Improving Patient Compliance with Vaginal Dilator Therapy by Implementation of Sexual Health Consult in Gynecologic Malignancies after Radiation Therapy

PURPOSE/OBJECTIVE(S)

Typical vaginal dilator therapy (VDT) compliance falls short at approximately 30% of patients in reported studies, which could lead to vaginal stenosis (VS) in as high as 88% of patients who undergo radiation therapy (RT) for gynecologic malignancies. In an ongoing effort to improve adherence to VDT aimed to prevent vaginal stenosis post pelvic and vaginal RT, a prospective study was implemented to assess the feasibility and the impact on vaginal dilator therapy adherence when implementing a consult with the oncology women's sexual health clinic following the completion of radiation therapy.

MATERIALS/METHODS

This was a single institution, prospective analysis and feasibility study that included patients diagnosed with a gynecologic cancer who were treated with RT to the pelvic and or vaginal tissues. Using purposive sampling, the treating radiation oncologists identified eligible patients and referred them to the oncology women's sexual health clinic for consult four to six weeks status post completion of RT in a six-month period. A post treatment survey was conducted via a telephone interview 12 weeks after the sexual health clinic initial consult to assess vaginal dilator therapy compliance. Descriptive statistics were calculated.

RESULTS

Pre-intervention retrospective data analysis revealed poor compliance to VDT with only 3 of 40 (7.5%) patients judged as compliant. Post-intervention, 30 of 37 (81.1%) patients in the sample were judged compliant. The adherence rate in the post-intervention group was significantly higher (Fisher's Exact Test two-tailed p-value < 0.0001). With confidence of 95%, the proportion of the potential population that would adhere post intervention was between 68.5% and 93.7%. Sociodemographic and clinical characteristics did not have a statistically significant correlation with VDT compliance.

CONCLUSION

Implementing a referral to an oncology women's sexual health clinic at the completion of RT for the sample population is feasible. Our project demonstrates that instituting this new sexual health clinic may have a large, positive impact on patient compliance to vaginal dilator therapy. More importantly, this may lead to decrease incidences of vaginal stenosis and improvement in patient health outcomes and quality of life (QoL).

Generation and Functional Analysis of Defective Viral Genomes during SARS-CoV-2 Infection

Defective viral genomes (DVGs) have been identified in many RNA viruses as a major factor influencing antiviral immune response and viral pathogenesis. However, the generation and function of DVGs in SARS-CoV-2 infection are less known. In this study, we elucidated DVG generation in SARS-CoV-2 and its relationship with host antiviral immune response. We observed DVGs ubiquitously from transcriptome sequencing (RNA-seq) data sets of in vitro infections and autopsy lung tissues of COVID-19 patients. Four genomic hot spots were identified for DVG recombination, and RNA secondary structures were suggested to mediate DVG formation. Functionally, bulk and single-cell RNA-seq analysis indicated the interferon (IFN) stimulation of SARS-CoV-2 DVGs. We further applied our criteria to the next-generation sequencing (NGS) data set from a published cohort study and observed a significantly higher amount and frequency of DVG in symptomatic patients than those in asymptomatic patients. Finally, we observed exceptionally diverse DVG populations in one immunosuppressive patient up to 140 days after the first positive test of COVID-19, suggesting for the first time an association between DVGs and persistent viral infections in SARS-CoV-2. Together, our findings strongly suggest a critical role of DVGs in modulating host IFN responses and symptom development, calling for further inquiry into the mechanisms of DVG generation and into how DVGs modulate host responses and infection outcome during SARS-CoV-2 infection. IMPORTANCE Defective viral genomes (DVGs) are generated ubiquitously in many RNA viruses, including SARS-CoV-2. Their interference activity to full-length viruses and IFN stimulation provide the potential for them to be used in novel antiviral therapies and vaccine development. SARS-CoV-2 DVGs are generated through the recombination of two discontinuous genomic fragments by viral polymerase complex, and this recombination is also one of the major mechanisms for the emergence of new coronaviruses. Focusing on the generation and function of SARS-CoV-2 DVGs, these studies identify new hot spots for nonhomologous recombination and strongly suggest that the secondary structures within viral genomes mediate the recombination. Furthermore, these studies provide the first evidence for IFN stimulation activity of de novo DVGs during natural SARS-CoV-2 infection. These findings set up the foundation for further mechanism studies of SARS-CoV-2 recombination and provide evidence to harness the immunostimulatory potential of DVGs in the development of a vaccine and antivirals for SARS-CoV-2.

Preparation of noninfectious scRNAseq samples from SARS-CoV-2-infected epithelial cells

Coronavirus disease (COVID-19) is an infectious disease caused by the SARS coronavirus 2 (SARS-CoV-2) virus. Direct assessment, detection, and quantitative analysis using high throughput methods like single-cell RNA sequencing (scRNAseq) is imperative to understanding the host response to SARS-CoV-2. One barrier to studying SARS-CoV-2 in the laboratory setting is the requirement to process virus-infected cell cultures, and potentially infectious materials derived therefrom, under Biosafety Level 3 (BSL-3) containment. However, there are only 190 BSL3 laboratory facilities registered with the U.S. Federal Select Agent Program, as of 2020, and only a subset of these are outfitted with the equipment needed to perform high-throughput molecular assays. Here, we describe a method for preparing non-hazardous RNA samples from SARS-CoV-2 infected cells, that enables scRNAseq analyses to be conducted safely in a BSL2 facility-thereby making molecular assays of SARS-CoV-2 cells accessible to a much larger community of researchers. Briefly, we infected African green monkey kidney epithelial cells (Vero-E6) with SARS-CoV-2 for 96 hours, trypsin-dissociated the cells, and inactivated them with methanol-acetone in a single-cell suspension. Fixed cells were tested for the presence of infectious SARS-CoV-2 virions using the Tissue Culture Infectious Dose Assay (TCID50), and also tested for viability using flow cytometry. We then tested the dissociation and methanol-acetone inactivation method on primary human lung epithelial cells that had been differentiated on an air-liquid interface. Finally, we performed scRNAseq quality control analysis on the resulting cell populations to evaluate the effects of our virus inactivation and sample preparation protocol on the quality of the cDNA produced. We found that methanol-acetone inactivated SARS-CoV-2, fixed the lung epithelial cells, and could be used to obtain noninfectious, high-quality cDNA libraries. This methodology makes investigating SARS-CoV-2, and related high-containment RNA viruses at a single-cell level more accessible to an expanded community of researchers.

Generation and functional analysis of defective viral genomes during SARS-CoV-2 infection.. [PMID: 36172120 PMCID: PMC9516852 DOI: 10.1101/2022.09.22.509123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Defective viral genomes (DVGs) have been identified in many RNA viruses as a major factor influencing antiviral immune response and viral pathogenesis. However, the generation and function of DVGs in SARS-CoV-2 infection are less known. In this study, we elucidated DVG generation in SARS-CoV-2 and its relationship with host antiviral immune response. We observed DVGs ubiquitously from RNA-seq datasets of in vitro infections and autopsy lung tissues of COVID-19 patients. Four genomic hotspots were identified for DVG recombination and RNA secondary structures were suggested to mediate DVG formation. Functionally, bulk and single cell RNA-seq analysis indicated the IFN stimulation of SARS-CoV-2 DVGs. We further applied our criteria to the NGS dataset from a published cohort study and observed significantly higher DVG amount and frequency in symptomatic patients than that in asymptomatic patients. Finally, we observed unusually high DVG frequency in one immunosuppressive patient up to 140 days after admitted to hospital due to COVID-19, first-time suggesting an association between DVGs and persistent viral infections in SARS-CoV-2. Together, our findings strongly suggest a critical role of DVGs in modulating host IFN responses and symptom development, calling for further inquiry into the mechanisms of DVG generation and how DVGs modulate host responses and infection outcome during SARS-CoV-2 infection.

1409. Genomic Variation Among Respiratory Syncytial Viruses

Background

Respiratory Syncytial Virus (RSV) can be easily classified into two subtypes (A and B) based on the nucleic acid sequence of their genome. Phylogenic approaches have shown that within both subtypes separate lineages of viruses exist and new lineages continue to emerge. The role these genomic variations play in disease severity during RSV infection is largely unknown.

