Lighting the way: recent developments and applications in molecular optogenetics

Molecular optogenetics utilizes genetically encoded, light-responsive protein switches to control the function of molecular processes. Over the last two years, there have been notable advances in the development of novel optogenetic switches, their utilization in elucidating intricate signaling pathways, and their progress toward practical applications in biotechnological processes, material sciences, and therapeutic applications. In this review, we discuss these areas, offer insights into recent developments, and contemplate future directions.

In Search of a Gold Standard Tool for Assessing Knowledge of Stroke: A Systematic Review

BACKGROUND

Knowledge of stroke is essential to empower people to reduce their risk of these events. However, valid tools are required for accurate and reliable measurement of stroke knowledge. We aimed to systematically review contemporary stroke knowledge assessment tools and appraise their content validity, feasibility, and measurement properties.

METHODS

The protocol was registered in PROSPERO (CRD42023403566). Electronic databases (MEDLINE, PsycInfo, CINAHL, Embase, Scopus, Web of Science) were searched to identify published articles (1 January 2015-1 March 2023), in which stroke knowledge was assessed using a validated tool. Two reviewers independently screened titles and abstracts prior to undertaking full-text review. COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methods guided the appraisal of content validity (relevance, comprehensiveness, comprehensibility), feasibility, and measurement properties.

RESULTS

After removing duplicates, the titles and abstracts of 718 articles were screened; 323 reviewed in full; with 42 included (N = 23 unique stroke knowledge tools). For content validity, all tools were relevant, two were comprehensive, and seven were comprehensible. Validation metrics were reported for internal consistency (n = 20 tools), construct validity (n = 17 tools), cross-cultural validity (n = 15 tools), responsiveness (n = 9 tools), reliability (n = 7 tools), structural validity (n = 3 tools), and measurement error (n = 1 tool). The Stroke Knowledge Test met all content validity criteria, with validation data for six measurement properties (n = 3 rated "Sufficient").

CONCLUSION

Assessment of stroke knowledge is not standardised and many tools lacked validated content or measurement properties. The Stroke Knowledge Test was the most comprehensive but requires updating and further validation for endorsement as a gold standard.

Sex differences in the association between stroke risk factors and pre-clinical predictors of stroke in the childhood determinants of Adult Health study

BACKGROUND AND AIMS

It is unclear why blood pressure (BP), metabolic markers and smoking increase stroke incidence in women more than men. We examined these associations with carotid artery structure and function in a prospective cohort study.

METHODS

Participants in the Australian Childhood Determinants of Adult Health study at ages 26-36 years (2004-06) were followed-up at 39-49 years (2014-19). Baseline risk factors included smoking, fasting glucose, insulin, systolic and diastolic BP. Carotid artery plaques, intima-media thickness [IMT], lumen diameter and carotid distensibility [CD] were assessed at follow up. Log binomial and linear regression with risk factor × sex interactions predicted carotid measures. Sex-stratified models adjusting for confounders were fitted when significant interactions were identified.

RESULTS

Among 779 participants (50% women), there were significant risk factor × sex interactions with baseline smoking, systolic BP and glucose associated with carotid measures in women only. Current smoking was associated with incidence of plaques (RRunadjusted 1.97 95% CI 1.4, 3.39), which reduced when adjusted for sociodemographics, depression, and diet (RRadjusted 1.82 95% CI 0.90, 3.66). Greater systolic BP was associated with lower CD adjusted for sociodemographics (βadjusted -0.166 95% CI -0.233, -0.098) and hypertension with greater lumen diameter (βunadjusted 0.131 95% CI 0.037, 0.225), which decreased when adjusted for sociodemographics, body composition and insulin (βadjusted 0.063 95% CI -0.052, 0.178). Greater glucose (βunadjusted -0.212 95% CI -0.397, -0.028) was associated with lower CD, which decreased when adjusted for sociodemographics, BP, depression and polycystic ovary syndrome (βadjusted -0.023 95% CI -0.249, 0.201).

CONCLUSIONS

Smoking, SBP and glucose affect carotid structure and function more in women than men with some of this risk due to co-occurring risk factors.

Genomic variation associated with cardiovascular disease progression following preeclampsia: a systematic review

Background

Women with a history of preeclampsia (PE) have been shown to have up to five times the risk of developing later-life cardiovascular disease (CVD). While PE and CVD are known to share clinical and molecular characteristics, there are limited studies investigating their shared genomics (genetics, epigenetics or transcriptomics) variation over time. Therefore, we sought to systematically review the literature to identify longitudinal studies focused on the genomic progression to CVD following PE.

Methods

A literature search of primary sources through PubMed, Scopus, Web of Science and Embase via OVID was performed. Studies published from January 1, 1980, to July 28, 2023, that investigated genomics in PE and CVD were eligible for inclusion. Included studies were screened based on Cochrane systematic review guidelines in conjunction with the PRISMA 2020 checklist. Eligible articles were further assessed for quality using the Newcastle-Ottawa scale.

Results

A total of 9,231 articles were screened, with 14 studies subjected to quality assessment. Following further evaluation, six studies were included for the final review. All six of these studies were heterogeneous in regard to CVD/risk factor as outcome, gene mapping approach, and in different targeted genes. The associated genes were RGS2, LPA, and AQP3, alongside microRNAs miR-122-5p, miR-126-3p, miR-146a-5p, and miR-206. Additionally, 12 differentially methylated regions potentially linked to later-life CVD following PE were identified. The only common variable across all six studies was the use of a case-control study design.

Conclusions

Our results provide critical insight into the heterogeneous nature of genomic studies investigating CVD following PE and highlight the urgent need for longitudinal studies to further investigate the genetic variation underlying the progression to CVD following PE.

Association Between Risk Factors in Childhood and Sex Differences in Prevalence of Carotid Artery Plaques and Intima-Media Thickness in Mid-Adulthood in the Childhood Determinants of Adult Health Study

Background The origins of sex differences in cardiovascular diseases are not well understood. We examined the contribution of childhood risk factors to sex differences in adult carotid artery plaques and intima-media thickness (carotid IMT). Methods and Results Children in the 1985 Australian Schools Health and Fitness Survey were followed up when they were aged 36 to 49 years (2014-19, n=1085-1281). Log binomial and linear regression examined sex differences in adult carotid plaques (n=1089) or carotid IMT (n=1283). Childhood sociodemographic, psychosocial, and biomedical risk factors that might contribute to sex differences in carotid IMT/plaques were examined using purposeful model building with additional adjustment for equivalent adult risk factors in sensitivity analyses. Women less often had carotid plaques (10%) than men (17%). The sex difference in the prevalence of plaques (relative risk [RR] unadjusted 0.59 [95% CI, 0.43 to 0.80]) was reduced by adjustment for childhood school achievement and systolic blood pressure (RR adjusted 0.65 [95% CI, 0.47 to 0.90]). Additional adjustment for adult education and systolic blood pressure further reduced sex difference (RR adjusted 0.72 [95% CI, 0.49 to 1.06]). Women (mean±SD 0.61±0.07) had thinner carotid IMT than men (mean±SD 0.66±0.09). The sex difference in carotid IMT (β unadjusted -0.051 [95% CI, -0.061 to -0.042]) reduced with adjustment for childhood waist circumference and systolic blood pressure (β adjusted -0.047 [95% CI, -0.057 to -0.037]) and further reduced with adjustment for adult waist circumference and systolic blood pressure (β adjusted -0.034 [95% CI, -0.048 to -0.019]). Conclusions Some childhood factors contributed to adult sex differences in plaques and carotid IMT. Prevention strategies across the life course are important to reduce adult sex differences in cardiovascular diseases.

