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Fernandez-Ferro J, Schwamm LH, Descalzo MA, MacIsaac R, Lyden PD, Lees KR. Missing outcome data management in acute stroke trials testing iv thrombolytics. Is there risk of bias? Eur Stroke J 2020; 5:148-154. [PMID: 32637648 PMCID: PMC7313360 DOI: 10.1177/2396987320905457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 01/20/2020] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Missing outcome data may undermine interpretation of randomised clinical trials by weakening power and limiting apparent effect size. We assessed bias and inefficiency of two imputation methods commonly used in stroke trials evaluating the efficacy of iv thrombolysis. PATIENTS AND METHODS We searched the virtual international stroke trials archive (VISTA)-acute for ischaemic stroke patients with 90-day modified Rankin scale as an outcome, and known thrombolysis status. We excluded any with missing 30-day modified Rankin scale. We planned two analyses; first, we calculated odds ratios for outcome in thrombolysed versus not thrombolysed from imputed-only data, (a) among patients with missing modified Rankin scale 90 and (b) among matched patients with intact data (using propensity score methods and relevant covariates). Imputation approaches were last observation carried forward (LOCF) or multiple imputation. Outcome comparisons used dichotomisation and shift analysis. Thereafter, we calculated whole-population odds ratios using LOCF and multiple imputation (also through dichotomisation and shift analysis); first with the original 1.5% missing outcome data, and then artificially increasing the burden (5%; 10%; 20%; 30%). RESULTS We considered 9657 patients from eight of the studies included in VISTA, 3034 (31%) thrombolysed. Missing data replacement by LOCF with analysis by dichotomisation gave the highest estimate of thrombolysis influence. Imputing while increasing the burden of missing data progressively raised the odds ratios estimates, though thresholds for overestimation were 10% for LOCF; 20% for multiple imputation.Discussion: Replacing missing outcome data tended to overestimate differences of thrombolysed versus non-thrombolysed patients, but had minimal impact below a 10% burden of missing data.Conclusion: In the specific context of acute stroke trials testing iv thrombolytics, replacing missing data by carrying forward the last observation tended to overestimate treatment odds ratios more than multiple imputation.
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Affiliation(s)
- Jose Fernandez-Ferro
- Department of Neurology, Hospital Universitario Rey Juan Carlos, Instituto de Investigacion Sanitaria – Hospital Universitario Fundación Jiménez Díaz, Universidad Autonóma de Madrid, Madrid, Spain
| | - Lee H Schwamm
- Department of Neurology, Comprehensive Stroke Center, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Miguel A Descalzo
- Fundación Piel Sana, Academia Española de Dermatología y Venereología, Madrid, Spain
| | - Rachael MacIsaac
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Patrick D Lyden
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Kennedy R Lees
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Ashokkumar S, Burns A, MacIsaac A, MacIsaac R, Prior D, La Gerche A, Roberts T. 369 Left Atrial Strain is not Associated With Reduced Exercise Capacity in Diabetes Mellitus Subjects. Heart Lung Circ 2020. [DOI: 10.1016/j.hlc.2020.09.376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Findlay M, MacIsaac R, MacLeod MJ, Metcalfe W, Sood MM, Traynor JP, Dawson J, Mark PB. The Association of Atrial Fibrillation and Ischemic Stroke in Patients on Hemodialysis: A Competing Risk Analysis. Can J Kidney Health Dis 2019; 6:2054358119878719. [PMID: 31632680 PMCID: PMC6767723 DOI: 10.1177/2054358119878719] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 08/02/2019] [Indexed: 12/16/2022] Open
Abstract
Background Stroke is common in patients with end-stage renal disease (ESRD) treated with hemodialysis (HD) and associated with high mortality rate. In the general population, atrial fibrillation (AF) is a major risk factor for stroke and therapeutic anticoagulation is associated with risk reduction, whereas in ESRD the relationship is less clear. Objective The purpose of this study is to demonstrate the influence of AF on stroke rates and probability in those on HD following competing risk analyses. Design A national record linkage cohort study. Setting All renal and stroke units in Scotland, UK. Patients All patients with ESRD receiving HD within Scotland from 2005 to 2013 (follow-up to 2015). Measurements Demographic, clinical, and laboratory data were linked between the Scottish Renal Registry, Scottish Stroke Care Audit, and hospital discharge data. Stroke was