Methods

Next-generation viral RNA sequencing was performed on archived frozen nasal swabs of children infected with RSV in Rochester, NY between 1977-1998. Genomic variation was compared across year-of-isolation, age of host, and inpatient/outpatient status of host. Local RSV genomic variation was compared to variation of publicly available sequences isolated from hosts residing in other parts of the world.

Results

A and B subtypes demonstrated significant differences in the genetic sequence and primary-protein structure over time. G-protein was the most variable in both subtypes, but they differed in the number of unique genotypes detected. We found a significant association with disease severity (inpatient/outpatient status) and RSV phylogenetic topology, although the magnitude of the association differed by subtype. Variation in the primary protein structure of RSV viral proteins was also significantly associated with disease severity, but depended on which viral protein, and which subtype, was investigated. Lastly, local RSV genomic and protein-structure variation was similar to what was seen globally during this time period.

Conclusion

Overall, both subtypes demonstrated significant genetic change over time and these changes were associated with disease severity. These results suggest that the genetic variability of RSV may affect RSV disease in humans.

Disclosures

All Authors: No reported disclosures

Sex differences in quality of life after stroke were explained by patient factors, not clinical care: evidence from the Australian Stroke Clinical Registry

BACKGROUND AND PURPOSE

Women may receive stroke care less often than men. We examined the contribution of clinical care on sex differences and health-related quality of life (HRQoL) after stroke.

METHODS

We included first-ever strokes registered in the Australian Stroke Clinical Registry (2010-2014) with HRQoL assessed between 90 and 180 days after onset (EQ-5D-3L instrument) that were linked to hospital administrative data (up to 2013). Study factors included sociodemographics, comorbidities, walking ability on admission (stroke severity proxy) and clinical care (e.g. stroke unit care). Responses to the EQ-5D-3L were transformed into a total utility value (-0.516 'worse than death' to 1 'best' health). Quantile regression models, adjusted for confounding factors, were used to determine median differences (MD) in utility scores by sex.

RESULTS

Approximately 60% (6852/11 418) of stroke survivors had an EQ-5D-3L assessment (median 139 days; 44% female). Compared with men, women were older (median age 77.1 years vs. men 71.2 years) and fewer could walk on admission (37.9% vs. men 46.1%, P < 0.001). Women had lower utility values than men, and the difference was explained by age and stroke severity, but not clinical care [MD_{adjusted =} -0.039, 95% confidence interval: -0.056, -0.021]. Poorer HRQoL was observed in younger men (aged <65 years), particularly those with more comorbidities, and in older women (aged ≥75 years).

CONCLUSIONS

Stroke severity and comorbidities contribute to the poorer HRQoL in young men and older women. Further studies are needed to understand age-sex interaction to better inform treatments for different subgroups and ensure evidence-based treatments to reduce the severity of stroke are prioritized.

Implementing sequence-based antigenic distance calculation into immunological shape space model

BACKGROUND

In 2009, a novel influenza vaccine was distributed worldwide to combat the H1N1 influenza "swine flu" pandemic. However, antibodies induced by the vaccine display differences in their specificity and cross-reactivity dependent on pre-existing immunity. Here, we present a computational model that can capture the effect of pre-existing immunity on influenza vaccine responses. The model predicts the region of the virus hemagglutinin (HA) protein targeted by antibodies after vaccination as well as the level of cross-reactivity induced by the vaccine. We tested our model by simulating a scenario similar to the 2009 pandemic vaccine and compared the results to antibody binding data obtained from human subjects vaccinated with the monovalent 2009 H1N1 influenza vaccine.

RESULTS

We found that both specificity and cross-reactivity of the antibodies induced by the 2009 H1N1 influenza HA protein were affected by the viral strain the individual was originally exposed. Specifically, the level of antigenic relatedness between the original exposure HA antigen and the 2009 HA protein affected antigenic-site immunodominance. Moreover, antibody cross-reactivity was increased when the individual's pre-existing immunity was specific to an HA protein antigenically distinct from the 2009 pandemic strain. Comparison of simulation data with antibody binding data from human serum samples demonstrated qualitative and quantitative similarities between the model and real-life immune responses to the 2009 vaccine.

CONCLUSION

We provide a novel method to evaluate expected outcomes in antibody specificity and cross-reactivity after influenza vaccination in individuals with different influenza HA antigen exposure histories. The model produced similar outcomes as what has been previously reported in humans after receiving the 2009 influenza pandemic vaccine. Our results suggest that differences in cross-reactivity after influenza vaccination should be expected in individuals with different exposure histories.

Characterizing Emerging Canine H3 Influenza Viruses

The continual emergence of novel influenza A strains from non-human hosts requires constant vigilance and the need for ongoing research to identify strains that may pose a human public health risk. Since 1999, canine H3 influenza A viruses (CIVs) have caused many thousands or millions of respiratory infections in dogs in the United States. While no human infections with CIVs have been reported to date, these viruses could pose a zoonotic risk. In these studies, the National Institutes of Allergy and Infectious Diseases (NIAID) Centers of Excellence for Influenza Research and Surveillance (CEIRS) network collaboratively demonstrated that CIVs replicated in some primary human cells and transmitted effectively in mammalian models. While people born after 1970 had little or no pre-existing humoral immunity against CIVs, the viruses were sensitive to existing antivirals and we identified a panel of H3 cross-reactive human monoclonal antibodies (hmAbs) that could have prophylactic and/or therapeutic value. Our data predict these CIVs posed a low risk to humans. Importantly, we showed that the CEIRS network could work together to provide basic research information important for characterizing emerging influenza viruses, although there were valuable lessons learned.

Collagen VI Deficiency Results in Structural Abnormalities in the Mouse Lung

Collagen VI (COL6) is known for its role in a spectrum of congenital muscular dystrophies, which are often accompanied by respiratory dysfunction. However, little is known regarding the function of COL6 in the lung. We confirmed the presence of COL6 throughout the basement membrane region of mouse lung tissue. Lung structure and organization were studied in a previously described Col6a1^-/- mouse, which does not produce detectable COL6 in the lung. The Col6a1^-/- mouse displayed histopathologic alveolar and airway abnormalities. The airspaces of Col6a1^-/- lungs appeared simplified, with larger (29%; P < 0.01) and fewer (31%; P < 0.001) alveoli. These airspace abnormalities included reduced isolectin B4⁺ alveolar capillaries and surfactant protein C-positive alveolar epithelial type-II cells. Alterations in lung function consistent with these histopathologic changes were evident. Col6a1^-/- mice also displayed multiple airway changes, including increased branching (59%; P < 0.001), increased mucosal thickness (34%; P < 0.001), and increased epithelial cell density (13%; P < 0.001). Comprehensive transcriptome analysis revealed that the loss of COL6 is associated with reductions in integrin-paxillin-phosphatidylinositol 3-kinase signaling in vivo. In vitro, COL6 promoted steady-state phosphorylated paxillin levels and reduced cell density (16% to 28%; P < 0.05) at confluence. Inhibition of phosphatidylinositol 3-kinase, or its downstream effectors, resulted in increased cell density to a level similar to that seen on matrices lacking COL6.

Programming of Distinct Chemokine-Dependent and -Independent Search Strategies for Th1 and Th2 Cells Optimizes Function at Inflamed Sites

T-helper (Th) cell differentiation drives specialized gene programs that dictate effector T cell function at sites of infection. Here, we have shown Th cell differentiation also imposes discrete motility gene programs that shape Th1 and Th2 cell navigation of the inflamed dermis. Th1 cells scanned a smaller tissue area in a G protein-coupled receptor (GPCR) and chemokine-dependent fashion, while Th2 cells scanned a larger tissue area independent of GPCR signals. Differential chemokine reliance for interstitial migration was linked to STAT6 transcription-factor-dependent programming of integrin α_Vβ₃ expression: Th2 cell differentiation led to high α_Vβ₃ expression relative to Th1 cells. Th1 and Th2 cell modes of motility could be switched simply by manipulating the amount of α_Vβ₃ on the cell surface. Deviating motility modes from those established during differentiation impaired effector function. Thus, programmed expression of α_Vβ₃ tunes effector T cell reliance on environmental cues for optimal exploration of inflamed tissues.