Is sex a predictor for delayed cerebral ischaemia (DCI) and hydrocephalus after aneurysmal subarachnoid haemorrhage (aSAH)? A systematic review and meta-analysis

OBJECTIVES

DCI and hydrocephalus are the most common complications that predict poor outcomes after aSAH. The relationship between sex, DCI and hydrocephalus are not well established; thus, we aimed to examine sex differences in DCI and hydrocephalus following aSAH in a systematic review and meta-analysis.

METHODS

A systematic search was conducted using the PubMed, Scopus and Medline databases from inception to August 2022 to identify cohort, case control, case series and clinical studies reporting sex and DCI, acute and chronic shunt-dependent hydrocephalus (SDHC). Random-effects meta-analysis was used to pool estimates for available studies.

RESULTS

There were 56 studies with crude estimates for DCI and meta-analysis showed that women had a greater risk for DCI than men (OR 1.24, 95% CI 1.11-1.39). The meta-analysis for adjusted estimates for 9 studies also showed an association between sex and DCI (OR 1.61, 95% CI 1.27-2.05). For acute hydrocephalus, only 9 studies were included, and meta-analysis of unadjusted estimates showed no association with sex (OR 0.95, 95%CI 0.78-1.16). For SDHC, a meta-analysis of crude estimates from 53 studies showed that women had a somewhat greater risk of developing chronic hydrocephalus compared to men (OR 1.14, 95% CI 0.99-1.31). In meta-analysis for adjusted estimates from 5 studies, no association of sex with SDHC was observed (OR 0.87, 95% CI 0.57-1.33).

CONCLUSIONS

Female sex is associated with the development of DCI; however, an association between sex and hydrocephalus was not detected. Strategies to target females to reduce the development of DCI may decrease overall morbidity and mortality after aSAH.

Organisational survey for acute stroke care in Vietnam: Regional Collaboration Programme

OBJECTIVES

Low-middle income countries, such as Vietnam have a greater burden from stroke than high-income countries. Few health professionals have stroke specialist training, and the quality of care may vary between hospitals. To support improvements to stroke care, we aimed to gain a better understanding of the resources available in hospitals in Vietnam to manage acute stroke.

MATERIALS AND METHODS

The survey questions were adapted from the Australian Organisational Survey of Stroke Services (Stroke Foundation). The final 65 questions covered the topics: hospital size and admissions for stroke; use of clinical protocols and assessments conducted; team structure and coordination; communication and team roles. The survey was distributed electronically or via paper form in Vietnamese to clinical leaders of 91 eligible hospitals (November-December 2020). Data were summarised descriptively.

RESULTS

Sixty-six (73%) hospitals responded, and doctors predominately completed the survey (98%). Approximately 70% of hospitals had a stroke unit; median 630 acute strokes/year (IQR: 250-1200) and >90% used stroke clinical protocols. The daytime nurse-patient ratio was 1:4. There was a perceived lack of access to allied health staff, including psychologists/neuropsychologists, occupational therapists, and speech pathologists. Only 50% reported having a standardised rehabilitation assessment process.

CONCLUSIONS

This is the first large-scale cross-sectional, national overview of stroke services in Vietnam. Future research should include a systematic clinical audit of stroke care to confirm aspects of the data from these hospitals. Repeating the survey in future years will enable the tracking of progress and may influence capacity building for stroke care in Vietnam.

Factors Contributing to Sex Differences in Health-Related Quality of Life After Ischemic Stroke: BASIC (Brain Attack Surveillance in Corpus Christi) Project

Background

Women have been reported to have worse health‐related quality of life (HRQoL) following stroke than men, but uncertainty exists over the reasons for the sex difference.

Methods and Results

We included all ischemic strokes registered with the BASIC (Brain Attack Surveillance in Corpus Christi) project (May 2010–December 2016), a population‐based stroke study, who completed a 90‐day outcome interview. Information on baseline characteristics was obtained from medical records and in‐person interviews. HRQoL was measured by the 12‐item short‐form Stroke Specific Quality of Life Scale. Multivariable Tobit regression was used to estimate the mean difference in overall HRQoL scores (range, 1–5; higher indicating better HRQoL) between sexes and to identify contributing factors to the differences. We included 1061 cases with complete data on HRQoL and covariates (median age, 67 years; 51% women). In unadjusted analyses, women had poorer overall HRQoL than men (mean difference, −0.26 [95% CI, −0.40 to −0.13]). Contributors to this difference included sociodemographic/prestroke factors (eg, age, race and ethnicity, prestroke function), risk factors/comorbidities (eg, history of stroke, Alzheimer disease/dementia), and initial stroke severity. Sociodemographic/prestroke factors explained 62% of the sex difference (mean difference, −0.08 [95% CI, −0.21 to 0.04]). In a fully adjusted model that included adjustment for all confounding factors, the sex difference was eliminated and became nonsignificant (mean difference, −0.03 [95% CI, −0.16 to 0.09]).

Conclusions

Poorer HRQoL in women compared with men was observed and explained by the combination of sociodemographic and prestroke factors, including physical function before stroke and stroke severity. The findings suggest potential subgroups of women who might benefit from more targeted interventions before and after stroke to improve HRQoL.

Impact of dementia literacy interventions for non-health-professionals: systematic review and meta-analysis

OBJECTIVES

To assess evidence regarding the effects of interventions aimed at improving dementia literacy for different groups of non-health-professionals.

METHODS

A systematic search for relevant interventions was conducted using a range of online databases (e.g. CINAHL, Embase, Medline, ProQuest, and PsycINFO) and hand-searching of reference lists. Eligible interventions were identified based on predefined inclusion/exclusion criteria and methodological quality criteria. Meta analyses were performed using a random-effects model.

RESULTS

The final review included 14 interventions, which were either randomised controlled trials or non-randomised controlled trials. The interventions had varied contents, approaches, settings, and outcome measures. Evidence of improved dementia literacy in various aspects was found, and the intervention effects were strongest on knowledge of dementia.

DISCUSSION

There is evidence for the positive impact of dementia literacy interventions on different groups of non-health-professionals. Best practices in intervention contents, approaches, and outcome measures should be examined to guide future interventions.

Primary stroke prevention worldwide: translating evidence into action

Stroke is the second leading cause of death and the third leading cause of disability worldwide and its burden is increasing rapidly in low-income and middle-income countries, many of which are unable to face the challenges it imposes. In this Health Policy paper on primary stroke prevention, we provide an overview of the current situation regarding primary prevention services, estimate the cost of stroke and stroke prevention, and identify deficiencies in existing guidelines and gaps in primary prevention. We also offer a set of pragmatic solutions for implementation of primary stroke prevention, with an emphasis on the role of governments and population-wide strategies, including task-shifting and sharing and health system re-engineering. Implementation of primary stroke prevention involves patients, health professionals, funders, policy makers, implementation partners, and the entire population along the life course.

