14 research outputs found
Efficiency Measurement in the Local Public Sector: Econometric and Mathematical Programming Frontier Techniques
No full textLocal government in advanced economies is undergoing a period of rapid reform aimed at enhancing its efficiency and effectiveness. Accordingly, the definition, measurement and improvement of organisational performance is crucial. Despite the importance of efficiency measurement in local government it is only relatively recently that econometric and mathematical frontier techniques have been applied to local public services. This paper attempts to provide a synoptic survey of the comparatively few empirical analyses of efficiency measurement in local government. We examine both the measurement of inefficiency in local public services and the determinants of local public sector efficiency. The implications of efficiency measurement for practitioners in local government are examined by way of conclusion.
Organised care of acute stroke at Groote Schuur Hospital : a controlled trial
No full textIncludes bibliographical references.Background and purpose: Groote Schuur Hospital (GSH) admits about 570 stroke patients annually. These patients about occupy 10% of acute medical beds. Recent investigations have demonstrated that stroke services are poorly organised Although "Organised stroke care" has been shown to improve outcomes, this has not been demonstrated locally. This study was undertaken to determine whether stroke unit care within a general medical ward improves outcomes. Study design and sampling: The study was a prospective non-randomised controlled trial, with systematic allocation by admission day. of all acute stroke admissions to the Department of Medicine from 1 January to 15 May 1996. Intervention: There were three comparison groups: in the Stroke Intervention Ward, the intervention was implemented by the author; in the Guidelines Ward, the manner in which the intervention can be set up and implemented was provided in the form of a Guidelines Booklet and in the Control Ward, stroke patients received routine care. The intervention consisted of (i) geographic/spatial unity and allocation of a designated nurse; (ii) use of a Stroke Clerking Pro forma and (iii) a multidisciplinary Team Care Plan and Post Intake Stroke Ward Round. Results: 58 patients were admitted to the Stroke Intervention Ward, 40 patients were admitted to the Guidelines Ward and 91 were admitted to the 2 Control Wards. The groups had similar baseline characteristics, except for the percentage of patients continent on admission. There were no significant differences in the Modified Barthel Index prior to admission, at discharge or at follow-up. There were no significant differences in the principal outcome measures (death, dependency, death or dependency, institutionalisation and death or institutionalisation) between the comparison groups. The median [inter-quartile range] length of hospital stay in days was significantly reduced in the Stroke Intervention Ward (6.5[5-9]) compared to the Guidelines Ward (9[7-14]) and the Control Wards (8[5-12]). The referral rates to Professionals Allied to Medicine were significantly increased in the Stroke Intervention Ward, except for referrals to the Community Liaison Sister. The referral rates to rehabilitation resources on discharge were significantly increased in the Stroke Intervention Ward, except for referrals to physiotherapy. Conclusions: Organised Stroke Care is feasible in our setting and results in improved utilisation of resources without increasing length of stay. However, principle outcome measures were not significantly altered in this study
What makes a cherry red?: an investigation into flavonoid pathway regulation in sweet cherry (Prunus avium L.) fruit.
