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1. Effects of antiplatelet therapy on stroke risk by brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases: subgroup analyses of the RESTART randomised, open-label trial

Author

Rustam Al-Shahi Salman, David P Minks, Dipayan Mitra, Mark A Rodrigues, Priya Bhatnagar, Johann C du Plessis, Yogish Joshi, Martin S Dennis, Gordon D Murray, David E Newby, Peter A G Sandercock, Nikola Sprigg, Jacqueline Stephen, Cathie L M Sudlow, David J Werring, William N Whiteley, Joanna M Wardlaw, Philip M White, Colin Baigent, Daniel Lasserson, Frank Sullivan, Johanna Carrie, Javier Rojas, Shannon Amoils, John Bamford, Jane Armitage, Gabriel Rinkel, Gordon Lowe, Jonathan Emberson, Karen Innes, Lynn Dinsmore, Jonathan Drever, Carol Williams, David Perry, Connor McGill, David Buchanan, Allan Walker, Aidan Hutchison, Christopher Matthews, Ruth Fraser, Aileen McGrath, Ann Deary, Rosemary Anderson, Pauli Walker, Christian Hansen, Richard Parker, Aryelly Rodriguez, Malcolm Macleod, Thomas Gattringer, Jeb Palmer, Eleni Sakka, Jennifer Adil-Smith, David Minks, Johannes du Plessis, Christine Lerpiniere, Richard O'Brien, Seona Burgess, Gillian Mead, Ruth Paulton, Fergus Doubal, Katrina McCormick, Neil Hunter, Pat Taylor, Ruwan Parakramawansha, Jack Perry, Gordon Blair, Allan MacRaild, Adrian Parry-Jones, Mary Johnes, Stephanie Lee, Kelly Marie Shaw, Ilse Burger, Martin Punter, Andrea Ingham, Jane Perez, Zin Naing, Jordi Morell, Tracy Marsden, Andrea Hall, Sally Marshall, Louise Harrison, Rowilson Jarapa, Edith Wood, Victoria O'Loughlin, David Cohen, Silvie Davies, Kelechi Njoku, Mushiya Mpelembue, Laura Burgess, Radim Licenik, Mmua Ngwako, Nabeela Nisar, Rangah Niranchanan, Tatjana Roganova, Rajaram Bathula, Joseph Devine, Anette David, Anne Oshodi, Fenglin Guo, Emmanuelle Owoyele, Varthi Sukdeo, Robert Ballantine, Mudhar Abbdul-saheb, Angela Chamberlain, Aberami Chandrakumar, Philip Poku, Kirsty Harkness, Catrin Blank, Emma Richards, Ali Ali, Faith Kibutu, Olesia Balitska, Kathryn Birchall, Pauline Bayliss, Clare Doyle, Kathy Stocks, Arshad Majis, Jo Howe, Christine Kamara, Luke Barron, Ahmad Maatouk, Ralf Lindert, Katy Dakin, Jessica Redgrave, Biju Bhaskaran, Isam Salih, Debs Kelly, Susan Szabo, Dawn Tomlin, Helen Bearne, Jean Buxton, Pauline Fitzell, Georgina Ayres, Afaq Saulat, Kathleen Horan, Joanne Garfield-Smith, Harbens Bhakri, Paul Guyler, Devesh Sinha, Thayalini Loganathan, Amber Siddiqui, Anwer Siddiqui, Lucy Coward, Swapna Kunhunny, Sharon Tysoe, Rajalakshmi Orath Prabakaran, Shyam Kelavkar, Sindhu Rashmi, David Ngo, Kheng Xiong Ng, Nisha Menon, Sweni Shah, Mark Barber, Derek Esson, Fiona Brodie, Talat Anjum, Mushtaq Wani, Manju Krishnan, Leanne Quinn, Jayne Spencer, Terry Jones, Helen Thompson-Jones, Lynne Dacey, Srikanth Chenna, Sharon Storton, Sarah Thomas, Teresa Beaty, Shelley Treadwell, Caroline