Safety and efficacy of tenecteplase versus alteplase in stroke patients with carotid tandem lesions: Results from the AcT trial

BACKGROUND

Carotid tandem lesions ((TL) ⩾70% stenosis or occlusion) account for 15-20% of acute stroke with large vessel occlusion.

AIMS

We investigated the safety and efficacy of intravenous tenecteplase (0.25 mg/kg) versus intravenous alteplase (0.9 mg/kg) in patients with carotid TL.

METHODS

This is a substudy of the alteplase compared with the tenecteplase trial. Patients with ⩾70% stenosis of the extracranial internal carotid artery (ICA) and concomitant occlusion of the intracranial ICA, M1 or M2 segments of the middle cerebral artery on baseline computed tomography angiography (CTA) were included. Primary outcome was 90-day-modified Rankin Scale (mRS) 0-1. Secondary outcomes were mRS 0-2, mortality, and symptomatic ICH (sICH). Angiographic outcomes were successful recanalization (revised Arterial Occlusive Lesion (rAOL) 2b-3) on first and successful reperfusion (eTICI 2b-3) on final angiographic acquisitions. Multivariable mixed-effects logistic regression was performed.

RESULTS

Among 1577 alteplase versus tenecteplase randomized controlled trial (AcT) patients, 128 (18.8%) had carotid TL. Of these, 93 (72.7%) underwent intravenous thrombolysis plus endovascular thrombectomy (IVT + EVT), while 35 (27.3%) were treated with IVT alone. In the IVT + EVT group, tenecteplase was associated with higher odds of 90-day-mRS 0-1 (46.0% vs. 32.6%, adjusted OR (aOR) 3.21; 95% CI = 1.06-9.71) compared with alteplase. No statistically significant differences in rates of mRS 0-2 (aOR 1.53; 95% CI = 0.51-4.55), initial rAOL 2b-3 (16.3% vs. 28.6%), final eTICI 2b-3 (83.7% vs. 85.7%), and mortality (18.0% vs. 16.3%) were found. SICH only occurred in one patient. There were no differences in outcomes between thrombolytic agents in the IVT-only group.

CONCLUSION

In patients with carotid TL treated with EVT, intravenous tenecteplase may be associated with similar or better clinical outcomes, similar angiographic reperfusion rates, and safety outcomes as compared with alteplase.

Quality of Life After Intravenous Thrombolysis for Acute Ischemic Stroke: Results From the AcT Randomized Controlled Trial

BACKGROUND

Recent evidence from thrombolysis trials indicates the noninferiority of intravenous tenecteplase to intravenous alteplase with respect to good functional outcomes in patients with acute stroke. We examined whether the health-related quality of life (HRQOL) of patients with acute stroke differs by the type of thrombolysis treatment received. In addition, we examined the association between the modified Rankin Scale score 0 to 1 and HRQOL and patient-reported return to prebaseline stroke functioning at 90 days.

METHODS

Data were from all patients included in the AcT trial (Alteplase Compared to Tenecteplase), a pragmatic, registry-linked randomized trial comparing tenecteplase with alteplase. HRQOL at 90-day post-randomization was assessed using the 5-item EuroQOL questionnaire (EQ5D), which consists of 5 items and a visual analog scale (VAS). EQ5D index values were estimated from the EQ5D items using the time tradeoff approach based on Canadian norms. Tobit regression and quantile regression models were used to evaluate the adjusted effect of tenecteplase versus alteplase treatment on the EQ5D index values and VAS score, respectively. The association between return to prebaseline stroke functioning and the modified Rankin Scale score 0 to 1 and HRQOL was quantified using correlation coefficient (r) with 95% CI.

RESULTS

Of 1577 included in the intention-to-treat analysis patients, 1503 (95.3%) had complete data on the EQ5D. Of this, 769 (51.2%) were administered tenecteplase and 717 (47.7%) were female. The mean EQ5D VAS score and EQ5D index values were not significantly higher for those who received intravenous tenecteplase compared with those who received intravenous alteplase (P=0.10). Older age (P<0.01), more severe stroke assessed using the National Institutes of Health Stroke Scale (P<0.01), and longer stroke onset-to-needle time (P=0.004) were associated with lower EQ5D index and VAS scores. There was a strong association (r, 0.85 [95% CI, 0.81-0.89]) between patient-reported return to prebaseline functioning and modified Rankin Scale score 0 to 1 Similarly, there was a moderate association between return to prebaseline functioning and EQ5D index (r, 0.45 [95% CI, 0.40-0.49]) and EQ5D VAS scores (r, 0.42 [95% CI, 0.37-0.46]).

CONCLUSIONS

Although there is no differential effect of thrombolysis type on patient-reported global HRQOL and EQ 5D-5L index values in patients with acute stroke, sex- and age-related differences in HRQOL were noted in this study.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03889249.

Sex-Based Analysis of Workflow and Outcomes in Acute Ischemic Stroke Patients Treated With Alteplase Versus Tenecteplase

BACKGROUND

Understanding sex differences in stroke care is important in reducing potential disparities. Our objective was to explore sex differences in workflow efficiency, treatment efficacy, and safety in the AcT trial (Alteplase Compared to Tenecteplase).

METHODS

AcT was a multicenter, registry-linked randomized noninferiority trial comparing tenecteplase (0.25 mg/kg) with alteplase (0.9 mg/kg) in acute ischemic stroke within 4.5 hours of onset. In this post hoc analysis, baseline characteristics, workflow times, successful reperfusion (extended Thrombolysis in Cerebral Infarction score ≥2b), symptomatic intracerebral hemorrhage, 90-day functional independence (modified Rankin Scale score, 0-1), and 90-day mortality were compared by sex. Mixed-effects regression analysis was used adjusting for age, stroke severity, and occlusion site for outcomes.

RESULTS

Of 1577 patients treated with intravenous thrombolysis (2019-2022), 755 (47.9%) were women. Women were older (median, 77 [68-86] years in women versus 70 [59-79] years in men) and had a higher proportion of severe strokes (National Institutes of Health Stroke Scale score >15; 32.4% versus 24.9%) and large vessel occlusions (28.7% versus 21.5%) compared with men. All workflow times were comparable between sexes. Women were less likely to achieve functional independence (31.7% versus 39.8%; unadjusted relative risk, 0.80 [95% CI, 0.70-0.91]) and had higher mortality (17.7% versus 13.3%; unadjusted relative risk, 1.33 [95% CI, 1.06-1.69]). Adjusted analysis showed no difference in outcomes between sexes.

CONCLUSIONS

Differences in prognostic factors of age, stroke severity, and occlusion site largely accounted for higher functional dependence and mortality in women. No sex disparities were apparent in workflow quality indicators. Given the integration of the AcT trial into clinical practice, these results provide reassurance that no major sex biases are apparent in acute stroke management throughout participating Canadian centers.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03889249.