Mutation of Respiratory Syncytial Virus G Protein's CX3C Motif Attenuates Infection in Cotton Rats and Primary Human Airway Epithelial Cells

Despite being a high priority for vaccine development, no vaccine is yet available for respiratory syncytial virus (RSV). A live virus vaccine is the primary type of vaccine being developed for young children. In this report, we describe our studies of infected cotton rats and primary human airway epithelial cells (pHAECs) using an RSV r19F with a mutation in the CX3C chemokine motif in the RSV G protein (CX4C). Through this CX3C motif, RSV binds to the corresponding chemokine receptor, CX3CR1, and this binding contributes to RSV infection of pHAECs and virus induced host responses that contribute to disease. In both the cotton rat and pHAECs, the CX4C mutation decreased virus replication and disease and/or host responses to infection. Thus, this mutation, or other mutations that block binding to CX3CR1, has the potential to improve a live attenuated RSV vaccine by attenuating both infection and disease pathogenesis.

Computer-Optimized Immunization Strategy to Boost Highly Cross-Reactive Antibodies to RSV

Respiratory Syncytial Virus (RSV) is a tremendous burden on public health. RSV infects humans within two years of life and causes continual infections throughout their lifetime. RSV is estimated to cause approximately 30 million episodes of acute lower respiratory infection resulting in over 100,000 deaths annually (in children ages 0 – 5 alone). Despite this burden, no vaccine is currently available for RSV. RSV has been classified into two subtypes (A and B) based on genomic and antigenic properties. Evolutionary rates are similar to other RNA viruses with estimates of 1.83–1.95 x 10−3 nucleotide substitutions/site/year. The high mutation rates of RSV produce an evolutionary landscape that has led to genetic and antigenic variation across and within subtypes. The attachment glycoprotein (G-protein) is must abundant on the surface of the virus and contains an almost completely conserved region, the central conserved domain (CCD). We developed a computational model of the humoral immune system that simulates B cell responses to G-protein antigen. We use a sequence-based approach to approximate antigenic differences across (&gt;1000) RSV strains. We then use computer simulations to identify an immunization strategy that can boost antibody levels to the CCD region. Last, we demonstrate that the immunization strategy results in a highly cross-reactive antibody response.

Crowd on a Chip: Label-Free Human Monoclonal Antibody Arrays for Serotyping Influenza

Rapid changes in influenza A virus (IAV) antigenicity create challenges in surveillance, disease diagnosis, and vaccine development. Further, serological methods for studying antigenic properties of influenza viruses often rely on animal models and therefore may not fully reflect the dynamics of human immunity. We hypothesized that arrays of human monoclonal antibodies (hmAbs) to influenza could be employed in a pattern-recognition approach to expedite IAV serology and to study the antigenic evolution of newly emerging viruses. Using the multiplex, label-free Arrayed Imaging Reflectometry (AIR) platform, we have demonstrated that such arrays readily discriminated among various subtypes of IAVs, including H1, H3 seasonal strains, and avian-sourced human H7 viruses. Array responses also allowed the first determination of antigenic relationships among IAV strains directly from hmAb responses. Finally, correlation analysis of antibody binding to all tested IAV subtypes allowed efficient identification of broadly reactive clones. In addition to specific applications in the context of understanding influenza biology with potential utility in "universal" flu vaccine development, these studies validate AIR as a platform technology for studying antigenic properties of viruses and also antibody properties in a high-throughput manner. We further anticipate that this approach will facilitate advances in the study of other viral pathogens.

Computer Simulations of the Humoral Immune System Reveal How Imprinting Can Affect Responses to Influenza HA Stalk with Implications for the Design of Universal Vaccines.. [DOI: 10.1101/346726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background

Successful vaccination against the H1N1 Influenza A virus has required the continuous development of new vaccines that are antigenically similar to currently circulating strains. Vaccine strategies that can increase the cross-reactivity of the antibody response, especially to conserved regions, are essential to creating long-lasting immunity to H1N1 viruses. How pre-existing immunity affects vaccine-induced antibody cross-reactivity is still not well understood.

Methods

An immunological shape space of antigenic sites of hemagglutinin (HA) was constructed using viral sequence data. A Gillespie Algorithm-based model of the humoral immune system was used to simulate B cell responses to A/California/07/2009 (CA09) HA antigen after prior immunization with an antigenically similar or dissimilar strain. The effect of pre-existing memory B cells and antibody on the resulting antibody responses was interrogated.

Results

We found increased levels of highly-cross-reactive antibodies after immunization with antigenically dissimilar strains. This increase was dependent on pre-existing memory B cells. Furthermore, pre-existing antibody also interfered with the cross-reactive antibody response, but this effect occurred irrespective of the priming antigen.

Conclusion

These findings suggest that vaccination by divergent strains will boost highly-cross-reactive antibodies by selectively targeting memory B cells specific to conserved antigenic sites and by reducing the negative interference caused by pre-existing antibody.

Antigenic cartography of H1N1 influenza viruses using sequence-based antigenic distance calculation

BACKGROUND

The ease at which influenza virus sequence data can be used to estimate antigenic relationships between strains and the existence of databases containing sequence data for hundreds of thousands influenza strains make sequence-based antigenic distance estimates an attractive approach to researchers. Antigenic mismatch between circulating strains and vaccine strains results in significantly decreased vaccine effectiveness. Furthermore, antigenic relatedness between the vaccine strain and the strains an individual was originally primed with can affect the cross-reactivity of the antibody response. Thus, understanding the antigenic relationships between influenza viruses that have circulated is important to both vaccinologists and immunologists.

RESULTS

Here we develop a method of mapping antigenic relationships between influenza virus stains using a sequence-based antigenic distance approach (SBM). We used a modified version of the p-all-epitope sequence-based antigenic distance calculation, which determines the antigenic relatedness between strains using influenza hemagglutinin (HA) genetic coding sequence data and provide experimental validation of the p-all-epitope calculation. We calculated the antigenic distance between 4838 H1N1 viruses isolated from infected humans between 1918 and 2016. We demonstrate, for the first time, that sequence-based antigenic distances of H1N1 Influenza viruses can be accurately represented in 2-dimenstional antigenic cartography using classic multidimensional scaling. Additionally, the model correctly predicted decreases in cross-reactive antibody levels with 87% accuracy and was highly reproducible with even when small numbers of sequences were used.

CONCLUSION

This work provides a highly accurate and precise bioinformatics tool that can be used to assess immune risk as well as design optimized vaccination strategies. SBM accurately estimated the antigenic relationship between strains using HA sequence data. Antigenic maps of H1N1 virus strains reveal that strains cluster antigenically similar to what has been reported for H3N2 viruses. Furthermore, we demonstrated that genetic variation differs across antigenic sites and discuss the implications.

Antigenicity of the 2015-2016 seasonal H1N1 human influenza virus HA and NA proteins

Antigenic drift of the hemagglutinin (HA) and neuraminidase (NA) influenza virus proteins contributes to reduced vaccine efficacy. To analyze antigenic drift in human seasonal H1N1 viruses derived from the 2009 pandemic H1N1 virus (pH1N1-like viruses) accounts for the limited effectiveness (around 40%) of vaccination against pH1N1-like viruses during the 2015-2016 season, nasal washes/swabs collected from adult subjects in the Rochester, NY area, were used to sequence and isolate the circulating viruses. The HA and NA proteins from viruses circulating during the 2015-2016 season encoded eighteen and fourteen amino acid differences, respectively, when compared to A/California/04/2009, a strain circulating at the origin of the 2009 pandemic. The circulating strains belonged to subclade 6B.1, defined by HA amino acid substitutions S101N, S179N, and I233T. Hemagglutination-inhibiting (HAI) and HA-specific neutralizing serum antibody (Ab) titers from around 50% of pH1N1-like virus-infected subjects and immune ferrets were 2-4 fold lower for the 2015-2016 circulating strains compared to the vaccine strain. In addition, using a luminex-based mPlex HA assay, the binding of human sera from subjects infected with pH1N1-like viruses to the HA proteins from circulating and vaccine strains was not identical, strongly suggesting antigenic differences in the HA protein. Additionally, NA inhibition (NAI) Ab titers in human sera from pH1N1-like virus-infected subjects increased after the infection and there were measurable antigenic differences between the NA protein of circulating strains and the vaccine strain using both ferret and human antisera. Despite having been vaccinated, infected subjects exhibited low HAI Ab titers against the vaccine and circulating strains. This suggests that poor responses to the H1N1 component of the vaccine as well as antigenic differences in the HA and NA proteins of currently circulating pH1N1-like viruses could be contributing to risk of infection even after vaccination.