Davies, Susan Tucker, Lynda Connor, Peter Slade, Glyn Gainard, Girish Muddegowda, Ranjan Sanyal, Alda Remegoso, Nenette Abano, Chelsea Causley, Racquel Carpio, Stephanie Stevens, Adrian Butler, Resti Varquez, Hayley Denic, Francis Alipio, Andrew Moores, Adrian Barry, Holly Maguire, Jeanette Grocott, Kay Finney, Sue Lyjko, Christine Roffe, Joanne Hiden, Phillip Ferdinand, Vera Cvoro, Khalil Ullah, Nicola Chapman, Mandy Couser, Susan Pound, Sean Mcauley, Senthil Raghunathan, Faye Shelton, Amanda Hedstrom, Margi Godfrey, Diane Havard, Amanda Buck, Kailash Krishnan, Nicola Gilzeane, Jack Roffe, Judith Clarke, Katherine Whittamore, Saima Sheikh, Rekha Keshvara, Carla Jordan, Benjamin Jackson, Gwendoline Wilkes, Jason Appleton, Zhe Law, Oliver Matias, Evangelos Vasileiadis, Cathy Mason, Anthea Parry, Geraldine Landers, Melinda Holden, Basaam Aweid, Khalid Rashed, Linda Balian, Carinna Vickers, Elizabeth Keeling, Sarah Board, Joanna Allison, Clare Buckley, Barbara Williams-Yesson, Joanne Board, Tressy Pitt-Kerby, Alfonso Tanate, Diane Wood, Manohar Kini, Dinesh Chadha, Deborah Walstow, Rosanna Fong, Robert Luder, Tolu Adesina, Jill Gallagher, Hayley Bridger, Elodie Murali, Maneesh Bhargava, Chloe van Someren, Frances Harrington, Abhijit Mate, Ali James, Gillian Courtauld, Christine Schofield, Katja Adie, Linda Lucas, Kirsty Bond, Bev Maund, Sam Ellis, Paul Mudd, Martin James, Samantha Keenan, Angela Bowring, Julie Cageao, Hayley Kingwell, Caroline Roughan, Anthony Hemsley, Jane Sword, David Strain, Keniesha Miller, Anita Goff, Karin Gupwell, Kevin Thorpe, Hedley Emsley, Shuja Punekar, Alison McLoughlin, Sulaiman Sultan, Bindu Gregory, Sonia Raj, Donna Doyle, Keith Muir, Wilma Smith, Angela Welch, Fiona Moreton, Bharath Kumar Cheripelli, Salwa El Tawil, Dheeraj Kalladka, Xuya Huang, Nicola Day, Sankaranarayanan Ramachandran, Caroline Crosbie, Jennifer Elliot, Tony Rudd, Katherine Marks, Ajay Bhalla, Jonathan Birns, Sagal Kullane, Nic Weir, Christopher Allen, Vanessa Pressly, Pam Crawford, Emma Battersby-Wood, Alex Blades, Shuna Egerton, Ashleigh Walters, Sue Evans, James Richard Marigold, Fiona Smith, Gabriella Howard, Imogen Gartrell, Simon Smith, Robyn Creeden, Chloe Cox, Cherish Boxall, Jonathan Hewitt, Claire Nott, Procter Sarah, Jessica Whiteman, Steve Buckle, Rebecca Wallace, Rina Mardania, Jane Gray, Claire Triscott, Anand Nair, Jill Greig, Pratap Rana, Matthew Robinson, Mohammad Irfan Alam, David Werring, Duncan Wilson, Caroline Watchurst, Maria Brezitski, Luci Crook, Ifan Jones, Azra Banaras, Krishna Patel, Renuka Erande, Caroline Hogan, Isabel Hostettler, Amy Ashton, Shez Feerick, Nina Francia, Nnebuife Oji, Emma Elliott, Talal Al-Mayhani, Martin Dennis, Cathie Sudlow, William Whiteley, Dipankar Dutta, Pauline Brown, Deborah Ward, Fiona Davis, Jennifer Turfrey, Chloe Hughes, Kayleigh Collins, Rehana Bakawala, Susan O'Connell, Jon Glass, David