No full textColour is an important fruit quality indicator because many consumers make their selections based primarily on this trait. Inheritance of colour has been studied within sweet cherry (Prunus avium L.) populations and as a result fruit colour is thought to be determined by three genetic factors. A flesh colour factor (F) and the major skin colour factor (A) are the main determinants of fruit colour, where red pigmentation is incompletely dominant over yellow. A third factor, the minor skin colour factor (B), can produce blush skin but is epistatically masked by a dominant A allele. The pigments that colour fruit are known as anthocyanins, synthesised via the transcriptionally regulated flavonoid pathway, which also synthesizes the related secondary metabolites, condensed tannins and flavonols. In other fruit and flower species, mutations in flavonoid pathway or regulatory genes can lead to non-functional alleles that explain the inheritance of colour. However the genes encoding the genetic colour factors are not known in sweet cherry. Therefore, this research has endeavoured to study the cherry flavonoid pathway and its transcriptional regulation, with a view to determining the genetic differences responsible for yellow, blush, red and black cultivars. To achieve this aim, genes encoding flavonoid pathway enzymes and putative regulators of flavonoid synthesis were isolated from the red sweet cherry cultivar ‘Lapins’. PaMYBA1, an R2R3-MYB factor, possessing a high degree of sequence similarity with characterised anthocyanin regulators and conserved C-terminal motifs common within this type of protein, was identified. Functional characterisation of PaMYBA1 demonstrated its ability to activate transcription from the promoters of chalcone synthase (MdCHS), which encodes an enzyme that performs the first committed step in the synthesis of flavonoids, and the anthocyanin biosynthetic gene UDP-glycosyl:flavonoid-3-O-glycosyltransferase (MdUFGT). Furthermore, correlation between anthocyanin accumulation and the expression profile of PaMYBA1 in developing ‘Lapins’ fruit and light-treated blush-skinned ‘Ranier’ fruit suggest that PaMYBA1 might be an important colour factor. Transcript analysis revealed that PaMYBA1 is necessary for the production of colour in cherries; PaMYBA1 is not expressed in the solid yellow fruit of ‘Yellow Glass’ that lacks anthocyanins. However, similar levels of expression of PaMYBA1 in blush, red and black sweet cherry fruit indicate that there are additional factors that contribute to differences in colour intensity. The intense colour and increased flavonoid levels of the black sweet cherry ‘Sam’, compared with the blush and red fruits tested, correlated with a large increase in the expression of the putative tannin regulator PaMYBPA1 in this cultivar. In a functional assay, PaMYBPA1 could trans-activate not only the promoters of the tannin genes anthocyanidin reductase (VvANR) and leucaonthocyanidin reductase (VvLAR), but also of MdCHS and MdUFGT. Therefore, it is possible that PaMYBPA1 could regulate both tannin and anthocyanin synthesis, particularly when expressed at high levels. Taking into consideration the expression of flavonoid pathway genes in different sweet cherry cultivars and tissues, and under different environmental conditions, together with published scientific observations of the genetic factors contributing to fruit colour, we have developed a working model for flavonoid pathway regulation in sweet cherry fruit. Aspects of the model remain to be determined, such as the involvement of two additional anthocyanin-type MYB factors PaMYBA2 and PaMYBA3 in fruit pigmentation. However, it provides a general understanding of differences in the activity of the flavonoid pathway between sweet cherry cultivars, and moves us closer to knowing the identity of the inherited factors that determine skin and flesh colour in sweet cherry fruit.Thesis (Ph.D) -- University of Adelaide, School of Agriculture, Food and Wine, 201
Uroplectes zambezicus Prendini 2015, sp. nov.