Natural and directed antigenic drift of the H1 influenza virus hemagglutinin stalk domain

The induction of antibodies specific for the influenza HA protein stalk domain is being pursued as a universal strategy against influenza virus infections. However, little work has been done looking at natural or induced antigenic variability in this domain and the effects on viral fitness. We analyzed human H1 HA head and stalk domain sequences and found substantial variability in both, although variability was highest in the head region. Furthermore, using human immune sera from pandemic A/California/04/2009 immune subjects and mAbs specific for the stalk domain, viruses were selected in vitro containing mutations in both domains that partially contributed to immune evasion. Recombinant viruses encoding amino acid changes in the HA stalk domain replicated well in vitro, and viruses incorporating two of the stalk mutations retained pathogenicity in vivo. These findings demonstrate that the HA protein stalk domain can undergo limited drift under immune pressure and the viruses can retain fitness and virulence in vivo, findings which are important to consider in the context of vaccination targeting this domain.

Family-led rehabilitation after stroke in India (ATTEND): a randomised controlled trial

BACKGROUND

Most people with stroke in India have no access to organised rehabilitation services. The effectiveness of training family members to provide stroke rehabilitation is uncertain. Our primary objective was to determine whether family-led stroke rehabilitation, initiated in hospital and continued at home, would be superior to usual care in a low-resource setting.

METHODS

The Family-led Rehabilitation after Stroke in India (ATTEND) trial was a prospectively randomised open trial with blinded endpoint done across 14 hospitals in India. Patients aged 18 years or older who had had a stroke within the past month, had residual disability and reasonable expectation of survival, and who had an informal family-nominated caregiver were randomly assigned to intervention or usual care by site coordinators using a secure web-based system with minimisation by site and stroke severity. The family members of participants in the intervention group received additional structured rehabilitation training-including information provision, joint goal setting, carer training, and task-specific training-that was started in hospital and continued at home for up to 2 months. The primary outcome was death or dependency at 6 months, defined by scores 3-6 on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]) as assessed by masked observers. Analyses were by intention to treat. This trial is registered with Clinical Trials Registry-India (CTRI/2013/04/003557), Australian New Zealand Clinical Trials Registry (ACTRN12613000078752), and Universal Trial Number (U1111-1138-6707).

FINDINGS

Between Jan 13, 2014, and Feb 12, 2016, 1250 patients were randomly assigned to intervention (n=623) or control (n=627) groups. 33 patients were lost to follow-up (14 intervention, 19 control) and five patients withdrew (two intervention, three control). At 6 months, 285 (47%) of 607 patients in the intervention group and 287 (47%) of 605 controls were dead or dependent (odds ratio 0·98, 95% CI 0·78-1·23, p=0·87). 72 (12%) patients in the intervention group and 86 (14%) in the control group died (p=0·27), and we observed no difference in rehospitalisation (89 [14%]patients in the intervention group vs 82 [13%] in the control group; p=0·56). We also found no difference in total non-fatal events (112 events in 82 [13%] intervention patients vs 110 events in 79 [13%] control patients; p=0·80).

INTERPRETATION

Although task shifting is an attractive solution for health-care sustainability, our results do not support investment in new stroke rehabilitation services that shift tasks to family caregivers, unless new evidence emerges. A future avenue of research should be to investigate the effects of task shifting to health-care assistants or team-based community care.

FUNDING

The National Health and Medical Research Council of Australia.

Novel Sequence-Based Mapping of Recently Emerging H5NX Influenza Viruses Reveals Pandemic Vaccine Candidates

Recently, an avian influenza virus, H5NX subclade 2.3.4.4, emerged and spread to North America. This subclade has frequently reassorted, leading to multiple novel viruses capable of human infection. Four cases of human infections, three leading to death, have already occurred. Existing vaccine strains do not protect against these new viruses, raising a need to identify new vaccine candidate strains. We have developed a novel sequence-based mapping (SBM) tool capable of visualizing complex protein sequence data sets using a single intuitive map. We applied SBM on the complete set of avian H5 viruses in order to better understand hemagglutinin protein variance amongst H5 viruses and identify any patterns associated with this variation. The analysis successfully identified the original reassortments that lead to the emergence of this new subclade of H5 viruses, as well as their known unusual ability to re-assort among neuraminidase subtypes. In addition, our analysis revealed distinct clusters of 2.3.4.4 variants that would not be covered by existing strains in the H5 vaccine stockpile. The results suggest that our method may be useful for pandemic candidate vaccine virus selection.

Directed selection of influenza virus produces antigenic variants that match circulating human virus isolates and escape from vaccine-mediated immune protection

Influenza vaccination does not provide 100% protection from infection, partly due to antigenic drift of the haemagglutinin (HA) protein. Low serum antibody titres increase the risk of infection. To determine whether there were additional correlates of risk, we examined the relationship between human serum immunity and antigenic variation in seasonal H3N2 influenza viruses. Seasonal H3N2 vaccine strains grown in the presence of heterogeneous human or mono‐specific ferret antisera selected variants with mutations in the HA antigenic sites. Surprisingly, circulating strains infecting human subjects in the same seasons displayed mutations in the same positions, although only in one case did the change correspond to the same amino acid. Serum antibody titres were lower against both the in vitro selected and clinical isolates compared with the vaccine strains, suggesting that the mutations are relevant to vaccine failure. Antibody titres were also significantly lower in sera from infected subjects than in non‐infected subjects, suggesting relatively poor responses to vaccination in the infected subjects. Collectively, the data suggest that risk from influenza infection is a result of poor response to vaccination, as well as encounter with drifted seasonal influenza virus antigenic variants. The results also show that directed selection under human immune pressure could reveal antigenic variants relevant to real‐world drifted viruses, helping in annual vaccine re‐formulation.

Advances in x-ray framing cameras at the National Ignition Facility to improve quantitative precision in x-ray imaging

We describe an experimental method to measure the gate profile of an x-ray framing camera and to determine several important functional parameters: relative gain (between strips), relative gain droop (within each strip), gate propagation velocity, gate width, and actual inter-strip timing. Several of these parameters cannot be measured accurately by any other technique. This method is then used to document cross talk-induced gain variations and artifacts created by radiation that arrives before the framing camera is actively amplifying x-rays. Electromagnetic cross talk can cause relative gains to vary significantly as inter-strip timing is varied. This imposes a stringent requirement for gain calibration. If radiation arrives before a framing camera is triggered, it can cause an artifact that manifests as a high-intensity, spatially varying background signal. We have developed a device that can be added to the framing camera head to prevent these artifacts.

Higher mortality in patients with right hemispheric intracerebral haemorrhage: INTERACT1 and 2

BACKGROUND AND PURPOSE

Controversy exists over the prognostic significance of the affected hemisphere in stroke. We aimed to determine the relationship between laterality of acute intracerebral haemorrhage (ICH) and poor clinical outcomes.

METHODS

A subsidiary analysis of the INTERACT Pilot and INTERACT2 studies--randomised controlled trials of patients with spontaneous acute ICH with elevated systolic blood pressure (BP), randomly assigned to intensive (target systolic BP <140 mm Hg) or guideline-based (<180 mm Hg) BP management. Outcomes were the combined and separate end points of death and major disability (modified Rankin scale (mRS) scores of 3-6, 6 and 3-5, respectively) at 90 days.

RESULTS

A total of 2708 patients had supratentorial/hemispheric ICH and information on mRS at 90 days. Patients with right hemispheric ICH (1327, 49%) had a higher risk of death at 90 days compared to those with left hemispheric ICH after adjustment for potential confounding variables (OR, 1.77 (95% CI 1.33 to 2.37)). There were no differences between patients with right and left hemispheric ICH regarding the combined end point of death or major disability or major disability in the multivariable-adjusted models (1.07 (0.89 to 1.29) and 0.85 (0.72 to 1.01), respectively).

CONCLUSIONS

Right hemispheric lesion was associated with increased risk of death in patients with acute ICH. The laterality of the ICH does not appear to affect the level of disability in survivors.