defined as a fatal or nonfatal event and mortality derived from national records. Methods Associations for stroke were determined using competing risk models: the cause-specific hazards model and the Fine and Gray subdistribution hazards model accounting for the competing risk of death in models of all stroke, ischemic stroke, and first-ever stroke. Results Of 5502 patients treated with HD with 12 348.6-year follow-up, 363 (6.6%) experienced stroke. The stroke incidence rate was 26.7 per 1000 patient-years. Multivariable regression on the cause-specific hazard for stroke demonstrated age, hazard ratio (HR) (95% confidence interval [CI]) = 1.04 (1.03-1.05); AF, HR (95% CI) = 1.88 (1.25-2.83); prior stroke, HR (95% CI) = 2.29 (1.48-3.54), and diabetes, HR (95% CI) = 1.92 (1.45-2.53); serum phosphate, HR (95% CI) = 2.15 (1.56-2.99); lower body weight, HR (95% CI) = 0.99 (0.98-1.00); lower hemoglobin, HR (95% CI) = 0.88 (0.77-0.99); and systolic blood pressure (BP), HR (95% CI) = 1.01 (1.00-1.02), to be associated with an increased stroke rate. In contrast, the subdistribution HRs obtained following Fine and Gray regression demonstrated that AF, weight, and hemoglobin were not associated with stroke risk. In both models, AF was significantly associated with nonstroke death. Limitations Our analyses derive from retrospective data sets and thus can only describe association not causation. Data on anticoagulant use are not available. Conclusions The incidence of stroke in HD patients is high. The competing risk of "prestroke" mortality affects the relationship between AF and risk of future stroke. Trial designs for interventions to reduce stroke risk in HD patients, such as anticoagulation for AF, should take account of competing risks affecting associations between risk factors and outcomes.
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Affiliation(s)
- Mark Findlay
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK.,The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, UK
| | - Rachael MacIsaac
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
| | - Mary Joan MacLeod
- Institute of Medical Sciences, University of Aberdeen, Foresterhill, UK.,On Behalf of the Scottish Stroke Care Audit, Information Services Division, Edinburgh, UK
| | - Wendy Metcalfe
- Department of Renal Medicine, Royal Infirmary of Edinburgh, UK.,On Behalf of the Scottish Renal Registry, Information Services Division, Glasgow, UK
| | - Manish M Sood
- Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada
| | - Jamie P Traynor
- The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, UK.,On Behalf of the Scottish Renal Registry, Information Services Division, Glasgow, UK
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK.,The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, UK
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK.,The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, UK
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Findlay M, MacIsaac R, MacLeod MJ, Metcalfe W, Traynor JP, Dawson J, Mark PB. Renal replacement modality and stroke risk in end-stage renal disease-a national registry study. Nephrol Dial Transplant 2019; 33:1564-1571. [PMID: 29069522 DOI: 10.1093/ndt/gfx291] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 09/06/2017] [Indexed: 11/12/2022] Open
Abstract
Background The risk of stroke in end-stage renal disease (ESRD) on renal replacement therapy (RRT) is up to 10-fold greater than the general population. However, whether this increased risk differs by RRT modality is unclear. Methods We used data contained in the Scottish Renal Registry and the Scottish Stroke Care Audit to identify stroke in all adult patients who commenced RRT for ESRD from 2005 to 2013. Incidence rate was calculated and regression analyses were performed to identify variables associated with stroke. We explored the effect of RRT modality at initiation and cumulative dialysis exposure by time-dependent regression analysis, using transplant recipients as the reference group. Results A total of 4957 patients commenced RRT for ESRD. Median age was 64.5 years, 41.5% were female and 277 patients suffered a stroke (incidence rate was 18.6/1000 patient-years). Patients who had stroke were older, had higher blood pressure and were more likely to be female and have diabetes. On multivariable regression older age, female sex, diabetes and higher serum phosphate were associated with risk of stroke. RRT modality at initiation was not. On time-dependent analysis, haemodialysis (HD) exposure was independently associated with increased risk of stroke. Conclusions In patients with ESRD who initiate RRT, HD use independently increases risk of stroke compared with transplantation. Use of peritoneal dialysis did not increase risk on adjusted analysis.
