Allopurinol and blood pressure variability following ischemic stroke and transient ischemic attack: a secondary analysis of XILO-FIST

Blood Pressure Variability (BPV) is associated with cardiovascular risk and serum uric acid level. We investigated whether BPV was lowered by allopurinol and whether it was related to neuroimaging markers of cerebral small vessel disease (CSVD) and cognition. We used data from a randomised, double-blind, placebo-controlled trial of two years allopurinol treatment after recent ischemic stroke or transient ischemic attack. Visit-to-visit BPV was assessed using brachial blood pressure (BP) recordings. Short-term BPV was assessed using ambulatory BP monitoring (ABPM) performed at 4 weeks and 2 years. Brain MRI was performed at baseline and 2 years. BPV measures were compared between the allopurinol and placebo groups, and with CSVD and cognition. 409 participants (205 allopurinol; 204 placebo) were included in the visit-to-visit BPV analyses. There were no significant differences found between placebo and allopurinol groups for any measure of visit-to-visit BPV. 196 participants were included in analyses of short-term BPV at week 4. Two measures were reduced by allopurinol: the standard deviation (SD) of systolic BP (by 1.30 mmHg (95% confidence interval (CI) 0.18-2.42, p = 0.023)); and the average real variability (ARV) of systolic BP (by 1.31 mmHg (95% CI 0.31-2.32, p = 0.011)). There were no differences in other measures at week 4 or in any measure at 2 years, and BPV was not associated with CSVD or cognition. Allopurinol treatment did not affect visit-to-visit BPV in people with recent ischemic stroke or TIA. Two BPV measures were reduced at week 4 by allopurinol but not at 2 years.

Prehospital transdermal glyceryl trinitrate for ultra-acute ischaemic stroke: data from the RIGHT-2 randomised sham-controlled ambulance trial

BACKGROUND

The effect of transdermal glyceryl trinitrate (GTN, a nitrovasodilator) on clinical outcome when administered before hospital admission in suspected stroke patients is unclear. Here, we assess the safety and efficacy of GTN in the prespecified subgroup of patients who had an ischaemic stroke within the Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2).

METHODS

RIGHT-2 was an ambulance-based multicentre sham-controlled blinded-endpoint study with patients randomised within 4 hours of onset. The primary outcome was a shift in scores on the modified Rankin scale (mRS) at day 90. Secondary outcomes included death; a global analysis (Wei-Lachin test) containing Barthel Index, EuroQol-5D, mRS, telephone interview for cognitive status-modified and Zung depression scale; and neuroimaging-determined 'brain frailty' markers. Data were reported as n (%), mean (SD), median [IQR], adjusted common OR (acOR), mean difference or Mann-Whitney difference (MWD) with 95% CI.

RESULTS

597 of 1149 (52%) patients had a final diagnosis of ischaemic stroke; age 75 (12) years, premorbid mRS>2 107 (18%), Glasgow Coma Scale 14 (2) and time from onset to randomisation 67 [45, 108] min. Neuroimaging 'brain frailty' was common: median score 2 [2, 3] (range 0-3). At day 90, GTN did not influence the primary outcome (acOR for increased disability 1.15, 95% CI 0.85 to 1.54), death or global analysis (MWD 0.00, 95% CI -0.10 to 0.09). In subgroup analyses, there were non-significant interactions suggesting GTN may be associated with more death and dependency in participants randomised within 1 hour of symptom onset and in those with more severe stroke.

CONCLUSIONS

In patients who had an ischaemic stroke, ultra-acute administration of transdermal GTN in the ambulance did not improve clinical outcomes in a population with more clinical and radiological frailty than seen in previous in-hospital trials.

Prehospital transdermal glyceryl trinitrate in patients with ultra-acute presumed stroke (RIGHT-2): effects on outcomes at day 365 in a randomised, sham-controlled, blinded, phase III, superiority ambulance-based trial

Background

The Rapid Intervention with Glyceryl Trinitrate in Hypertensive Stroke Trial-2 (RIGHT-2) reported no overall treatment difference between glyceryl trinitrate (GTN) and sham at day 90. Here we assess participants' outcomes 1 year after randomisation.