TRIAL REGISTRATION NUMBER

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00226096 and NCT00716079.

Essential role of Elmo1 in Dock2-dependent lymphocyte migration

Elmo1 and Elmo2 are highly homologous cytoplasmic adaptor proteins that interact with Dock family guanine nucleotide exchange factors to promote activation of the small GTPase Rac. In T lymphocytes, Dock2 is essential for CCR7- and CXCR4-dependent Rac activation and chemotaxis, but the role of Elmo proteins in regulating Dock2 function in primary T cells is not known. In this article, we show that endogenous Elmo1, but not Elmo2, interacts constitutively with Dock2 in mouse and human primary T cells. CD4(+) T cells from Elmo1(-/-) mice were profoundly impaired in polarization, Rac activation, and chemotaxis in response to CCR7 and CXCR4 stimulation. Transfection of full-length Elmo1, but not Elmo2 or a Dock2-binding mutant of Elmo1, rescued defective migration of Elmo1(-/-) T cells. Interestingly, Dock2 protein levels were reduced by 4-fold in Elmo1(-/-) lymphocytes despite normal levels of Dock2 mRNA. Dock2 polyubiquitination was increased in Elmo1(-/-) T cells, and treatment with proteasome inhibitors partially restored Dock2 levels in Elmo1(-/-) T cells. Finally, we show that Dock2 is directly ubiquitinated in CD4(+) T cells and that Elmo1 expression in heterologous cells inhibits ubiquitination of Dock2. Taken together, these findings reveal a previously unknown, nonredundant role for Elmo1 in controlling Dock2 levels and Dock2-dependent T cell migration in primary lymphocytes. Inhibition of Dock2 has therapeutic potential as a means to control recruitment of pathogenic lymphocytes in diseased tissues. This work provides valuable insights into the molecular regulation of Dock2 by Elmo1 that can be used to design improved inhibitors that target the Elmo-Dock-Rac signaling complex.

Significance of perihematomal edema in acute intracerebral hemorrhage: the INTERACT trial

BACKGROUND

Uncertainty surrounds the effects of cerebral edema on outcomes in intracerebral hemorrhage (ICH).

METHODS

We used data from the INTERACT trial to determine the predictors and prognostic significance of "perihematomal" edema over 72 hours after ICH. INTERACT included 404 patients with CT-confirmed ICH and elevated systolic blood pressure (BP) (150-220 mm Hg) who had the capacity to commence BP lowering treatment within 6 hours of ICH. Baseline and repeat CT (24 and 72 hours) were performed using standardized techniques, with digital images analyzed centrally. Predictors of growth in edema were determined using generalized estimating equations, and its effects on clinical outcomes were estimated using a logistic regression model.

RESULTS

Overall, 270 patients had 3 sequential CT scans available for analyses. At baseline, there was a highly significant correlation between hematoma and perihematomal edema volumes (r(2) = 0.45). Lower systolic BP and baseline hematoma volume were independently associated with absolute increase in perihematomal edema volume. History of hypertension, baseline hematoma volume, and earlier time from onset to CT were independently associated with relative increase in edema volume. Both absolute and relative increases in perihematomal edema growth were significantly associated with death or dependency at 90 days after adjustment for age, gender, and randomized treatment, but not when additionally adjusted for baseline hematoma volume.

CONCLUSIONS

The degree of, and growth in, perihematomal edema are strongly related to the size of the underlying hematoma of acute intracerebral hemorrhage, and do not appear to have a major independent effect in determining the outcome from this condition.

Psychosocial Impact of Screening for Intracranial Aneurysms in Relatives With Familial Subarachnoid Hemorrhage

Background and Purpose— In families with ≥2 relatives with intracranial aneurysms (IAs), screening for IAs in asymptomatic first-degree relatives is often recommended. We assessed the long-term psychosocial impact of such screening.

Methods— We identified all persons with IA (screen-positives) and matched them for age and sex with 2 controls without IA (screen-negatives) from hospital-based registers of familial IA. Persons underwent telephone interviews using questionnaires that covered the areas of psychosocial impact of screening, health-related quality of life (HRQoL), and mood. Data were compared between screen-positives and screen-negatives, and with reference populations.

Results— Overall, 105 persons from 33 families with IA were included, of whom 35 were screen-positive and 70 were screen-negative. Of the screen-positives, 12 (44%) had reduced their work and 23 (66%) had experienced changes in ≥1 area of independence, self-esteem, future outlook, or personal relationships. In contrast, only 1 (2%) screen-negative person had stopped working and 12 (17%) others had experienced changes in their self-esteem, future outlook, or relationships. Screen-positives had lower HRQoL compared with screen-negatives and the reference population, whereas both screen groups had higher mean depression scores than the reference population. Despite these effects, only 3 persons regretted participating in screening.

Conclusion— Although screening for IA is an important preventative strategy in high-risk individuals, it is associated with considerable psychosocial effects, both positive and negative. Greater awareness of such outcomes, and appropriate intervention where necessary, would appear to be a necessary component of IA screening programs.

Pharmaceutical interventions for emotionalism after stroke

BACKGROUND

Antidepressants may be useful in the treatment of abnormal crying associated with stroke.

OBJECTIVES

To determine whether pharmaceutical treatment reduces the frequency of emotional displays in people who suffer from emotionalism after stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched June 2003). In addition we searched the following electronic databases: Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3 2002), MEDLINE (1966 to September 2002), EMBASE (1980 to September 2002), CINAHL (1982 to September 2002), PsychINFO (1967 to September 2002), Applied Science and Technology Plus (1986 to September 2002), Arts and Humanities Index (1991 to September 2002), Biological Abstracts (1969 to September 2002), General Science Plus (1994 to September 2002), Science Citation Index (1992 to September 2002), Social Sciences Citation Index (1991 to September 2002), and Sociofile (1974 to September 2002). We searched reference lists from relevant articles and textbooks, and contacted authors of known studies and pharmaceutical companies who manufacture psychotropic medications.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials, comparing psychotropic medication to placebo, in people with stroke and emotionalism (also known as emotional lability or pathological crying and laughing).

DATA COLLECTION AND ANALYSIS

Data were obtained on people who no longer met criteria for emotionalism, as defined in studies, and on reduction in frequency of crying at the end of treatment. Data were not pooled because of the multiplicity of definitions and outcome measures.

MAIN RESULTS

Five trials involving 103 participants were included. Four trials showed large effects of treatment: 50% reduction in emotionalism, improvements (reduction) in the frequency of compulsive laughter, and lower (better) scores on the Pathological Laughter and Crying scale. The confidence intervals were wide, however, indicating that treatment may have had only a small positive effect, or even a small negative effect (in one trial). Subgroup analysis was not performed due to the multiple methods of assessment of emotionalism within and between trials. Only one study systematically recorded and reported adverse events; no discernible difference was seen between groups. Participants allocated active treatment were more likely to leave early from trials.

REVIEWERS' CONCLUSIONS

Antidepressants can reduce the frequency and severity of crying or laughing episodes. The effect do not seem specific to one drug or class of drugs. However, our conclusions must be qualified by several methodological deficiencies in the studies. More reliable data are required before recommendations can be made about the treatment of post-stroke emotionalism.

Interventions for treating depression after stroke

BACKGROUND

Depressive and anxiety disorders following stroke are often undiagnosed or inadequately treated. This may reflect difficulties with the diagnosis of abnormal mood among older people with stroke-related disability, but may also reflect uncertainty about the effectiveness of such therapies in this setting.

OBJECTIVES

To determine whether pharmacological, psychological, or electroconvulsive treatment (ECT) of depression in patients with stroke can improve outcome.

SEARCH STRATEGY

The Cochrane Stroke Group Trials Register (last searched June 2003). The Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2002), MEDLINE (1966 to September 2002), EMBASE (1980 to September 2002), CINAHL (1982 to September 2002), PsychINFO (1967 to September 2002), Applied Science and Technology Plus (1986 to September 2002), Arts and Humanities Index (1991 to September 2002), Biological Abstracts (1969 to September 2002), General Science Plus (1994 to September 2002), Science Citation Index (1992 to September 2002), Social Sciences Citation Index (1991 to September 2002), and Sociofile (1974 to September 2002). Reference lists from relevant articles and textbooks were searched, and authors of known studies and pharmaceutical companies who manufacture psychotropic medications were contacted.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing different types of pharmaceutical agents with placebo, or various forms of psychotherapy with standard care (or attention control), in patients with recent, clinically diagnosed, acute stroke, where treatment was explicitly intended of treat depression.