No full textUroplectes zambezicus, sp. nov. Figures 1, 2D, F, 3C, D, 4E, F, 7B, D, 8B, D, 9B, D, 12, 13; table 2 Uroplectes chubbi Hirst, 1911: FitzPatrick, 1996: 64; FitzPatrick, 2001: 191 [misidentification: NHMZ S84/89, S85/17, S86/5, S86/71, S90/17, S95/129]. HOLOTYPE: MOZAMBIQUE: Tete Province: Tete District: Zambezi River, N side, 2.4 km towards Chiuta on road EN222 from junction with road EN103 (Tete – Zòbué), 16°06′50″S 33°37′01″E, 150 m, 10.xii.2007, L. Prendini and W. R. Schmidt, arid mopane savanna on alluvial silty-loam soil with scattered shale and sandstone outcrops, taken under small stone during day, 1 ♂ (AMNH). PARATYPES: MOZAMBIQUE: Tete Province: Moatize District: Tenge Hill, 15°43.424′S 33°46.313′E, 361 m, 22–24.iii.2013, P.G. Hawkes and J.N. Fisher, 2 ♀ (AMNH), 6.ix.2013, P.G. Hawkes and J.N. Fisher, day collecting, 11 ♂, 1 ♀ (AMNH), night collecting with UV, 18:30– 20:30, 1 ♂ (AMNH), 7.ix.2013, P.G. Hawkes and J.N. Fisher, day collecting, 1 ♂, 2 ♀ (AMNH); 15°44.900′S 33°46.159′E, 237 m, 7.ix.2013, P.G. Hawkes and J.N. Fisher, mopane woodland, night collecting with UV, 19:00, 1 ♀ (AMNH). Tete District: Zambezi River, N side, 2.4 km towards Chiuta on road EN222 from junction with road EN103 (Tete – Zòbué), 16°06′50″S 33°37′01″E, 150 m, 10.xii.2007, L. Prendini and W. R. Schmidt, arid mopane savanna on alluvial silty-loam soil with scattered shale and sandstone outcrops, collected with UV detection on warm and humid, still, dark night, running or walking on surface, mainly in leaf-litter around base of bushes and in rocky areas, syntopic with Hottentotta trilineatus (Peters, 1861), 11 ♂, 7 ♀ (AMNH), 3 first instars (AMCC [LP 8230]); Tete, base of hill with communications tower overlooking town (at bend in road), 16°12′58.9″S 33°34′27.7″E, 189 m, 10.xii.2007, L. Prendini and W. R. Schmidt, arid savanna with baobabs on alluvial silty-loam soil, fairly dense vegetation cover, UV light detection on warm and humid, dark night, running on ground surface, especially in leaf-litter under tree canopy, syntopic with H. trilineatus and Uroplectes planimanus (Karsch, 1879), 4 ♂, 3 ♀ (AMNH), 1 ♂ (AMCC [LP 8229]); Tete, midslope on hill with communications tower overlooking town, 16°12′55″S 33°34′12″E, 245 m, 10.xii.2007, L. Prendini and W. R. Schmidt, arid savanna with baobabs, UV detection on warm and humid, dark night, on rocky slopes along road, sympatric with Hadogenes troglodytes (Peters, 1861), H. trilineatus and U. planimanus, 1 ♂ (AMNH). ZAMBIA: Lusaka Province: Chiawa, junction of Kafue and Zambezi rivers, 15°53.011′S 28°53.942′E, 442 m, 21.iv.2015, W. Conradie, mopane woodland, caught in reptile trap (bucket pitfalls), 1 ♂, 1 ♀ (AMNH), 1 ♂ (AM). ZIMBABWE: Mashonaland Central Province: Guruve District: Guruve, 4 km NE Gonono School [16°05′S 30°50′E], 28.iii.1997, F. Nyathi, under log, 1 ♀ (NHMZ S97/21), 31.iii.1997, F. Nyathi, pitfall traps, 1 ♂ (NHMZ S97/2); Guruve, 7 km E Mushumbi Pools [16°06′S 30°32′E], 22.iii.1997, F. Nyathi, under mopane bark, 3 ♀ (NHMZ S97/11). Mashonaland West Province: Hurungwe District: Hurungwe Safari Area: Rifa Conservation Camp [16°10′S 28°50′E], 4–9.xii.1995, Girls’ College and NHMZ, pitfall traps, 10 ♂, 4 ♀, 1 subad. ♀, 1 juv. ♂, 2 first instars (NHMZ S 96/9). Mana Pools National Park: Nyakasikana Fly Gate, Mana Pools [16°03′S 29°24′E], 9.xii.1984, Falcon College Expedition, 1 ♀ (NHMZ S 86/5). Kariba District: Matusadona National Park: Chin- gachereyari, Matusadona, 16°44′S 28°40′E, 13.viii.1983, Zimbabwe Schools Expedition Society, 1 subad. ♂ (NHMZ S 83/141); Mbizi Pan, Matusadona [16°49′S 28°28′E], 12.xii.1983, G. Putterill, 1 ♂ (NHMZ S 84/89). Matabeleland North Province: Hwange District: Chisuma area [18°01′S 25°57′E], 31.vii.1990, F. Nyathi, 2 ♂, 1 subad. ♂, 2 subad. ♀ (NHMZ S 90/17); Dete [18°38′S 26°52′E], 6.ii.1985, D. Adams, 1 ♀ (NHMZ S 85/17); Mzola Camp [18°30′S 27°24′E], 4.xii.1997, Girls’ College and NHMZ, 1 ♀ (NHMZ S 13/4 ex S 99/20); Mzola Camp, 2 km N Homestead [18°30′S 27°24′E], 11.xii.1997, Girls’ College and NHMZ, under bark, 2 ♀ (NHMZ S 99/16, S 99/17). Hwange National Park: Robin’s Camp [18°38′S 25°59′E], 1.ii.1986, N. English, 1 ♀ (NHMZ S 86/71); Wankie [Hwange], 18°22′S 26°29′E, v.1961, D.G. Broadley, 1 ♀ (NMSA 8319). Matetsi Safari Area: Kasetsheti Weirs, Matetsi [18°18′S 25°48′E], 11.x.1988, F. Nyathi, 1 ♂ (NHMZ S 89/3); Rosslyn Camp, Matetsi, Tshowe River [18°30′S 25°55′E], 5–10.xii.1994, Girls’ College and NHMZ, 1 ♀ (NHMZ S 95/129). ETYMOLOGY: The specific epithet is derived from the Zambezi River Valley, where all the known localities of the new species are located. DIAGNOSIS: Uroplectes zambezicus, sp. nov., appears to be most closely related to U. malawicus, sp. nov., based on the lower pectinal tooth count (15–17) and enlarged basal pectinal tooth of the female in both species, by means of which they may be separated from U. katangensis, sp. nov., in which the pectinal tooth count is higher (18–19) and the basal pectinal tooth unmodified in the female. Uroplectes zambezicus, sp. nov., differs from U. malawicus, sp. nov., and U. katangensis, sp. nov., in possessing a slightly broader chela manus and a shorter, broader metasoma (more so in the adult male) as well as less uniform coloration. The tergites exhibit a narrow immaculate stripe medially and sometimes a pair of narrow immaculate stripes laterally in U. zambezicus, sp. nov., but are almost entirely infuscate in U. malawicus, sp. nov., and U. katangensis, sp. nov. The chelicerae, pedipalp trochanter, femur, patella, and legs are entirely immaculate in U. zambezicus, sp. nov., whereas the dorsal surfaces of the chelicerae, lateral surfaces of the pedipalp patella, and often dorsal and prodorsal surfaces of the pedipalp femur and trochanter, as well as dorsal and retrolateral surfaces of the leg femora, patellae, and tibia are partially infuscate in U. malawicus, sp. nov. Metasomal segment IV is often paler in U. zambezicus, sp. nov., than in U. malawicus, sp. nov. Uroplectes zambezicus, sp. nov., differs further from U. katangensis, sp. nov., in the lower counts of median denticle subrows on the fixed and movable fingers of the pedipalp chela (11 or 12 vs. 13, respectively), and from U. malawicus, sp. nov., in the less numerous and pronounced spiniform granules in the distal half of the chela manus prodorsal surface in the adult male. DESCRIPTION: The following account, which is based on the type material, describes only those characters that differ from U. malawicus, sp. nov. Total length: Adult: small, maximum length, measured from anterior margin of carapace to tip of aculeus, 23 mm (20–27 mm, n = 6) (♂), 26 mm (24–27 mm, n = 6) (♀) (table 2). Color: As for U. malawicus, sp. nov., except as follows (figs. 2D, F, 12). Chelicerae, pedipalp trochanter, femur, patella, and legs entirely immaculate. Carapace mostly infuscate except for a pair of narrow immaculate stripes laterally in some specimens. Tergites mostly infuscate except for narrow immaculate stripe medially and, in some specimens, a pair of narrow immaculate stripes laterally Carapace: As for U. malawicus, sp. nov., except as follows (fig. 3C, D). Anterior width of posterior width, 52% (51%–46%, n = 6) (♂), 56% (47%–78%, n = 6) (♀) (table 2); posterior width of length, 104% (96%–110%, n = 6) (♂), 106% (75%–119%, n = 6) (♀). Median ocular tubercle, distance from anterior carapace margin 41% (n = 6) (♂), 40% (n = 6) (♀) of carapace length. . Pedipalps: As for U. malawicus, sp. nov., except as follows (fig. 13). Femur width of length, 32% (30%–34%, n = 6) (♂), 34% (30%–36%, n = 6) (♀) (table 2). Patella width of length, 37% (35%–40%, n = 6) (♂), 39% (38%–40%, n = 6) (♀). Chela manus, width of height, 102% (100%–107%, n = 6) (♂), 108% (100%–116%, n = 6) (♀); width of length along ventroexternal carina, 57% (54%–62%, n = 6) (♂), 62% (56%–67%, n = 6) (♀); length along ventroexternal carina of length movable finger, 68% (59%–90%, n = 6) (♂), 57% (53%–63%, n = 6) (♀). Manus surfaces smooth except prodorsal surface with relatively dense spiniform granules, more numerous and pronounced in distal half (♂) (fig. 13E–H) or few small scattered spiniform granules (♀). Fixed and movable fingers, median denticle rows respectively comprising 11 (11–12, n = 12) and 12 (12–13, n = 12) oblique denticle subrows. Pectines: As for U. malawicus, sp. nov., except as follows (fig. 4E, F). Pectinal teeth curved, all similar in size (♂) or basal pectinal tooth enlarged, approximately twice