Methods

RIGHT-2 was an ambulance-based prospective randomised controlled trial where patients with presumed stroke and systolic blood pressure (BP) of >120 mm Hg received either GTN (5 mg/day) or sham patch. Centralised blinded telephone follow-up was performed at days 90 (primary endpoint) and 365 (secondary endpoint). The lead outcome was dependency assessed with the modified Rankin Scale (mRS).

Results

1149 patients were recruited to RIGHT-2 between October 2015 and May 2018, and 1097 (95.5%) had outcome data recorded at day 365. At baseline, the patients were; female (48%), had a mean age of 73 (15) years, BP of 162 (25)/92 (18) mm Hg, onset to randomisation of 70 (45-115) min, diagnosis of ischaemic stroke (52%), intracerebral haemorrhage (ICH) (13%), transient ischaemic attack (TIA) (9%) and mimics (26%). There was no effect of GTN on mRS score at day 365 in participants with confirmed stroke/TIA (adjusted common odds ratio (acOR) 1.10, 95% CI 0.86 to 1.42) or in all patients. In patients randomised to GTN, mRS at day 365 tended to be worse in those with ICH (acOR 1.65, 95% CI 0.84 to 3.25) and better in those with a mimic diagnosis (acOR 0.53, 95% CI 0.33 to 0.84).

Conclusion

At 1 year post randomisation, dependency did not differ between GTN and sham treatment in either the target population or overall. In prespecified subgroup analyses, GTN was associated with reduced dependency in participants with a final diagnosis of mimic and a non-significant worse outcome in participants with ICH.

Trial registration number

ISRCTN26986053.

Xanthine oxidase inhibition and white matter hyperintensity progression following ischaemic stroke and transient ischaemic attack (XILO-FIST): a multicentre, double-blinded, randomised, placebo-controlled trial

BACKGROUND

People who experience an ischaemic stroke are at risk of recurrent vascular events, progression of cerebrovascular disease, and cognitive decline. We assessed whether allopurinol, a xanthine oxidase inhibitor, reduced white matter hyperintensity (WMH) progression and blood pressure (BP) following ischaemic stroke or transient ischaemic attack (TIA).

METHODS

In this multicentre, prospective, randomised, double-blinded, placebo-controlled trial conducted in 22 stroke units in the United Kingdom, we randomly assigned participants within 30-days of ischaemic stroke or TIA to receive oral allopurinol 300 mg twice daily or placebo for 104 weeks. All participants had brain MRI performed at baseline and week 104 and ambulatory blood pressure monitoring at baseline, week 4 and week 104. The primary outcome was the WMH Rotterdam Progression Score (RPS) at week 104. Analyses were by intention to treat. Participants who received at least one dose of allopurinol or placebo were included in the safety analysis. This trial is registered with ClinicalTrials.gov, NCT02122718.

FINDINGS

Between 25th May 2015 and the 29th November 2018, 464 participants were enrolled (232 per group). A total of 372 (189 with placebo and 183 with allopurinol) attended for week 104 MRI and were included in analysis of the primary outcome. The RPS at week 104 was 1.3 (SD 1.8) with allopurinol and 1.5 (SD 1.9) with placebo (between group difference -0.17, 95% CI -0.52 to 0.17, p = 0.33). Serious adverse events were reported in 73 (32%) participants with allopurinol and in 64 (28%) with placebo. There was one potentially treatment related death in the allopurinol group.

INTERPRETATION

Allopurinol use did not reduce WMH progression in people with recent ischaemic stroke or TIA and is unlikely to reduce the risk of stroke in unselected people.

FUNDING

The British Heart Foundation and the UK Stroke Association.

Lemierre's syndrome

Lemierre's syndrome is a rare and potentially life-threatening condition that follows an oropharyngeal infection, typically from Fusobacterium necrophorum, and usually affects healthy adolescents or young adults. The characteristic features are septic thrombophlebitis of the internal jugular vein and septic embolism leading to multiorgan involvement, commonly the brain, lungs and bones. We report a man with presenting symptoms suggesting hemicrania continua, whose initial imaging showed no features of dural venous sinus or jugular thrombosis. Two weeks later, he had fever, sore throat, cervical lymphadenopathy and Actinomyces meyeri grew from peripheral blood cultures. Further imaging identified thrombosis of the internal jugular vein and cerebral venous sinuses, with multifocal cavitating lung lesions. Following antibiotics and anticoagulation, he recovered without residual deficits. Lemierre's syndrome when recognised and treated early has a good prognosis but delayed treatment may result in significant morbidity or mortality.

