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Caso V, Martins S, Mikulik R, Middleton S, Groppa S, Pandian JD, Thang NH, Danays T, van der Merwe J, Fischer T, Hacke W. Six years of the Angels Initiative: Aims, achievements, and future directions to improve stroke care worldwide. Int J Stroke 2023; 18:898-907. [PMID: 37226325 PMCID: PMC10507995 DOI: 10.1177/17474930231180067] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/01/2023] [Indexed: 05/26/2023]
Abstract
The rate of stroke-related death and disability is four times higher in low- and middle-income countries (LMICs) than in high-income countries (HICs), yet stroke units exist in only 18% of LMICs, compared with 91% of HICs. In order to ensure universal and equitable access to timely, guideline-recommended stroke care, multidisciplinary stroke-ready hospitals with coordinated teams of healthcare professionals and appropriate facilities are essential.Established in 2016, the Angels Initiative is an international, not-for-profit, public-private partnership. It is run in collaboration with the World Stroke Organization, European Stroke Organisation, and regional and national stroke societies in over 50 countries. The Angels Initiative aims to increase the global number of stroke-ready hospitals and to optimize the quality of existing stroke units. It does this through the work of dedicated consultants, who help to standardize care procedures and build coordinated, informed communities of stroke professionals. Angels consultants also establish quality monitoring frameworks using online audit platforms such as the Registry of Stroke Care Quality (RES-Q), which forms the basis of the Angels award system (gold/platinum/diamond) for all stroke-ready hospitals across the world.The Angels Initiative has supported over 1700 hospitals (>1000 in LMICs) that did not previously treat stroke patients to become "stroke ready." Since its inception in 2016, the Angels Initiative has impacted the health outcomes of an estimated 7.46 million stroke patients globally (including an estimated 4.68 million patients in LMICs). The Angels Initiative has increased the number of stroke-ready hospitals in many countries (e.g. in South Africa: 5 stroke-ready hospitals in 2015 vs 185 in 2021), reduced "door to treatment time" (e.g. in Egypt: 50% reduction vs baseline), and increased quality monitoring substantially.The focus of the work of the Angels Initiative has now expanded from the hyperacute phase of stroke treatment to the pre-hospital setting, as well as to the early post-acute setting. A continued and coordinated global effort is needed to achieve the target of the Angels Initiative of >10,000 stroke-ready hospitals by 2030, and >7500 of these in LMICs.
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Affiliation(s)
| | - Sheila Martins
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Robert Mikulik
- International Clinical Research Center, St. Anne’s University Hospital, Brno, Czech Republic
| | - Sandy Middleton
- Australian Catholic University and St. Vincent’s Health Network Sydney, Sydney, NSW, Australia
| | - Stanislav Groppa
- State University of Medicine and Pharmacy ‘Nicolae Testemitanu,’ Chisinau, Moldova
| | | | | | | | - Jan van der Merwe
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Thomas Fischer
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Werner Hacke
- Ruprecht-Karl-University Heidelberg, Heidelberg, Germany
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Ma L, Hu X, Song L, Chen X, Ouyang M, Billot L, Li Q, Malavera A, Li X, Muñoz-Venturelli P, de Silva A, Thang NH, Wahab KW, Pandian JD, Wasay M, Pontes-Neto OM, Abanto C, Arauz A, Shi H, Tang G, Zhu S, She X, Liu L, Sakamoto Y, You S, Han Q, Crutzen B, Cheung E, Li Y, Wang X, Chen C, Liu F, Zhao Y, Li H, Liu Y, Jiang Y, Chen L, Wu B, Liu M, Xu J, You C, Anderson CS. The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial. Lancet 2023; 402:27-40. [PMID: 37245517 PMCID: PMC10401723 DOI: 10.1016/s0140-6736(23)00806-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/03/2023] [Accepted: 04/17/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND Early control of elevated blood pressure is the most promising treatment for acute intracerebral haemorrhage. We aimed to establish whether implementing a goal-directed care bundle incorporating protocols for early intensive blood pressure lowering and management algorithms for hyperglycaemia, pyrexia, and abnormal anticoagulation, implemented in a hospital setting, could improve outcomes for patients with acute