Case-Fatality and Functional Outcome after Subarachnoid Hemorrhage (SAH) in INternational STRoke oUtComes sTudy (INSTRUCT)

BACKGROUND

There are few large population-based studies of outcomes after subarachnoid hemorrhage (SAH) than other stroke types.

METHODS

We pooled data from 13 population-based stroke incidence studies (10 studies from the INternational STRroke oUtComes sTudy (INSTRUCT) and 3 new studies; N=657). Primary outcomes were case-fatality and functional outcome (modified Rankin scale score 3-5 [poor] vs. 0-2 [good]). Harmonized patient-level factors included age, sex, health behaviours (e.g. current smoking at baseline), comorbidities (e.g.history of hypertension), baseline stroke severity (e.g. NIHSS >7) and year of stroke. We estimated predictors of case-fatality and functional outcome using Poisson regression and generalized estimating equations using log-binomial models respectively at multiple timepoints.

RESULTS

Case-fatality rate was 33% at 1 month, 43% at 1 year, and 47% at 5 years. Poor functional outcome was present in 27% of survivors at 1 month and 15% at 1 year. In multivariable analysis, predictors of death at 1-month were age (per decade increase MRR 1.14 [1.07-1.22]) and SAH severity (MRR 1.87 [1.50-2.33]); at 1 year were age (MRR 1.53 [1.34-1.56]), current smoking (MRR 1.82 [1.20-2.72]) and SAH severity (MRR 3.00 [2.06-4.33]) and; at 5 years were age (MRR 1.63 [1.45-1.84]), current smoking (MRR 2.29 [1.54-3.46]) and severity of SAH (MRR 2.10 [1.44-3.05]). Predictors of poor functional outcome at 1 month were age (per decade increase RR 1.32 [1.11-1.56]) and SAH severity (RR 1.85 [1.06-3.23]), and SAH severity (RR 7.09 [3.17-15.85]) at 1 year.

CONCLUSION

Although age is a non-modifiable risk factor for poor outcomes after SAH, however, severity of SAH and smoking are potential targets to improve the outcomes.

The state of stroke services across the globe: Report of World Stroke Organization-World Health Organization surveys

BACKGROUND

Improving stroke services is critical for reducing the global stroke burden. The World Stroke Organization-World Health Organization-Lancet Neurology Commission on Stroke conducted a survey of the status of stroke services in low and middle-income countries (LMICs) compared to high-income countries.

METHODS

Using a validated World Stroke Organization comprehensive questionnaire, we collected and compared data on stroke services along four pillars of the stroke quadrangle (surveillance, prevention, acute stroke, and rehabilitation) in 84 countries across World Health Organization regions and economic strata. The World Health Organization also conducted a survey of non-communicable diseases in 194 countries in 2019.

RESULTS

Fewer surveillance activities (including presence of registries, presence of recent risk factors surveys, and participation in research) were reported in low-income countries than high-income countries. The overall global score for prevention was 40.2%. Stroke units were present in 91% of high-income countries in contrast to 18% of low-income countries (p < 0.001). Acute stroke treatments were offered in ∼ 60% of high-income countries compared to 26% of low-income countries (p = 0.009). Compared to high-income countries, LMICs provided less rehabilitation services including in-patient rehabilitation, home assessment, community rehabilitation, education, early hospital discharge program, and presence of rehabilitation protocol.

CONCLUSIONS

There is an urgent need to improve access to stroke units and services globally especially in LMICs. Countries with less stroke services can adapt strategies from those with better services. This could include establishment of a framework for regular monitoring of stroke burden and services, implementation of integrated prevention activities and essential acute stroke care services, and provision of interdisciplinary care for stroke rehabilitation.

Right ventricular dysfunction and tricuspid regurgitation in functional mitral regurgitation

AIM

The objective of this study was to investigate the prognostic importance of right ventricular dysfunction (RVD) and tricuspid regurgitation (TR) in patients with moderate-severe functional mitral regurgitation (FMR) receiving MitraClip procedure. RVD and TR grade are associated with cardiovascular mortality in the general population and other cardiovascular diseases. However, there are limited data from observational studies on the prognostic significance of RVD and TR in FMR receiving MitraClip procedure.

METHODS AND RESULTS

A systemic review and meta-analysis were performed using MEDLINE, Scopus, and Embase to assess the prognostic value of RVD and TR grade for mortality in patients with functional mitral regurgitation (FMR) receiving MitraClip procedure. Hazard ratios were extracted from multivariate models reporting on the association of RVD and TR with mortality and described as pooled estimates with 95% confidence intervals. A total of eight non-randomized studies met the inclusion criteria with seven studies having at least 12 months follow-up with a mean follow-up of 20.9 months. Among the aforementioned studies, a total of 1112 patients (71.5% being male) were eligible for being included in our meta-analysis with an overall mortality rate of 28.4% (n = 316). Of the enrolled patients, RVD was present in 46.1% and moderate-severe TR in 29.2%. RVD was significantly associated with mortality compared to normal RV function (HR, 1.79, 95% CI, 1.39-2.31, P < 0.001, I²  = 0). Patients with moderate-severe TR showed increased risk of mortality compared with those in the none-mild TR group (HR, 1.61. 95% CI, 1.11-2.33, P = 0.01, I²  = 14).

CONCLUSIONS

This meta-analysis demonstrates the prognostic importance of RVD and TR grade in predicting all-cause mortality in patients with significant FMR. RV function and TR parameters may therefore be useful in the risk stratification of patients with significant FMR undergoing MitraClip procedure.

Abstract P146: Sex Differences In The Association Between Systolic Blood Pressure And Carotid Distensibility In Adults

Background and Aim: We explored sex differences in the association between systolic and diastolic blood pressure (SBP), in early adulthood with carotid plaques, carotid IMT and carotid distensibility (CD) in mid-adulthood.

Methods: Participants in the Childhood Determinants of Adult Health study at ages 26-36 years were followed-up at ages 39-49 years. Systolic BP and diastolic BP and carotid ultrasound measures (plaques, IMT and CD) were performed in clinics. We used log binomial and linear regression models with risk factor*gender interactions for predicting these carotid measures. Sex-stratified models adjusted for sociodemographic, health-related behavior and biomedical factors were fitted when likelihood ratio tests suggested the effect of risk factors on outcomes differed by sex.

Results: Among 1,286 participants (53% women), men, compared to women, had higher prevalence of carotid plaques (17% vs. 10%), thicker carotid IMT (Mean 0.66 ± 0.09 vs. 0.61 ± 0.07) and lower CD (Mean 1.87 ± 0.60 vs. 2.37 ± 0.77). In women, greater SBP in early adulthood was sharply associated with significantly smaller CD (β -0.016 95%CI -0.023, -0.010 vs. β -0.006 95%CI -0.012, -0.001) than men in mid-adulthood adjusted for sociodemographic factors (Figure 1a). In analyses restricted to women, the effect of SBP on CD has decreased after adjusting for age, education, occupation, DBP and use of contraceptives (β -0.009 95%CI -0.019, 0.000) (Figure 1b).