Safety and Efficacy of Tenecteplase Compared With Alteplase in Patients With Large Vessel Occlusion Stroke: A Prespecified Secondary Analysis of the ACT Randomized Clinical Trial

Importance

It is unknown whether intravenous thrombolysis using tenecteplase is noninferior or preferable compared with alteplase for patients with acute ischemic stroke.

Objective

To examine the safety and efficacy of tenecteplase compared to alteplase among patients with large vessel occlusion (LVO) stroke.

Design, Setting, and Participants

This was a prespecified analysis of the Intravenous Tenecteplase Compared With Alteplase for Acute Ischaemic Stroke in Canada (ACT) randomized clinical trial that enrolled patients from 22 primary and comprehensive stroke centers across Canada between December 10, 2019, and January 25, 2022. Patients 18 years and older with a disabling ischemic stroke within 4.5 hours of symptom onset were randomly assigned (1:1) to either intravenous tenecteplase or alteplase and were monitored for up to 120 days. Patients with baseline intracranial internal carotid artery (ICA), M1-middle cerebral artery (MCA), M2-MCA, and basilar occlusions were included in this analysis. A total of 1600 patients were enrolled, and 23 withdrew consent.

Exposures

Intravenous tenecteplase (0.25 mg/kg) vs intravenous alteplase (0.9 mg/kg).

Main Outcomes and Measures

The primary outcome was the proportion of modified Rankin scale (mRS) score 0-1 at 90 days. Secondary outcomes were an mRS score from 0 to 2, mortality, and symptomatic intracerebral hemorrhage. Angiographic outcomes were successful reperfusion (extended Thrombolysis in Cerebral Infarction scale score 2b-3) on first and final angiographic acquisitions. Multivariable analyses (adjusting for age, sex, National Institute of Health Stroke Scale score, onset-to-needle time, and occlusion location) were carried out.

Results

Among 1577 patients, 520 (33.0%) had LVO (median [IQR] age, 74 [64-83] years; 283 [54.4%] women): 135 (26.0%) with ICA occlusion, 237 (45.6%) with M1-MCA, 117 (22.5%) with M2-MCA, and 31 (6.0%) with basilar occlusions. The primary outcome (mRS score 0-1) was achieved in 86 participants (32.7%) in the tenecteplase group vs 76 (29.6%) in the alteplase group. Rates of mRS 0-2 (129 [49.0%] vs 131 [51.0%]), symptomatic intracerebral hemorrhage (16 [6.1%] vs 11 [4.3%]), and mortality (19.9% vs 18.1%) were similar in the tenecteplase and alteplase groups, respectively. No difference was noted in successful reperfusion rates in the first (19 [9.2%] vs 21 [10.5%]) and final angiogram (174 [84.5%] vs 177 [88.9%]) among 405 patients who underwent thrombectomy.

Conclusions and Relevance

The findings in this study indicate that intravenous tenecteplase conferred similar reperfusion, safety, and functional outcomes compared to alteplase among patients with LVO.

Novel paradigm enables accurate monthly gestational screening to prevent congenital toxoplasmosis and more

Background

Congenital toxoplasmosis is a treatable, preventable disease, but untreated causes death, prematurity, loss of sight, cognition and motor function, and substantial costs worldwide.

Methods/Findings

In our ongoing USA feasibility/efficacy clinical trial, data collated with other ongoing and earlier published results proved high performance of an Immunochromatographic-test(ICT) that enables accurate, rapid diagnosis/treatment, establishing new paradigms for care. Overall results from patient blood and/or serum samples tested with ICT compared with gold-standard-predicate-test results found ICT performance for 4606 sera/1876 blood, 99.3%/97.5% sensitive and 98.9%/99.7% specific. However, in the clinical trial the FDA-cleared-predicate test initially caused practical, costly problems due to false-positive-IgM results. For 58 persons, 3/43 seronegative and 2/15 chronically infected persons had false positive IgM predicate tests. This caused substantial anxiety, concerns, and required costly, delayed confirmation in reference centers. Absence of false positive ICT results contributes to solutions: Lyon and Paris France and USA Reference laboratories frequently receive sera with erroneously positive local laboratory IgM results impeding patient care. Therefore, thirty-two such sera referred to Lyon's Reference laboratory were ICT-tested. We collated these with other earlier/ongoing results: 132 of 137 USA or French persons had false positive local laboratory IgM results identified correctly as negative by ICT. Five false positive ICT results in Tunisia and Marseille, France, emphasize need to confirm positive ICT results with Sabin-Feldman-Dye-test or western blot. Separate studies demonstrated high performance in detecting acute infections, meeting FDA, CLIA, WHO ASSURED, CEMark criteria and patient and physician satisfaction with monthly-gestational-ICT-screening.

Conclusions/Significance

This novel paradigm using ICT identifies likely false positives or raises suspicion that a result is truly positive, rapidly needing prompt follow up and treatment. Thus, ICT enables well-accepted gestational screening programs that facilitate rapid treatment saving lives, sight, cognition and motor function. This reduces anxiety, delays, work, and cost at point-of-care and clinical laboratories.

Author’s Summary

Toxoplasmosis is a major health burden for developed and developing countries, causing damage to eyes and brain, loss of life and substantial societal costs. Prompt diagnosis in gestational screening programs enables treatment, thereby relieving suffering, and leading to > 14-fold cost savings for care. Herein, we demonstrate that using an ICT that meets WHO ASSURED-criteria identifying persons with/without antibody to Toxoplasma gondii in sera and whole blood with high sensitivity and specificity, is feasible to use in USA clinical practice. We find this new approach can help to obviate the problem of detection of false positive anti- T.gondii IgM results for those without IgG antibodies to T.gondii when this occurs in present, standard of care, predicate USA FDA cleared available assays. Thus, this accurate test facilitates gestational screening programs and a global initiative to diagnose and thereby prevent and treat T.gondii infection. This minimizes likelihood of false positives (IgG and/or IgM) while maintaining maximum sensitivity. When isolated IgM antibodies are detected, it is necessary to confirm and when indicated continue follow up testing in ∼2 weeks to establish seroconversion. Presence of a positive ICT makes it likely that IgM is truly positive and a negative ICT makes it likely that IgM will be a false positive without infection. These results create a new, enthusiastically-accepted, precise paradigm for rapid diagnosis and validation of results with a second-line test. This helps eliminate alarm and anxiety about false-positive results, while expediting needed treatment for true positive results and providing back up distinguishing false positive tests.