Peripheral nerve blocks for headache disorders

Headache is a common neurological referral and a frequent cause for acute hospital admissions. Despite peripheral nerve blocks being widely used in headache and pain services to treat patients with headache disorders, there is no readily accessible resource with instructions for the delivery of peripheral nerve blocks. Here we provide a practical approach for administering peripheral nerve blocks and cover the current evidence base for such procedures in different headache disorders. We provide instructions and an audiovisual guide for administering greater and lesser occipital, supratrochlear, supraorbital and auriculotemporal nerves blocks, and give information on their adverse effects and potential complications. This information will provide a reference for headache practitioners when giving peripheral nerve blocks safely to people with headache.

Prehospital Transdermal Glyceryl Trinitrate for Ultra-Acute Intracerebral Hemorrhage: Data From the RIGHT-2 Trial

Supplemental Digital Content is available in the text.

Pilot trials suggest that glyceryl trinitrate (GTN; nitroglycerin) may improve outcome when administered early after stroke onset.

Chronic Sound-induced Tinnitus and Auditory Attention in Animals

Attention may be an important factor in tinnitus. Individuals most disturbed by their tinnitus differ from those who are not in terms of attention allocation. This study used an operant-conditioning animal model to examine the interaction between tinnitus and auditory vigilant attention as well as auditory selective attention. Tinnitus was induced in 90-day-old rats by a unilateral exposure to band-limited noise (120 dB, SPL). Tinnitus testing began 90 days following exposure; afterward animals were divided into three groups: Unexposed controls without tinnitus, Exposed without tinnitus, and Exposed with tinnitus. Tinnitus was evident in the vicinity of 20 kHz. Vigilant attention was quantified by the behavioral (operant) response to unpredictable sound transitions signaling changes in food availability. Tinnitus animals were more vigilant, i.e., responded more rapidly, to 20-kHz tone onsets than Unexposed or Exposed animals without tinnitus. There were no significant vigilant attention differences between groups to non-tinnitus like sounds. The same animals were further trained and tested on a selective attention task. A brief free-field sound cue, consisting of either a short train of identical noise pulses (standard stimulus), or a noise train with one substituted tone pulse (oddball stimulus), cued a left or right nose poke for food. On this selective attention task, Tinnitus animals performed consistently worse than Non-tinnitus or Unexposed control animals regardless of stimulus features. As predicted, animals with behavioral evidence of tinnitus showed tinnitus-related attentional changes, including impaired selective attention but increased vigilance to sounds approximating their tinnitus.

Triple versus guideline antiplatelet therapy to prevent recurrence after acute ischaemic stroke or transient ischaemic attack: the TARDIS RCT

BACKGROUND

Two antiplatelet agents are better than one for preventing recurrent stroke after acute ischaemic stroke or transient ischaemic attack (TIA). Therefore, intensive treatment with three agents might be better still, providing it does not cause undue bleeding.

OBJECTIVE

To compare the safety and efficacy of intensive therapy with guideline antiplatelet therapy for acute ischaemic stroke and TIA.

DESIGN

International prospective randomised open-label blinded end-point parallel-group superiority clinical trial.

SETTING

Acute hospitals at 106 sites in four countries.

PARTICIPANTS

Patients > 50 years of age with acute non-cardioembolic ischaemic stroke or TIA within 48 hours of ictus (stroke).

INTERVENTIONS

Participants were allocated at random by computer to 1 month of intensive (combined aspirin, clopidogrel and dipyridamole) or guideline (combined aspirin and dipyridamole, or clopidogrel alone) antiplatelet agents, and followed for 90 days.

MAIN OUTCOME MEASURES

The primary outcome was the incidence and severity of any recurrent stroke (ischaemic, haemorrhagic; assessed using the modified Rankin Scale) or TIA within 90 days by blinded telephone follow-up. Analysis using ordinal logistic regression was by intention to treat. Other outcomes included bleeding and its severity, death, myocardial infarction (MI), disability, mood, cognition and quality of life.