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Affiliation(s)
- Mark Findlay
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,The Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Rachael MacIsaac
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Mary Joan MacLeod
- Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK.,Scottish Stroke Care Audit, ISD, Edinburgh, UK
| | - Wendy Metcalfe
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK.,Scottish Renal Registry, ISD, Glasgow, UK
| | - Jamie P Traynor
- The Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK.,Scottish Renal Registry, ISD, Glasgow, UK
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,The Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,The Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
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TORKAMANI N, Jerums G, Crammer P, Skene A, Power D, Panagiotopoulos S, Clarke M, MacIsaac R, Ekinci E. SUN-148 THREE DIMENSIONAL GLOMERULAR RECONSTRUCTION: A NOVEL APPROACH TO EVALUATE RENAL MICROANATOMY IN DIABETIC KIDNEY DISEASE. Kidney Int Rep 2019. [DOI: 10.1016/j.ekir.2019.05.549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Findlay MD, Dawson J, MacIsaac R, Jardine AG, MacLeod MJ, Metcalfe W, Traynor JP, Mark PB. Inequality in Care and Differences in Outcome Following Stroke in People With ESRD. Kidney Int Rep 2018; 3:1064-1076. [PMID: 30197973 PMCID: PMC6127409 DOI: 10.1016/j.ekir.2018.04.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 04/18/2018] [Accepted: 04/23/2018] [Indexed: 11/27/2022] Open
Abstract
Introduction Stroke rate and mortality are greater in individuals with end-stage renal disease (ESRD) than in those without ESRD. We examined discrepancies in stroke care in ESRD patients and their influence on mortality. Methods This is a national record linkage cohort study of hospitalized stroke individuals from 2005 to 2013. Presentation, measures of care quality (admission to stroke unit, swallow assessment, antithrombotics, or thrombolysis use), and outcomes were compared in those with and without ESRD after propensity score matching (PSM). We examined the effect of being admitted to a stroke unit on survival using Kaplan-Meier and Cox survival analyses. Results A total of 8757 individuals with ESRD and 61,367 individuals with stroke were identified. ESRD patients (n =486) experienced stroke over 34,551.9 patient-years of follow-up; incidence rates were 25.3 (dialysis) and 4.5 (kidney transplant)/1000 patient-years. After PSM, dialysis patients were less likely to be functionally independent (61.4% vs. 77.7%; P < 0.0001) before stroke, less frequently admitted to stroke units (64.6% vs. 79.6%; P < 0.001), or to receive aspirin (75.3% vs. 83.2%; P = 0.01) than non-ESRD stroke patients. There were no significant differences in management of kidney transplantation patients. Stroke with ESRD was associated with a higher death rate during admission (dialysis 22.9% vs.14.4%, P = 0.002; transplantation: 19.6% vs. 9.3%; P = 0.034). Managing ESRD patients in a stroke unit was associated with a lower risk of death at follow-up (hazard ratio: 0.68; 95% confidence interval: 0.55-0.84). Conclusion Stroke incidence is high in ESRD. Individuals on dialysis are functionally more dependent before stroke and less frequently receive optimal stroke care. After a stroke, death is more likely in ESRD patients. Acute stroke unit care may be associated with lower mortality.