Observation of Myocardial Involvement in Patients Recovered From COVID-19 by Using Cardiac Magnetic Resonance Imaging, In a Tertiary Care Hospital, Bangladesh

It was previously reported that coronavirus caused myocardial injury in hospitalized patients. However, delayed cardiac involvement in symptomatic patient recovery from COVID-19 is not yet well known. The objective of this study was to evaluate cardiac involvement by using cardiac magnetic resonance (CMR) in symptomatic post-COVID-19 recovered patients. Thirty (30) patients who recovered from COVID-19 and had recently reported cardiac symptoms were studied in a prospective observational study performed at Popular Medical College Hospital, Dhaka, Bangladesh from March 2021 to September 2021. They underwent CMR examinations. CMR scanning protocol included the following: black blood, cine sequence, both short-axis and long-axis, T2-weight short tau inversion recovery (STIR) sequence, T2- weighted imaging (T2WI) and late gadolinium enhancement (LGE) and quantitative mapping sequences-native T1/T2 mapping and post-contrast T1 mapping. Myocardial edema and late gadolinium enhancement were assessed in all patients. Quantitative evaluation of native T1/T2 and ECV value and cardiac function were evaluated. There were 30 people in all in this study. The average age of the participants in the study was 36.6 years. Fourteen (46.6%) of the patients had abnormal cardiac MRI results, while the remaining 15(53.3%) had negative CMR findings. Among positive findings patients, 8(57.1%) of 14 had increased T2 signal. Increased myocardial edema was found in the same no of patients, involving 53.2% (128 of 224) of LV segments. Only 2 cases (2 of 14) showed mid myocardial and subepicardial LGE, involving 18 of 224, 8.03% of myocardial segments. Global native T1, T2 and ECV values are significantly elevated in all CMR positive findings patients. Native T1 1231ms (IQR: 1281.25-1257.5 versus 1155.5 (IQR: 1137.25-1172.75), T2 40 (IQR: 34.5-43.25) versus 35.5 (IQR: 34-37), ECV 31 (29.75-33.25) versus 23.5 (21.25-24.0), p<0.001; p<0.011 and p<0.001 respectively. Reduced RV functional were found in positive as compared with negative CMR findings patients, EF, 32.05 (IQR: 25.25-39.0) versus 54.5 (IQR: 52.0-57.75) and EDV, 117.5 (IQR: 102.0-134.25) versus 95.0 (IQR: 71.75-99.75), p<0.001 and p<0.001 respectively. In this study cardiac involvement was found in the post-COVID-19 recovered patient with cardiac symptoms. Cardiac MRI findings included myocardial edema, fibrosis and reduced right ventricular function. So attention should be paid to symptomatic post-COVID-19 recovered patients.

Intravenous tenecteplase compared with alteplase for acute ischaemic stroke in Canada (AcT): a pragmatic, multicentre, open-label, registry-linked, randomised, controlled, non-inferiority trial

BACKGROUND

Intravenous thrombolysis with alteplase bolus followed by infusion is a global standard of care for patients with acute ischaemic stroke. We aimed to determine whether tenecteplase given as a single bolus might increase reperfusion compared with this standard of care.

METHODS

In this multicentre, open-label, parallel-group, registry-linked, randomised, controlled trial (AcT), patients were enrolled from 22 primary and comprehensive stroke centres across Canada. Patients were eligible for inclusion if they were aged 18 years or older, with a diagnosis of ischaemic stroke causing disabling neurological deficit, presenting within 4·5 h of symptom onset, and eligible for thrombolysis per Canadian guidelines. Eligible patients were randomly assigned (1:1), using a previously validated minimal sufficient balance algorithm to balance allocation by site and a secure real-time web-based server, to either intravenous tenecteplase (0·25 mg/kg to a maximum of 25 mg) or alteplase (0·9 mg/kg to a maximum of 90mg; 0·09 mg/kg as a bolus and then a 60 min infusion of the remaining 0·81 mg/kg). The primary outcome was the proportion of patients who had a modified Rankin Scale (mRS) score of 0-1 at 90-120 days after treatment, assessed via blinded review in the intention-to-treat (ITT) population (ie, all patients randomly assigned to treatment who did not withdraw consent). Non-inferiority was met if the lower 95% CI of the difference in the proportion of patients who met the primary outcome between the tenecteplase and alteplase groups was more than -5%. Safety was assessed in all patients who received any of either thrombolytic agent and who were reported as treated. The trial is registered with ClinicalTrials.gov, NCT03889249, and is closed to accrual.

FINDINGS

Between Dec 10, 2019, and Jan 25, 2022, 1600 patients were enrolled and randomly assigned to tenecteplase (n=816) or alteplase (n=784), of whom 1577 were included in the ITT population (n=806 tenecteplase; n=771 alteplase). The median age was 74 years (IQR 63-83), 755 (47·9%) of 1577 patients were female and 822 (52·1%) were male. As of data cutoff (Jan 21, 2022), 296 (36·9%) of 802 patients in the tenecteplase group and 266 (34·8%) of 765 in the alteplase group had an mRS score of 0-1 at 90-120 days (unadjusted risk difference 2·1% [95% CI - 2·6 to 6·9], meeting the prespecified non-inferiority threshold). In safety analyses, 27 (3·4%) of 800 patients in the tenecteplase group and 24 (3·2%) of 763 in the alteplase group had 24 h symptomatic intracerebral haemorrhage and 122 (15·3%) of 796 and 117 (15·4%) of 763 died within 90 days of starting treatment INTERPRETATION: Intravenous tenecteplase (0·25 mg/kg) is a reasonable alternative to alteplase for all patients presenting with acute ischaemic stroke who meet standard criteria for thrombolysis.

FUNDING

Canadian Institutes of Health Research, Alberta Strategy for Patient Oriented Research Support Unit.

P-243 Automating tracking of cell division for human embryo development in time lapse videos

Study question

Can tracking cell division and predicting human embryo cleavage stages be automated in time-lapse videos (TLV) using AI object detection methods?

Summary answer

We developed software predicting blastomere count and tracking cell cleavages up until 4-5 stage. The software employs object detection technique called YOLOv5 to detect cells.

What is known already

Embryo morphology plays an important part in determining viability. Parameters such as number of cells present following fertilization, abnormal cell division (reverse/direct) and evaluating cleavage stages have correlation with pregnancy rates. However, continuous manual evaluation can be time-consuming, and automation will assist in embryo viability assessment. YOLOv5 has proven to accurately detect objects in videos. YOLOv5 uses mean average precision (mAP) as a metric to quantify the portions of frames in videos having the correct count of the objects.

Study design, size, duration

We have developed a software that uses YOLOv5 to detect cells present in frames of TLV, then marks each cell boundary with different colored circular overlays using OpenCV. We trained YOLOv5 to detect objects: cell, morula and blastocyst using 150 images of different cell-stages, morula, blastocyst. For object cell mAP was 0.65. Annotated location of objects in images and YOLOv5 predictions were reviewed by embryologists. We evaluated the software on TLV from 11 patients.

Participants/materials, setting, methods

After YOLOv5 detects cells in frames of TLV, our software computes cell count and assigns each cell a different color which is maintained until cell division into daughter cells. Later, daughter cells were also assigned different colors. If the frame has a preceding frame, software calculates detected cells' proximity with each cell in the preceding frame and copies color scheme provided proximity is within some threshold. The software provides TLV with colored overlays as output.

