scholarly journals Cerebral Edema in Patients With Large Hemispheric Infarct Undergoing Reperfusion Treatment: A HERMES Meta-Analysis

Stroke ◽  
2021 ◽  
Author(s):  
Felix C. Ng ◽  
Nawaf Yassi ◽  
Gagan Sharma ◽  
Scott B. Brown ◽  
Mayank Goyal ◽  
...  
Keyword(s):  
Cerebral Edema ◽  
Odds Ratio ◽  
Ct Perfusion ◽  
Meta Analysis ◽  
National Institutes Of Health ◽  
Functional Improvement ◽  
Common Odds Ratio ◽  
Core Volume ◽  
Hemispheric Infarction

Background and Purpose: Whether reperfusion into infarcted tissue exacerbates cerebral edema has treatment implications in patients presenting with extensive irreversible injury. We investigated the effects of endovascular thrombectomy and reperfusion on cerebral edema in patients presenting with radiological evidence of large hemispheric infarction at baseline. Methods: In a systematic review and individual patient-level meta-analysis of 7 randomized controlled trials comparing thrombectomy versus medical therapy in anterior circulation ischemic stroke published between January 1, 2010, and May 31, 2017 (Highly Effective Reperfusion Using Multiple Endovascular Devices collaboration), we analyzed the association between thrombectomy and reperfusion with maximal midline shift (MLS) on follow-up imaging as a measure of the space-occupying effect of cerebral edema in patients with large hemispheric infarction on pretreatment imaging, defined as diffusion-magnetic resonance imaging or computed tomography (CT)-perfusion ischemic core 80 to 300 mL or noncontrast CT-Alberta Stroke Program Early CT Score ≤5. Risk of bias was assessed using the Cochrane tool. Results: Among 1764 patients, 177 presented with large hemispheric infarction. Thrombectomy and reperfusion were associated with functional improvement (thrombectomy common odds ratio =2.30 [95% CI, 1.32–4.00]; reperfusion common odds ratio =4.73 [95% CI, 1.66–13.52]) but not MLS (thrombectomy β=−0.27 [95% CI, −1.52 to 0.98]; reperfusion β=−0.78 [95% CI, −3.07 to 1.50]) when adjusting for age, National Institutes of Health Stroke Score, glucose, and time-to-follow-up imaging. In an exploratory analysis of patients presenting with core volume >130 mL or CT-Alberta Stroke Program Early CT Score ≤3 (n=76), thrombectomy was associated with greater MLS after adjusting for age and National Institutes of Health Stroke Score (β=2.76 [95% CI, 0.33–5.20]) but not functional improvement (odds ratio, 1.71 [95% CI, 0.24–12.08]). Conclusions: In patients presenting with large hemispheric infarction, thrombectomy and reperfusion were not associated with MLS, except in the subgroup with very large core volume (>130 mL) in whom thrombectomy was associated with increased MLS due to space-occupying ischemic edema. Mitigating cerebral edema-mediated secondary injury in patients with very large infarcts may further improve outcomes after reperfusion therapies.

Midterm and Long-term Results of Medial Versus Lateral Meniscal Allograft Transplantation: A Meta-analysis

2017 ◽  
Vol 46 (5) ◽  
pp. 1243-1250 ◽  
Author(s):  
Seong-Il Bin ◽  
Kyung-Wook Nha ◽  
Ji-Young Cheong ◽  
Young-Soo Shin
Keyword(s):  
Clinical Outcomes ◽  
Meta Analysis ◽  
Survival Rates ◽  
Long Term Results ◽  
Functional Improvement ◽  
Meniscal Allograft Transplantation ◽  
Allograft Transplantation ◽  
Meniscal Allograft