the size of other teeth (♀); tooth count, 16/17 (15–17/15–18, n = 12) (♂), 16/16 (15–17/16–17, n = 12) (♀) (table 2). Mesosoma: As for U. malawicus, sp. nov., except as follows. Sternite VII, length of width, 62% (49–74%, n = 6) (♂), 53% (48–57%, n = 6) (♀) (table 2). Metasoma and telson: As for U. malawicus, sp. nov., except as follows (figs. 7B, D, 8B, D, 9B, D). Metasomal segment V, width of segment I, width, 109% (107%–114%, n = 6) (♂), 109% (105%–113%, n = 6) (♀) (table 2). Metasoma width of length, segment I, 92% (84%– 98%, n = 6) (♂), 107% (103%–110%, n = 6) (♀); II, 81% (78%–88%, n = 6) (♂), 96% (93%–102%, n = 6) (♀); III, 80% (75%–88%, n = 6) (♂), 92% (87%–96%, n = 6) (♀); IV, 74% (70%–83%, n = 6) (♂), 84% (80%–87%, n = 6) (♀); V, 71% (67%–79%, n = 6) (♂), 81% (80%–85%, n = 6) (♀). Telson vesicle, width of metasomal segment V, 62% (57%–66%, n = 6) (♂), 64% (58%–86%, n = 6) (♀); height of length, 64% (60%–68%, n = 6) (♂), 65% (62%–70%, n = 6) (♀). Aculeus length of vesicle length, 70% (65%–76%, n = 6) (♂), 69% (59%–81%, n = 6) (♀). Length metasoma and telson, of total length, 59% (56%–60%, n = 6) (♂), 56% (55%–57%, n = 6) (♀). DISTRIBUTION: Presently recorded from five localities in Mozambique, one in Zambia and thirteen in Zimbabwe (fig. 1). All known locality records fall within the Zambezi River Valley. ECOLOGY: The known material was collected in arid savanna, dominated by the mopane tree, Colophospermum mopane (Benth.) J. Léonard, in the Zambezi River Valley. Zimbabwean material deposited in the NHMZ was collected under tree bark and logs, and in pitfall traps. Recently collected material originates from three localities at elevations of 150–360 m in the vicinity of Tete, Mozambique, and a fourth locality, at an elevation of 442 m, north of the junction of the Kafue and Zambezi rivers, in Zambia. The two Mozambican localities at which material was collected by the author differ in habitat. The habitat near Tete was fairly dense mixed broadleaf woodland with baobab trees, Adansonia digitata L. (fig. 2C), on alluvial silty-loam soil, around the base and on the lower slopes of a rocky hill. Specimens were collected with UV light detection on a warm and humid, moonless night, running on the ground surface, especially in leaf litter under the tree canopy (fig. 2E). The habitat on the north side of the Zambezi River was more open, arid mopane woodland with scattered shale and sandstone outcrops, also on alluvial silty-loam soil. One specimen was found under a small stone during the day. The others were found with UV detection on a warm, still, moonless, humid night, running or walking on the ground surface, mainly in leaf litter around the base of bushes and in rocky areas. The material from Zambia was collected in reptile traps (bucket pitfall traps) in mopane woodland (W. Conradie, personal commun.). The habitat and habitus (figs. 2D, F, 12) of U. zambezicus, sp. nov., are consistent with the lapidicolous and corticolous ecomorphotypes (Prendini, 2001). Five buthids, Hottentotta trilineatus, Parabuthus mossambicensis (Peters, 1861), Uroplectes flavoviridis, U. planimanus, and U. xanthogrammus, a hormurid, Hadogenes troglodytes, and two scorpionids, Opistophthalmus carinatus (Peters, 1861) and O. glabrifrons, were collected in sympatry at one or more of the collection localities in Mozambique and Zimbabwe.Published as part of Prendini, Lorenzo, 2015, Three new Uroplectes (Scorpiones: Buthidae) with punctate metasomal segments from tropical central Africa, pp. 1-32 in American Museum Novitates 2015 (3840) on pages 21-26, DOI: 10.1206/3840.1, http://zenodo.org/record/536835
Practical “1-2-3-4-Day” Rule for Starting Direct Oral Anticoagulants After Ischemic Stroke With Atrial Fibrillation: Combined Hospital-Based Cohort Study