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Affiliation(s)
- Mark D Findlay
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Rachael MacIsaac
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Alan G Jardine
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Mary Joan MacLeod
- Institute of Medical Sciences, University of Aberdeen, Foresterhill, Aberdeen, UK
| | - Wendy Metcalfe
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Jamie P Traynor
- The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
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Ali M, MacIsaac R, Quinn TJ, Bath PM, Veenstra DL, Xu Y, Brady MC, Patel A, Lees KR. Dependency and health utilities in stroke: Data to inform cost-effectiveness analyses. Eur Stroke J 2017; 2:70-76. [PMID: 30009266 PMCID: PMC6027777 DOI: 10.1177/2396987316683780] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 11/18/2016] [Indexed: 11/17/2022] Open
Abstract
Introduction Health utilities (HU) assign preference weights to specific health states and are required for cost-effectiveness analyses. Existing HU for stroke inadequately reflect the spectrum of post-stroke disability. Using international stroke trial data, we calculated HU stratified by disability to improve precision in future cost-effectiveness analyses. Materials and methods We used European Quality of Life Score (EQ-5D-3L) data from the Virtual International Stroke Trials Archive (VISTA) to calculate HU, stratified by modified Rankin Scale scores (mRS) at 3 months. We applied published value sets to generate HU, and validated these using ordinary least squares regression, adjusting for age and baseline National Institutes of Health Stroke Scale (NIHSS) scores. Results We included 3858 patients with acute ischemic stroke in our analysis (mean age: 67.5 ± 12.5, baseline NIHSS: 12 ± 5). We derived HU using value sets from 13 countries and observed significant international variation in HU distributions (Wilcoxon signed-rank test p < 0.0001, compared with UK values). For mRS = 0, mean HU ranged from 0.88 to 0.95; for mRS = 5, mean HU ranged from -0.48 to 0.22. OLS regression generated comparable HU (for mRS = 0, HU ranged from 0.9 to 0.95; for mRS = 5, HU ranged from -0.33 to 0.15). Patients' mRS scores at 3 months accounted for 65-71% of variation in the generated HU. Conclusion We have generated HU stratified by dependency level, using a common trial endpoint, and describing expected variability when applying diverse value sets to an international population. These will improve future cost-effectiveness analyses. However, care should be taken to select appropriate value sets.
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Affiliation(s)
- Myzoon Ali
- Institutes of Cardiovascular and Medical Sciences, Queen Elizabeth University Hospital, Glasgow, UK
| | - Rachael MacIsaac
- Institutes of Cardiovascular and Medical Sciences, Queen Elizabeth University Hospital, Glasgow, UK
| | - Terence J Quinn
- Institutes of Cardiovascular and Medical Sciences, Glasgow Royal Infirmary, Glasgow, UK
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | | | - Yaping Xu
- Genentech Inc., South San Francisco, CA, USA
| | - Marian C Brady
- NMAHP Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Anita Patel
- Centre for Primary Care & Public Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Kennedy R Lees
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, BHF Cardiovascular Research Centre, Glasgow, UK
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Roberts T, Burns A, MacIsaac R, Mooney D, Prior D, La Gerche A. Sildenafil Does not Improve VO2max in Subjects with Diabetes Despite Augmenting Non-Invasively Assessed Central Haemodynamics. Heart Lung Circ 2016. [DOI: 10.1016/j.hlc.2016.06.212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Findlay MD, Thomson PC, MacIsaac R, Jardine AG, Patel RK, Stevens KK, Rutherford E, Clancy M, Geddes CC, Dawson J, Mark PB. Risk factors and outcome of stroke in renal transplant recipients. Clin Transplant 2016; 30:918-24. [DOI: 10.1111/ctr.12765] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Mark D. Findlay
- Institute of Cardiovascular and Medical Sciences; University of Glasgow; Glasgow UK
- The Glasgow Renal & Transplant Unit; Queen Elizabeth University Hospital; Glasgow UK
| | - Peter C. Thomson
- The Glasgow Renal & Transplant Unit; Queen Elizabeth University Hospital; Glasgow UK
| | - Rachael MacIsaac
- Institute of Cardiovascular and Medical Sciences; University of Glasgow; Glasgow UK
| | - Alan G. Jardine