Background: It is unclear whether lateral meniscal allograft transplantation (MAT) procedures lead to better clinical outcomes than medial MAT. Hypothesis: The survival rates are similar between medial and lateral MAT, but the clinical outcomes of lateral MAT are better than those of medial MAT at final follow-up. Study Design: Meta-analysis. Methods: In this meta-analysis, we reviewed studies that assessed survival rates in patients who underwent medial or lateral MAT with more than 5 years of follow-up and that used assessments such as pain and Lysholm scores to compare postoperative scores on knee outcome scales. The survival time was considered as the time to conversion to knee arthroplasty and/or subtotal resection of the allograft. Results: A total of 9 studies (including 287 knees undergoing surgery using medial MAT and 407 with lateral MAT) met the inclusion criteria and were analyzed in detail. The proportion of knees in which midterm (5-10 years) survival rates (medial, 97/113; lateral, 108/121; odds ratio [OR] 0.71; 95% CI, 0.31-1.64; P = .42) and long-term (>10 years) survival rates (medial, 303/576; lateral, 456/805; OR 0.78; 95% CI, 0.52-1.17; P = .22) were evaluated did not differ significantly between medial and lateral MAT. In addition, both groups had substantial proportions of knees exhibiting midterm survivorship (85.8% for medial MAT and 89.2% for lateral MAT) but much lower proportions of knees exhibiting long-term survivorship (52.6% for medial MAT and 56.6% for lateral MAT). In contrast, overall pain score (medial, 65.6 points; lateral, 71.3 points; 95% CI, −3.95 to −0.87; P = .002) and Lysholm score (medial, 67.5 points; lateral, 72.0 points; 95% CI, −10.17 to −3.94; P < .00001) were significantly higher for lateral MAT compared with medial MAT. Conclusion: Meta-analysis indicated that 85.8% of medial and 89.2% of lateral meniscal allograft transplants survive at midterm (5-10 years) while 52.6% of medial and 56.6% of lateral meniscal allograft transplants survive long term (>10 years). Patients undergoing lateral meniscal allograft transplantation demonstrated greater pain relief and functional improvement than patients undergoing medial meniscal allograft transplantations.

scholarly journals Conjoined versus separate technique: a meta-analysis of anastomosis techniques for urinary diversion after bladder cancer

2019 ◽  
Author(s):  
Liu Daqian ◽  
Wang Yonghua ◽  
Zhao Yang ◽  
Yang Xuecheng ◽  
wang xinsheng ◽  
...  
Keyword(s):  
Bladder Cancer ◽  
Urinary Diversion ◽  
Odds Ratio ◽  
Meta Analysis ◽  
Anastomosis Group ◽  
Separate Group ◽  
Cochrane Central Register ◽  
Central Register ◽  
The Difference

Abstract Introduction: This was a meta-analysis of studies on conjoined and separate anastomosis for urinary diversion after radical cystectomy due to bladder cancer. Methods: We searched databases (PubMed, Embase and the Cochrane Central Register of Controlled Trials) for studies regarding anastomosis for urinary diversion due to bladder cancer. The meta-analysis was designed to determine the difference between conjoined and separate anastomosis. Six studies including 1601 patients were considered in the meta-analysis (654 in the separate group and 947 in the conjoined group). Results: There were no significant differences with respect to age, gender or duration of follow-up. There were seven studies that compared the rate of stricture and the rate of hydronephrosis. For overall stricture, there were 186 of 1163 ureters in the separate group and 64 of 1718 ureters in the conjoined group (odds ratio, 4.53; 95% CI, 2.01-10.22; P = 0.0003). For overall hydronephrosis patients, there were 55 of 205 ureters in the separate group and 51 of 254 ureters in the conjoined group (odds ratio, 1.48; 95% CI, 0.95-2.29; P = 0.08). Conclusion: The separate anastomosis had a higher ratio of strictures than did the conjoined group. The separate anastomosis group experienced hydronephrosis more often than did the conjoined anastomosis group. The separate anastomosis is the better choice for surgery during the operation.

scholarly journals Association of Oral Anticoagulation With Stroke in Atrial Fibrillation or Heart Failure: A Comparative Meta-Analysis

Stroke ◽  
2021 ◽  
Author(s):  
Catriona Reddin ◽  
Conor Judge ◽  
Elaine Loughlin ◽  
Robert Murphy ◽  
Maria Costello ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Treatment Effect ◽  
Oral Anticoagulation ◽  
Clinical Benefit ◽  
Odds Ratio ◽  
Meta Analysis ◽  
Major Hemorrhage ◽  
Net Clinical Benefit