Broughton, Dinesh Tryambake, Lynn Dixon, Kath Chapman, Andrew Young, Adrian Bergin, Andrew Sigsworth, Aravind Manoj, Glyn Fletcher, Paula Lopez, Penelope Cox, Mark Wilkinson, Paul Fitzsimmons, Nikhil Sharma, James Choulerton, Denise Button, Lindsey Dow, Lukuman Gbadamoshi, Joanne Avis, Barbara Madigan, Stephanie McCann, Louise Shaw, Deborah Howcroft, Suzanne Lucas, Andrew Stone, Gillian Cluckie, Caroline Lovelock, Brian Clarke, Neha Chopra, Natasha Clarke, Bhavini Patel, Kate Kennedy, Rebecca Williams, Adrian Blight, Joanna O'Reilly, Chukwuka Orefo, Nilofer Dayal, Rita Ghatala, Temi Adedoyin, Fran Watson, Sarah Trippier, Lillian Choy, Barry Moynihan, Usman Khan, Val Jones, Naomi Jeyaraj, Lourda Kerin, Kamy Thavanesan, Divya Tiwari, Chantel Cox, Anja Ljubez, Laura Tucker, Arshi Iqbal, Caroline Bagnall, Marketa Keltos, Josh Roberts, Becky Jupp, Catherine Ovington, Emily Rogers, Owen David, Jo Bell, Barbara Longland, Gail Hann, Martin Cooper, Mohammad Nasar, Anoja Rajapakse, Inez Wynter, Ijaz Anwar, Helen Skinner, Tarn Nozedar, Damian McArdle, Balakrishna Kumar, Susan Crawford, Arunkumar Annamalai, Alex Ramshaw, Clare Holmes, Sarah Caine, Mairead Osborn, Emily Dodd, Peter Murphy, Nicola Devitt, Pauline Baker, Amy Steele, Lucy Belle Guthrie, Samantha Clarke, Ahamad Hassan, Dean Waugh, Emelda Veraque, Linetty Makawa, Mary Kambafwile, Marc Randall, Vasileios Papavasileiou, Claire Cullen, Jenny Peters, Hlaing Thant, Tanya Ingram, Mellor Zoe, Ramesh Durairaj, Melanie Harrison, Sarah Stevenson, Daniela Shackcloth, Jordan Ewing, Victoria Sutton, Mark McCarron, Jacqueline McKee, Mandy Doherty, Ferghal McVerry, Caroline Blair, Mary MacLeod, Janice Irvine, Heather Gow, Jacqueline Furnace, Anu Joyson, Baljit Jagpal, Sarah Ross, Katrina Klaasen, Sandra Nelson, Rebecca Clarke, Nichola Crouch, Beverly MacLennan, Vicky Taylor, Daniel Epstein, Avani Shukla, Vinodh Krishnamurthy, Paul Nicholas, Sammie Qureshi, Adam Webber, Justin Penge, Hawraman Ramadan, Stuart Maguire, Chris Patterson, Ruth Bellfield, Brigid Hairsine, Kelvin Stewart, Michaela Hooley, Outi Quinn, Bella Richard, Sally Moseley, Mandy Edwards, Heidi Lawson, Michelle Tayler, Yogish Pai, Mahesh Dhakal, Bernard Esisi, Sofia Dima, Gemma Marie Smith, Mark Garside, Muhammad Naeem, Vidya Baliga, Gill Rogers, Ellen Brown, David Bruce, Rachel Hayman, Susan Clayton, Ed Gamble, Rebecca Grue, Bethan Charles, Adam Hague, Sujata Blane, Caroline Lambert, Afnan Chaudhry, Thomas Harrison, Kari Saastamoinen, Dionne Hove, Laura Howaniec, Gemma Grimwood, Ozlem Redjep, Fiona Humphries, Lucia Argandona, Larissa Cuenoud, Esther Erumere, Sageet Amlani, Grace Auld, Afraim Salek-Haddadi, Ursula Schulz, James Kennedy, Gary Ford, Philip Mathieson, Ian Reckless, Rachel Teal, Giulia Lenti, George Harston, Eoin O'Brien, Joanne Mcgee, Jennifer Mitchell, Elaine Amis, Dominic Handley, Siobhan Kelly, George Zachariah, Jobbin Francis, Sarah