- Institute of Cardiovascular and Medical Sciences; University of Glasgow; Glasgow UK
- The Glasgow Renal & Transplant Unit; Queen Elizabeth University Hospital; Glasgow UK
| | - Rajan K. Patel
- Institute of Cardiovascular and Medical Sciences; University of Glasgow; Glasgow UK
- The Glasgow Renal & Transplant Unit; Queen Elizabeth University Hospital; Glasgow UK
| | - Kathryn K. Stevens
- Institute of Cardiovascular and Medical Sciences; University of Glasgow; Glasgow UK
- The Glasgow Renal & Transplant Unit; Queen Elizabeth University Hospital; Glasgow UK
| | - Elaine Rutherford
- Institute of Cardiovascular and Medical Sciences; University of Glasgow; Glasgow UK
- The Glasgow Renal & Transplant Unit; Queen Elizabeth University Hospital; Glasgow UK
| | - Marc Clancy
- The Glasgow Renal & Transplant Unit; Queen Elizabeth University Hospital; Glasgow UK
| | - Colin C. Geddes
- The Glasgow Renal & Transplant Unit; Queen Elizabeth University Hospital; Glasgow UK
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences; University of Glasgow; Glasgow UK
| | - Patrick B. Mark
- Institute of Cardiovascular and Medical Sciences; University of Glasgow; Glasgow UK
- The Glasgow Renal & Transplant Unit; Queen Elizabeth University Hospital; Glasgow UK
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Cheripelli BK, Huang X, MacIsaac R, Muir KW. Interaction of Recanalization, Intracerebral Hemorrhage, and Cerebral Edema After Intravenous Thrombolysis. Stroke 2016; 47:1761-7. [PMID: 27301943 DOI: 10.1161/strokeaha.116.013142] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 05/17/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Both intracerebral hemorrhage (ICH) and brain edema have been attributed to reperfusion after intravenous thrombolysis. We explored the interaction of recanalization and core size for imaging outcomes (ICH and vasogenic brain edema). METHODS In patients with anterior circulation occlusion given intravenous thrombolysis <4.5 hours and imaged with computed tomographic (CT) perfusion and CT angiography, we defined volumes of core (relative delay time >2 s and relative cerebral blood flow <40%) and penumbra (relative delay time >2 s). CT and CT angiography at 24 hours were reviewed for ICH (European Cooperative Acute Stroke Study [ECASS]-2 definition), early vasogenic edema (third International Stroke Trial [IST-3] criteria), and recanalization (thrombolysis in myocardial infarction 2-3). Independent effects of recanalization, core volume and potential interactions on edema, ICH and day 90 outcomes were estimated by logistic regression. RESULTS In 123 patients, there was a trend for recanalization to be associated with H1/2 ICH (odds ratio [OR], 2.3 [0.97-5.5]; P=0.06) but not with PH1/2 ICH (OR, 1.7 [0.33-8.8]; P=0.5), any edema, or significant brain edema (OR, 1.45 [0.4-4.9]; P=0.55). Ischemic core (>50 mL) was associated with any ICH (OR, 4.0 [1.6-9.5]; P=0.003), edema (OR, 5.4 [2-14]; P<0.01), and significant brain edema (OR, 17.4 [5.3-57]; P<0.01) but not with PH1/2 ICH (OR, 1.2 [0.23-6.5]; P=0.8), after controlling for recanalization. There was no significant interaction of recanalization and large core for any adverse outcomes. CONCLUSIONS Large ischemic core was associated with poorer outcomes and both early vasogenic brain edema and ICH, but recanalization on 24-hour CT angiography was associated with clinically favorable outcome. There was no significant interaction of recanalization and large core volume for any outcomes. The association of hemorrhage or brain edema with post-thrombolysis reperfusion is unclear.
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Affiliation(s)
- Bharath Kumar Cheripelli
- From the Institute of Neuroscience and Psychology (B.K.C., X.H., K.W.M.) and Institute of Cardiovascular and Medical Sciences (R.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow, Scotland, United Kingdom
| | - Xuya Huang
- From the Institute of Neuroscience and Psychology (B.K.C., X.H., K.W.M.) and Institute of Cardiovascular and Medical Sciences (R.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow, Scotland, United Kingdom
| | - Rachael MacIsaac
- From the Institute of Neuroscience and Psychology (B.K.C., X.H., K.W.M.) and Institute of Cardiovascular and Medical Sciences (R.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow, Scotland, United Kingdom
| | - Keith W Muir
- From the Institute of Neuroscience and Psychology (B.K.C., X.H., K.W.M.) and Institute of Cardiovascular and Medical Sciences (R.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow, Scotland, United Kingdom.