Main results and the role of chance

In starting frames of TLV with single cell, software accurately detected 1-cell (high precision=0.99, high recall=0.83, high F1-score=0.90). We observed some misclassification between 1-cell and morula. The reason could be that compacted morula looks like 1-cell. Best performance is observed for 2-cells (high precision=0.91, high recall=0.98, high F1-score=0.95). 4-cells were sometimes misclassified with 3 or 5-cells (high precision=0.88, low recall=0.59, high F1-score=0.71). One reason for the misclassification can be that overlapping between cells increases with number of cells. 3-cell and 5-cell are confused with other stages, still cleavage stage detection is better than random: 3-cell (average precision=0.43, high recall=0.83, average F1-score=0.49), 5-cell (average precision=0.44, average recall=0.40, average F1-score=0.40). For cell-stages&gt;5, YOLOv5 detects less cells than actual count and software predicts cleavage later than actual by 9-10 frames on average. The proximity threshold used was 0.10 for cell-count&lt;4 and 0.05 for count&gt;4.

In 5 TLV, overlay color for cells changes abruptly between frames, possibly because once YOLOv5 detected a stage, in consecutive frames less cell-number was recorded, and then again reported correct count. Sometimes, software selected the wrong parent for daughter cells (incorrect colored overlay). 2 TLV had direct and reverse cleavages and software could detect these two patterns.

Limitations, reasons for caution

Overall, our software can precisely detect cells, cell divisions and cleavage stages up to 4-cell stages. We hypothesize that training YOLOv5 on a bigger dataset and including several focal plane information will enable our software to detect overlapping cells and cleavage stages &gt; =5.

Wider implications of the findings

Object detection proved to be pragmatic for ART and tracking cell division using our software will reduce time consumed in manual annotations, easier prediction of abnormal cleavages and more objective assessments. Qualitative evaluation by embryologists resulted in the overall verdict that this is useful and promising for further development.

Trial registration number

not applicable

1294 Online Education for Patients Undergoing Elective Orthopaedic Surgery During A Global Pandemic

Introduction

lective hip and knee joint replacement patients at the East Lancashire Hospitals NHS Trust (ELHT) are required to attend the ‘Hip and Knee Joint School’. This is an award-winning patient education programme. Pre-pandemic, it was a day at the hospital dedicated to introducing patients to the specifics of a hip and knee joint replacement surgery. This takes the patient from the process of anaesthesia to post-operative ward care.

Method

Due to the virulent transmission of COVID-19, strict social distancing rules have been implemented. Therefore, it was decided that converting the joint school into online videos would be the best medium for patient education. Various healthcare professionals contributed to the videos included orthopaedic surgeons, anaesthetists, specialist nurses, healthcare assistants, occupational therapists, and physiotherapists.

Results

Eleven videos were filmed, edited, and approved by the trust’s communications team. These included, ‘Introduction to the Joint School’, ‘You and your surgery’, ‘Leading up to your operation’, ‘Your Operation Journey’, ‘Introducing the Anaesthetist’ ‘Total Hip Replacement Surgery’, ‘Total Knee Replacement Surgery’, ‘Post-op Wound Care’, ‘Your Safe Discharge Home’, ‘FAQ’s’ and ‘COVID-19 Green Pathway’.

Conclusions

The global pandemic has driven innovation and novel ideas in medicine. We have seen similar changes in our trust with the online patient education videos being a prime example. This joint school was originally started in our trust, but now as it had been converted to videos, we believe that it can be modified and used across all trusts in the NHS.

Effect of Implantable vs Prolonged External Electrocardiographic Monitoring on Atrial Fibrillation Detection in Patients With Ischemic Stroke: The PER DIEM Randomized Clinical Trial

IMPORTANCE

The relative rates of detection of atrial fibrillation (AF) or atrial flutter from evaluating patients with prolonged electrocardiographic monitoring with an external loop recorder or implantable loop recorder after an ischemic stroke are unknown.

OBJECTIVE

To determine, in patients with a recent ischemic stroke, whether 12 months of implantable loop recorder monitoring detects more occurrences of AF compared with conventional external loop recorder monitoring for 30 days.

DESIGN, SETTING, AND PARTICIPANTS

Investigator-initiated, open-label, randomized clinical trial conducted at 2 university hospitals and 1 community hospital in Alberta, Canada, including 300 patients within 6 months of ischemic stroke and without known AF from May 2015 through November 2017; final follow-up was in December 2018.

INTERVENTIONS

Participants were randomly assigned 1:1 to prolonged electrocardiographic monitoring with either an implantable loop recorder (n = 150) or an external loop recorder (n = 150) with follow-up visits at 30 days, 6 months, and 12 months.

MAIN OUTCOMES AND MEASURES

The primary outcome was the development of definite AF or highly probable AF (adjudicated new AF lasting ≥2 minutes within 12 months of randomization). There were 8 prespecified secondary outcomes including time to event analysis of new AF, recurrent ischemic stroke, intracerebral hemorrhage, death, and device-related serious adverse events within 12 months.

RESULTS

Among the 300 patients who were randomized (median age, 64.1 years [interquartile range, 56.1 to 73.7 years]; 121 were women [40.3%]; and 66.3% had a stroke of undetermined etiology with a median CHA2DS2-VASc [congestive heart failure, hypertension, age ≥75 years, diabetes, stroke or transient ischemic attack, vascular disease, age 65 to 74 years, sex category] score of 4 [interquartile range, 3 to 5]), 273 (91.0%) completed cardiac monitoring lasting 24 hours or longer and 259 (86.3%) completed both the assigned monitoring and 12-month follow-up visit. The primary outcome was observed in 15.3% (23/150) of patients in the implantable loop recorder group and 4.7% (7/150) of patients in the external loop recorder group (between-group difference, 10.7% [95% CI, 4.0% to 17.3%]; risk ratio, 3.29 [95% CI, 1.45 to 7.42]; P = .003). Of the 8 specified secondary outcomes, 6 were not significantly different. There were 5 patients (3.3%) in the implantable loop recorder group who had recurrent ischemic stroke vs 8 patients (5.3%) in the external loop recorder group (between-group difference, -2.0% [95% CI, -6.6% to 2.6%]), 1 (0.7%) vs 1 (0.7%), respectively, who had intracerebral hemorrhage (between-group difference, 0% [95% CI, -1.8% to 1.8%]), 3 (2.0%) vs 3 (2.0%) who died (between-group difference, 0% [95% CI, -3.2% to 3.2%]), and 1 (0.7%) vs 0 (0%) who had device-related serious adverse events.

CONCLUSIONS AND RELEVANCE

Among patients with ischemic stroke and no prior evidence of AF, implantable electrocardiographic monitoring for 12 months, compared with prolonged external monitoring for 30 days, resulted in a significantly greater proportion of patients with AF detected over 12 months. Further research is needed to compare clinical outcomes associated with these monitoring strategies and relative cost-effectiveness.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02428140.