No full textBackground: The "1-3-6-12-day rule" for starting direct oral anticoagulants (DOACs) in patients with nonvalvular atrial fibrillation after acute ischemic stroke or transient ischemic attack recommends timings that may be later than used in clinical practice. We investigated more practical optimal timing of DOAC initiation according to stroke severity. Methods: The combined data of prospective registries in Japan, Stroke Acute Management with Urgent Risk-factor Assessment and Improvement-nonvalvular atrial fibrillation (September 2011 to March 2014) and RELAXED (February 2014 to April 2016) were used. Patients were divided into transient ischemic attack and 3 stroke subgroups by the National Institutes of Health Stroke Scale score: mild (0-7), moderate (8-15), and severe (>= 16). The early treatment group was defined as patients starting DOACs earlier than the median initiation day in each subgroup. Outcomes included a composite of recurrent stroke or systemic embolism, ischemic stroke, and severe bleeding within 90 days. Six European prospective registries were used for validation. Results: In the 1797 derivation cohort patients, DOACs were started at median 2 days after transient ischemic attack and 3, 4, and 5 days after mild, moderate, and severe strokes, respectively. Stroke or systemic embolism was less common in Early Group (n=785)-initiating DOACS within 1, 2, 3, and 4 days, respectively-than Late Group (n=1012) (1.9% versus 3.9%; adjusted hazard ratio, 0.50 [95% CI, 0.27-0.89]), as was ischemic stroke (1.7% versus 3.2%, 0.54 [0.27-0.999]). Major bleeding was similarly common in the 2 groups (0.8% versus 1.0%). On validation, both ischemic stroke (2.4% versus 2.2%) and intracranial hemorrhage (0.2% versus 0.6%) were similarly common in Early (n=547) and Late (n=1483) Groups defined using derivation data. Conclusions: In Japanese and European populations, early DOAC initiation within 1, 2, 3, or 4 days according to stroke severity seemed to be feasible to decrease the risk of recurrent stroke or systemic embolism and no increase in major bleeding. These findings support ongoing randomized trials to better establish the optimal timing of DOAC initiation
Oral Anticoagulants in the Oldest Old with Recent Stroke and Atrial Fibrillation
No full textObjective: To investigate the safety and effectiveness of direct oral anticoagulants (DOAC) versus vitamin K antagonists (VKA) after recent stroke in patients with atrial fibrillation (AF) aged ≥85 years. Methods: Individual patient data analysis from seven prospective stroke cohorts. We compared DOAC versus VKA treatment among patients with AF and recent stroke (<3 months) aged ≥85 versus <85 years. Primary outcome was the composite of recurrent stroke, intracranial hemorrhage (ICH) and all-cause death. We used simple, adjusted, and weighted Cox regression to account for confounders. We calculated the net benefit of DOAC versus VKA by balancing stroke reduction against the weighted ICH risk. Results: In total, 5,984 of 6,267 (95.5%) patients were eligible for analysis. Of those, 1,380 (23%) were aged ≥85 years and 3,688 (62%) received a DOAC. During 6,874 patient-years follow-up, the impact of anticoagulant type (DOAC versus VKA) on the hazard for the composite outcome did not differ between patients aged ≥85 (HR≥85y = 0.65, 95%-CI [0.52, 0.81]) and < 85 years (HR<85y = 0.79, 95%-CI [0.66, 0.95]) in simple (pinteraction = 0.129), adjusted (pinteraction = 0.094) or weighted (pinteraction = 0.512) models. Analyses on recurrent stroke, ICH and death separately were consistent with the primary analysis, as were sensitivity analyses using age dichotomized at 90 years and as a continuous variable. DOAC had a similar net clinical benefit in patients aged ≥85 (+1.73 to +2.66) and < 85 years (+1.90 to +3.36 events/100 patient-years for ICH-weights 1.5 to 3.1). Interpretation: The favorable profile of DOAC over VKA in patients with AF and recent stroke was maintained in the oldest old. ANN NEUROL 2022;91:78-88
Potential missed opportunities to prevent ischaemic stroke: prospective multicentre cohort study of atrial fibrillation-associated ischaemic stroke and TIA