RESULTS

The trial was stopped early on the recommendation of the Data Monitoring Committee after recruitment of 3096 participants (intensive, n = 1556; guideline, n = 1540) from 106 hospitals in four countries between April 2009 and March 2016. The incidence and severity of recurrent stroke or TIA did not differ between intensive and guideline therapy in 3070 (99.2%) participants with data [93 vs. 105 stroke/TIA events; adjusted common odds ratio 0.90, 95% confidence interval (CI) 0.67 to 1.20; p = 0.47]. Major (encompassing fatal) bleeding was increased with intensive as compared with guideline therapy [39 vs. 17 participants; adjusted hazard ratio (aHR) 2.23, 95% CI 1.25 to 3.96; p = 0.006]. There were no differences between the treatment groups in all-cause mortality, or the composite of death, stroke, MI and major bleeding (aHR 1.02, 95% CI 0.77 to 1.35; p = 0.88).

LIMITATIONS

Patients and investigators were not blinded to treatment. The comparator group comprised two guideline strategies because of changes in national guidelines during the trial. The trial was stopped early, thereby reducing its statistical power.

CONCLUSIONS

The use of three antiplatelet agents is associated with increased bleeding without any significant reduction in recurrence of stroke or TIA.

FUTURE WORK

The safety and efficacy of dual antiplatelet therapy (combined aspirin and clopidogrel) versus aspirin remains to be defined. Further research is required on identifying individual patient response to antiplatelets, and the relationship between response and the subsequent risks of vascular recurrent events and bleeding complications.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN47823388.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 48. See the NIHR Journal Library website for further project information. The Triple Antiplatelets for Reducing Dependency after Ischaemic Stroke (TARDIS) vanguard phase was funded by the British Heart Foundation (grant PG/08/083/25779, from 1 April 2009 to 30 September 2012) and indirect funding was provided by the Stroke Association through its funding of the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK. There was no commercial support for the trial and antiplatelet drugs were sourced locally at each site. The trial was sponsored by the University of Nottingham.

Effects of fluoxetine on functional outcomes after acute stroke (FOCUS): a pragmatic, double-blind, randomised, controlled trial

BACKGROUND

Results of small trials indicate that fluoxetine might improve functional outcomes after stroke. The FOCUS trial aimed to provide a precise estimate of these effects.

METHODS

FOCUS was a pragmatic, multicentre, parallel group, double-blind, randomised, placebo-controlled trial done at 103 hospitals in the UK. Patients were eligible if they were aged 18 years or older, had a clinical stroke diagnosis, were enrolled and randomly assigned between 2 days and 15 days after onset, and had focal neurological deficits. Patients were randomly allocated fluoxetine 20 mg or matching placebo orally once daily for 6 months via a web-based system by use of a minimisation algorithm. The primary outcome was functional status, measured with the modified Rankin Scale (mRS), at 6 months. Patients, carers, health-care staff, and the trial team were masked to treatment allocation. Functional status was assessed at 6 months and 12 months after randomisation. Patients were analysed according to their treatment allocation. This trial is registered with the ISRCTN registry, number ISRCTN83290762.

FINDINGS

Between Sept 10, 2012, and March 31, 2017, 3127 patients were recruited. 1564 patients were allocated fluoxetine and 1563 allocated placebo. mRS data at 6 months were available for 1553 (99·3%) patients in each treatment group. The distribution across mRS categories at 6 months was similar in the fluoxetine and placebo groups (common odds ratio adjusted for minimisation variables 0·951 [95% CI 0·839-1·079]; p=0·439). Patients allocated fluoxetine were less likely than those allocated placebo to develop new depression by 6 months (210 [13·43%] patients vs 269 [17·21%]; difference 3·78% [95% CI 1·26-6·30]; p=0·0033), but they had more bone fractures (45 [2·88%] vs 23 [1·47%]; difference 1·41% [95% CI 0·38-2·43]; p=0·0070). There were no significant differences in any other event at 6 or 12 months.

INTERPRETATION

Fluoxetine 20 mg given daily for 6 months after acute stroke does not seem to improve functional outcomes. Although the treatment reduced the occurrence of depression, it increased the frequency of bone fractures. These results do not support the routine use of fluoxetine either for the prevention of post-stroke depression or to promote recovery of function.

FUNDING

UK Stroke Association and NIHR Health Technology Assessment Programme.

