Decreased clot burden is associated with factor XIII Val34Leu polymorphism and better functional outcomes in acute ischemic stroke patients treated with intravenous thrombolysis

BACKGROUND

Intravenous thrombolysis using recombinant tissue plasminogen activator remains the mainstay treatment of acute ischemic stroke (AIS), although endovascular treatment is becoming standard of care in case of large vessel occlusions (LVO). To quantify the thrombus burden in LVO, a semiquantitative CT angiography (CTA) grading system, the clot burden score (CBS) can be used. Here we aimed to study the association between CBS and various hemostasis parameters, and to evaluate which parameters are major determinants of thrombolysis outcome.

METHODS

In this single-centered prospective observational case-control study, 200 anterior circulation AIS patients receiving intravenous thrombolysis treatment without thrombectomy were enrolled: 100 AIS patients with LVO (CBS 0-9) and 100 age- and sex-matched AIS patients without LVO (CBS 10). Fibrinogen, α2-plasmin inhibitor, plasminogen, factor XIII and D-dimer were assessed from blood samples taken before and 24 h after thrombolysis, and FXIII-A Val34Leu was genotyped. CBS was calculated using admission CTA. Short-term outcomes were defined based on the change in NIHSS by day 7, long-term outcomes were assessed according to the modified Rankin scale at 3 months post-event.

RESULTS

Poor outcomes were significantly more frequent in the CBS 0-9 group. Plasminogen activity on admission was significantly higher in the CBS 0-9 group. In a univariate analysis, significant protective effect of the Leu34 allele against developing larger clots (CBS 0-9) could be demonstrated (OR:0.519; 95%CI:0.298-0.922, p = 0.0227). Multivariate regression analysis revealed that CBS is an independent predictor of short- and long-term functional outcomes, while such effect of the studied hemostasis parameters could not be demonstrated.

CONCLUSIONS

CBS was found to be a significant independent predictor of thrombolysis outcomes. FXIII-A Leu34 carrier status was associated with smaller thrombus burden, which is consistent with the in vitro described whole blood clot mass reducing effects of the allele, but the polymorphism had no effect on thrombolysis outcomes.

Evaluation of primary care services in Hungary: a comprehensive description of provision, professional competences, cooperation, financing, and infrastructure, based on the findings of the Hungarian-arm of the QUALICOPC study

BACKGROUND

Primary health care provision in terms of quality, equity, and costs are different by countries. The Quality and Costs of Primary Care (QUALICOPC) study evaluated these domains and parameters in 35 countries, using uniformized method with validated questionnaires filled out by family physicians/general practitioners (GPs).This paper aims to provide data of the Hungarian-arm of the QUALICOPC study and to give an overview about the recent Hungarian primary care (PC) system.

METHODS

The questionnaires were completed in 222 Hungarian GP practices, delivered by fieldworkers, in a geographically representative distribution. Descriptive analysis was performed on the data.

FINDINGS

Financing is based mostly on capitation, with additional compensatory elements and minor financial incentives. The gate-keeping function is weak. The communication between GPs and specialists is often insufficient. The number of available devices and equipment are appropriate. Single-handed practices are predominant. Appointment instead of queuing is a new option and is becoming more popular, mainly among better-educated and urban patients. GPs are involved in the management of almost all chronic condition of all generations. Despite the burden of administrative tasks, half of the GPs estimate their job as still interesting, burn-out symptoms were rarely found. Among the evaluated process indicators, access, continuity, comprehensiveness, and coordination were rated as satisfactory, together with equity among health outcome indicators. Financing is insufficient; therefore, many GPs are involved in additional income-generating activities. The old age of the GPs and the lack of the younger GPs generation contributes to a shortage in manpower. Cooperation and communication between different levels of health care provision should be improved, focusing better on community orientation and on preventive services. Financing needs continuous improvement and appropriate incentives should be implemented. There is a need for specific PC-oriented guidelines to define properly the tasks and competences of GPs.

Elevated Factor VIII and von Willebrand Factor Levels Predict Unfavorable Outcome in Stroke Patients Treated with Intravenous Thrombolysis

Introduction

Plasma factor VIII (FVIII) and von Willebrand factor (VWF) levels have been associated with the rate and severity of arterial thrombus formation and have been linked to outcomes following thrombolytic therapy in acute myocardial infarction patients. Here, we aimed to investigate FVIII and VWF levels during the course of thrombolysis in acute ischemic stroke (AIS) patients and to find out whether they predict long-term outcomes.

Materials and methods

Study population included 131 consecutive AIS patients (median age: 69 years, 60.3% men) who underwent i.v. thrombolysis with recombinant tissue plasminogen activator (rt-PA). Blood samples were taken on admission, 1 and 24 h after rt-PA administration to measure FVIII activity and VWF antigen levels. Neurological deficit of patients was determined according to the National Institutes of Health Stroke Scale (NIHSS). ASPECT scores were assessed using computer tomography images taken before and 24 h after thrombolysis. Intracranial hemorrhage was classified according to the European Cooperative Acute Stroke Study (ECASS) II criteria. Long-term functional outcome was determined at 90 days after the event by the modified Rankin scale (mRS).

Results

VWF levels on admission were significantly elevated in case of more severe AIS [median and IQR values: NIHSS <6:189.6% (151.9-233.2%); NIHSS 6-16: 199.6% (176.4-250.8%); NIHSS >16: 247.8% (199.9-353.8%), p = 0.013]; similar, but non-significant trend was observed for FVIII levels. FVIII and VWF levels correlated well on admission (r = 0.748, p < 0.001) but no significant correlation was found immediately after thrombolysis (r = 0.093, p = 0.299), most probably due to plasmin-mediated FVIII degradation. VWF levels at all investigated occasions and FVIII activity before and 24 h after thrombolysis were associated with worse 24 h post-lysis ASPECT scores. In a binary backward logistic regression analysis including age, gender, high-sensitivity C-reactive protein, active smoking, diabetes, and NIHSS >5 on admission, elevated FVIII and VWF levels after thrombolysis were independently associated with poor functional outcomes (mRS ≥ 3) at 90 days (immediately after thrombolysis: FVIII: OR: 7.10, 95% CI: 1.77-28.38, p = 0.006, VWF: OR: 6.31, 95% CI: 1.83-21.73, p = 0.003; 24 h after thrombolysis: FVIII: OR: 4.67, 95% CI: 1.42-15.38, p = 0.011, VWF: OR: 19.02, 95% CI: 1.94-186.99, p = 0.012).

Conclusion

Elevated FVIII activity and VWF antigen levels immediately after lysis and at 24 h post-therapy were shown to have independent prognostic values regarding poor functional outcomes at 90 days.

[QUALICOPC -- primary care study on quality, costs and equity in European countries: the Hungarian branch]

The importance of primary care has already been recognized in the developed countries, where the structure and function of primary care is very heterogeneous. In the QUALICOPC study, the costs, quality and equity of primary care systems will be compared in the 34 participating countries. Representative samples of primary care practices were recruited in Hungary. An evaluation with questionnaire was performed in 222 practices on the work circumstances, conditions, competency and financial initiatives. Ten patients in each practice were also questioned by independent fieldworkers. In this work, the methodology and Hungarian experience are described. The final results of the international evaluation will be analyzed and published later. It is expected that data obtained from the QUALICOPC study may prove to be useful in health service planning and may be shared with policy makers.