spontaneous intracerebral haemorrhage. METHODS We performed a pragmatic, international, multicentre, blinded endpoint, stepped wedge cluster randomised controlled trial at hospitals in nine low-income and middle-income countries (Brazil, China, India, Mexico, Nigeria, Pakistan, Peru, Sri Lanka, and Viet Nam) and one high-income country (Chile). Hospitals were eligible if they had no or inconsistent relevant, disease-specific protocols, and were willing to implement the care bundle to consecutive patients (aged ≥18 years) with imaging-confirmed spontaneous intracerebral haemorrhage presenting within 6 h of the onset of symptoms, had a local champion, and could provide the required study data. Hospitals were centrally randomly allocated using permuted blocks to three sequences of implementation, stratified by country and the projected number of patients to be recruited over the 12 months of the study period. These sequences had four periods that dictated the order in which the hospitals were to switch from the control usual care procedure to the intervention implementation of the care bundle procedure to different clusters of patients in a stepped manner. To avoid contamination, details of the intervention, sequence, and allocation periods were concealed from sites until they had completed the usual care control periods. The care bundle protocol included the early intensive lowering of systolic blood pressure (target <140 mm Hg), strict glucose control (target 6·1-7·8 mmol/L in those without diabetes and 7·8-10·0 mmol/L in those with diabetes), antipyrexia treatment (target body temperature ≤37·5°C), and rapid reversal of warfarin-related anticoagulation (target international normalised ratio <1·5) within 1 h of treatment, in patients where these variables were abnormal. Analyses were performed according to a modified intention-to-treat population with available outcome data (ie, excluding sites that withdrew during the study). The primary outcome was functional recovery, measured with the modified Rankin scale (mRS; range 0 [no symptoms] to 6 [death]) at 6 months by masked research staff, analysed using proportional ordinal logistic regression to assess the distribution in scores on the mRS, with adjustments for cluster (hospital site), group assignment of cluster per period, and time (6-month periods from Dec 12, 2017). This trial is registered at Clinicaltrials.gov (NCT03209258) and the Chinese Clinical Trial Registry (ChiCTR-IOC-17011787) and is completed. FINDINGS Between May 27, 2017, and July 8, 2021, 206 hospitals were assessed for eligibility, of which 144 hospitals in ten countries agreed to join and were randomly assigned in the trial, but 22 hospitals withdrew before starting to enrol patients and another hospital was withdrawn and their data on enrolled patients was deleted because regulatory approval was not obtained. Between Dec 12, 2017, and Dec 31, 2021, 10 857 patients were screened but 3821 were excluded. Overall, the modified intention-to-treat population included 7036 patients enrolled at 121 hospitals, with 3221 assigned to the care bundle group and 3815 to the usual care group, with primary outcome data available in 2892 patients in the care bundle group and 3363 patients in the usual care group. The likelihood of a poor functional outcome was lower in the care bundle group (common odds ratio 0·86; 95% CI 0·76-0·97; p=0·015). The favourable shift in mRS scores in the care bundle group was generally consistent across a range of sensitivity analyses that included additional adjustments for country and patient variables (0·84; 0·73-0·97; p=0·017), and with different approaches to the use of multiple imputations for missing data. Patients in the care bundle group had fewer serious adverse events than those in the usual care group (16·0% vs 20·1%; p=0·0098). INTERPRETATION Implementation of a care bundle protocol for intensive blood pressure lowering and other management algorithms for physiological control within several hours of the onset of symptoms resulted in improved functional outcome for patients with acute intracerebral haemorrhage. Hospitals should incorporate this approach into clinical practice as part of active management for this serious condition. FUNDING Joint Global Health Trials scheme from the Department of Health and Social Care, the Foreign, Commonwealth & Development Office, and the Medical Research Council and Wellcome Trust; West China Hospital; the National Health and Medical Research Council of Australia; Sichuan Credit Pharmaceutic and Takeda China.