Antiplatelet therapy with aspirin, clopidogrel, and dipyridamole versus clopidogrel alone or aspirin and dipyridamole in patients with acute cerebral ischaemia (TARDIS): a randomised, open-label, phase 3 superiority trial

BACKGROUND

Intensive antiplatelet therapy with three agents might be more effective than guideline treatment for preventing recurrent events in patients with acute cerebral ischaemia. We aimed to compare the safety and efficacy of intensive antiplatelet therapy (combined aspirin, clopidogrel, and dipyridamole) with that of guideline-based antiplatelet therapy.

METHODS

We did an international, prospective, randomised, open-label, blinded-endpoint trial in adult participants with ischaemic stroke or transient ischaemic attack (TIA) within 48 h of onset. Participants were assigned in a 1:1 ratio using computer randomisation to receive loading doses and then 30 days of intensive antiplatelet therapy (combined aspirin 75 mg, clopidogrel 75 mg, and dipyridamole 200 mg twice daily) or guideline-based therapy (comprising either clopidogrel alone or combined aspirin and dipyridamole). Randomisation was stratified by country and index event, and minimised with prognostic baseline factors, medication use, time to randomisation, stroke-related factors, and thrombolysis. The ordinal primary outcome was the combined incidence and severity of any recurrent stroke (ischaemic or haemorrhagic; assessed using the modified Rankin Scale) or TIA within 90 days, as assessed by central telephone follow-up with masking to treatment assignment, and analysed by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN47823388.

FINDINGS

3096 participants (1556 in the intensive antiplatelet therapy group, 1540 in the guideline antiplatelet therapy group) were recruited from 106 hospitals in four countries between April 7, 2009, and March 18, 2016. The trial was stopped early on the recommendation of the data monitoring committee. The incidence and severity of recurrent stroke or TIA did not differ between intensive and guideline therapy (93 [6%] participants vs 105 [7%]; adjusted common odds ratio [cOR] 0·90, 95% CI 0·67-1·20, p=0·47). By contrast, intensive antiplatelet therapy was associated with more, and more severe, bleeding (adjusted cOR 2·54, 95% CI 2·05-3·16, p<0·0001).

INTERPRETATION

Among patients with recent cerebral ischaemia, intensive antiplatelet therapy did not reduce the incidence and severity of recurrent stroke or TIA, but did significantly increase the risk of major bleeding. Triple antiplatelet therapy should not be used in routine clinical practice.

FUNDING

National Institutes of Health Research Health Technology Assessment Programme, British Heart Foundation.

Solving multi-objective water management problems using evolutionary computation

Water as a resource is becoming increasingly more valuable given the changes in global climate. In an agricultural sense, the role of water is vital to ensuring food security. Therefore the management of it has become a subject of increasing attention and the development of effective tools to support participative decision-making in water management will be a valuable contribution. In this paper, evolutionary computation techniques and Pareto optimisation are incorporated in a model-based system for water management. An illustrative test case modelling optimal crop selection across dry, average and wet years based on data from the Murrumbidgee Irrigation Area in Australia is presented. It is shown that sets of trade-off solutions that provide large net revenues, or minimise environmental flow deficits can be produced rapidly, easily and automatically. The system is capable of providing detailed information on optimal solutions to achieve desired outcomes, responding to a variety of factors including climate conditions and economics.

Stroke Severity Is a Crucial Predictor of Outcome: An International Prospective Validation Study

Background

Stroke is among the leading causes of morbidity and mortality worldwide. Without reliable prediction models and outcome measurements, comparison of care systems is impossible. We analyzed prospectively collected data from 4 countries to explore the importance of stroke severity in outcome prediction.

Methods and Results

For 2 months, all acute ischemic stroke patients from the hospitals participating in the Global Comparators Stroke GOAL (Global Outcomes Accelerated Learning) collaboration received a National Institutes of Health Stroke Scale (NIHSS) score on admission and a modified Rankin Scale score at 30 and 90 days. These data were added to the administrative data set, and risk prediction models including age, sex, comorbidity index, and NIHSS were derived for in‐hospital death within 7 days, all in‐hospital death, and death and good outcome at 30 and 90 days. The relative importance of each variable was assessed using the proportion of explained variation. Of 1034 admissions for acute ischemic stroke, 614 had a full set of NIHSS and both modified Rankin Scale values recorded; of these, 507 patients could be linked to administrative data. The marginal proportion of explained variation was 0.7% to 4.0% for comorbidity index, and 11.3 to 25.0 for NIHSS score. The percentage explained by the model varied by outcome (16.6–29.1%) and was highest for good outcome at 30 and 90 days. There was high agreement between 30‐ and 90‐day modified Rankin Scale scores (weighted κ=0.82).