Conclusion: CV health was worse in men than women. However, elevated SBP in women put them at greater risk of poorer CV health compared to men, which was partly explained by sociodemographic, biomedical and female-specific factors.

Utility of the Hospital Frailty Risk Score Derived From Administrative Data and the Association With Stroke Outcomes

[Figure: see text].

Abstract P38: Pooled Analysis of Long and Short Term Outcomes After Subarachnoid Hemorrhage - International Stroke Outcomes Study (INSTRUCT)

Background: Outcomes after subarachnoid hemorrhage (SAH) have been rarely examined in large cohorts.

Methods: This is an extension of the International Stroke Outcomes Study (INSTRUCT) pooling 13 ‘ideal’ stroke incidence studies (n=657 with SAH from 1993-2017, median age 56 years; 46% men). The primary outcomes were mortality and functional outcome (mRS score 3-5). Harmonized study factors included age, sex, behaviors (current smoking, alcohol intake), comorbidities (history of hypertension, ischemic heart disease, atrial fibrillation), stroke severity (e.g. NIHSS score) and year of stroke. In the pooled dataset, we estimated predictors of mortality using Poisson regression, to estimate incidence rate ratio (IRR) at 1 month (11 studies), 1 year (12 studies) and 5 years (7 studies). Generalized equation estimates in the log-binomial family were used to calculate risk ratios (RRs) for predictors of poor functional outcome at 1 month (5 studies) and 1 year (8 studies).

Results: Mortality was 33% at 1 month, 43% at 1 year, and 47% at 5 years (Fig 1). Poor functional outcome was 25% at 1 month and 15% at 1 year (Fig 1). In multivariable analysis, age and stroke severity were associated with mortality at all time points, together with current smoking at 1 and 5 years, and history of hypertension at 5 years (Fig 2). Poor functional outcome was predicted by age (RR 1.03; 95% CI 1.01-1.04) at 1 month and by age (RR 1.04; 95% CI 1.00-1.08) and stroke severity (RR 1.94; 95% CI 1.02-2.87) at 1 year.

Conclusion: Risk factors that predict SAH incidence including hypertension and smoking make outcomes worse. Better management of older patients and those with severe strokes could improve outcomes after SAH.

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.

How to check whether a blood pressure monitor has been properly validated for accuracy

Hypertension guidelines recommend that blood pressure (BP) should be measured using a monitor that has passed validation testing for accuracy. BP monitors that have not undergone rigorous validation testing can still be cleared by regulatory authorities for marketing and sale. This is the situation for most BP monitors worldwide. Thus, consumers (patients, health professionals, procurement officers, and general public) may unwittingly purchase BP monitors that are non-validated and more likely to be inaccurate. Without prior knowledge of these issues, it is extremely difficult for consumers to distinguish validated from non-validated BP monitors. For the above reasons, the aim of this paper is to provide consumers guidance on how to check whether a BP monitor has been properly validated for accuracy. The process involves making an online search of listings of BP monitors that have been assessed for validation status. Only those monitors that have been properly validated are recommended for BP measurement. There are numerous different online listings of BP monitors, several are country-specific and two are general (international) listings. Because monitors can be marketed using alternative model names in different countries, if a monitor is not found on one listing, it may be worthwhile cross-checking with a different listing. This information is widely relevant to anyone seeking to purchase a home, clinic, or ambulatory BP monitor, including individual consumers for use personally or policy makers and those procuring monitors for use in healthcare systems, and retailers looking to stock only validated BP monitors.

Sex Differences in Disease Profiles, Management, and Outcomes Among People with Atrial Fibrillation After Ischemic Stroke: Aggregated and Individual Participant Data Meta-Analyses

Objectives: To examine sex differences in disease profiles, management, and survival at 1 and 5 years after ischemic stroke (IS) among people with atrial fibrillation (AF).

Methods: We performed a systematic literature search of reports of AF at IS onset according to sex. We undertook an individual participant data meta-analysis (IPDMA) of nine population-based stroke incidence studies conducted in Australasia, Europe, and South America (1993–2014). Poisson regression was used to estimate women:men mortality rate ratios (MRRs). Study-specific MRRs were combined using random effects meta-analysis.

Results: In our meta-analysis based on aggregated data from 101 studies, the pooled AF prevalence was 23% (95% confidence interval [CI]: 22%–25%) in women and 17% (15%–18%) in men. Our IPDMA is of 1,862 IS-AF cases, with women (79.2 ± 9.1, years) being older than men (76.5 ± 9.5, years). Crude pooled mortality rate was greater for women than for men (1-year MRR 1.24; 1.01–1.51; 5-year 1.12; 1.03–1.22). However, the sex difference was greatly attenuated after accounting for age, prestroke function, and stroke severity (1-year 1.09; 0.97–1.22; 5-year 0.98; 0.84–1.16). Women were less likely to have anticoagulant prescription at discharge (odds ratio [OR] 0.94; 95% CI: 0.89–0.98) than men when pooling IPDMA and aggregated data.

Conclusions: AF was more prevalent after IS among women than among men. Among IS-AF cases, women were less likely to receive anticoagulant agents at discharge; however, greater mortality rate in women was mostly attributable to prestroke factors. Further information needs to be collected in population-based studies to understand the reasons for lower treatment of AF in women.

App-based supplemental exercise in rehabilitation, adherence, and effect on outcomes: a randomized controlled trial

QUESTION

To determine the uptake of an app-based supplemental exercise programme in a rehabilitation setting and the effect of such a programme on length of stay and function compared to usual care physiotherapy.

DESIGN

Randomized controlled trial with random allocation and assessor blinding.

PARTICIPANTS

A total of 144 individuals with mixed diagnoses (orthopaedic, neurological, reconditioning) admitted for inpatient sub-acute rehabilitation.

INTERVENTIONS

Participants were randomly allocated to usual care physiotherapy (control group) or usual care physiotherapy with the addition of an app-based supplemental exercise programme (intervention group).

OUTCOME MEASURES

The primary measure of interest was total supplementary exercise dosage completed by the intervention group. The primary between-group outcome measure was length of stay with secondary measures including walking endurance (Six-Minute Walk Test), walking speed (10-Metre Walk Test), functional mobility (Timed Up and Go Test) and level of disability (Functional Independence Measure).

RESULTS

Participants in the intervention group performed 7 minutes (SD: 9) or 49 repetitions (SD: 48) of supplementary exercise using the app each day. There were no differences between the groups for length of stay (mean difference (MD): -0.5 days, 95% confidence interval (CI): -3.2 to 2.2) or change in any secondary functional outcome measures, including walking speed (MD: -0.1 m/s, 95% CI: -0.2 to 0.0) and disability (MD: -0.9, 95% CI: -3.6 to 1.8).

CONCLUSION

A small supplementary exercise dose was achieved by participants in the intervention group. However, such a programme did not affect length of stay or functional outcomes when compared to usual care.