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Affiliation(s)
- Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xin Hu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Lili Song
- The George Institute for Global Health China, Beijing, China; The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Xiaoying Chen
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Menglu Ouyang
- The George Institute for Global Health China, Beijing, China; The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Laurent Billot
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Qiang Li
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Alejandra Malavera
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Xi Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Paula Muñoz-Venturelli
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Clinical Research Center, Faculty of Medicine Clinica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Asita de Silva
- Clinical Trials Unit, Faculty of Medicine, University of Kelaniya, Colombo, Sri Lanka
| | | | - Kolawole W Wahab
- Department of Medicine, University of Ilorin & University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Jeyaraj D Pandian
- Neurology Department, Christian Medical College and Hospital, Ludhiana, India
| | - Mohammad Wasay
- Department of Medicine, The Aga Khan University, Karachi, Pakistan
| | - Octavio M Pontes-Neto
- Department of Neurology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Carlos Abanto
- The Cerebrovascular Disease Research Center, National Institute of Neurological Sciences, Lima, Peru
| | - Antonio Arauz
- Instituto Nacional de Neurologia y Neurocirugia Manuel Velasco Suarez, Mexico City, Mexico
| | - Haiping Shi
- Department of Neurosurgery, Suining Central Hospital, Suining, China
| | - Guanghai Tang
- Department of Neurology, Liaoning Thrombus Treatment Centre of Integrated Chinese and Western Medicine, Shenyang, China
| | - Sheng Zhu
- Department of Neurosurgery, Dazhu County People's Hospital, Dazhou, China
| | - Xiaochun She
- Department of Neurosurgery, Jiangsu Rudong County People's Hospital, Nantong, China
| | - Leibo Liu
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Yuki Sakamoto
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Shoujiang You
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Qiao Han
- Department of Neurology, Suzhou Hospital of Traditional Chinese Medicine, Suzhou, China
| | - Bernard Crutzen
- Department of Radiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Department of Radiology, Grand Hôpital de Charleroi, Charleroi, Belgium
| | - Emily Cheung
- Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia
| | - Yunke Li
- The George Institute for Global Health China, Beijing, China
| | - Xia Wang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Chen Chen
- The George Institute for Global Health China, Beijing, China; The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Department of Neurology, Shanghai East Hospital, Tongji University, Shanghai, China
| | - Feifeng Liu
- Department of Neurology, Shanghai East Hospital, Tongji University, Shanghai, China
| | - Yang Zhao
- The George Institute for Global Health China, Beijing, China
| | - Hao Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yi Liu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yan Jiang
- Department of Nursing and Evidence-based Nursing Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lei Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Bo Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Ming Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Jianguo Xu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China.
| | - Craig S Anderson
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China; The George Institute for Global Health China, Beijing, China; The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Clinical Research Center, Faculty of Medicine Clinica Alemana Universidad del Desarrollo, Santiago, Chile; Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia; Heart Health Research Center, Beijing, China.
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Anderson CS, Rodgers A, de Silva HA, Martins SO, Klijn CJ, Senanayake B, Freed R, Billot L, Arima H, Thang NH, Zaidi WAW, Kherkheulidze T, Wahab K, Fisher U, Lee TH, Chen C, Pontes-Neto O, Robinson T, Wang J, Naismith S, Song L, Schreuder FH, Lindley RI, Woodward M, MacMahon S, Salman RAS, Chow CK, Chalmers J. Triple Therapy Prevention of Recurrent Intracerebral Disease Events Trial: Rationale, design and progress. Int J Stroke 2022; 17:1156-1162. [PMID: 34994269 DOI: 10.1177/17474930211068671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients who suffer intracerebral hemorrhage (ICH) are at very high risk of recurrent ICH and other serious cardiovascular events. A single-pill combination (SPC) of blood pressure (BP) lowering drugs offers a potentially powerful but simple strategy to optimize secondary prevention. OBJECTIVES The Triple Therapy Prevention of Recurrent Intracerebral Disease Events Trial (TRIDENT) aims to determine the effects of a novel SPC "Triple Pill," three generic antihypertensive drugs with demonstrated efficacy and complementary mechanisms of action at half standard dose (telmisartan 20 mg, amlodipine 2.5 mg, and indapamide 1.25 mg), with placebo for the prevention of recurrent stroke, cardiovascular events, and cognitive impairment after ICH. DESIGN An international, double-blind, placebo-controlled, randomized trial in adults with ICH and mild-moderate hypertension (systolic BP: 130-160 mmHg), who are not taking any Triple Pill component drug at greater than half-dose. A total of 1500 randomized patients provide 90% power to detect a hazard ratio of 0.5, over an average follow-up of 3 years, according to a total primary event rate (any stroke) of 12% in the control arm and other assumptions. Secondary outcomes include recurrent ICH, cardiovascular events, and safety. RESULTS Recruitment started 28 September 2017. Up to 31 October 2021, 821 patients were randomized at 54 active sites in 10 countries. Triple Pill adherence after 30 months is 86%. The required sample size should be achieved by 2024. CONCLUSION Low-dose Triple Pill BP lowering could improve long-term outcome from ICH.
