sirivanakarn and Belkin, Psorophora ferox (Humboldt), Ps. albipes (Theobald), and Ps. cingulata (F.). Very few mosquitoes were captured during the (day in the open area outside the forest, suggesting that any virus export from the forest may occur at night. The following mosquitoes seemed to be mostly restricted to the forest habitat: Ae. serratus, Ps. ferox, Ps. albipes, sabethines, Cx. spissipes, Cx. pedroi, Cx. dunni Dyar, and Ae. fulvus. The main species implicated its potential virus export were Cx. nigripalpus, Ae. scapularis, and Mansonia titillans (Walker).