Crisp, Juliana Sesay, Sarah Finlay, Helen Hayhoe, Niamh Hannon, Tom Hughes, Bethan Morse, Henry De Berker, Emma Tallantyre, Ahmed Osman, Susan White, Stefan Schwarz, Benjamin Jelley, Rajendra Yadava, Khalid Azhar, Julie Reddan, Mirriam Sangombe, Samantha Stafford, Ken Fotherby, Debbie Morgan, Farrukh Baig, Karla Jennings-Preece, Donna Butler, Nasar Ahmad, Angela Willberry, Angela Stevens, Baljinder Rai, Prasad Siddegowda, Peter Howard, Lisa Hyatt, Tracey Dobson, David Jarrett, Suheil Ponnambath, Jane Tandy, Yasmin Harrington-Davies, Rebecca Butler, Claire James, Stacey Valentine, Anne Suttling, Peter Langhorne, Gillian Kerr, Fiona Wright, Ruth Graham, Christine McAlpine, Mohammad Shahzad Iqbal, Louise Humphreys, Kath Pasco, Olga Balazikova, Ashraf Nasim, Cassilda Peixoto, Louise Gallagher, Shahrzad Shahmehri, Sandip Ghosh, Elizabeth Barrie, Danielle Gilmour, Margo Henry, Tom Webb, Linda Cowie, Hannah Rudenko, Shanni McDonald, Natasha Schumacher, Susannah Walker, Tracey Cosier, Anna Verrion, Eva Beranova, Audrey Thomson, Marius Venter, Arindam Kar, Sheila Mashate, Kirsten Harvey, Léjeune Gardener, Vinh Nguyen, Omid Halse, Olivia Geraghty, Beth Hazel, Peter Wilding, Victoria Tilley, Tim Cassidy, Beverley McClelland, Maria Bokhari, Timothy England, Mohana Maddula, Richard Donnelly, Paul Findlay, Ashish Macaden, Ian Shread, Charlotte Barr, Azlisham Mohd Nor, Claire Brown, Nicola Persad, Charlotte Eglinton, Marie Weinling, Benjamin Hyams, Alex Shah, John Baker, Anthony Byrne, Caroline McGhee, Amanda Smart, Claire Copeland, Michael Carpenter, Marion Walker, Richard Davey, Ann Needle, Razik Fathima, Gavin Bateman, Prabal Datta, Andrew Stanners, Linda Jackson, Julie Ball, Michelle Davis, Natalie Atkinson, Michelle Fawcett, Teresa Thompson, Helen Guy, Valerie Hogg, Carole Hays, Stephen Woodward, Mohammad Haque, Eluzai Hakim, Stuart Symonds, Mehran Maanoosi, Jane Herman, Toby Black, Skelton Miriam, Caroline Clarke, Alpha Anthony, Michele Tribbeck, Julie Cronin, Denise Mead, Ruth Fennelly, James McIlmoyle, Christina Dickinson, Carol Jeffs, Sajjad Anwar, Joanne Howard, Kirsty Jones, Saikat Dhar, Caroline Clay, Muhammad Siddiq, Simone Ivatts, Yolanda Baird, Moore Sally, Isobel Amey, Sophie Newton, Lisa Clayton-Evans, Indra Chadbourn, Rayessa Rayessa, Charde Naylor, Alicia Rodgers, Lisa Wilson, Sarah Wilson, Emma Clarkson, Ruth Davies, Paula Owings, Graeme Sangster, Valerie Gott, Victoria Little, Pauline Weir, Suja Cherian, Deepa Jose, Helen Moroney, Susan Downham, Angela Dodd, Venetia Vettimootal Johnson, Laura Codd, Naomi Robinson, Ashraf Ahmed, Mo Albazzaz, Sharon Johnson, Carol Denniss, Mishell Cunningham, Tajammal Zahoor, Timothy Webster, Sandra Leason, Syed Haider, Kausic Chatterjee, Arumugam Nallasivan, Charlotte Perkins, Samantha Seagrave, Colin Jenkins, Fiona Price, Claire Hughes, Lily Mercer, Malik Hussain, Sarah Brown, Miriam Harvey, Jane Homan, Mohammad