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Abstract
BACKGROUND The Stroke Impact Scale (SIS) is a stroke-specific, quality of life measure recommended for research and clinical practice. Completion rates are suboptimal and could relate to test burden. We derived and validated a short form SIS (SF-SIS). METHODS AND RESULTS We examined data from the Virtual International Stroke Trial Archive, generating derivation and validation populations. We derived an SF-SIS by selecting 1 item per domain of SIS, choosing items most highly correlated with total domain score. Our validation described agreement of SF-SIS with original SIS and the SIS-16 and correlation with Barthel Index, modified Rankin Scale, National Institutes of Health Stroke Scale, and Euro-QoL 5 dimensions visual analog scales. We assessed discriminative validity (associations between SF-SIS and factors known to influence outcome [age, physiological parameters, and comorbidity]). We assessed face validity and acceptability by sharing the SF-SIS with a focus group of stroke survivors and multidisciplinary stroke healthcare staff. From 5549 acute study patients (mean age 68.5 [SD 13] years, mean SIS 64 [SD 32]) and 332 rehabilitation patients (mean age 65.7 [SD 11] years, mean SIS 61 [SD 11]), we derived an 8-item SF-SIS that demonstrated good agreement with original SIS and good correlation with our chosen functional and quality of life measures (all ρ>0.70, P<0.0001). Significant associations were seen with our chosen predictors of stroke outcome in the acute group (P<0.0001). The focus group agreed with the choice of items for SF-SIS across 7 of 8 domains. CONCLUSIONS Using multiple, complementary methods, we have derived an SF-SIS and demonstrated content, convergent, and discriminant validity. This shortened SIS should allow collection of robust quality of life data with less associated test burden.
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Affiliation(s)
- Rachael MacIsaac
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
| | - Myzoon Ali
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
| | - Michele Peters
- Nuffield Department of Population Health, University of Oxford, UK
| | - Coralie English
- School of Health Sciences, University of Newcastle, Australia
| | - Helen Rodgers
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | | | - Kennedy R Lees
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
| | - Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
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Huang X, MacIsaac R, Thompson JLP, Levin B, Buchsbaum R, Haley EC, Levi C, Campbell B, Bladin C, Parsons M, Muir KW. Tenecteplase versus alteplase in stroke thrombolysis: An individual patient data meta-analysis of randomized controlled trials. Int J Stroke 2016; 11:534-43. [DOI: 10.1177/1747493016641112] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Accepted: 01/17/2016] [Indexed: 11/16/2022]
Abstract
Background Tenecteplase, a modified plasminogen activator with higher fibrin specificity and longer half-life, may have advantages over alteplase in acute ischemic stroke thrombolysis. Aims We undertook an individual patient data meta-analysis of randomized controlled trials that compared alteplase with tenecteplase in acute stroke. Methods Eligible studies were identified by a MEDLINE search, and individual patient data were acquired. We compared clinical outcomes including modified Rankin Scale at three months, early neurological improvement at 24 h, intracerebral hemorrhage, symptomatic intracerebral hemorrhage, and mortality at three months between all dose tiers of tenecteplase and alteplase. Results Three relevant studies (Haley et al., Parsons et al., and ATTEST) included 291 patients and investigated three doses of tenecteplase (0.1, 0.25, 0.4 mg/kg). There were no differences between any dose of tenecteplase and alteplase for either efficacy or safety end points. Tenecteplase 0.25 mg/kg had the greatest odds to achieve early neurological improvement (OR [95%CI] 3.3 [1.5, 7.2], p = 0.093), excellent functional outcome (modified Rankin Scale 0–1) at three months (OR [95%CI] 1.9 [0.8, 4.4], p = 0.28), with reduced odds of intracerebral hemorrhage (OR [95%CI] 0.6 [0.2, 1.8], P = 0.43) compared with alteplase. Only 19 patients were treated with tenecteplase 0.4 mg/kg, which showed increased odds of symptomatic intracerebral hemorrhage compared with alteplase (OR [95% CI] 6.2 [0.7, 56.3]). Conclusions While no significant differences between tenecteplase and alteplase were found, point estimates suggest potentially greater efficacy of 0.25 and 0.1 mg/kg doses with no difference in symptomatic intracerebral hemorrhage, and potentially higher symptomatic intracerebral hemorrhage risk with the 0.4 mg/kg dose. Further investigation of 0.25 mg/kg tenecteplase is warranted.