DATA COLLECTION AND ANALYSIS

Primary analyses focussed on the prevalence of diagnosable depressive disorder at the end of treatment. Secondary outcomes included depression or mood scores on standard scales, disability or physical function, death, recurrent stroke, and adverse effects. We did not pool the data for summary scores. We performed meta-analysis for only some binary endpoints and data on adverse events.

MAIN RESULTS

Nine trials, with 780 participants, were included in the review. Data were available for seven trials of pharmaceutical agents, and two trials of psychotherapy. There were no trials of ECT. The analyses were complicated by the lack of standardised diagnostic and outcome criteria, and differing analytic methods. There was no strong evidence of benefit of either pharmacotherapy or psychotherapy in terms of a complete remission of depression following stroke. There was evidence of a reduction (improvement) in scores on depression rating scales, and an increase in the proportion of participants with anxiety at the end of follow up.

REVIEWERS' CONCLUSIONS

This review found no evidence to support the routine use of pharmacotherapeutic or psychotherapeutic treatment for depression after stroke. More research is required before recommendations can be made about the most appropriate management of depression following stroke.

Interventions for preventing depression after stroke

BACKGROUND

Abnormal mood is an important consequence of stroke and may affect recovery and outcome. However, depression and anxiety are often not detected or inadequately treated. This may in part be due to doubts about whether anti-depressant treatments commenced early after the onset of stroke will prevent depression and improve outcome.

OBJECTIVES

To determine if pharmaceutical or psychological interventions can prevent the onset of depression, including depressive illness and abnormal mood, and improve physical and psychological outcomes, in patients with stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group trials register (June 2003). In addition we searched the following electronic databases: Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2002), MEDLINE (1966 to September 2002), EMBASE (1980 to September 2002), CINAHL (1982 to September 2002), PsychINFO (1967 to September 2002), Applied Science and Technology Plus (1986 to September 2002), Arts and Humanities Index (1991 to September 2002), Biological Abstracts (1969 to September 2002), General Science Plus (1994 to September 2002), Science Citation Index (1992 to September 2002), Social Sciences Citation Index (1991 to September 2002), and Sociofile (1974 to September 2002). Reference lists from relevant articles and textbooks were searched, and authors of known studies and pharmaceutical companies who manufacture psychotropic medications were contacted.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing different types of pharmaceutical agents (eg selective serotonin reuptake inhibitors) with placebo, or various forms of psychotherapy against standard care (or attention control), in patients with a recent clinical diagnosis of stroke, where the treatment was undertaken with the explicit intention of preventing depression.

DATA COLLECTION AND ANALYSIS

The primary analyses focussed on the proportion of patients who met the standard diagnostic criteria for depression applied in the trials at the end of follow-up. Secondary outcomes included depression or mood scores on standard scales, disability or physical function, death, recurrent stroke, and adverse effects.

MAIN RESULTS

Twelve trials involving 1245 participants were included in the review. Data were available for nine trials (11 comparisons) involving different pharmaceutical agents, and three trials of psychotherapy. The time from stroke onset to entry ranged from a few hours to six months, but most patients were recruited within one month of acute stroke. The duration of treatments ranged from two weeks to one year. There was no clear effect of pharmacological therapy on the prevention of depression or on other measures. A significant improvement in mood was evident for psychotherapy, but this treatment effect was small and from a single trial. There was no effect on diagnosed depression.

REVIEWERS' CONCLUSIONS

This review identified a small but significant effect of psychotherapy on improving mood, but no effect of either pharmacotherapy or psychotherapy on the prevention of depressive illness, disability, or other outcomes. More evidence is therefore required before any recommendations can be made about the routine use of such treatments to improve recovery after stroke.

Thyrotoxicosis after complete or partial lithium withdrawal in two patients with bipolar affective disorder

OBJECTIVES

To highlight and discuss thyrotoxicosis after lithium withdrawal as a potential complication of lithium therapy for bipolar disorder.

CASE REPORTS

Both patients presented developed thyrotoxicosis, the first patient after stopping the lithium completely, and the second patient after a reduction in the lithium dose.

CONCLUSIONS

Clinicians should be alert to the possibility of thyrotoxicosis emerging when lithium is being completely or partially withdrawn. Such withdrawal could unmask a latent hyperthyroidism.

Subarachnoid haemorrhage occurrence exhibits a temporal pattern - evidence from meta-analysis

The aim of the present meta-analysis was to determine a temporal pattern of occurrence of subarachnoid haemorrhage (SAH). A MEDLINE 1966-2001 and EMBASE (1980-2001) literature search and hand search of relevant references were performed for population-based incidence studies that reported the time of SAH occurrence. Data from all identified relevant studies were combined into a pooled rate ratio (RR), with corresponding 95% confidence intervals (CI) using the Mantel-Haenszel method. Overall, eight population-based studies were included in the analysis. A total of 2533 first-ever cases of SAH were reported in the studies identified. Risk of SAH occurrence was the highest in the period between 6 am and 12 am (RR = 3.19; 95% CI 3.03-3.36; early morning as a reference variable) and between 12 p.m. and 6 p.m. (RR = 2.63; 95% CI 2.47-2.80), in winter and spring (RR = 1.10; 95% CI: 1.02-1.17; and RR = 1.07; 95% CI: 1.01-1.13, respectively; summer as a reference variable) and on Sunday (RR = 1.22; 95% CI 1.09-1.37; Monday as a reference variable). The evidence suggests that occurrence of SAH exhibits a seasonal (winter and spring) peak, diurnal (late morning peak) and daily (Sunday peak) pattern. It is suggested that the occurrence of some major acute vascular events (total ischaemic strokes, intracerebral haemorrhage and myocardial infarction) may be influenced by common triggering factors.

Activation of sickle red blood cell adhesion via integrin-associated protein/CD47-induced signal transduction

Peripheral human red blood cells (RBCs) are not generally known to become activated and adhesive in response to cell signaling. We show, however, that soluble thrombospondin via integrin-associated protein (IAP; CD47) increases the adhesiveness of sickle RBCs (SS RBCs) by activating signal transduction in the SS RBC. This stimulated adhesion requires occupancy of IAP and shear stress and is mediated by the activation of large G proteins and tyrosine kinases. Reticulocyte-enriched RBCs derived from sickle-cell disease (SCD) patients are most responsive to IAP-induced activation. These studies therefore establish peripheral SS RBCs as signaling cells that respond to a novel synergy between IAP-induced signal transduction and shear stress, suggesting new therapeutic targets in SCD.

Integrin-associated protein is an adhesion receptor on sickle red blood cells for immobilized thrombospondin

The adhesive protein thrombospondin (TSP) potentially mediates sickle (SS) red blood cell (RBC) adhesion to the blood vessel wall, thereby contributing to vaso-occlusive crises in sickle cell disease. We previously reported that SS RBCs bind to immobilized TSP under flow conditions, whereas normal (AA) red cells do not. However, the SS RBC receptors that mediate this interaction are largely unknown. Here it is reported that integrin-associated protein (IAP), or CD47, mediates the adhesion of these cells to immobilized TSP under both flow and static conditions. A peptide derived from the C-terminal IAP binding site of TSP also supports sickle cell adhesion; adhesion to this peptide or to TSP is inhibited specifically by the anti-IAP monoclonal antibody, 1F7. Furthermore, these data suggest that IAP on SS RBCs is structurally different from that expressed on AA RBCs but that IAP expression levels do not vary between AA and SS RBCs. This structural difference may contribute to the enhanced adhesion of SS RBCs to immobilized TSP. These results identify IAP as a TSP receptor on SS RBCs and suggest that this receptor and its binding site within TSP represent potential therapeutic targets to decrease vaso-occlusion. (Blood. 2001;97:2159-2164)

Is there a temporal pattern in the occurrence of subarachnoid hemorrhage in the southern hemisphere? Pooled data from 3 large, population-based incidence studies in Australasia, 1981 to 1997

BACKGROUND AND PURPOSE

Publications on the temporal pattern of the occurrence of subarachnoid hemorrhage (SAH) have produced conflicting results. Variations between studies may relate to the relatively small numbers of SAH cases analyzed, including those in meta-analyses.