Khan, Robert Whiting, Leanne Foote, Nicholas Hunt, Helen Durman, Lucy Brotherton, Jayne Foot, Corinne Pawley, Eliza Foster, Alison Whitcher, Kneale Metcalf, Jenny Jagger, Susan McDonald, Kelly Waterfield, Patrick Sutton, Naval Shinh, Ajmal Anversha, Garth Ravenhill, Richard Greenwood, Janak Saada, Alison Wiltshire, Rebekah Perfitt, Sreeman Andole, Naveen Gadapa, Karen Dunne, Magdalini Krommyda, Evelyne Burssens, Sam King, Catherine Plewa, Nigel Smyth, Jenny Wilson, Elio Giallombardo, Lucy Sykes, Pradeep Kumar, James Barker, Isabel Huggett, Linda Dunn, Charlotte Culmsee, Philip Thomas, Min Myint, Helen Brew, Nikhil Majmudar, Janice OConnell, George Bunea, Charlotte Fox, Diane Gulliver, Andrew Smith, Betty Mokoena, Naweed Sattar, Ramesh Krishnamurthy, Emily Osborne, David Wilson, Belinda Wroath, Kevin Dynan, Michael Power, Susan Thompson, Victoria Adell, Enoch Orugun, Una Poultney, Rachel Glover, Hannah Crowther, Sarah Thornthwaite, Ivan Wiggam, Aine Wallace, Enda Kerr, Ailsa Fulton, Annemarie Hunter, Suzanne Tauro, Sarah Cuddy, David Mangion, Anne Hardwick, Skarlet Markova, Tara Lawrence, Carmen Constantin, Jo Fletcher, Isobel Thomas, Kerry Pettitt, Lakshmanan Sekaran, Margaret Tate, Kiranjit Bharaj, Rohan Simon, Frances Justin, Sakthivel Sethuraman, Duke Phiri, Niaz Mohammed, Meena Chauhan, Khaled Elfandi, Uzma Khan, David Eveson, Amit Mistri, Lisa Manning, Shagufta Khan, Champa Patel, Mohammed Moqsith, Saira Sattar, Man Yee Lam, Kashif Musarrat, Claire Stephens, Latheef Kalathil, Richard Miller, Maqsud Salehin, Nikki Gautam, Duncan Bailey, Kelly Amor, Julie Meir, Anne Nicolson, Javed Imam, Lisa Wood, Julie White, Mahmud Sajid, George Ghaly, Margaret Ball, Rachel Gascoyne, Harald Proeschel, Simon Sharpe, Sarah Horton, Emily Beaves, Stephanie Jones, Brigitte Yip, Murdina Bell, Linda MacLiver, Brian MacInnes, Don Sims, Jennifer Hurley, Mark Willmot, Claire Sutton, Edward Littleton, Susan Maiden, Rachael Jones, James Cunningham, Carole Green, Michelle Bates, Raj Shekhar, Ellie Gilham, Iman Ahmed, Rachel Crown, Tracy Fuller, Neetish Goorah, Angela Bell, Christine Kelly, Arun Singh, Jamie Walford, Benjamin Tomlinson, Farzana Patel, Stephen Duberley, Ingrid Kane, Chakravarthi Rajkumar, Jane Gaylard, Joanna Breeds, Nicola Gainsborough, Alexandra Pitt-Ford, Emma Barbon, Laura Latter, Philip Thompson, Simon Hervey, Shrivakumar Krishnamoorthy, Joseph Vassallo, Deborah Walter, Helen Cochrane, Meena Srinivasan, Robert Campbell, Denise Donaldson, Nichola Motherwell, Frances Hurford, Indranil Mukherjee, Antony Kenton, Sheila Nyabadza, Irene Martin, Benjamin Hunt, Hardi Hassan, Sarah O'Toole, Bander Dallol, Janet Putterill, Ratneshwari Jha, Rachel Gallifent, Puneet Kakar, Aparna Pusalkar, kelly Chan, Puneet Dangri, Hannah Beadle, Angela Cook, Karen Crabtree, Santhosh Subramonian, Peter Owusu-Agyei, Natalie Temple, Nicola Butterworth-Cowin, Suzanne