Provincial Door-to-Needle Improvement Initiative Results in Improved Patient Outcomes Across an Entire Population

Background and Purpose:

Improving door-to-needle times (DNTs) for thrombolysis of acute ischemic stroke patients improves outcomes, but participation in DNT improvement initiatives has been mostly limited to larger, academic medical centers with an existing interest in stroke quality improvement. It is not known whether quality improvement initiatives can improve DNT at a population level, including smaller community hospitals. This study aims to determine the effect of a provincial improvement collaborative intervention on improvement of DNT and patient outcomes.

Methods:

A pre post cohort study was conducted over 10 years in the Canadian province of Alberta with 17 designated stroke centers. All ischemic stroke patients who received thrombolysis in the Canadian province of Alberta were included in the study. The quality improvement intervention was an improvement collaborative that involved creation of interdisciplinary teams from each stroke center, participation in 3 workshops and closing celebration, site visits, webinars, and data audit and feedback.

Results:

Two thousand four hundred eighty-eight ischemic stroke patients received thrombolysis in the pre- and postintervention periods (630 in the post period). The mean age was 71 years (SD, 14.6 years), and 46% were women. DNTs were reduced from a median of 70.0 minutes (interquartile range, 51–93) to 39.0 minutes (interquartile range, 27–58) for patients treated per guideline ( P <0.0001). The percentage of patients discharged home from acute care increased from 45.6% to 59.5% ( P <0.0001); the median 90-day home time increased from 43.3 days (interquartile range, 27.3–55.8) to 53.6 days (interquartile range, 36.8–64.6) ( P =0.0015); and the in-hospital mortality decreased from 14.5% to 10.5% ( P =0.0990).

Conclusions:

The improvement collaborative was likely the key contributing factor in reducing DNTs and improving outcomes for ischemic stroke patients across Alberta.

Correction to: Topical antimicrobial prophylaxis in colorectal surgery for the prevention of surgical wound infection: a systematic review and meta-analysis

Unfortunately, an author name (Nuzhat Iqbal) was missed out in the original publication. The complete updated author list is given below.

Abstract P6-18-33: GI toxicities in metastatic breast cancer: A comprehensive literature review

Background

Treatments for advanced or metastatic breast cancer (aBC/mBC) are associated with gastrointestinal (GI) toxicities. The objective of this study was to assess the association between GI toxicities in mBC/aBC and health-related quality of life (HRQoL) and economic burden.

Methods

We conducted a comprehensive literature search of the Cochrane Central Register of Controlled Trials (2017), NHS Economic Evaluation Database (2016), Embase (1988 – 2017 week 34), and Ovid MEDLINE (1946 to August 2017). Eligible studies evaluated an intervention/comparator treatment in adult patients (age ≥18 years) with aBC/mBC and reported a direct connection between GI toxicities (ie, diarrhea, constipation, nausea, vomiting) and HRQoL and economic evidence. All studies published from January 2000 to August 2017 were assessed for eligibility. Editorials, case reports, conference abstracts, and studies of early, locally advanced, or inflammatory BC were excluded. Abstract and title screening, and full-text screening were conducted by single reviewers. Data were extracted by a single reviewer and verified by a second. Results were synthesized narratively.

Results

Database searches identified 3,428 articles; an additional 16 articles were identified through other sources. Ninety-four studies underwent full-text review, of which 27 reported a direct connection between GI toxicities and HRQoL (n = 11) and economic burden (n = 19). Some studies reported both HRQoL and economic data.

Patients identified treatment-related adverse events (AEs), such as GI events, as an important aspect of treatment that can affect therapy choice, discontinuation, and switching. Generally, patients with mBC had lower HRQoL than other BC groups, and increasing toxicity was associated with a greater degree of HRQoL impairment. When patients were asked to rank which AEs they most wanted to avoid, only pain ranked higher than nausea and vomiting. In a willingness to pay study, women with mBC were willing to pay $3,894 (2014 USD) per year to avoid severe diarrhea and $3,211 to avoid severe nausea.

Gastrointestinal events were among the costliest class of AEs, with mean costs as high as $4,809 (2016 USD) per episode; costs increased by 24% if events were persistent or recurrent.

Conclusions

Gastrointestinal toxicities are common in patients with aBC/mBC and have significant consequences for HRQoL and system-level economic outcomes. Frequency and implications of GI effects of treatment regimens should be considered carefully during patient counseling,, prescribing and coverage decisions in metastatic breast cancer.

Citation Format: Disher T, Siddiqui M, Mitra D, Cameron C, Zhan L, Iyer S. GI toxicities in metastatic breast cancer: A comprehensive literature review [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-18-33.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Population-based study of the impact of surgical and adjuvant therapy at the same or a different institution on survival of patients with pancreatic adenocarcinoma

Background

Pancreatic cancer surgery is increasingly regionalized in high‐volume centres. Provision of adjuvant chemotherapy in the same institution can place a burden on patients, whereas receiving adjuvant chemotherapy at a different institution closer to home may create disparities in care. This study compared long‐term outcomes of patients with pancreatic adenocarcinoma receiving adjuvant chemotherapy at the institution where they had undergone surgery with outcomes for those receiving chemotherapy at a different institution.

Methods

This was a population‐based study of patients receiving adjuvant chemotherapy after resection of pancreatic adenocarcinoma performed at ten designated hepatopancreatobiliary centres in Ontario, Canada, between 2004 and 2014. Patients were divided into those receiving chemotherapy at the same institution as surgery or a different institution from where surgery was performed. The primary outcome was overall survival (OS). Multivariable Cox regression assessed the association between OS and each chemotherapy group, adjusted for potential confounders.

Results

Of 589 patients, 374 (63·5 per cent) received adjuvant chemotherapy at the same institution as surgery. After adjusting for age, sex, co‐morbidity, socioeconomic status, rural living, tumour stage, margin positivity and year of surgery, the location of adjuvant chemotherapy was not independently associated with OS (hazard ratio 1·03, 95 per cent c.i. 0·85 to 1·24). For patients who underwent chemotherapy at a different institution, mean travel distance to receive chemotherapy was less (22·9 km) than that needed for surgery (106·7 km).

Conclusion

After pancreatectomy for pancreatic adenocarcinoma at specialized hepatopancreatobiliary surgery centres, OS was not affected by the location of the centre delivering adjuvant chemotherapy. Receiving this treatment in a local centre reduced patients' travel burden.

Geographic variation in surgical practice patterns and outcomes for resected nonmetastatic gastric cancer in Ontario

Background

Gastrectomy with negative resection margins and adequate lymph node dissection is the cornerstone of curative treatment for gastric cancer (gc). However, gastrectomy is a complex and invasive operation with significant morbidity and mortality. Little is known about surgical practice patterns or short- and long-term outcomes in early-stage gc in Canada.