Background and Purpose: Atrial fibrillation and heart failure with reduced ejection fraction (HFrEF) are common sources of cardioembolism. While oral anticoagulation is strongly recommended for atrial fibrillation, there are marked variations in guideline recommendations for HFrEF due to uncertainty about net clinical benefit. This systematic review and meta-analysis evaluates the comparative association of oral anticoagulation with stroke and other cardiovascular risk in populations with atrial fibrillation or HFrEF in sinus rhythm and identify factors mediating different estimates of net clinical benefit. Methods: PubMed and Embase were searched from database inception to November 20, 2019 for randomized clinical trials comparing oral anticoagulation to control. A random-effects meta-analysis was used to estimate a pooled treatment-effect overall and within atrial fibrillation and HFrEF trials. Differences in treatment effect were assessed by estimating I 2 among all trials and testing the between-trial-population P -interaction. The primary outcome measure was all stroke. Secondary outcome measures were ischemic stroke, hemorrhagic stroke, mortality, myocardial infarction, and major hemorrhage. Results: Twenty-one trials were eligible for inclusion, 15 (n=19 332) in atrial fibrillation (mean follow-up: 23.1 months), and 6 (n=9866) in HFrEF (mean follow-up: 23.9 months). There were differences in primary outcomes between trial populations, with all-cause mortality included for 95.2% of HFrEF trial population versus 0.38% for atrial fibrillation. Mortality was higher in controls groups of HFrEF populations (19.0% versus 9.6%) but rates of stroke lower (3.1% versus 7.0%) compared with atrial fibrillation. The association of oral anticoagulation with all stroke was consistent for atrial fibrillation (odds ratio, 0.51 [95% CI, 0.42–0.63]) and HFrEF (odds ratio, 0.61 [95% CI, 0.47–0.79]; I 2 =12.4%; P interaction=0.31). There were no statistically significant differences in the association of oral anticoagulation with cardiovascular events, mortality or bleeding between populations. Conclusions: The relative association of oral anticoagulation with stroke risk, and other cardiovascular outcomes, is similar for patients with atrial fibrillation and HFrEF. Differences in the primary outcomes employed by trials in HFrEF, compared with atrial fibrillation, may have contributed to differing conclusions of the relative efficacy of oral anticoagulation.

scholarly journals Endovascular Treatment Effect Diminishes With Increasing Thrombus Perviousness

Stroke ◽  
2021 ◽  
Author(s):  
Manon Kappelhof ◽  
Manon L. Tolhuisen ◽  
Kilian M. Treurniet ◽  
Bruna G. Dutra ◽  
Heitor Alves ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Odds Ratio ◽  
Infarct Volume ◽  
Treatment Allocation ◽  
Common Odds Ratio

Background and Purpose: Thrombus perviousness estimates residual flow along a thrombus in acute ischemic stroke, based on radiological images, and may influence the benefit of endovascular treatment for acute ischemic stroke. We aimed to investigate potential endovascular treatment (EVT) effect modification by thrombus perviousness. Methods: We included 443 patients with thin-slice imaging available, out of 1766 patients from the pooled HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke trials) data set of 7 randomized trials on EVT in the early window (most within 8 hours). Control arm patients (n=233) received intravenous alteplase if eligible (212/233; 91%). Intervention arm patients (n=210) received additional EVT (prior alteplase in 178/210; 85%). Perviousness was quantified by thrombus attenuation increase on admission computed tomography angiography compared with noncontrast computed tomography. Multivariable regression analyses were performed including multiplicative interaction terms between thrombus attenuation increase and treatment allocation. In case of significant interaction, subgroup analyses by treatment arm were performed. Our primary outcome was 90-day functional outcome (modified Rankin Scale score), resulting in an adjusted common odds ratio for a one-step shift towards improved outcome. Secondary outcomes were mortality, successful reperfusion (extended Thrombolysis in Cerebral Infarction score, 2B–3), and follow-up infarct volume (in mL). Results: Increased perviousness was associated with improved functional outcome. After adding a multiplicative term of thrombus attenuation increase and treatment allocation, model fit improved significantly ( P =0.03), indicating interaction between perviousness and EVT benefit. Control arm patients showed significantly better outcomes with increased perviousness (adjusted common odds ratio, 1.2 [95% CI, 1.1–1.3]). In the EVT arm, no significant association was found (adjusted common odds ratio, 1.0 [95% CI, 0.9–1.1]), and perviousness was not significantly associated with successful reperfusion. Follow-up infarct volume (12% [95% CI, 7.0–17] per 5 Hounsfield units) and chance of mortality (adjusted odds ratio, 0.83 [95% CI, 0.70–0.97]) decreased with higher thrombus attenuation increase in the overall population, without significant treatment interaction. Conclusions: Our study suggests that the benefit of best medical care including alteplase, compared with additional EVT, increases in patients with more pervious thrombi.