Ragab, Kerstin Knops, Emma Jinks, Christine Dickson, Laura Gleave, Judith Dube, Jacqui Leggett, Tatiana Garcia, Sissy Ispoglou, Rachel Evans, Sandeep Ankolekar, Anne Hayes, Hlaing Ni, Bithi Rahman, Josette Milligan, Carol Graham, Josin Jose, Breffni Keegan, Jim Kelly, Richard Dewar, James White, Kelly Thomas, Rajkumar, C, University of St Andrews. School of Medicine, University of St Andrews. Sir James Mackenzie Institute for Early Diagnosis, University of St Andrews. Population and Behavioural Science Division, University of St Andrews. Pure Mathematics, University of St Andrews. School of Psychology and Neuroscience, and University of St Andrews. School of Biology

Subjects
Male, MICROBLEEDS, 030204 cardiovascular system & hematology, AMYLOID ANGIOPATHY, Brain Ischemia, law.invention, 0302 clinical medicine, Randomized controlled trial, law, Secondary Prevention, ACUTE ISCHEMIC-STROKE, Aged, 80 and over, Aspirin, Manchester Cancer Research Centre, medicine.diagnostic_test, Hazard ratio, Brain, Magnetic Resonance Imaging, Superficial siderosis, Cerebral Small Vessel Diseases, Stroke, Treatment Outcome, Female, medicine.drug, CT, medicine.medical_specialty, ANTITHROMBOTIC THERAPY, Clinical Neurology, Neuroimaging, Subgroup analysis, 03 medical and health sciences, Internal medicine, medicine, Journal Article, Humans, Aged, Cerebral Hemorrhage, business.industry, ResearchInstitutes_Networks_Beacons/mcrc, DAS, Magnetic resonance imaging, medicine.disease, SIGNS, ASPIRIN, Neurology (clinical), Tomography, X-Ray Computed, business, SUPERFICIAL SIDEROSIS, Platelet Aggregation Inhibitors, 030217 neurology & neurosurgery
Abstract

Background: Findings from the RESTART trial suggest that starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. Brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases (such as cerebral microbleeds) are associated with greater risks of recurrent intracerebral haemorrhage. We did subgroup analyses of the RESTART trial to explore whether these brain imaging features modify the effects of antiplatelet therapy.Methods: RESTART was a prospective, randomised, open-label, blinded-endpoint, parallel-group trial at 122 hospitals in the UK that assessed whether starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. For this prespecified subgroup analysis, consultant neuroradiologists masked to treatment allocation reviewed brain CT or MRI scans performed before randomisation to confirm participant eligibility and rate features of the intracerebral haemorrhage and surrounding brain. We followed participants for primary (recurrent symptomatic intracerebral haemorrhage) and secondary (ischaemic stroke) outcomes for up to 5 years (reported elsewhere). For this report, we analysed eligible participants with intracerebral haemorrhage according to their treatment allocation in primary subgroup analyses of cerebral microbleeds on MRI and