Multimerization strategies for efficient production and purification of highly active synthetic cytokine receptor ligands

Cytokine signaling is transmitted by cell surface receptors which act as natural biological switches to control cellular functions such as immune reactions. Recently, we have designed synthetic cytokine receptors (SyCyRs) consisting of green fluorescent protein (GFP)- and mCherry-nanobodies fused to the transmembrane and intracellular domains of cytokine receptors. Following stimulation with homo- and heterodimeric GFP-mCherry fusion proteins, the resulting receptors phenocopied signaling induced by physiologically occurring cytokines. GFP and mCherry fusion proteins were produced in E. coli or CHO-K1 cells, but the overall yield and stability was low. Therefore, we applied two alternative multimerization strategies and achieved immunoglobulin Fc-mediated dimeric and coiled-coil GCN4pII-mediated trimeric assemblies. GFP- and/or mCherry-Fc homodimers activated synthetic gp130 cytokine receptors, which naturally respond to Interleukin 6 family cytokines. Activation of these synthetic gp130 receptors resulted in STAT3 and ERK phosphorylation and subsequent proliferation of Ba/F3-gp130 cells. Half-maximal effective concentrations (EC50) of 8.1 ng/ml and 0.64 ng/ml were determined for dimeric GFP-Fc and mCherry-Fc, respectively. This is well within the expected EC50 range of the native cytokines. Moreover, we generated tetrameric and hexameric GFP-mCherry-Fc fusion proteins, which were also biologically active. This highlighted the importance of close juxtaposition of two cytokine receptors for efficient receptor activation. Finally, we used a trimeric GCN4pII motif to generate homo-trimeric GFP and mCherry complexes. These synthetic cytokines showed improved EC50 values (GFP3: 0.58 ng/ml; mCherrry3: 0.37 ng/ml), over dimeric Fc fused variants. In conclusion, we successfully generated highly effective and stable multimeric synthetic cytokine receptor ligands for activation of synthetic cytokine receptors.

Sex Differences in Severity of Stroke in the INSTRUCT Study: a Meta-Analysis of Individual Participant Data

Background

Women have worse outcomes after stroke than men, and this may be partly explained by stroke severity. We examined factors contributing to sex differences in severity of acute stroke assessed by the National Institutes of Health Stroke Scale.

Methods and Results

We pooled individual participant data with National Institutes of Health Stroke Scale assessment (N=6343) from 8 population‐based stroke incidence studies (1996–2014), forming part of INSTRUCT (International Stroke Outcomes Study). Information on sociodemographics, stroke‐related clinical factors, comorbidities, and pre‐stroke function were obtained. Within each study, relative risk regression using log‐binominal modeling was used to estimate the female:male relative risk (RR) of more severe stroke (National Institutes of Health Stroke Scale>7) stratified by stroke type (ischemic stroke and intracerebral hemorrhage). Study‐specific unadjusted and adjusted RRs, controlling for confounding variables, were pooled using random‐effects meta‐analysis. National Institutes of Health Stroke Scale data were recorded in 5326 (96%) of 5570 cases with ischemic stroke and 773 (90%) of 855 participants with intracerebral hemorrhage. The pooled unadjusted female:male RR for severe ischemic stroke was 1.35 (95% CI 1.24–1.46). The sex difference in severity was attenuated after adjustment for age, pre‐stroke dependency, and atrial fibrillation but remained statistically significant (pooled RR_adjusted 1.20, 95% CI 1.10–1.30). There was no sex difference in severity for intracerebral hemorrhage (RR_crude 1.08, 95% CI 0.97–1.21; RR_adjusted 1.08, 95% CI 0.96–1.20).

Conclusions

Although women presented with more severe ischemic stroke than men, much although not all of the difference was explained by pre‐stroke factors. Sex differences could potentially be ameliorated by strategies to improve pre‐stroke health in the elderly, the majority of whom are women. Further research on the potential biological origin of sex differences in stroke severity may also be warranted.

Sex differences in risk factors for aneurysmal subarachnoid haemorrhage: Systematic review and meta-analysis

BACKGROUND

Aneurysmal subarachnoid haemorrhage (aSAH) disproportionally affects women. We conducted a systematic review and meta-analysis to explore sex differences in aSAH risk factors.

METHODS

Case-control/cohort studies were searched to November 2017 with sex-specific risk factors for aSAH. Meta-analysis was performed when a risk factor was reported in ≥2 studies.

RESULTS

Of 31 studies, 22 were eligible for meta-analysis. Female sex was associated with greater odds of aSAH (HR_adjusted 1.90 [1.47-2.46]. There was no detectable difference between the sexes for hypertension (OR_adjusted: men 3.13 [2.26-4.34]; women 3.65 [2.87-4.63], p = .18), smoking (OR_adjusted: men 2.96 [1.68-5.21]; women 3.11 [1.21-7.97], p = .95), aSAH family history, systolic blood pressure, age and some genetic variations. Alcohol (OR_adjusted: men 1.50 [1.04-2.17]; women 0.83 [0.48-1.45], p = .003), high alanine aminotransferase levels, and some gene variants increased the risk of aSAH in men. Reproductive factors, divorce and some genetic variations increased the risk in women. High aspartate aminotransferase levels in men and, diabetes (OR_adjusted: men 0.57 [0.32-1.01]; women 0.24 [0.13-0.43], p = .01) and parity in women reduced aSAH risk.

CONCLUSION

We recommend sex-specific re-analysis of existing studies of aSAH risk factors. Known aSAH risk factors (hypertension, smoking and alcohol consumption) should be targeted to prevent aSAH in men and women. Registration PROSPERO (ID: CRD42018091521).

Sex Differences in Long-Term Quality of Life Among Survivors After Stroke in the INSTRUCT

Background and Purpose- Women are reported to have poorer health-related quality of life (HRQoL) after stroke than men, but the underlying reasons are uncertain. We investigated factors contributing to the sex differences. Methods- Individual participant data on 4288 first-ever strokes (1996-2013) were obtained from 4 high-quality population-based incidence studies from Australasia and Europe. HRQoL utility scores among survivors after stroke (range from negative scores=worse than death to 1=perfect health) were calculated from 3 scales including European Quality of Life-5 Dimensions, Short-Form 6-Dimension, and Assessment of Quality of Life at 1 year (3 studies; n=1210) and 5 years (3 studies; n=1057). Quantile regression was used to estimate the median differences in HRQoL for women compared to men with adjustment for covariates. Study factors included sociodemographics, prestroke dependency, stroke-related factors (eg, stroke severity), comorbidities, and poststroke depression. Study-specific median differences were combined into pooled estimates using random-effect meta-analysis. Results- Women had lower pooled HRQoL than men (median difference_unadjusted 1 year, -0.147; 95% CI, -0.258 to -0.036; 5 years, -0.090; 95% CI, -0.119 to -0.062). After adjustment for age, stroke severity, prestroke dependency, and depression, these pooled median differences were attenuated, more greatly at 1 year (-0.067; 95% CI, -0.111 to -0.022) than at 5 years (-0.085; 95% CI, -0.135 to -0.034). Conclusions- Women consistently exhibited poorer HRQoL after stroke than men. This was partly attributable to women's advanced age, more severe strokes, prestroke dependency, and poststroke depression, suggesting targets to reduce the differences. There was some evidence of residual differences in HRQoL between sexes but they were small and unlikely to be clinically significant.