Abstract TP91: Unfavorable Baseline Hypoperfusion Intensity Ratio is Associated With Infarct Growth and Poor Outcome in Patients With Distal MCA Occlusions

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Adam MacLellan ◽  
Michael Mlynash ◽  
Stephanie Kemp ◽  
Soren Christensen ◽  
Michael Marks ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Intensity Ratio ◽  
Ct Perfusion ◽  
Anterior Circulation ◽  
Excellent Functional Outcome ◽  
The Mean ◽  
Ischemic Core ◽  
Core Volume ◽  
Distal Middle Cerebral Artery

Background: A low hypoperfusion intensity ratio (HIR) predicts good collateral vessel status and correlates with infarct growth and functional outcome in early window patients with proximal large vessel anterior circulation occlusions. Its performance in predicting clinical and radiologic outcome has not been assessed in patients with more distal occlusions. In this retrospective analysis of the CT Perfusion to Predict Response to Recanalization in Ischemic Stroke (CRISP) study, we hypothesized that a favorable baseline HIR would predict less infarct growth in patients with distal middle cerebral artery (MCA) occlusions. Methodology: Patients with occlusions of an M2 or M3 branch of the MCA on catheter angiography were included; all patients underwent mechanical thrombectomy with TICI2B/3 reperfusion. Baseline ischemic core volume and HIR (Tmax >10s / Tmax >6s) were assessed with RAPID software; late follow-up infarct volumes (>36 hours from initial CT perfusion) were manually determined from DWI MRI. Excellent functional outcome was defined as a modified Rankin score of 0-1. Results: Fourteen patients with baseline perfusion and late follow-up imaging were included; nine patients presented with M2 occlusions, and 5 with M3 occlusions. The mean baseline HIR of 0.48 was used to dichotomize patients into favorable or unfavorable baseline profiles. Patients with a favorable baseline HIR had significantly smaller baseline ischemic core volumes (0 mL [IQR 0-3.3] vs. 14.0 mL [IQR 8.7-22.1], p=0.01), smaller final infarct volumes (16.1 mL [IQR 12.7-41.2] vs. 71.4 mL [IQR 43.8-113.5], p=0.01) and less infarct growth (16.1 mL [IQR 9.4-31.9] vs. 49.0 mL [IQR 31.1-100.8], p=0.03). Excellent functional outcome was achieved in 6/6 (100%) of those with favorable baseline HIR, versus 3/8 (37.5%) with unfavorable baseline profile (p=0.03). Conclusion: In patients with distal MCA occlusions, poor collateral status at baseline as demonstrated by a high HIR score is associated with more infarct growth and worse clinical outcomes. HIR may be helpful for guiding thrombectomy decisions in patients with distal occlusions and warrants further prospective study in this population.

Dietary Inflammatory Index and the Risk of Frailty Among Older Adults: A Systematic Review and Meta-Analysis

2020 ◽  
pp. 016402752094817
Author(s):  
Sajjad Moradi ◽  
Amir Hadi ◽  
Hamed Mohammadi ◽  
Omid Asbaghi ◽  
Mehdi Zobeiri ◽  
...  
Keyword(s):  
Systematic Review ◽  
Older Adults ◽  
Odds Ratio ◽  
Meta Analysis ◽  
Ratio Analysis ◽  
Dietary Inflammatory Index ◽  
Inflammatory Index ◽  
Prospective Cohort Studies ◽  
Low Bmi