Conclusions

In this prospective pilot study, the baseline NIHSS score was essential for prediction of acute ischemic stroke outcomes, followed by age; whereas traditional comorbidity index contributed little to the overall model. Future studies of stroke outcomes between different care systems will benefit from including a baseline NIHSS score.

Abstract W MP99: Seven-Day Mortality After Ischemic Stroke: International Comparison Among Industrialized Nations

Introduction: Stroke is the 2 nd leading cause of death worldwide, yet best practices for acute stroke care are lacking even among premier hospitals in industrialized countries. We compared 7-day mortality after ischemic stroke between academic medical centers in the Netherlands (NL), United Kingdom (UK), and United States (US).

Methods: This was an observational study using in-hospital administrative data from select academic medical centers in the NL (n=8), UK (n=10), and US (n=11) from 2005-12. Chi-square was used to compare 7-day in-hospital mortality between countries and across years, and to explore the effect of weekend admission. Multiple logistic regression was conducted to further examine factors associated with mortality, including sex, age, weekend admission, year, and country.

Results: From 2005-12, 51,409 patients were discharged with ischemic stroke from hospitals in the NL (n=6331), UK (n=25574), and US (n=19204). Mortality was significantly higher in the UK (8.1%) compared to the NL (6.4%) and US (4.8%) (p<0.0001). Moreover, mortality was higher in patients admitted on week-ends compared to weekdays in the UK (9.2% vs. 7.7%, p=0.0001), but not in the NL (6.8% vs. 6.3%, p=0.44) or US (4.8% vs. 4.9%, p=0.73). This “week-end effect” was consistent throughout all hospitals in the UK (p=0.0002) but much more variable in hospitals in the other two countries. In the UK, 7-day mortality improved with time, declining from 10.7% in 2006 to 6.3% in 2012 (p<0.0001). A decline in mortality was also seen in the NL (p=0.03), but remained unchanged in the US (p=0.72). The UK “weekend effect” also disappeared with time. Multiple logistic regression demonstrated that country and weekend admission remained a significant risk factor associated with mortality after controlling for age, gender, and year.

Conclusions: A comparison of 7-day mortality among academic medical centers in industrialized counties reveals stark variability. Although 2006 stroke mortality in UK hospitals was almost double that of US hospitals, dramatic reductions were subsequently seen. Further analysis of national policy or practice changes that have driven these improvements promise to be revealing.

Cognitive screening in the acute stroke setting

BACKGROUND

current literature suggests that two-thirds of patients will have cognitive impairment at 3 months post-stroke. Post-stroke cognitive impairment is associated with impaired function and increased mortality. UK guidelines recommend all patients with stroke have a cognitive assessment within 6 weeks. There is no 'gold standard' cognitive screening tool. The Montreal cognitive assessment (MoCA) is more sensitive than the Mini-Mental State Examination (MMSE) in mild cognitive impairment and for cognitive impairment in the non-acute post-stroke setting and in a Chinese-speaking acute stroke setting.

METHODS

a convenience sample of 50 patients, admitted with stroke or transient ischaemic attack (TIA), were screened within 14 days, using the MoCA and the MMSE.

RESULTS

the mean MoCA was 21.80 versus a mean MMSE of 26.98; 70% were impaired on the MoCA (cut-off <26) versus 26% on MMSE (cut-off <27). The MoCA could be completed in <10 min in 90% of cases.

CONCLUSION

the MoCA is easy and quick to use in the acute stroke setting. Further work is required to determine whether a low score on the MoCA in the acute stroke setting will predict the cognitive and functional status and to explore what the best cut-off should be in an acute post-stroke setting.

SU-E-T-462: Calculation of Prescribed Dose for Permanent Implant with Cs-131 Using LQ Equation including Resensitization

PURPOSE

To develop a new biological equivalent dose (BED) formulism that includes repair, repopulation and resensitization (redistribution and reoxygenation), and can be used to calculate prescribed dose for permanent implant with Cs-131.