No full textObjective We report on: (1) the proportion of patients with known atrial fibrillation (AF); and (2) demographic, clinical or radiological differences between patients with known AF (and not treated) and patients with newly diagnosed AF, in a cohort of patients who presented with ischaemic stroke or transient ischaemic attack (TIA) not previously treated with anticoagulation.Design We reviewed cross-sectional baseline demographic and clinical data from a prospective observational cohort study, (CROMIS-2).Setting Patients were recruited from 79 hospital stroke centres throughout the UK and one centre in the Netherlands.Participants Patients were eligible if they were adults who presented with ischaemic stroke or TIA and AF and had not been previously treated with oral anticoagulation.Main outcome measures Proportion of patients with known AF before index ischaemic stroke or TIA from a cohort of patients who have not been previously treated with oral anticoagulation. Secondary analysis includes the comparison of CHA2DS2-VASc and HAS-BLED scores and other demographics and risk factors between those with newly diagnosed AF and those with previously known AF.Results Of 1470 patients included in the analysis (mean age 76 years (SD 10)), 622 (42%) were female; 999 (68%) patients had newly diagnosed AF and 471 (32%) patients had known AF. Of the 471 patients with known AF, 68% had a strong indication for anticoagulation and 89% should have been considered for anticoagulation based upon CHA2DS2-VASc score. Patients with known AF were more likely to have a prior history of dementia (4% vs 2%, p=0.02) and had higher HAS-BLED scores (median 3 vs 2). CHA2DS2-VASc, other risk factors and demographics were similar.Conclusions About 1/3 of patients who present with stroke and have AF who have not been treated with oral anticoagulation have previously known AF. Of these patients, at least 68% were not adequately treated with oral anticoagulation.Trial registration number NCT02513316
Baseline factors associated with early and late death in intracerebral haemorrhage survivors
No full textBackground and purpose:
The aim of this study was to determine whether early and late death are associated with different baseline factors in intracerebral haemorrhage (ICH) survivors.
Methods:
This was a secondary analysis of the multicentre prospective observational CROMIS‐2 ICH study. Death was defined as ‘early’ if occurring within 6 months of study entry and ‘late’ if occurring after this time point.
Results:
In our cohort (n = 1094), there were 306 deaths (per 100 patient‐years: absolute event rate, 11.7; 95% confidence intervals, 10.5–13.1); 156 were ‘early’ and 150 ‘late’. In multivariable analyses, early death was independently associated with age [per year increase; hazard ratio (HR), 1.05, P = 0.003], history of hypertension (HR, 1.89, P = 0.038), pre‐event modified Rankin scale score (per point increase; HR, 1.41, P < 0.0001), admission National Institutes of Health Stroke Scale score (per point increase; HR, 1.11, P < 0.0001) and haemorrhage volume >60 mL (HR, 4.08, P < 0.0001). Late death showed independent associations with age (per year increase; HR, 1.04, P = 0.003), pre‐event modified Rankin scale score (per point increase; HR, 1.42, P = 0.001), prior anticoagulant use (HR, 2.13, P = 0.028) and the presence of intraventricular extension (HR, 1.73, P = 0.033) in multivariable analyses. In further analyses where time was treated as continuous (rather than dichotomized), the HR of previous cerebral ischaemic events increased with time, whereas HRs for Glasgow Coma Scale score, National Institutes of Health Stroke Scale score and ICH volume decreased over time.
Conclusions:
We provide new evidence that not all baseline factors associated with early mortality after ICH are associated with mortality after 6 months and that the effects of baseline variables change over time. Our findings could help design better prognostic scores for later death after ICH
Cognitive impairment before intracerebral hemorrhage is associated with cerebral amyloid angiopathy
No full textBackground and Purpose—Although the association between cerebral amyloid angiopathy (CAA) and cognitive impairment is increasingly recognized, it is not clear whether this is because of the impact of recurrent intracerebral hemorrhage (ICH) events, disruptions caused by cerebral small vessel damage, or both. We investigated this by considering whether cognitive impairment before ICH was associated with neuroimaging features of CAA on magnetic resonance imaging.