METHODS

We identified all cases of SAH from 3 well-designed population-based studies in Australia (Adelaide, Hobart, and Perth) and New Zealand (Auckland) during 3 periods between 1981 and 1997. The diagnosis of SAH was confirmed with CT, cerebral angiography, cerebrospinal fluid analysis, or autopsy in all cases. Information on the time of occurrence of each event was obtained. Risk ratios (RRs) and 95% CIs were calculated using Poisson regression, with age, sex, smoking status, and history of hypertension entered in the model as covariates.

RESULTS

A total of 783 cases of SAH were registered. Age- and sex-adjusted RRs of SAH occurrence were highest in the period between 6 AM and 12 MIDNIGHT (RR 3.2, 95% CI 2.4-4.3) and in winter and spring (RR 1.3, 95% CI 1.1-1.5; RR 1.3, 95% CI 1.1-1.5; respectively). No particular pattern of SAH occurrence was observed according to the day of the week. Restriction of the analyses to proved aneurysmal SAH did not substantially change the point estimates.

CONCLUSIONS

Circadian and circaseptan (weekly) fluctuations of SAH occurrence in the southern hemisphere are similar to those in the northern hemisphere, but the occurrence of SAH in Australasia exhibits clear seasonal (winter and spring) peaks.

Health outcomes 1 year after subarachnoid hemorrhage: An international population-based study. The Australian Cooperative Research on Subarachnoid Hemorrhage Study Group

BACKGROUND

There is limited information about the long-term consequences of subarachnoid hemorrhage (SAH).

METHODS

Data were obtained from a population-based study of aneurysmal SAH conducted in Australia and New Zealand between 1995 and 1998. The authors report health outcomes for survivors 1 year after the onset of SAH.

RESULTS

From a total of 432 first-ever cases of SAH (76% due to confirmed cerebral aneurysm rupture) registered in four cities in Australia and New Zealand, 242 (56%) were alive approximately 1 year later (mean time 1.2 years), with 230 (95%) available for interview. Of those interviewed, 105 (46%) reported an incomplete recovery, with ongoing problems with memory (50%), mood (39%), speech (14%), and self-care (10%). Compared with age- and sex-adjusted Australian population norms, health-related quality of life, as determined by Short Form-36, was significantly lower for cases in the domains of role limitations that result from physical problems. However, there were no patient or disease characteristics that predicted complete recovery from SAH.

CONCLUSIONS

A high proportion of long-term survivors of SAH experience ongoing deficits in high level (neuropsychological) functioning. These deficits result in impairment in social roles.

Five-year survival after first-ever stroke and related prognostic factors in the Perth Community Stroke Study

BACKGROUND AND PURPOSE

Few community-based studies have examined the long-term survival and prognostic factors for death within 5 years after an acute first-ever stroke. This study aimed to determine the absolute and relative survival and the independent baseline prognostic factors for death over the next 5 years among all individuals and among 30-day survivors after a first-ever stroke in a population of Perth, Western Australia.

METHODS

Between February 1989 and August 1990, all individuals with a suspected acute stroke or transient ischemic attack of the brain who were resident in a geographically defined region of Perth, Western Australia, with a population of 138 708 people, were registered prospectively and assessed according to standardized diagnostic criteria. Patients were followed up prospectively at 4 months, 12 months, and 5 years after the index event.

RESULTS

Three hundred seventy patients with first-ever stroke were registered, and 362 (98%) were followed up at 5 years, by which time 210 (58%) had died. In the first year after stroke the risk of death was 36.5% (95% CI, 31.5% to 41.4%), which was 10-fold (95% CI, 8.3% to 11.7%) higher than that expected among the general population of the same age and sex. The most common cause of death was the index stroke (64%). Between 1 and 5 years after stroke, the annual risk of death was approximately 10% per year, which was approximately 2-fold greater than expected, and the most common cause of death was cardiovascular disease (41%). The independent baseline factors among 30-day survivors that predicted death over 5 years were intermittent claudication (hazard ratio [HR], 1.9; 95% CI, 1.2 to 2.9), urinary incontinence (HR, 2.0; 95% CI, 1. 3 to 3.0), previous transient ischemic attack (HR, 2.4; 95% CI, 1.4 to 4.1), and prestroke Barthel Index <20/20 (HR, 2.0; 95% CI, 1.2 to 3.2).

CONCLUSIONS

One-year survivors of first-ever stroke continue to die over the next 4 years at a rate of approximately 10% per year, which is twice the rate expected among the general population of the same age and sex. The most common cause of death is cardiovascular disease. Long-term survival after stroke may be improved by early, active, and sustained implementation of effective strategies for preventing subsequent cardiovascular events.

Predictors of death and vascular events in the elderly : the Perth Community Stroke Study

BACKGROUND AND PURPOSE

The goal of the present study was to identify risk factors for vascular disease in the elderly.

METHODS

We conducted a prospective study of control subjects from a population-based study of stroke in Perth, Western Australia, that was completed in 1989 to 1990 and used record linkage and a survey of survivors to identify deaths and nonfatal vascular events. Data validated through reference to medical records were analyzed with the use of Cox proportional hazards models.

RESULTS

Follow-up for the 931 subjects was 88% complete. By June 24, 1994, 198 (24%) of the subjects had died (96 from vascular disease), and there had been 45 nonfatal strokes or myocardial infarctions. The hazard ratio for diabetes exceeded 2.0 for all end points, whereas the consumption of meat >4 times weekly was associated with a reduction in risk of </=30%. In most models, female sex and consumption of alcohol were associated with reduced risks, whereas previous myocardial infarction was linked to an increase in risk.

CONCLUSIONS

There are only limited associations between lifestyle and major vascular illness in old age. Effective health promotion activities in early and middle life may be the key to a longer and healthier old age.

Health-related quality of life among long-term survivors of stroke : results from the Auckland Stroke Study, 1991-1992

BACKGROUND AND PURPOSE

The consequences of stroke are a major health concern. This study was conducted to compare the health-related quality of life among long-term survivors of stroke with that of the general population.

METHODS

Our data are taken from a population-based case-control study of all 6-year survivors of stroke with an age- and sex-matched control population. SF-36 mean scores for cases were compared with raw and standardized control and New Zealand norm mean scores.

RESULTS

Of the original 1761 registered cases, 639 were still alive at 6-year follow-up, and all of these participated in the study. Case patients were more likely than control subjects to be dependent in all basic activities of daily living. Crude mean scores were lower for women; as age increased; for those living in institutions; when the SF-36 was completed by proxy; and when help was required with the activities of daily living. Cases had statistically lower mean scores than both the control group and New Zealand norms for physical functioning and general health. After standardization for age and sex, no differences were found between cases and controls in mental health and bodily pain.

CONCLUSIONS

Health-related quality of life appears to be relatively good for the majority of patients 6 years after stroke. Despite significant ongoing physical disability, survivors of stroke appear to adjust well psychologically to their illness.

Trends in the incidence, severity, and short-term outcome of stroke in perth, Western Australia

BACKGROUND AND PURPOSE

This report describes trends in the key indices of cerebrovascular disease over 6 years from the end of the 1980s in a geographically defined segment of the city of Perth, Western Australia.

METHODS

Identical methods were used to find and assess all cases of suspected stroke in a population of approximately 134 000 residents in a triangular area of the northern suburbs of Perth. Case fatality was measured as vital status at 28 days after the onset of symptoms. Data for first-ever strokes and for all strokes for equivalent periods of 12 months in 1989-1990 and 1995-1996 were compared by age-standardized rates and proportions and Poisson regression.

RESULTS

There were 355 strokes in 328 patients and 251 first-ever strokes (71%) for 1989-1990 and 290 events in 281 patients and 213 first-ever strokes (73%) for 1995-1996. In Poisson models including age and period, overall trends in the incidence of both first-ever strokes (rate ratio=0.75; 95% confidence limits, 0.63, 0.90) and all strokes (rate ratio=0.73; 95% confidence limits, 0.62, 0.85) were obviously significant, but only the changes in men were independently significant. Case fatality did not change, and the balance between hemorrhagic and occlusive strokes in 1995-1996 was almost indistinguishable from that observed in 1989-1990.