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Affiliation(s)
- Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,The George Institute China at Peking University Health Sciences Center, Beijing, China.,Heart Health Research Center, Beijing, China.,Neurology Department, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Anthony Rodgers
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - H Asita de Silva
- Clinical Trials Unit, Department of Pharmacology, Faculty of Medicine, University of Kelaniya, Colombo, Sri Lanka.,Institute of Neurology, National Hospital of Sri Lanka, Colombo, Sri Lanka
| | - Sheila Ouriques Martins
- Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.,Neurology Service, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Catharina Jm Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bimsara Senanayake
- Neurology Department, National Hospital of Sri Lanka, Colombo, Sri Lanka
| | - Ruth Freed
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Laurent Billot
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,The George Institute for Global Health, School of Public Health, Imperial College London, London, UK.,University of Bordeaux, Bordeaux, France
| | - Hisatomi Arima
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | | | - Wan Asyraf Wan Zaidi
- Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | | | - Kolawole Wahab
- Department of Medicine, University of Ilorin, Ilorin, Nigeria
| | - Urs Fisher
- Department of Neurology, University Hospital Bern and University of Bern, Bern, Switzerland.,Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Tsong-Hai Lee
- Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan, UK.,College of Medicine, Chang Gung University, Taoyuan, UK
| | - Christopher Chen
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Octavio Pontes-Neto
- Department of Neurosciences and Behavioural Sciences, Ribeirao Preto School of Medicine, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Thompson Robinson
- College of Life Sciences and NIHR Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Jiguang Wang
- Centre for Epidemiological Studies and Clinical Trials, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Sharon Naismith
- Faculty of Science, Charles Perkins Centre and Brain and Mind Centre, University of Sydney, Sydney, NSW, Australia
| | - Lili Song
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,The George Institute China at Peking University Health Sciences Center, Beijing, China
| | - Floris H Schreuder
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Richard I Lindley
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead Hospital, Westmead, NSW, Australia
| | - Mark Woodward
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,The George Institute for Global Health, School of Public Health, Imperial College London, London, UK
| | - Stephen MacMahon
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,The George Institute for Global Health, School of Public Health, Imperial College London, London, UK
| | | | - Clara K Chow
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead Hospital, Westmead, NSW, Australia
| | - John Chalmers
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
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4
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Song L, Hu X, Ma L, Chen X, Ouyang M, Billot L, Li Q, Muñoz-Venturelli P, Abanto C, Pontes-Neto OM, Antonio A, Wasay M, Silva AD, Thang NH, Pandian JD, Wahab KW, You C, Anderson CS. INTEnsive care bundle with blood pressure reduction in acute cerebral hemorrhage trial (INTERACT3): study protocol for a pragmatic stepped-wedge cluster-randomized controlled trial. Trials 2021; 22:943. [PMID: 34930428 PMCID: PMC8686093 DOI: 10.1186/s13063-021-05881-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 10/08/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Early intensive blood pressure (BP) lowering remains the most promising treatment for acute intracerebral hemorrhage (ICH), despite discordant results between clinical trials and potential variation in the treatment effects by approach to control BP. As the third in a series of clinical trials on this topic, the INTEnsive care bundle with blood pressure Reduction in Acute Cerebral hemorrhage Trial (INTERACT3) aims to determine the effectiveness of a goal-directed care bundle protocol of early physiological control (intensive BP lowering, glycemic control, and pyrexia treatment) and reversal of anticoagulation, in acute ICH. METHODS INTERACT3 is a pragmatic, international, multicenter, stepped-wedge (4 phases/3 steps), cluster-randomized controlled trial to determine the effectiveness of a multifaceted care package in adult (age ≥ 18 years) patients (target 8360) with acute ICH (< 6 h of onset) recruited from 110 hospitals (average of 19 consecutive patients per phase) in low- and middle-income countries. After a control phase, each hospital implements the intervention (intensive BP lowering, target systolic < 140 mmHg; glucose control, target 6.1-7.8 mmol/L and 7.8-10.0 mmol/L in those without and with diabetes mellitus, respectively; anti-pyrexia treatment to target body temperature ≤ 37.5 °C; and reversal of anticoagulation, target international normalized ratio < 1.5 within 1 h). Information will be obtained on demographic and baseline clinical characteristics, in-hospital management, and 7-day outcomes. Central trained blinded assessors will conduct telephone interviews to assess physical function and health-related quality of life at 6 months. The primary outcome is the modified Rankin scale (mRS) at 6 months analyzed using ordinal logistic regression. The sample size of 8360 subjects provides 90% power (α = 0.05) to detect a 5.6% absolute improvement (shift) in the primary outcome of the intervention versus control standard care, with various assumptions. DISCUSSION As the largest clinical trial in acute ICH, INTERACT3 is on schedule to provide an assessment of the effectiveness of a widely applicable goal-directed care bundle for a serious condition in which a clearly proven treatment has yet to be established. TRIAL REGISTRATION ClinicalTrials.gov NCT03209258. Registered on 1 July 2017. Chinese Trial Registry ChiCTR-IOC-17011787. Registered on 28 June 2017.