METHODS

Because of lack of sufficient clinical data, the prescribed dose with new isotopes is usually calculated based on BED compared with other isotopes that have already been used in clinical practice. The current widely used formulism of BED calculation for permanent implant which was given by Dale includes cell repair and repopulation but not resensitization. Resensitization can be included in the extended LQ equation (LQR) proposed by Brenner. Applying Dales formulism to Brenners LQR, we obtained a new BED calculation formula that accounts for resensitization. We used this new formulism to calculate the BED that corresponds to the prescribed dose for cervix (with Au-198) and prostate (with I-125) permanent implant. Then, we obtained the prescribed dose with Cs-131 which has the same BED as Au-198 or I-125.

RESULTS

The new formulism was used for prostate and cervix cancer permanent implant. The prescribed dose with Cs-131 for cervix was 40 Gy (42 Gy without resensitization) and 66 Gy (69 Gy without resensitization) which were equivalent to 35 Gy and 60 Gy with Au-198, respectively. For prostate implant, the prescribed dose with Cs-131 that corresponded to 144 Gy with I-125 was 135 Gy (124 Gy without resensitization).

CONCLUSION

Resensitization led to significant dose correction for permanent implant. The calculation of BED and dose was dependent on dose itself and thus should be patient-specific. Since this calculation relied on many biological parameters, and may not be accurate if the parameters are not accurate. Also, the dose prescription should be adjusted based on clinical outcomes.

Stretch syncope: reflex vasodepressor faints easily mistaken for epilepsy

The pathophysiology of stretch syncope is demonstrated through the clinical, electrophysiological, and hemodynamic findings in three patients. Fifty-seven attacks were captured by video/EEG monitoring. Simultaneous EEG, transcranial (middle cerebral artery) doppler, and continuous arterial pressure measurements were obtained for at least one typical attack of each patient. They all experienced a compulsion to precipitate their attacks. Episodes started with a stereotyped phase of stretching associated with neck torsion and breath holding, followed by a variable degree of loss of consciousness and asymmetric, recurrent facial and upper limb jerks in the more prolonged episodes. Significant sinus tachycardia coincided with the phase of stretching and was followed within 9-16 seconds by rhythmic generalized slow wave abnormalities on the EEG in attacks with impairment of consciousness. Transcranial doppler studies showed a dramatic drop in cerebral perfusion in the middle cerebral arteries during the episodes. The combination of the stereotyped semiology of the attacks, the pseudofocal myoclonic jerking, and the rhythmic generalized slow wave EEG abnormalities with the tachycardia make differential diagnosis from epilepsy challenging.

No cookie-cutter oncology: individualized treatment approaches for women with corpus endometrial cancer

Endometrial adenocarcinoma is the most common gynecologic malignancy and, for the majority of patients who present with stage I (approximately 70%) or stage II ( approximately 10%) disease, 5-year overall survival rates approach 85%. However, the complicated mix of medical comorbidities, the broad spectrum of techniques and treatment modalities and controversial clinical trial outcomes makes treating this heterogeneous group of patients unique and challenging. Similar management controversies exist and, when one factors in histologic variability, no flow-chart treatment algorithm can be easily constructed. This article will discuss data from key clinical trials, consider the role of routine lymphadenectomy as a component of surgical staging, discuss the heterogeneity of stage III patients in both presentation and response to treatment, review options for medically inoperable patients and reflect on current and upcoming protocols.

Changes in shape, ossification and quality of bones in children with spina bifida

Changes in the cross-sectional shape, size, bone mass and amount of unmineralised osteoid tissue were studied in 17 dissected tibiae from spina-bifida babies who died with paralysis and foot deformities and in 14 tibiae from non-spina bifida controls of matching age. In addition, 12 tibiae from young experimental rats with myotomy of foot dorsiflexors and foot plantiflexors were double-labelled with bone-seeking markers and studied in order to find the role of experimental muscle imbalance in the dynamic remodelling of the developing long bones. It was found that in tibiae from spina-bifida children with paralysis the total area of cortical bone, its thickness, number of Haversian systems and number of large remodelling cavities are diminished. Significant changes in the cross-sectional shape of the midshaft of the tibia were found, ranging from the triangular shape seen in normal babies and in those with spina bifida and calcaneus-type foot deformity, to the circular shape of tibiae from babies with spina-bifida paralysis and no foot deformity or with spina bifida and equinovarus-type of deformity. Results of experimental myotomy on growing rats showed the direct influence of working muscles on the remodelling process of growing tibiae. On the side of myotomy the flat cortex resumed a bulging convex shape and the centre of gravity shifted towards the myotomised side. These principles cannot on their own explain the specific changes in the shape of human tibiae found during anatomical studies. There is, however, a common denominator in these apparently contradictory findings. This is the combined action of two factors previously reported: the combination of paralysis of the growing limb and mechanical intra-uterine pressure acting on it. The findings in the present study also indicate that they played a major role in the production of deformities. The total amount of osteoid tissue in spina-bifida paralysed bone is increased. This delay of mineralisation of newly laid-down bone matrix would lead to softening of the new bone matrix and osteoid-rich subepiphyseal and metaphyseal regions. This 'paralytic rickets', together with the diminished total bone mass found, could probably be the cause of the common spina-bifida fractures in these regions.