CONCLUSIONS

Our results, which are the only longitudinal population-based data available for Australia for key indices of stroke, suggest that it is a change in the frequency of stroke, rather than its outcome, that is chiefly responsible nationally for the fall in mortality from cerebrovascular disease.

Long-term risk of first recurrent stroke in the Perth Community Stroke Study

BACKGROUND AND PURPOSE

Few community-based studies have examined the long-term risk of recurrent stroke after an acute first-ever stroke. This study aimed to determine the absolute and relative risks of a first recurrent stroke over the first 5 years after a first-ever stroke and the predictors of such recurrence in a population-based series of people with first-ever stroke in Perth, Western Australia.

METHODS

Between February 1989 and August 1990, all people with a suspected acute stroke or transient ischemic attack of the brain who were resident in a geographically defined region of Perth, Western Australia, with a population of 138 708 people, were registered prospectively and assessed according to standardized diagnostic criteria. Patients were followed up prospectively at 4 months, 12 months, and 5 years after the index event.

RESULTS

Three hundred seventy patients with a first-ever stroke were registered, of whom 351 survived >2 days. Data were available for 98% of the cohort at 5 years, by which time 199 patients (58%) had died and 52 (15%) had experienced a recurrent stroke, 12 (23%) of which were fatal within 28 days. The 5-year cumulative risk of first recurrent stroke was 22.5% (95% confidence limits [CL], 16.8%, 28.1%). The risk of recurrent stroke was greatest in the first 6 months after stroke, at 8.8% (95% CL, 5.4%, 12.1%). After adjustment for age and sex, the prognostic factors for recurrent stroke were advanced, but not extreme, age (75 to 84 years) (hazard ratio [HR], 2.6; 95% CL, 1.1, 6.2), hemorrhagic index stroke (HR, 2.1; 95% CL, 0.98, 4.4), and diabetes mellitus (HR, 2.1; 95% CL, 0.95, 4.4).

CONCLUSIONS

Approximately 1 in 6 survivors (15%) of a first-ever stroke experience a recurrent stroke over the next 5 years, of which 25% are fatal within 28 days. The pathological subtype of the recurrent stroke is the same as that of the index stroke in 88% of cases. The predictors of first recurrent stroke in this study were advanced age, hemorrhagic index stroke, and diabetes mellitus, but numbers of recurrent events were modest. Because the risk of recurrent stroke is highest (8.8%) in the first 6 months after stroke, strategies for secondary prevention should be initiated as soon as possible after the index event.

Radiometers, autocorrelators, and matched-filter receivers by means of acousto-optic spectrum analysis

Acousto-optic spectrum analyzers provide a convenient means of separating wide-bandwidth signals into their frequency components. By a change in the rf input signal into the spectrum analyzer and by the provision of additional digital postprocessing, it is possible to perform radiometry, signal autocorrelation, and matched-filter reception. Although the acousto-optic device has a space-integrating architecture, the matched-filter receiver can be implemented for signals having time durations much longer than the acousto-optic cell. The resulting signal-to-noise ratio improvements from the receiver are consistent with the time-bandwidth product of the waveform, rather than the time-bandwidth product of the acousto-optic device. A mathematical foundation of the processor is presented along with specific receiver implementations. Computer-simulation and experimental results demonstrate key findings. In one experimental example, a linear-frequency-modulated waveform is matched-filter processed to recover a signal that is -24 dB with respect to the input noise floor.

Contribution of prevention to vascular cerebral disease management

BACKGROUND

Epidemiological studies suggest that significant reductions in the incidence of stroke, as with coronary heart disease, can be expected by reducing the prevalence or shifting the distribution of risk factors across the entire population. Thus, identifying risk factors and intervening to control or modify them remains the most important means of further reducing the incidence and case fatality of stroke in developed countries, and controlling the emerging epidemic of cardiovascular disease in developing countries. All people should be encouraged to stop smoking, reduce weight, and increase physical activity and the consumption of fruit and vegetables.

METHODS

The high-risk strategy involves the identification and management of people at high risk of developing stroke. Therapies of proven benefit in the prevention of stroke among certain individuals are blood pressure lowering therapy, antiplatelet therapy, anticoagulation therapy and carotid endarterectomy. Evidence is mounting that aggressive treatment of hypercholestrolaemia and hyperglycaemia is also effective in reducing the risk of stroke, but the role of aspirin and carotid endarterectomy in the primary prevention of stroke remains uncertain. This article will review strategies for the prevention of stroke, except blood pressure lowering therapy, which is discussed elsewhere, and address some of the questions about which individuals have the most to gain from various interventions.

Fringe visibility, irradiance, and accuracy in common path interferometers for visualization of phase disturbances

Common-path interferometers have been used to perform phase visualization for over 40 years. A number of techniques have been proposed, including dark central ground, phase contrast (π/2 and π), and field-absorption interferometers. The merits of the interferometers have been judged ad hoc by either tests with a small number of phase objects or by computer simulation. Three standardized criteria, which consolidate the work of others, are proposed to evaluate common-path interferometers: fringe visibility, fringe irradiance, and fringe accuracy. The interferometers can be described as one generic class of Fourier-plane filters and can be analyzed for all input conditions. Closed-form expressions are obtained for visibility and irradiance under the forced condition that little inaccuracy is tolerated. This analysis finds that the π-phase-contrast interferometer is a good choice if the optical phase disturbance is at least 2π; for smaller disturbances, the Π/2 filter selected by Zernike is near optimum. It is shown mathematically that the resulting fringe visibility is highly object dependent, and good results are not ensured. By allowing the optical beam to be 50% larger than the phase object, the interferometer performs well under all conditions. With this approach and a combination π-phase/field-absorption filter, interference fringe visibility is greater than 0.8 for all phase objects.

A population-based assessment of the impact and burden of caregiving for long-term stroke survivors

BACKGROUND AND PURPOSE

Little attention has been focused on the demands on caregivers in stroke outcome research. A major aim of this study was to identify factors in patients associated with emotional distress in caregivers 1 year after stroke.

METHODS

One-year stroke survivors with residual handicap (defined by the Oxford Handicap Scale) and their chief caregivers were interviewed as part of the follow-up activities for patients (n = 492) registered with the Perth Community Stroke Study. We assessed emotional distress in caregivers using the Hospital Anxiety and Depression Scale and the 28-item General Health Questionnaire. Appropriate sections of the Social Behaviour Assessment Schedule were used to assess the patient's behavior and the impact on the caregiver's life. Other aspects of the patient's functional state were assessed with the Barthel Index, the Mini-Mental State Examination, the Frenchay Activities Index, and the Psychiatric Assessment Schedule (at 4 months after stroke).

RESULTS

Of 241 patients who survived to 1 year after stroke and were living outside of an institution, 103 patients (43%; 95% confidence interval, 37% to 49%) were handicapped. Eighty-four patient/caregiver units were assessed from this latter group. Almost all caregivers reported adverse effects on their emotional health, social activities, and leisure time, and more than half reported adverse effects on family relationships. Forty-six caregivers (55%) showed evidence of emotional distress on either of the two screening instruments, particularly if they were caregiving for patients with dementia and/or abnormal behavior. There was no significant relationship between emotional illness among caregivers and the degree of patients' physical disability.

CONCLUSIONS

In this population, the high level of emotional distress among caregivers of stroke patients suggests that many caregivers have unmet needs. Community services need to focus attention on the neuropsychological aspects of stroke patients and the social functioning of caregivers who support them.

Screening instruments for depression and anxiety following stroke: experience in the Perth community stroke study

Evaluation of the relative efficacy of three screening instruments for depression and anxiety in a group of stroke patients was undertaken as part of the Perth community stroke study. Data are presented on the sensitivity and specificity of the Hospital Anxiety and Depression Scale (HAPS), the Geriatric Depression Scale and the General Health Questionnaire (GHQ) (28-item version) in screening patients 4 months after stroke for depressive and anxiety disorders diagnosed according to DSM-III criteria. The GHQ-28 and GDS but not the HADS depression, were shown to be satisfactory screening instruments for depression, with the GHQ-28 having an overall superiority. The performance of all 3 scales for screening post-stroke anxiety disorders was less satisfactory. The HADS anxiety had the best level of sensitivity, but the specificity and positive predictive values were low and the misclassification rate high.