Methods

We undertook a population-based retrospective cohort study of patients with gc diagnosed between 1 April 2005 and 31 March 2008. Chart review provided clinical and operative details such as disease stage, primary tumour location, surgical approach, operation, lymph nodes, and resection margins. Administrative data provided patient demographics, geography, and vital status. Variations in treatment and outcomes were compared for 14 local health integration networks. Descriptive statistics and log-rank tests were used to examine geographic variation.

Results

We identified 722 patients with nonmetastatic resected gc. We documented significant provincial variation in case mix, including primary tumour location, stage at diagnosis, and tumour grade. Short-term surgical outcomes varied across the province. The percentage of patients with 15 or fewer lymph nodes removed and examined varied from 41.8% to 73.8% (p = 0.02), and the rate of positive surgical margins ranged from 15.2% to 50.0% (p = 0.002). The 30-day surgical mortality rates did not vary statistically significantly across the province (p = 0.13); however, rates ranged from 0% to 16.7%. Overall 5-year survival was 44% and ranged from 31% to 55% across the province.

Conclusions

This cohort of patients with resected stages i-iii gc is the largest analyzed in Canada, providing important historical information about treatment outcomes. Understanding the causes of regional variation will support interventions aiming to improve gc operative outcomes in the cancer system.

An Ecosystem for Comprehensive Cervical Cancer Prevention in India: Formative Study in India

Background: Despite being preventable, cervical cancer is the third most common cancer in India, accounting for the highest number of cancer deaths. India has made limited progress toward introducing the safe and effective vaccine to prevent human papilloma virus (HPV) infections, which has been available for a decade. Aim: Using qualitative research, we examined opportunities for comprehensive cervical cancer prevention, including HPV vaccination in two Indian states - Tamil Nadu (TN) and Karnataka (KA). Methods: We used a socio-ecological framework to identify and map key stakeholders and structures that create the ecosystem for comprehensive cervical cancer prevention. Data were collected through semistructured in-depth interviews and focus group discussions. Key stakeholders included women and men (30-45 years) residing in selected slums/villages, community influencers (village government, self-help group members), district and state-level government health and education officials, specialist doctors, frontline health workers, staff of cancer-related nongovernmental organizations, and journalists. Results: As neither state had initiated public provision of the HPV vaccine, discussions focused on stakeholders' knowledge about the vaccine and factors that could inform a policy decision and facilitate or pose barriers to roll-out. Government officials and specialists in both states were aware of HPV vaccination for primary prevention of cervical cancer. Officials in KA noted concerns about the vaccine's safety and efficacy more emphatically than officials in TN. Specialists, particularly those in leadership positions in the Federation of Obstetrics and Gynecology Societies of India and the Indian Academy of Pediatrics were strong advocates of vaccination. Several specialists contrasted the numerous implementation challenges of cervical cancer screening with India's successes in routine immunization. However, a few specialists also expressed concerns regarding safety of the HPV vaccine. Community members lacked awareness about the vaccine and raised concerns on its safety, side effects and benefits as they would have for any new vaccine. All stakeholders highlighted cost as a major barrier to public provision of the vaccine. Government officials were concerned about how a vaccine program could be financed and sustained. The consensus, particularly in TN, was that the HPV vaccine would need to be introduced through the Universal Immunization Program as a partnership between the health and education departments to ensure widespread access. Conclusion: State-level implementation of comprehensive cervical cancer prevention hinges on the inclusion of HPV vaccination in the national immunization program. Cultivating vaccine champions and identifying appropriate financing mechanisms to implement and sustain comprehensive cervical cancer prevention along with careful planning and implementation has the potential to save the lives of many women.

A Research Agenda for Cancer and Noncommunicable Disease Prevention and Control in India

Background: Noncommunicable diseases (NCDs), including cancer, account for approximately 38 million deaths each year, and almost 75% of these deaths occur in low and middle-income countries. NCDs contribute to 60% of total deaths in India, and of concern are the premature deaths, which account for a staggering 48% mortality and can be prevented. Aim: Establish a consensus research agenda for cancer and NCD prevention and control that has the potential to impact polices, programs and health care delivery. Methods: To develop a NCD research agenda for India, we engaged our community collaborative board (CCB), which included NCD-focused global, national- and state-level stakeholders, and our scientific advisory group (SAG), which included global and national NCD experts, in a three-step process using two Web-based surveys and one in-person meeting. First, we used Delphi methodology to generate topics. Eighteen stakeholders from both CCB and SAG responded to the first Web-based survey generating 165 research ideas during the first round. After accounting for clustering and duplication, we had 56 unique research ideas. Second, these ideas were deliberated upon during the in-person meeting where each participant with a set of 10 stickers placed them next to the research priority(ies) that they felt are important for prevention and control of cancer and NCDs in India. This generated 23 research ideas, which were subjected to SWOT analysis in pairs by the stakeholders using Snowcard methodology with SAG and CCB. The stakeholders prioritized the shortlisted topics based on level of effort and potential to impact NCDs in India. Finally, 15 low effort, high impact priority research ideas for various health outcomes across research disciplines were identified based on discussion with the larger group to reach consensus. The second Web-based survey resulted in identification of 5 key priority research ideas by all stakeholders as being the most important. Results: The 5 prioritized research ideas in order of importance are: (1) development of interventions to empower primary physicians and health workers in early diagnosis of NCDs; (2) evaluation of health system strengthening programs for NCD control; (3) feasibility of integrated care models at primary care level to address multimorbid chronic conditions; (4) development of India specific methods and tools for monitoring trends on NCD morbidity, mortality and risk factors; and (5) identification of effective strategies to mobilize individuals toward NCD screening activities. Conclusion: Development of a consensus research agenda for India is a critical gap needed to pursue resources required to address pressing needs in cancer and other NCDs. The rising mortality and morbidity resulting from cancer and NCDs with similar risk factors, warrants the timely implementation of this agenda. This will generate the evidence-base from which new policies and practices can be used to reduce cancer and other NCDs in India.

Topical antimicrobial prophylaxis in colorectal surgery for the prevention of surgical wound infection: a systematic review and meta-analysis

BACKGROUND

Among the techniques investigated to reduce the risk of surgical wound infection or surgical space infection (SSI) in patients having colorectal surgery are topical application of antimicrobials (antibiotics and antiseptics) to the open wound or immediately after closure. The aim of the present study was to perform a systematic review of the literature on those treatments, with the exception of antibiotic ointments applied to closed skin, which are adequately assessed elsewhere, and a meta-analysis.

METHODS

Only randomized trials of patients having only colorectal surgery were included in this review. Studies were sought in MEDLINE, EMBASE, the Cochrane Register of Controlled Trials, Clinical Trials.gov, and the World Health Organization Internet clinical trials register portal. In addition, reference lists of included studies and other published reviews were screened. Meta-analysis was performed for all included studies and subgroup analyses done for each individual intervention. Risk of bias was assessed for each included study, paying particular attention to the preoperative antibiotic prophylaxis used in each study. Sensitivity analyses were done to investigate heterogeneity of the analyses, excluding those studies with a significant risk of bias issues. Absolute risk reduction (RR) was calculated. The overall quality of the evidence for each individual intervention was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, and was classified as high, moderate, low or very low.