in exploratory subgroup analyses of other features on CT or MRI. The trial is registered with the ISRCTN registry, number ISRCTN71907627.Findings: Between May 22, 2013, and May 31, 2018, 537 participants were enrolled, of whom 525 (98%) had intracerebral haemorrhage: 507 (97%) were diagnosed on CT (252 assigned to start antiplatelet therapy and 255 assigned to avoid antiplatelet therapy, of whom one withdrew and was not analysed) and 254 (48%) underwent the required brain MRI protocol (122 in the start antiplatelet therapy group and 132 in the avoid antiplatelet therapy group). There were no clinically or statistically significant hazards of antiplatelet therapy on recurrent intracerebral haemorrhage in primary subgroup analyses of cerebral microbleed presence (2 or more) versus absence (0 or 1) (adjusted hazard ratio [HR] 0·30 [95% CI 0·08–1·13] vs 0·77 [0·13–4·61]; pinteraction=0·41), cerebral microbleed number 0–1 versus 2–4 versus 5 or more (HR 0·77 [0·13–4·62] vs 0·32 [0·03–3·66] vs 0·33 [0·07–1·60]; pinteraction=0·75), or cerebral microbleed strictly lobar versus other location (HR 0·52 [0·004–6·79] vs 0·37 [0·09–1·28]; pinteraction=0·85). There was no evidence of heterogeneity in the effects of antiplatelet therapy in any exploratory subgroup analyses (all pinteraction>0·05).Interpretation: Our findings exclude all but a very modest harmful effect of antiplatelet therapy on recurrent intracerebral haemorrhage in the presence of cerebral microbleeds. Further randomised trials are needed to replicate these findings and investigate them with greater precision.Funding: British Heart Foundation.

Published
2019
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2. Impact of evidence-based stroke care on patient outcomes : A multilevel analysis of an international study

Author

Paula Muñoz Venturelli, Xian Li, Sandy Middleton, Caroline Watkins, Pablo M. Lavados, Verónica V. Olavarría, Alejandro Brunser, Octavio Pontes‐Neto, Taiza E. G. Santos, Hisatomi Arima, Laurent Billot, Maree L. Hackett, Lily Song, Thompson Robinson, Craig S. Anderson, Gillian Mead, H. Asita De Silva, Jeyaraj D. Pandian, Ruey‐Tay Lin, Tsong‐Hai Lee, Liying Cui, Bin Peng, Stephane Heritier, Richard Lindley, Stephen Jan, Elizabeth Boaden, Christopher P. L. H. Chen, Anne Forster, Mark Woodward, Kris Rogers, Anish Scaria, Joyce Y. Lim, Natalie Espinosa, Lucy McEvoy, Lee Blackburn, Sarah S. Richtering, Shoujiang You, Simon Ladwig, Gabrielle P. Merritt, Bryce Thomsen, Kerry Jenson, Penelope Gordon, Dennis Ryan Nguyen, Wei Wei Quan, Tessa Pei‐Yi Lo, Jonathan Lim, Selena Goh, Leibo Liu, Mirza Ahmad Baig, Ravider Singh, Paul Donnelly, Manuela Armenis, Marna Van Zyl, Helen Monaghan, Phillipa Smith, Parisa Glass, Fanli Zhou, Yun Shen, Li Lei, Di Li, Ting Zhang, Xiaoyan Zhang, Yun Peng, Lingling Feng, Zhiping Ye, Philip Gregory, Jeyaraj D. Pandain, Deepti Arora, Francisca Gonzalez, Bernardita