Sex Differences in Care and Long-Term Mortality After Stroke: Australian Stroke Clinical Registry

Introduction: There is some evidence that women receive evidence-based care less often than men, but how this influences long-term mortality after stroke is unclear. We explored this issue using data from a national stroke registry. Materials and Methods: Data are first-ever hospitalized strokes (2010-2014) in the Australian Stroke Clinical Registry from 39 hospitals linked to the national death registrations. Multilevel Poisson regression was used to estimate the women:men mortality rate ratio (MRR), with adjustment for sociodemographics, stroke severity, and processes of care (stroke unit care, intravenous thrombolysis, antihypertensive agent[s], and discharge care plan). Results: Among 14,118 events (46% females), women were 7 years older and had greater baseline severity compared to men (29% vs. 37%; p < 0.001), but there were no differences in the four processes of care available across hospitals. In the whole cohort, 1-year mortality was greater in women than men (MRR_unadjusted 1.44, 95% confidence interval [CI] 1.34-1.54). However, there were no differences after adjusting for age and stroke severity (MRR_adjusted 1.03, 95% CI 0.95-1.10). In analyses of additional processes from Queensland hospitals (n = 5224), women were less often administered aspirin ≤48 hours (61% vs. men 69%, p < 0.015). In Queensland hospitals, there were no statistically significant sex differences in 1-year mortality after adjusting for age, stroke severity, and early administration of aspirin. Conclusion: Greater mortality in women can be explained by differences in age and stroke severity. This highlights the importance of better management of risk factors in the elderly and, potentially, the need for greater access to early aspirin for women with stroke.

Abstract WP237: Risk Factors for Aneurysmal Subarachnoid Hemorrhage in Women: Systematic Review and Meta-Analysis

Background: Aneurysmal subarachnoid hemorrhage (aSAH) affects women more than men, unlike other stroke types. We completed a systematic review and meta-analysis of risk factors associated with the occurrence of aSAH in women.

Methods: A systematic search was conducted using the Pubmed, Scopus, Embase, and Medline databases from inception to November 2017 to identify studies that included aSAH risk factors among women only or mentioned female sex as a risk factor. The risk factors were assessed using meta-analysis if reported by at least two studies.

Results: Fourteen studies (10 case-control; 4 cohort) were included. Female sex was associated with higher odds or risk of aSAH in pooled estimates of cohort studies (HR adjusted 1.90, 95% CI 1.47-2.46) but not in case-control studies (OR adjusted 1.44, 95% CI 0.83-2.52). Menarche at an early age (age <12 years HR crude 1.15 [95% CI 0.52-2.55], age <13 years OR adjusted 3.24 [95% CI 1.25-4.03]), pregnancy at ≥26 years (OR adjusted 1.78 [95% CI 1.13-2.80]), use of contraceptive pills (RR crude range, 5.3-6.5), nulligravidity (OR adjusted 4.23 [95% CI 1.05-7.56]), aSAH predilection area (RR crude 1.81) and being divorced (RR crude 1.89) increased the risk for aSAH in women. Parity moderately decreased the risk for aSAH (parity >3 HR crude 1.21 [95% CI 0.68-2.14], parity=2 OR adjusted 0.87 [95% CI 0.64-1.19], parity ≥5, OR adjusted 0.25 [95% CI 0.03-1.89]).

Conclusion: A number of risk factors, primarily related to reproductive hormones, for aSAH were identified in women. These could be potential causes of higher incidence of aSAH in women compared to men. There is a need for further research focused on aSAH in order to explore the association of these risk factors with aSAH in women.

Abstract WMP58: Sex Differences in Risk Factors for Aneurysmal Subarachnoid Hemorrhage: Systematic Review and Meta-Analysis

Background: Aneurysmal subarachnoid hemorrhage (aSAH) disproportionally affects women. The etiology of this is unclear, and the contribution of sex differences in aSAH risk factors is unknown. We aimed to identify sex differences in aSAH risk factors in a systematic review and meta-analysis.

Methods: A systematic search was conducted using the Pubmed, Scopus, Embase, and Medline databases from inception to November 2017 to identify studies that included aSAH risk factors stratified by sex. aSAH risk factors were assessed using meta-analysis with pooled odds ratios (OR) calculated for risk factors with at least 2 studies.

Results: There were 34 eligible case-control studies; however, 15 did not report sex specific findings with 19 were included. Hypertension (men pooled OR adjusted 3.13 [95% CI 2.26-4.34]; women pooled OR adjusted 3.65 [95% CI 2.87-4.63], p=0.18), smoking (men pooled OR adjusted 2.96 [95% CI 1.68-5.21]; women pooled OR adjusted 3.11 [95% CI 1.21-7.97], p=0.95), family history of aSAH, increased systolic blood pressure, age, angiotensin-converting enzyme gene polymorphism and variation in a protease gene had the same odds for aSAH in both sexes. Alcohol intake (men pooled OR adjusted 1.50 [95% CI 1.04-2.17], women pooled OR adjusted 0.83 [95% CI 0.48-1.45], p=0.003), high alanine aminotransferase levels, and endothelial nitric oxide synthase gene variant were associated with higher odds of aSAH in men than women. Cold temperature, polymorphisms in factor XIII gene and genetic variation on chromosome 9p21 increased the odds of aSAH in women but not men. High aspartate aminotransferase levels were associated with a reduced risk in men while diabetes mellitus decreased the risk in women (men pooled OR adjusted 0.57 [95% CI 0.32-1.01], women pooled OR adjusted 0.24 [95% CI 0.13-0.43], p=0.017).

Conclusion: Except for alcohol intake and diabetes mellitus, the magnitude of aSAH risk associated with most common risk factors were similar for both sexes. We advocate for re-analysis of existing studies with regard to sex differences.

Factors contributing to sex differences in functional outcomes and participation after stroke

Objective

To examine factors contributing to the sex differences in functional outcomes and participation restriction after stroke.

Methods

Individual participant data on long-term functional outcome or participation restriction (i.e., handicap) were obtained from 11 stroke incidence studies (1993–2014). Multivariable log-binomial regression was used to estimate the female:male relative risk (RR) of poor functional outcome (modified Rankin Scale score >2 or Barthel Index score <20) at 1 year (10 studies, n = 4,852) and 5 years (7 studies, n = 2,226). Multivariable linear regression was used to compare the mean difference (MD) in participation restriction by use of the London Handicap Scale (range 0–100 with lower scores indicating poorer outcome) for women compared to men at 5 years (2 studies, n = 617). For each outcome, study-specific estimates adjusted for confounding factors (e.g., sociodemographics, stroke-related factors) were combined with the use of random-effects meta-analysis.

Results

In unadjusted analyses, women experienced worse functional outcomes after stroke than men (1 year: pooled RRunadjusted 1.32, 95% confidence interval [CI] 1.18–1.48; 5 years: RRunadjusted 1.31, 95% CI 1.16–1.47). However, this difference was greatly attenuated after adjustment for age, prestroke dependency, and stroke severity (1 year: RRadjusted 1.08, 95% CI 0.97–1.20; 5 years: RRadjusted 1.05, 95% CI 0.94–1.18). Women also had greater participation restriction than men (pooled MDunadjusted −5.55, 95% CI −8.47 to −2.63), but this difference was again attenuated after adjustment for the aforementioned factors (MDadjusted −2.48, 95% CI −4.99 to 0.03).