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Affiliation(s)
- Xuya Huang
- Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, UK
| | - Rachael MacIsaac
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | - Bruce Levin
- Department of Biostatistics, Columbia University, New York, USA
| | | | - E Clarke Haley
- Department of Neurology, University of Virginia, Charlottesville, USA
| | - Christopher Levi
- Department of Neurology, University of Newcastle, Newcastle, Australia
| | - Bruce Campbell
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Australia
| | - Christopher Bladin
- The Department of Neurosciences, Monash University, Melbourne, Australia
| | - Mark Parsons
- Department of Neurology, University of Newcastle, Newcastle, Australia
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, UK
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Huang X, Moreton FC, Kalladka D, Cheripelli BK, MacIsaac R, Tait RC, Muir KW. Coagulation and Fibrinolytic Activity of Tenecteplase and Alteplase in Acute Ischemic Stroke. Stroke 2015; 46:3543-6. [PMID: 26514192 DOI: 10.1161/strokeaha.115.011290] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 09/09/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE We compared the fibrinolytic activity of tenecteplase and alteplase in patients with acute ischemic stroke, and explored the association between hypofibrinogenaemia and intracerebral hemorrhage. METHODS Venous blood samples from a subgroup of participants in the Alteplase-Tenecteplase Trial Evaluation for Stroke Thrombolysis (ATTEST) study were obtained at pretreatment, 3 to 12 hours, and 24±3 hours post-intravenous thrombolysis for analyses of plasminogen, plasminogen activator inhibitor-1, d-dimer, factor V, fibrinogen, and fibrin(ogen) degradation products, in addition to routine coagulation assays. Related sample Wilcoxon signed-rank tests were used to test the within-group changes, and independent Mann-Whitney tests for between-group differences. RESULTS Thirty patients were included (alteplase=14 and tenecteplase=16) with similar baseline demographics. Compared with baseline, alteplase caused significant hypofibrinogenaemia (P=0.002), prolonged prothrombin time (P=0.011), hypoplasminogenaemia (P=0.001), and lower factor V (P=0.002) at 3 to 12 hours after administration with persistent hypofibrinogenaemia at 24 hours (P=0.011), whereas only minor hypoplasminogenaemia (P=0.029) was seen in the tenecteplase group. Tenecteplase consumed less plasminogen (P<0.001) and fibrinogen (P=0.002) compared with alteplase. CONCLUSIONS In patients with acute ischemic stroke, alteplase 0.9 mg/kg caused significant disruption of the fibrinolytic system, whereas tenecteplase 0.25 mg/kg did not, consistent with the trend toward lower intracerebral hemorrhage incidence with tenecteplase in the ATTEST study. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01472926.
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Affiliation(s)
- Xuya Huang
- From the Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, United Kingdom (X.H., F.C.M., D.K., B.K.C., K.W.M.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (R.M.); and Haematology Department, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, United Kingdom (R.C.T.)
| | - Fiona Catherine Moreton
- From the Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, United Kingdom (X.H., F.C.M., D.K., B.K.C., K.W.M.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (R.M.); and Haematology Department, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, United Kingdom (R.C.T.)
| | - Dheeraj Kalladka
- From the Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, United Kingdom (X.H., F.C.M., D.K., B.K.C., K.W.M.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (R.M.); and Haematology Department, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, United Kingdom (R.C.T.)
| | - Bharath Kumar Cheripelli
- From the Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, United Kingdom (X.H., F.C.M., D.K., B.K.C., K.W.M.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (R.M.); and Haematology Department, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, United Kingdom (R.C.T.)
| | - Rachael MacIsaac
- From the Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, United Kingdom (X.H., F.C.M., D.K., B.K.C., K.W.M.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (R.M.); and Haematology Department, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, United Kingdom (R.C.T.)
| | - R Campbell Tait
- From the Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, United Kingdom (X.H., F.C.M., D.K., B.K.C., K.W.M.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (R.M.); and Haematology Department, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, United Kingdom (R.C.T.)
| | - Keith W Muir
- From the Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, United Kingdom (X.H., F.C.M., D.K., B.K.C., K.W.M.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (R.M.); and Haematology Department, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, United Kingdom (R.C.T.).
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Power D, Donnelly R, MacIsaac R. Spherical scattering of superpositions of localized waves. Phys Rev E Stat Phys Plasmas Fluids Relat Interdiscip Topics 1993; 48:1410-1417. [PMID: 9960728 DOI: 10.1103/physreve.48.1410] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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