RESULTS

A total of 30 studies are included in this review with 5511 patients, 665 of whom had SSI. The interventions included: 10 studies of gentamicin impregnated sponge or beads wound inlays, 4 studies of chlorhexidine impregnated suture, 11 studies of direct wound lavage or powder application or injection of antibiotics before closure, 4 studies of ionized silver dressing applied to the closed skin, and 1 study of vitamin E oil applied to the open wound. All but one study used preoperative antibiotic prophylaxis in addition to topical procedures, although, in some studies, the systemic antibiotic prophylaxis was not the same between groups or varied significantly from the recommended guidelines. Use of gentamycin sponge did not decrease SSI (RR 0.93, 95% CI 0.75-1.16; low-quality evidence) even after including only the studies of abdominal wounds (RR 1.02, 95% CI 0.80-1.30; low-quality evidence). However, sensitivity analysis excluding studies at high risk of bias decreased the heterogeneity and increased the effect of the prophylaxis for all wounds (RR 0.5, 95% CI 0.33-0.78; low-quality evidence) and for abdominal wounds only (RR 0.38, 95% CI 0.20-0.72; moderate-quality evidence). Chlorhexidine impregnated suture showed no effect on SSI (RR 0.79, 95% CI 0.56-1.10; low-quality evidence) and an increased efficacy after sensitivity analysis (RR 0.42, 95% CI 0.22-0.79; low-quality evidence). Antibiotic lavage showed a significant decrease in SSI (RR 0.45, 95% CI 0.26-0.79; low-quality evidence) which increased after sensitivity analysis (RR 0.33, 95% CI 0.15-0.72; moderate-quality evidence). Application of silver dressing to the closed wound resulted in a decrease of SSI (RR 0.55, 95% CI 0.35-0.85; moderate-quality evidence). The one study of topical vitamin E oil applied to the open wound showed a significant risk reduction (RR 0.22, 95% CI 0.05-0.98; low-quality evidence).

CONCLUSIONS

Each of these interventions appears to be effective in decreasing SSI, but the number of studies for each is small and the quality of evidence is very low to moderate. Within the various outcomes of GRADE assessment, even a moderate classification suggests that further studies may well have very different results.. No randomized trials exist of combinations of two or more of the above interventions to see if there is a combined effect. Future studies should make sure that the antibiotic used preoperatively is uniform within a study and is consistent with the current guidelines. Deviation from this leads to a significant heterogeneity and risk of bias.

Session 2: What causes liver metastases - lymph nodes or is it something else?

The traditional view of progression of disease in cancer is the sequential spread of tumour to locoregional lymph nodes and then to distant metastases. However, this view may need to be challenged and modern pathology techniques such as immunohistochemistry and tumour profiling can provide us with a greater insight into the pathways and mechanisms of distant spread. Professor Nagtegaal discusses the evidence for reconsidering the current paradigm and reflects on the need for further investigation into mechanisms of distant metastatic spread.

Session 2: Mutational discordance: the big challenge in personalized treatments - any solutions?

The great challenge for oncologists treating patients who are developing or progressing with metastatic disease is to be able to offer a truly personalized and targeted therapy that can have an early and meaningful effect on the course of the disease. At present the known molecular markers are limited in their frequency and reliability in determining the use of newer chemotherapies. Professor Eng discusses the challenges faced in ensuring timely and effective treatments based on the molecular profile of the tumour and the potential role of real-time analysis of mutational changes in the tumour when progression occurs.

Assessment of serum apolipoprotein B and apolipoprotein A-1 and their ratio in healthy full term small for gestational age newborns

BACKGROUND

Programmed changes in growth restricted fetuses can increase the risk of adulthood diseases due to elevated serum cholesterol and apolipoprotein-B (Apo-B) concentrations. Increasing evidence demonstrated the role of apoB/apoA-I ratio as a strong risk factor for cardiovascular diseases.

OBJECTIVE

To determine the concentration of cord blood lipoproteins and apolipoproteins as well as their correlation with birth weight.

METHODS

This cross-sectional study was conducted in a teaching institution in central India. Healthy full-term newborns, born out of normal vaginal deliveries, were recruited. Cases include term small for gestational age (SGA) babies while term appropriate for gestational age (AGA) babies were taken as controls. Their umbilical venous blood was collected and sent for biochemical analysis.

RESULTS

Out of 126 healthy newborns, 66 were cases and 60 were controls. Mean values of serum triglyceride (141.56±69.67 mg/dl vs. 113.67±33.38 mg/dl; p < 0.006; 95% CI = 8.31 to 47.46) and serum apo-B/apo-A-1 ratio (0.67±0.28 vs. 0.55±0.20; p < 0.007; 95% CI = 0.033 to 0.206) were significantly high and that of serum high density cholesterol (35.84±10.42 mg/dl vs. 40.73±11.70 mg/dl; p < 0.014; 95% CI = -8.79 to -0.98) and Apo-A1 [87.59±12.44 mg/dl vs. 101.87±35.07 mg/dl; p = 0.002; 95% CI = -23.39 to -5.16) were significantly low in SGA newborns. Serum cholesterol, very low-density cholesterol rlow-density cholesterol rand Apo-B did not show any significant difference. Among SGA newborns significant negative correlation was seen between birth weight and apo-B/apo-A1 and serum triglyceride, while birth weight and serum apo-A1 level showed significant positive correlation. There was no statistically significant correlation between birth weight and other parameters.

CONCLUSION

These findings further support the association of prenatal factors with lipid profile rand can serve as starting point for studying lipid transport system changes during early life in Indian population.

Randomised clinical study: GR-MD-02, a galectin-3 inhibitor, vs. placebo in patients having non-alcoholic steatohepatitis with advanced fibrosis

BACKGROUND

Non-alcoholic steatohepatitis (NASH) and resultant liver fibrosis is a major health problem without approved pharmacotherapy. Pre-clinical results of GR-MD-02, a galectin-3 inhibitor, suggested potential efficacy in NASH with advanced fibrosis/cirrhosis and prompted initiation of a clinical development programme in NASH with advanced fibrosis.

AIM

To evaluate the safety, pharmacokinetics and exploratory pharmacodynamic markers of GR-MD-02 in subjects having NASH with bridging fibrosis.

METHODS

The GT-020 study was a first-in-human, sequential dose-ranging, placebo controlled, double-blinded study with the primary objective to assess the safety, tolerability and dose limiting toxicity of GR-MD-02, in subjects with biopsy-proven NASH with advanced fibrosis (Brunt stage 3). The secondary objectives were to characterise first-dose and multiple-dose pharmacokinetic profiles and to evaluate changes in potential serum biomarkers and liver stiffness as assessed by FibroScan.