Conclusions

Worse outcomes after stroke among women were explained mostly by age, stroke severity, and prestroke dependency, suggesting these potential targets to improve the outcomes after stroke in women.

Sex Differences in Long-Term Mortality After Stroke in the INSTRUCT (INternational STRoke oUtComes sTudy)

Background—

Women are reported to have greater mortality after stroke than men, but the reasons are uncertain. We examined sex differences in mortality at 1 and 5 years after stroke and identified factors contributing to these differences.

Methods and Results—

Individual participant data for incident strokes were obtained from 13 population-based incidence studies conducted in Europe, Australasia, South America, and the Caribbean between 1987 and 2013. Data on sociodemographics, stroke-related factors, prestroke health, and 1- and 5-year survival were obtained. Poisson modeling was used to estimate the mortality rate ratio (MRR) for women compared with men at 1 year (13 studies) and 5 years (8 studies) after stroke. Study-specific adjusted MRRs were pooled to create a summary estimate using random-effects meta-analysis. Overall, 16 957 participants with first-ever stroke followed up at 1 year and 13 216 followed up to 5 years were included. Crude pooled mortality was greater for women than men at 1 year (MRR 1.35; 95% confidence interval, 1.24–1.47) and 5 years (MRR 1.24; 95% confidence interval, 1.12–1.38). However, these pooled sex differences were reversed after adjustment for confounding factors (1 year MRR, 0.81; 95% confidence interval, 0.72–0.92 and 5-year MRR, 0.76; 95% confidence interval, 0.65–0.89). Confounding factors included age, prestroke functional limitations, stroke severity, and history of atrial fibrillation.

Conclusions—

Greater mortality in women is mostly because of age but also stroke severity, atrial fibrillation, and prestroke functional limitations. Lower survival after stroke among the elderly is inevitable, but there may be opportunities for intervention, including better access to evidence-based care for cardiovascular and general health.

Abstract TP171: Differences Between Men and Women in Long-term Participation Restriction After Stroke: The International Stroke Outcomes Study (INSTRUCT)

Introduction: As women suffer worse functional outcomes of stroke than men, they may also face more challenges with community reintegration but data are scarce. We examined sex differences in participation after stroke and which factors might account for these disparities.

Methods: INSTRUCT is an individual participant data pooling study of incident strokes obtained from 13 population-based cohorts worldwide. Two of the cohorts (Melbourne ’96-‘99 and Auckland ’02-‘03) included assessment of participation at 5 years after stroke using the London Handicap Scale (LHS). The LHS is used to assess the individual’s perspective of their involvement in life situations including orientation (person’s awareness of surroundings), physical independence, mobility, occupation, social interaction and economic self-efficiency. The total score ranges from 0 (worst disadvantage) to 100 (no disadvantage). Linear regression was used to compare LHS total scores and sub-domains for women compared to men. Study-specific multivariable models incorporated adjustment for socio-demographics, stroke-related factors, pre-stroke health and post-stroke factors were combined using random-effects meta-analysis.

Results: At 5 years after stroke, there were data on participation for 351/592 (59%) of survivors in Melbourne and 266/881 (30%) of survivors in Auckland. Women suffered greater participation restriction than men (total LHS, pooled mean difference, MD -5.55 [95% CI -8.47, -2.63]). The magnitude of the difference attenuated after adjusting for covariates (pooled MD -2.48 [-4.99, 0.03]). Significant confounders in study-specific models included age, stroke severity, pre-stroke dependency and pre-stroke dementia for Melbourne; and age, stroke severity and pre-stroke dependency for Auckland. In sub-dimensions, women had greater restriction than men in mobility, physical independence and occupation. Additionally, women in Melbourne experienced poorer social integration and orientation than men.

Conclusion: Greater restriction in participation after stroke among women than men was mostly attributable to their advanced age and greater pre-stroke dependency. Interventions targeting participation could reduce the impact of stroke in women.

Abstract 51: Differences in Stroke Management do not Account for the Greater Long-term Mortality After Stroke in Women Compared to Men: Australian Stroke Clinical Registry (AuSCR)

Introduction: Women have been reported to receive evidence-based care less often than men, but it is uncertain whether this contributes to sex differences in outcomes after stroke. We examined this using data obtained from the Australian Stroke Clinical Registry (AuSCR).

Methods: We included first-ever strokes admitted to 40 hospitals participating in the AuSCR during 2010-2013. Mortality one year after stroke was obtained from linkage to the National Death Index. Multilevel Poisson modelling, accounting for hospital, was used to estimate the mortality rate ratio (MRR) for women compared to men. Multivariable models were adjusted for sociodemographics, stroke type, severity (ability to walk on admission) and the provision of evidence-based therapies while in hospital (stroke unit care, thrombolysis, secondary prevention medications, dysphagia screening and mobilization).

Results: Data were available for 9,549 strokes (47% women, 80% ischaemic stroke). Women, compared to men, were older (mean [SD] 75.0 [15.0] vs 70.3 [13.9], p<0.001) and less able to walk on admission (32% vs 41%, p<0.001). Overall, there were no sex differences in access to evidence-based therapies in hospital, although it appeared that slightly fewer women were admitted to a stroke unit (79% vs 81%, p=0.001). In a subset of patients from Queensland (n=3,013), women were less often mobilised (74% vs 79%, p=0.04) or administered aspirin within 48 hours of stroke onset (66% vs 74%, p<0.001). Mortality was greater in women than men at one year (MRR crude 1.42 [95% CI 1.31, 1.55]). This association was attenuated when adjusting for age and severity of stroke (MRR adjusted 1.00 [95% CI 0.92, 1.09] but not by any of the evidence-based therapies.

Conclusion: Greater mortality in women was associated with differences in age and stroke severity and not differences in access to care. Improvements in care for the elderly and the management of modifiable factors of stroke severity should reduce sex differences in outcomes.

Abstract WMP53: Sex Differences n Long-term Mortality and Disability After Stroke: The International Stroke Outcomes Study

Introduction: It is uncertain why women suffer worse long-term outcomes after stroke than men. We examined sex differences in mortality and disability 1 and 5 years after stroke and identified factors contributing to these differences.

Methods: Individual patient data pooling study of incident strokes (ischemic and hemorrhagic) from 1987-2013 obtained from 12 population-based cohorts from Australasia, Europe, South America and the Caribbean. Data on socio-demographics, stroke-related factors and pre-stroke health were obtained for each patient and harmonized between studies. Poisson modelling estimated the mortality rate ratio (MRR) for women compared to men at 1 year (12 studies) and 5 years (7 studies) post-stroke. Log binomial regression estimated the relative risk (RR) of poor outcome (modified Rankin scale>2 or Barthel Index <20) for women compared to men at 1 year (9 studies) and 5 years (6 studies) after stroke. Multivariable models were adjusted for potential confounders including age, pre-stroke dependency, stroke severity and comorbidities.