A systematic review and meta-analysis was conducted to comprehensively examine the association between Dietary Inflammatory Index (DII®) score and risk of frailty. Frailty risk were available from five studies comprising 13,908 older adults. Furthermore, frailty related parameters were extacted from two studies with 7,539 individuals. A pooled adjusted odds ratio analysis indicated that there was an association between DII® score and frailty risk (OR = 1.24, 95%CI: 1.6–1.33, P < 0.001, I2 = 0.0%). The results of frailty related parameters demonstrated that DII® score was associated with weakness risk (OR = 1.12, 95%CI: 1.05–1.19, P = 0.014, I2 = 0.0%), but not other frailty-related parameters including exhaustion, low BMI or low physical activity. The results of this meta-analysis suggest that older adults who exhibit higher DII® scores have an increased frailty risk. Further prospective cohort studies with longer follow-up periods, are needed to support this possible association between DII® score and frailty risk.

Association between pre-treatment perfusion profile and cerebral edema after reperfusion therapies in ischemic stroke

2021 ◽  
pp. 0271678X2110176
Author(s):  
Felix C Ng ◽  
Leonid Churilov ◽  
Nawaf Yassi ◽  
Timothy J Kleinig ◽  
Vincent Thijs ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Cerebral Edema ◽  
Significant Interaction ◽  
Ct Perfusion ◽  
Physiological State ◽  
Pooled Analysis ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Pre Treatment ◽  
Core Volume

The relationship between reperfusion and edema is unclear, with experimental and clinical data yielding conflicting results. We investigated whether the extent of salvageable and irreversibly-injured tissue at baseline influenced the effect of therapeutic reperfusion on cerebral edema. In a pooled analysis of 415 patients with anterior circulation large vessel occlusion from the Tenecteplase-versus-Alteplase-before-Endovascular-Therapy-for-Ischemic-Stroke (EXTEND-IA TNK) part 1 and 2 trials, associations between core and mismatch volume on pre-treatment CT-Perfusion with cerebral edema at 24-hours, and their interactions with reperfusion were tested. Core volume was associated with increased edema (p < 0.001) with no significant interaction with reperfusion (p = 0.82). In comparison, a significant interaction between reperfusion and mismatch volume (p = 0.03) was observed: Mismatch volume was associated with increased edema in the absence of reperfusion (p = 0.009) but not with reperfusion (p = 0.27). When mismatch volume was dichotomized at the median (102 ml), reperfusion was associated with reduced edema in patients with large mismatch volume (p < 0.001) but not with smaller mismatch volume (p = 0.35). The effect of reperfusion on edema may be variable and dependent on the physiological state of the cerebral tissue. In patients with small to moderate ischemic core volume, the benefit of reperfusion in reducing edema is related to penumbral salvage.

scholarly journals No Increased Risk of Secondary Neoplasms in Patients Treated with Rituximab for Non-Hodgkin’s Lymphoma : A Meta-Analysis of 9 Trials

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 1659-1659
Author(s):  
Isabelle Fleury ◽  
Sylvie Chevret ◽  
Michael Pfreundschuh ◽  
Gilles Salles ◽  
Bertrand Coiffier ◽  
...  
Keyword(s):  
T Cell ◽  
Board Of Directors ◽  
Odds Ratio ◽  
Research Funding ◽  
Meta Analysis ◽  
Advisory Committees ◽  
Secondary Neoplasms ◽  
Increased Risk ◽  
American Society