Methods—We studied 166 patients with neuroimaging-confirmed ICH recruited to a prospective multicentre observational study. Preexisting cognitive impairment was determined using the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Magnetic resonance imaging markers of cerebral small vessel disease, including CAA, were rated by trained observers according to consensus guidelines.
Results—The prevalence of cognitive impairment before ICH was 24.7% (n=41) and, in adjusted analyses, was associated with fulfilling the modified Boston criteria for probable CAA at presentation (odds ratio, 4.01; 95% confidence interval, 1.53–10.51; P=0.005) and a higher composite CAA score (for each point increase, odds ratio, 1.42; 95% confidence interval, 1.03–1.97; P=0.033). We also found independent associations between pre-ICH cognitive decline and the presence of cortical superficial siderosis, strictly lobar microbleeds, and lobar ICH location, but not with other neuroimaging markers, or a composite small vessel disease score.
Conclusions—CAA (defined using magnetic resonance imaging markers) is associated with cognitive decline before symptomatic ICH. This provides evidence that small vessel disruption in CAA makes an independent contribution to cognitive impairment, in addition to effects due to brain injury caused directly by ICH
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Cerebral microbleeds and intracranial haemorrhage risk in patients anticoagulated for atrial fibrillation after acute ischaemic stroke or transient ischaemic attack (CROMIS-2): a multicentre observational cohort study
No full textSummary Background: Cerebral microbleeds are a potential neuroimaging biomarker of cerebral small vessel diseases that are prone to intracranial bleeding. We aimed to determine whether presence of cerebral microbleeds can identify patients at high risk of symptomatic intracranial haemorrhage when anticoagulated for atrial fibrillation after recent ischaemic stroke or transient ischaemic attack. Methods: Our observational, multicentre, prospective inception cohort study recruited adults aged 18 years or older from 79 hospitals in the UK and one in the Netherlands with atrial fibrillation and recent acute ischaemic stroke or transient ischaemic attack, treated with a vitamin K antagonist or direct oral anticoagulant, and followed up for 24 months using general practitioner and patient postal questionnaires, telephone interviews, hospital visits, and National Health Service digital data on hospital admissions or death. We excluded patients if they could not undergo MRI, had a definite contraindication to anticoagulation, or had previously received therapeutic anticoagulation. The primary outcome was symptomatic intracranial haemorrhage occurring at any time before the final follow-up at 24 months. The log-rank test was used to compare rates of intracranial haemorrhage between those with and without cerebral microbleeds. We developed two prediction models using Cox regression: first, including all predictors associated with intracranial haemorrhage at the 20% level in univariable analysis; and second, including cerebral microbleed presence and HAS-BLED score. We then compared these with the HAS-BLED score alone. This study is registered with ClinicalTrials.gov, number NCT02513316. Findings: Between Aug 4, 2011, and July 31, 2015, we recruited 1490 participants of whom follow-up data were available for 1447 (97%), over a mean period of 850 days (SD 373; 3366 patient-years). The symptomatic intracranial haemorrhage rate in patients with cerebral microbleeds was 9·8 per 1000 patient-years (95% CI 4·0–20·3) compared with 2·6 per 1000 patient-years (95% CI 1·1–5·4) in those without cerebral microbleeds (adjusted hazard ratio 3·67, 95% CI 1·27–10·60). Compared with the HAS-BLED score alone (C-index 0·41, 95% CI 0·29–0·53), models including cerebral microbleeds and HAS-BLED (0·66, 0·53–0·80) and cerebral microbleeds, diabetes, anticoagulant type, and HAS-BLED (0·74, 0·60–0·88) predicted symptomatic intracranial haemorrhage significantly better (difference in C-index 0·25, 95% CI 0·07–0·43, p=0·0065; and 0·33, 0·14–0·51, p=0·00059, respectively). Interpretation In patients with atrial fibrillation anticoagulated after recent ischaemic stroke or transient ischaemic attack, cerebral microbleed presence is independently associated with symptomatic intracranial haemorrhage risk and could be used to inform anticoagulation decisions. Large-scale collaborative observational cohort analyses are needed to refine and validate intracranial haemorrhage risk scores incorporating cerebral microbleeds to identify patients at risk of net harm from oral anticoagulation. Funding The Stroke Association and the British Heart Foundation.Version of Recor