Results: A total of 16557 first-ever-stroke patients with follow-up data to 1 year and 12,839 with follow-up to 5 years were included. The pooled crude mortality was greater in women than men at 1-year (MRR 1.37 95% CI 1.27-1.48) and 5 years (MRR 1.25 95% CI 1.13-1.39). However, these sex differences were reversed after adjustment for confounders at both 1 year (MRR 0.94 95% CI 0.82-1.06) and 5-years post stroke (MRR 0.74 95% CI 0.66-0.84). Similarly, the pooled crude RR for disability after stroke was greater in women than men at 1-year (RR 1.28 95% CI 1.17-1.39 and 5-year (RR 1.32 95% CI 1.18-1.47), but these sex differences disappeared after adjustment at both 1 year (RR 1.08 95%CI 0.98-1.18) and 5-years post stroke (RR 1.08 95% CI 0.97-1.20). The key contributors to worse outcomes in women were greater age, pre-stroke dependency, severe strokes and atrial fibrillation (AF, mortality only) compared with men.

Conclusion: Worse outcomes in women were mostly due to age and potentially modifiable factors of stroke severity and AF providing potential targets to reduce the impact of stroke in women.

Abstract 89: Trends in Long-term Case-mortality After Stroke From the International Stroke Outcomes Study (INSTRUCT): An Individual Participant Data Meta-analysis of Incident Strokes

Introduction: Reductions in early case-mortality after stroke have occurred over the past few decades, but whether this has translated into increases in longer term survival is unknown.

Hypothesis: Case-mortality at 1 and 5 years after stroke will have decreased over time.

Methods: Individual participant data on sociodemographics, pre-stroke dependency, stroke type and severity (e.g. NIH Stroke Scale, Glasgow Coma Scale) and vital status (including date of death) were obtained from study investigators from 12 high-quality population-based stroke incidence studies undertaken in Australasia, Europe, South America and the Caribbean between 1987 and 2012. We used random effects Poisson regression to model changes in case-mortality at 1 and 5 years after stroke between 1987 and 2013, adjusted for age, sex and stroke severity.

Results: There were 16,557 participants with 1 year follow-up (mean [SD] age 73.6 [14] years; 53% female, 79% ischaemic stroke, 21% intracerebral hemorrhage) and 12,839 with 5 year follow-up. In 1987, case-mortality was 42.9% at 1 year and 61.5% at 5-years. By the end of the study period, 1-year case-mortality was 31.3% and 5-year case-mortality was 49.6%. During the period 1987 to 2013 adjusted 1-year case-mortality following stroke decreased by 0.56% (95% CI 0.55, to 0.57) per year independent of age, sex and stroke severity (Figure, black line). Similarly, the adjusted 5-year case-mortality decreased by 1.19% (95% CI 1.17 to 1.20) per year (Figure, blue line).

Conclusion: Long term survival after stroke has improved since 1987. Further work is required to determine the relative role of changes in natural history, secondary prevention and clinical care on these findings.

Figure. Reduction in 1 year (12 studies during 1987-2013, n=16,557) and 5 year (7 studies during 1987-2008, n=12,839) case-mortality according to year of stroke estimated with random effects Poisson regression.

The Encapsulation of Hemagglutinin in Protein Bodies Achieves a Stronger Immune Response in Mice than the Soluble Antigen

Zein is a water-insoluble polymer from maize seeds that has been widely used to produce carrier particles for the delivery of therapeutic molecules. We encapsulated a recombinant model vaccine antigen in newly formed zein bodies in planta by generating a fusion construct comprising the ectodomain of hemagglutinin subtype 5 and the N-terminal part of γ-zein. The chimeric protein was transiently produced in tobacco leaves, and H5-containing protein bodies (PBs) were used to immunize mice. An immune response was achieved in all mice treated with H5-zein, even at low doses. The fusion to zein markedly enhanced the IgG response compared the soluble H5 control, and the effect was similar to a commercial adjuvant. The co-administration of adjuvants with the H5-zein bodies did not enhance the immune response any further, suggesting that the zein portion itself mediates an adjuvant effect. While the zein portion used to induce protein body formation was only weakly immunogenic, our results indicate that zein-induced PBs are promising production and delivery vehicles for subunit vaccines.

ELPylated haemagglutinins produced in tobacco plants induce potentially neutralizing antibodies against H5N1 viruses in mice

Reducing the cost of vaccine production is a key priority for veterinary research, and the possibility of heterologously expressing antigen in plants provides a particularly attractive means of achieving this. Here, we report the expression of the avian influenza virus haemagglutinin (AIV HA) in tobacco, both as a monomer and as a trimer in its native and its ELPylated form. We firstly presented evidence to produce stabilized trimers of soluble HA in plants. ELPylation of these trimers does not influence the trimerization. Strong expression enhancement in planta caused by ELPylation was demonstrated for trimerized H5-ELP. ELPylated trimers could be purified by a membrane-based inverse transition cycling procedure with the potential of successful scale-up. The trimeric form of AIV HA was found to enhance the HA-specific immune response compared with the monomeric form. Plant-derived AIV HA trimers elicited potentially neutralizing antibodies interacting with both homologous virus-like particles from plants and heterologous inactivated AIV. ELPylation did not influence the functionality and the antigenicity of the stabilized H5 trimers. These data allow further developments including scale-up of production, purification and virus challenge experiments with the final goal to achieve suitable technologies for efficient avian flu vaccine production.

Fetus in fetu: a case report and literature review

Fetus in fetu is a rare condition in which a fetiform calcified mass often is present in the abdomen of its host, a newborn or an infant. We report on a case of a 19-month-old girl whose plain abdominal radiograph, ultrasonography, and computed tomography scan revealed a mass in which the contents favor a fetus in fetu rather than a teratoma. The noncalcified vertebral column invisible on the radiographs was identified by the pathologist; therefore, the nonvisualization of the vertebral axis on radiography or on computed tomography scan does not exclude the diagnosis of fetus in fetu.

Partial failure of sternal fusion in an adolescent

We describe the case of an adolescent girl who had an isolated cranial sternal cleft without any associated abnormalities; the cleft had been well tolerated since her birth. A review of the literature shows that such cases are uncommon. In such cases, surgery is only for cosmetic reasons.

Mediastinal lipomatosis

Mediastinal lipomatosis is a benign condition characterized by a large amount of mature adipose tissue within the mediastinum. It widens the mediastinum and may simulate mass lesions, thus leading to diagnostic errors. We describe a new case of a huge mediastinal lipomatosis and review 36 cases previously reported in the literature. Computed tomography has an important role in the diagnosis of this disease. To avoid invasive and unnecessary procedures, this diagnosis should be considered in any patient with Cushing's syndrome.

[Endobronchial lipoma: apropos of a case with dual localization]

Endobronchial lipoma is an uncommon benign tumor. It is composed of fat tissue and is visible on CT scanner. We report an unusual case of a patient who developed two endobronchial lipomas. The first lipoma was removed 10 years earlier. We emphasize the contribution of computed tomography in the diagnosis of endobronchial lipoma. Cases of multiple lipomas are very scarce in the literature.