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Affiliation(s)
- Lili Song
- The George Institute China, Peking University Health Science Center, Room 011, Unit 2, Tayuan Diplomatic Office Building, No. 14 Liangmahe Nan Lu, Chaoyang District, Beijing, China
- The George Institute for Global Health, Faculty of Medicine, UNSW, Level 5, King Street, Newtown, NSW, 2042, Australia
| | - Xin Hu
- Department of Neurosurgery, West China Hospital, Sichuan University, NO.43, St. Guoxuexiang, Chengdu, China
| | - Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, NO.43, St. Guoxuexiang, Chengdu, China
| | - Xiaoying Chen
- The George Institute for Global Health, Faculty of Medicine, UNSW, Level 5, King Street, Newtown, NSW, 2042, Australia
| | - Menglu Ouyang
- The George Institute China, Peking University Health Science Center, Room 011, Unit 2, Tayuan Diplomatic Office Building, No. 14 Liangmahe Nan Lu, Chaoyang District, Beijing, China
- The George Institute for Global Health, Faculty of Medicine, UNSW, Level 5, King Street, Newtown, NSW, 2042, Australia
| | - Laurent Billot
- The George Institute for Global Health, Faculty of Medicine, UNSW, Level 5, King Street, Newtown, NSW, 2042, Australia
| | - Qiang Li
- The George Institute for Global Health, Faculty of Medicine, UNSW, Level 5, King Street, Newtown, NSW, 2042, Australia
| | - Paula Muñoz-Venturelli
- The George Institute for Global Health, Faculty of Medicine, UNSW, Level 5, King Street, Newtown, NSW, 2042, Australia
- Clinical Research Center, Faculty of Medicine, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Carlos Abanto
- The Cerebrovascular Disease Research Center, National Institute of Neurological Sciences, Cercado de Lima, Peru
| | | | - Arauz Antonio
- Instituto Nacional de Neurologia y Neurocirugia Manuel Velasco Suarez, Mexico City, Mexico
| | - Mohammad Wasay
- Department of Medicine, The Aga Khan University, Karachi, Pakistan
| | - Asita de Silva
- Clinical Trials Unit, Faculty of Medicine, University of Kelaniya, Colombo, Sri Lanka
| | | | | | - Kolawole Wasiu Wahab
- Department of Medicine, University of Ilorin & University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, NO.43, St. Guoxuexiang, Chengdu, China.
| | - Craig S Anderson
- The George Institute China, Peking University Health Science Center, Room 011, Unit 2, Tayuan Diplomatic Office Building, No. 14 Liangmahe Nan Lu, Chaoyang District, Beijing, China.
- The George Institute for Global Health, Faculty of Medicine, UNSW, Level 5, King Street, Newtown, NSW, 2042, Australia.
- Department of Neurosurgery, West China Hospital, Sichuan University, NO.43, St. Guoxuexiang, Chengdu, China.
- Sydney Medical School, University of Sydney, Sydney, Australia.
- Department of Neurology, Royal Prince Alfred Hospital, Sydney, Australia.
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5
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Abstract
Biological indicator organisms have been widely used for monitoring and banking purposes for many years. Although the complexity of the interactions between organisms and their environment is generally not easily comprehensible, environmental quality assessment using the bioindicator approach offers some convincing advantages compared to direct analysis of soil, water, or air. Measurement of air particulates is restricted to experienced laboratories with access to expensive sampling equipment. Additionally, the amount of material collected generally is just enough for one determination per sampling and no multidimensional characterization might be possible. Further, fluctuations in air masses have a pronounced effect on the results from air filter sampling. Combining the integrating property of bioindicators with the world wide availability and particular matrix characteristics of air particulate matter as a prerequisite for global monitoring of air pollution is discussed. A new approach for sampling urban dust using large volume filtering devices installed in air conditioners of large hotel buildings is assessed. A first experiment was initiated to collect air particulates (300-500 g each) from a number of hotels during a period of 3-4 months by successive vacuum cleaning of used inlet filters from high volume air conditioning installations reflecting average concentrations per 3 months in different large cities. This approach is expected to be upgraded and applied for global monitoring. Highly positive correlated elements were found in lichens such as K/S, Zn/P, the rare earth elements (REE) and a significant negative correlation between Hg and Cu was observed in these samples. The ratio of concentrations of elements in dust and Usnea spp. is highest for Cz, Zn and Fe (400-200) and lowest for elements such as Ca, Rb, and Sr (20-10).
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Affiliation(s)
- M Rossbach
- Institute of Applied Physical Chemistry, Research Center of Juelich, Germany.
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