Abstract Background. Rituximab improved outcomes of all CD20+ non-Hodgkin lymphoma (NHL) subtypes. Rituximab induces a transient B-cell depletion and a dose-dependent T-cell inactivation (Stroopinsky et al., Cancer Immunol Immunother 2012) predisposing to T-cell dependent infections and to a potential impaired T-cell immunosurveillance. Secondary neoplasms (SN) is infrequent in trials including rituximab and the SN risk associated to rituximab across multiple trials has not been reported. We performed a systematic review of published trials comparing chemotherapy with or without rituximab to evaluate SN occurrence. Methods. Our primary endpoint was SN risk in patients with NHL treated with rituximab. We searched PubMed and Embase databases for randomised controlled trials on rituximab and lymphoma where rituximab constituted the only difference between treatment arms and where SN incidence or SN related death were reported. Authors were contacted for SN related rituximab exposure if not detailed. Chronic lymphocytic leukemia and HIV-related lymphomas were excluded due to increased risk of SN. Updated follow-up of eligible trials presented at annual meetings of the American Society of Clinical Oncology and American Society of Hematology were retrieved. Data were extracted independently by two authors. A random effects DerSimonian-Laird meta-analysis was performed to estimate the summary effect of rituximab on the hazard of SN. Statistical heterogeneity was tested using Woolf test. Results. We identified nine trials cumulating 4621 patients with 2312 exposed to rituximab and 2309 not exposed. These nine trials are known with the following names: PRIMA (1), GELA LNH98.5 (2), MINT (3), CORAL (4), IELSG-19 (5), EORTC20981 (6), OSHO#39 (7), SAKK 35/98 (8), RICOVER60 (9). Histology were diffuse large B cell (n=4), follicular (n=4) and marginal zone (n=1) lymphomas. Median age was 58.1 years. Sex distribution was available for seven trials with 1650 (47.6%) women and 1814 (52.4%) men. In all these trials but one (SAKK 35/98), rituximab was used associated with chemotherapy: CHOP, CHOEP, FCM, MCP, DHAP, ICE, or chlorambucil. At a median follow-up of 73 months [interquartile range: 72-84], a total of 334 SN was observed, including 169 SN in patients randomised to rituximab as compared to 165 SN in patients not randomised to rituximab (OR= 0.88; 95%CI: 0.66-1.19) (Figure 1). No evidence of significant heterogeneity was noticed across trials (p = 0.93). Notably, the proportion of females, histology subtypes, use of rituximab in first line, and use of rituximab over prolonged periods in maintenance did not influence SN risk (p = 0.94, p = 0.80, p = 0.87, p = 0.87 respectively). The SN risk was not increased in protocols administrating rituximab over periods of 8 months to 12 months (CORAL , OSHO#39) as opposed to periods of 24 months (PRIMA, EORTC20981) (p=0.86). Conclusions. This meta-analysis of nine trials randomising rituximab in NHL patients suggests no SN predisposition at a median follow-up of 6 years. SN risk associated with the combination of rituximab and new targeted therapies warrants prospective monitoring. Figure 1. Standard meta-analysis plot of the odds ratio of SN prevalence in the rituximab arm compared to the control arm Figure 1. Standard meta-analysis plot of the odds ratio of SN prevalence in the rituximab arm compared to the control arm Disclosures Fleury: Lundbeck: Membership on an entity's Board of Directors or advisory committees, Preceptorship Other. Pfreundschuh:Amgen: Membership on an entity's Board of Directors or advisory committees, Research Funding; Boehringer Ingelheim: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees; Onyx: Membership on an entity's Board of Directors or advisory committees; Pfizer: Membership on an entity's Board of Directors or advisory committees; Roche: Membership on an entity's Board of Directors or advisory committees, Research Funding; Spectrum: Research Funding. Salles:Roche: Honoraria, Research Funding. van Oers:Roche: Consultancy. Gisselbrecht:Roche: Research Funding. Zucca:Roche: Consultancy, Membership on an entity's Board of Directors or advisory committees; Johnson and Johnson: Consultancy, Membership on an entity's Board of Directors or advisory committees; Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees. Herold:Roche Pharma AG/Germany: Honoraria, Research Funding. Ghielmini:Roche: Research Funding, Speakers Bureau.