Hypoxanthine-guanine phosphoribosyltransferase deficiency: biochemical and molecular findings in six Argentine patients

Hypoxanthine-guanine phosphoribosyltransferase (HPRT) deficiency is an inborn error of purine metabolism responsible for Lesch-Nyhan Disease (LND) and its partial phenotypes, HPRT-related hyperuricemia with neurologic dysfunction (HRND) and hyperuricemia alone. We report here the recognition of six Argentine patients, two with LND and four with HRND. All patients presented elevated excretion of uric acid, hypoxanthine, and xanthine and decreased HPRT enzyme activities <1 nmol/h/mg Hb. The molecular analysis demonstrated in the two LND patients a novel inherited transition mutation, c.203T >C (L68P), in one subject and a germline transition mutation, c.209G >A (G70E), in the other. In the HRND patients a novel transversion mutation, c.584 A >C (Y195S), was found in three related patients and an inherited transition mutation, c.143G >A (R48H), in the fourth subject.

Safety of Arch Aortography for Assessment of Carotid Arteries

PURPOSE

To retrospectively review the safety of arch aortography and compare complication rates with published figures for selective catheter angiography.

METHODS

The medical records of patients undergoing arch aortography over the last 3 years (n=311; 180 male, 131 female; mean+/-SD age 71.0+/-9.2 years, range 42-90 years) were retrospectively reviewed. Any peri-procedural (0-48 h) complications were recorded. A certified neurologist (MSR/GSV) classified all questionable neurological events.

RESULTS

There were no focal neurological events or deaths (n=0; 0%; CI: 0-0.96%). Non-focal neurological events included mild disorientation (n=2; 0.6%; CI: 0.176-2.31) and unequal pupils (n=1; 0.3%; CI: 0.056-1.79%). Cardiovascular events included symptomatic hypotension (n=4; 1.3%; CI: 0.50-3.25%), angina (n=1; 0.3%; CI: 0.056-1.79%) and arrhythmia (n=4; 1.3%; CI: 0.50-3.25). There were 27 minor access site complications (8.7%; CI: 6.0-12.3). None of these complications extended hospital stay. None of the arch angiograms had to be followed by selective carotid angiography.

CONCLUSION

Arch aortography appears to have a lower neurological complication rate than selective carotid angiography.

Contamination dose from photoneutron processes in bodily tissues during therapeutic radiation delivery

Dose to the total body from induced radiation resulting from primary exposure to radiotherapeutic beams is not detailed in routine treatment planning though this information is potentially important for better estimates of health risks including secondary cancers. This information can also allow better management of patient treatment logistics, suggesting better timing, sequencing, and conduct of treatment. Monte Carlo simulations capable of taking into account all interactions contributing to the dose to the total body, including neutron scattering and induced radioactivity, provide the most versatile and accurate tool for investigating these effects. MCNPX code version 2.2.6 with full IAEA library of photoneutron cross sections is particularly suited to trace not only photoneutrons but also protons and heavy ion particles that result from photoneutron interactions. Specifically, the MCNPX code is applied here to the problem of dose calculations in traditional (non-IMRT) photon beam therapy. Points of calculation are located in the head, where the primary irradiation has been directed, but also in the superior portion of the torso of the ORNL Mathematical Human Phantom. We calculated dose contributions from neutrons, protons, deutrons, tritons and He-3 that are produced at the time of photoneutron interactions in the body and that would not have been accounted for by conventional radiation oncology dosimetry.