RESULTS

GR-MD-02 single and three weekly repeated of 2, 4 and 8 mg/kg revealed no meaningful clinical differences in treatment emergent adverse events, vital signs, electrocardiographic findings or laboratory tests. Pharmokinetic parameters showed a dose-dependent relationship with evidence of drug accumulation following 8 mg/kg (~twofold).

CONCLUSIONS

GR-MD-02 doses were in the upper range of the targeted therapeutic dose determined from pre-clinical data and were safe and well tolerated with evidence of a pharmacodynamic effect. These results provide support for a Phase 2 development programme in advanced fibrosis due to NASH.

Current trends of seroprevalence of transfusion transmitted infections in Pakistani β-thalassaemic patients

BACKGROUND

Though regular blood transfusion improves the survival, it carries the unavoidable risk of transfusion transmitted infections (TTI) in β-thalassaemic patients. Owing to the lack of uniformity in blood screening practices in Pakistan, TTI is still a major challenge.

OBJECTIVES

To study the current trends of TTI in regularly transfused β-thalassaemics and their correlation with age, number of transfusions, hematological and biochemical markers.

METHODS

We carried out a prospective case-control study. 100 β-thalassemic patients and 200 healthy donors were recruited from June 2011 to June 2014. HCV antibodies, Hepatitis B surface antigen and human immunodeficiency virus antibodies (I & II) were evaluated. Complete blood counts, LFTs and serum ferritin were tested on all patients.

RESULTS

Mean age of patients and controls was 11.18±5.07 and 20.5±1.87 years respectively. In patients, 54% and 46% were males and females respectively. Anti-HCV antibody and HbsAg were positive in 27% versus 3% and 3% versus 2% in patients and controls respectively. None of the patients and controls was HIV reactive. Seropositivity of Anti-HCV was significantly higher in patients than that of controls (P<0.001). Anti-HCV positively correlated with age above 10 years, numbers of transfusions (≥150 units), high serum ferritin, elevated ALT and alkaline phosphatase (P<0.001).

CONCLUSIONS

Over the decade, TTI magnitude has significantly reduced, but hepatitis C is still a main hazard. Further preventive measures including nucleic acid testing, voluntary donation and stringent donor selection will be required for reducing TTI in β-thalassaemics.

Relationship between carotid intima thickness and silent cerebral infarction in patients with type 2 diabetic nephropathy

AIM

To examine the relationship between carotid intima media thickness (CIMT) and silent cerebral infarction (SCI) in order to determine whether CIMT is a predictor of SCI in patients of type 2 diabetic nephropathy.

METHODS

A total of 80 patients of type 2 diabetic nephropathy were selected on the basis of fasting and 2-hour post-prandial blood sugar, 24 hrs albumin estimation in urine, urea and creatinine in the serum. The selected candidates underwent MRI brain and carotid B mode ultrasonography to find out the event of SCI and to evaluate the CIMT respectively.

RESULTS

The SCI was found in 30 (37.5%) patients with type 2 diabetic nephropathy. The mean age, BMI, blood pressure (BP), macroalbuminuria, S. lipids, low GFR, duration of diabetes and CIMT were significantly higher in the subject with SCI than in those without it. Multiple logistic analyses indicated that age, BP, and CIMT were found to be significant and independent risk factors of SCI in type 2 diabetic nephropathy subjects.

CONCLUSION

CIMT is a surrogate and reliable predictor of higher risk of SCI among type 2 diabetic nephropathy patients.

Abstract T P354: The Role of Lindegaard Ratio on TCD for Predicting Angiographic Vasospasm Following Aneurysmal Subarachnoid Haemorrhage

Background and objective: Middle cerebral artery (MCA) Lindegaard ratio (LR) has been used as indicator of moderate to severe vasospasm (VSP) following subarachnoid hemorrhage (SAH). However there have been many criticisms about the ability to detect impending vasospasm using Transcranial Doppler (TCD). The purpose of this study was to determine the correlation between TCD Mean Flow Velocities (MFV) and angiographic VSP after aneurysmal SAH using LR of several anterior circulation vessels.

Methods: The study population included prospective collected data of 134 patients with aneurysmal SAH admitted to University of Alberta hospital from January 2006 to December 2008. Complete TCD was performed daily from day 2 to 14 from symptoms onset. All patients underwent cerebral angiography on admission and within 7 days following onset of symptoms. The M1, M2 MCA, ACA and intracranial ICA/ipsilateral extra cranial ICA velocity ratios (LR) were calculated and correlation was made with the presence of angiographic vasospasm (defined as more than one-third luminal narrowing). Then, anterior circulation LR was defined as the highest LR in the ipsilateral anterior circulation arteries. Moderate to severe VSP was defined as LR > 3.

Results: Results are shown in table.

The probability of VSP in the presence of one anterior circulation vessel LR > 3 is 14 % (2/14), 2 vessels LR >3 (4/16. 16 %), 3 vessels LR > 3 (3/6, 50 %) and 4 vessels LR >3 (5/5 = 100 %). (P< 0.001)

Conclusion: LR of M2 MCA has higher sensitivity compared to other vessels and ACA LR has less sensitivity but more specificity whereas the rest of anterior circulation LR had modest predictive value. The likelihood of VSP increases as more number of vessels in anterior circulation shows LR>3. LR should not be interpreted in a blind fashion to the rest of TCD MFV numbers.

Biochemical alteration of hepatic functions by histamine H3-receptor agonist and antagonist in immunized rabbits

AIM

The aim of our study was to investigate the functional roles of H3R agonist and antagonist in the development of hepatic functions impairment in immunized rabbits.

METHODS

The study comprised of six groups containing 18 rabbits in each. Group-I (negative control) and group-II (positive control) received sterile distilled water intramuscularly while Group III-VI received histamine (100 µgkg-1, s.c.), R-[-]-α-methylhistamine (H3R-agonist, 10 µgkg-1, s.c.), iodophenpropit (H3R-antagonist, 1 µgkg-1, i.m.), and the combination of iodophenpropit (1 µgkg-1, i.m.) plus histamine (100 µgkg-1, s.c.), respectively, b.i.d. (12 hours [8 am and 8 pm]) for 10 days. Groups II-VI were immunized on day 3 with intravenous injection of sheep red blood cells (1×109 cells/ml).

RESULTS

On each experimental day, the mean values of serum enzymes and bilirubin in group-I and group-II showed no changes while in groups III, IV, V, and VI, these enzymes and bilirubin levels showed significant changes (p<0.05), when compared with their values within the group. Profile of ALT and AST production revealed that ALT and AST levels moderately were changed due to degeneration of the liver.

CONCLUSION

Our results suggest that R-[-]-α-methylhistamine showed moderate, and histamine and iodophenpropit showed mild degeneration of liver functions; while iodophenpropit plus histamine showed hepatic functions similar to control group. This study suggests that H3R antagonist in combination with histamine may be a non-toxic therapeutic target for histamine research (Fig. 7, Ref. 28). Text in PDF www.elis.sk.