Abstract 100: Reperfusion Improves Clinical Outcome Across the 4.5-9h and Wake-Up Stroke Time Continuum in EXTEND and EPITHET

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Bruce C Campbell ◽  
Henry Ma ◽  
Mark W Parsons ◽  
Leonid Churilov ◽  
Nawaf Yassi ◽  
...  
Keyword(s):  
Odds Ratio ◽  
Randomized Trials ◽  
Time Window ◽  
Functional Improvement ◽  
Lesion Volume ◽  
Common Odds Ratio ◽  
Shift Analysis ◽  
Intravenous Alteplase ◽  
Interaction Term ◽  
Time Continuum

Introduction: Intravenous alteplase reduces disability after ischemic stroke in patients 4.5-9h after onset and with wake-up onset stroke who have favorable perfusion imaging. We examined the benefit of reperfusion in reducing disability, including by onset to randomization time strata in the EXTEND and EPITHET randomized trials. Methods: Patients were randomized to alteplase or placebo after perfusion mismatch imaging. Reperfusion was defined as >90% reduction in Tmax>6s lesion volume at 24h. Ordinal logistic regression adjusted for baseline age and NIHSS was used to analyze functional improvement in day 90 modified Rankin scale overall, including a reperfusion*time to randomization interaction term, and in the 4.5-6h, 6-9h and wake-up time strata. Symptomatic hemorrhage was defined as large parenchymal hematoma with ≥4 point NIHSS increase (SITS). Results: Reperfusion was assessable in 270/294 (92%) patients, 68/133 (51%) alteplase and 38/137 (28%) placebo reperfused (p<0.001). Median age 76 (IQR 66-81) in reperfused vs 74 (IQR 64.5-81) in non-reperfused, median baseline NIHSS 10 (IQR 7-15) in reperfused vs 12 (IQR 8-17.5) in non-reperfused. Overall, reperfusion was associated with common odds ratio 7.7 (95%CI 4.6-12.8, p<0.0001) in ordinal “shift” analysis. There was no heterogeneity in the beneficial effect of reperfusion effect by time to randomization (p=0.63). Reperfusion was associated with significantly improved functional outcome in each of the 4.5-6h, 6-9h and wake-up time strata (figure). Symptomatic hemorrhage, assessed in all 294 patients, occurred in 3/51 (5.9%) 4.5-6h, 2/28 (7.1%) 6-9h, 4/73 (5.5%) wake-up stroke in the alteplase-treated patients (van Elteren p=0.66). Conclusions: Strong benefits of reperfusion in all time strata without differential risk in symptomatic hemorrhage support the durable treatment effect of alteplase in perfusion mismatch-selected patients throughout the 4.5-9h and wake-up stroke time window.

Effect of raloxifene therapy on venous thromboembolism in postmenopausal women: A meta-analysis

2008 ◽  
Vol 99 (02) ◽  
pp. 338-342 ◽  
Author(s):  
Jurga Adomaityte ◽  
Maria Farooq ◽  
Rehan Qayyum
Keyword(s):  
Confidence Interval ◽  
Postmenopausal Women ◽  
Odds Ratio ◽  
English Language ◽  
Meta Analysis ◽  
Cochrane Collaboration ◽  
P Value ◽  
Receptor Modulator ◽  
Prevention Of Osteoporosis

SummaryRaloxifene, a selective estrogen receptor modulator, is indicated for the prevention of osteoporosis in postmenopausal women. However, its effect on the risk of deep venous thrombosis (DVT) and pulmonary embolism (PE) is unclear. Therefore, we conducted a meta-analysis to evaluate the effect of raloxifene on these outcomes. To identify randomized controlled trials of raloxifene, a systematic search of PubMed, EMBASE, and Cochrane Collaboration databases was performed from the date of inception of these databases to October 2007. Search was limited to trials that were published in peer-reviewed English-language medical journals. Articles were included in the meta-analysis if they had reported on DVT, PE, or thromboembolic events. Nine trials, including 24,523 postmenopausal women, (median age 59.4 years, range 55 to 67 years; median follow-up 24 months, range 3 to 67 months) met inclusion criteria. Therapy with raloxifene was associated with a 62% increase in odds of either DVT or PE (odds ratio = 1.62; 95% confidence interval = 1.25 to 2.09; p-value < 0.001). Similarly, raloxifene therapy was associated with 54% increase in odds of DVT (odds ratio = 1.54; 95% confidence interval = 1.13 to 2.11; p-value = 0.006) and 91% increase in odds of PE alone (odds ratio = 1.91;95% confidence interval = 1.05 to 3.47; p-value = 0.03). Raloxifene increases the risk of DVT and PE in postmenopausal women.

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