Portales, Taiza Santos‐Pontelli, Brunna Rimoli, Monica Braga, Carolina Vidal, Dafna Benadof, Rodrigo J. Rivas, Laura Carvallo, Pamela Carvallo, Rubia Miranda, Brunna Pileggi, H. Asita de Silva, Shalomi Weerawardena, Thanushanthan Jeevarajah, Devaki Dharmawardena, Dumindi Ranasinghe, Matheesha Dharshana, Nilesh Nandadeva, Savithri Nawarathna, Jiu‐Haw Yin, Shoou‐Jeng Yeh, Ruei‐Jen Ma, Caroline L. Watkins, Gemma Whiteley, Denise Forshaw, Catherine Elizabeth Lightbody, Joanna Cox, Jane Fitzgerald, John F. Heney, Helen Byfield, Simone Finley, Hayley E. Tyrer, Carole Bruce, Alison Gibbon, Brett Jones, Emma Siracusa, Koushik Gowda, Shahla Cowans, Briana Forman, Sherin Jacob, Kristine Caprecho, Roshan Khatri, Po Yi Wan, Maria Lopez, Sifiso Vanika, Wilhelmina Bleeker, Marinka Ireland, Sheila Jala, Susan Day, Eric Ha, Martin Krause, Melissa Passer, Sarah Giaccari, Nadia Burkolter, Michael Braithwaite, Kylie Tastula, Darshan Ghia, Tapuwa Musuka, Anthony Alvaro, Gillian Edmonds, Nicole O'Loughin, Rebecca Phair, Joanne Kaoutal, David J. Blacker, Belinda L Saint, Kim Parrey, Michelle Coad, Matthew Kinchington, Nishantha Senanayake, Johanna Alaban, Irma Kuehne, Millene Camilo, Milena Libardi, Sheila Martins, Batista Carlos, Magda Martins, Leonardo Carbonera, Andrea Almeida, Martin Kelin, Carla Pauli, Mariana Lunardi, Luciane Silveira, Olga Chagas, Daily Souza, Gabriel Braga, Priscila Ribeiro, Gustavo Luvizutto, Marcia Polin, Fernanda Winckler, Jinfeng Liu, Zhenjiang Wang, Huibing Wang, Suying Lin, Jing Dong, Junshan Zhou, Suping Qin, Hui Zhan, Yongquan Xue, Dong Tian, Dan Yang, Yan Yin, He Li, Changming Geng, Jieyi Liu, Xiaolin Jiang, Yujun Wu, Wei Sun, Bingqi Yu, Yanmei Guan, Qin Wang, Bo Wei, Huirong Wang, Yan Wang, Liwen Tai, Wenchao Zhang, Weili Zhao, Xueying Wang, Guoli Li, Zhiming Ni, Fudong Guo, Lan Cen, Jun Lu, Zheng Chen, Guoming Yin, Yingchun Wang, Jiping Zheng, Zhimin Zhou, Hongquan Wang, Renlin Zou, Bin Xue, Airu Li, Jing Guo, Ying Guo, Xingguo Jiang, Xiuge Tan, Chunpeng Zhang, Bei Shao, Xiaoting Niu, Chunfeng Liu, Dongqin Chen, Ping Liang, Xia Zhang, Chunqing Zhang, Wenjie Gong, Zhichao Huang, Huihui Liu, Junying Huang, Rongfang Shi, Cuilan Wang, Ying Liu, Jinchao Wang, Guojun Wu, Zhihong Gao, Qunli Lin, Cong Xu, Huile Zheng, Xinghai Ye, Xiaoqiong Jin, Junyan Liu, Xiaoyun Cao, Yan Zhang, Jinyang Wang, Yuzhu Xu, Yan Li, Xin Ma, Qi Kong, Yanlei Hao, Baojun Qiao, Hui Yan, Zhiyong Huang, Baoqiang Chang, Jinjin Yan, Pinjun Liao, Wei Zhang, Ling Liu, Tingting Zhu, Xuehui Liu, Yongping Li, Ruifang Dong, Miao Chen, Xiaoli Ge, Hairong Wang, Lihua Dai, Jiafu Liu, Shixia Wang, Jihui Du, Aixiu Song, Yunhai Li, Jie Feng, Cheng Yu, Honglin Feng, Xiaojia Sun, Ruihong Sun, Weisong Liu, Jianfeng Liu, Xuesheng Lu, Enzhuo Chen, Wei Gao, Hui Liu, Heping Wang, Yanxia Wang, Juan Song, Dongqi Liu, Wenhui Du, Guixia Li, Cuiling Li, Yanling Liang, Xuekun Cai, Jinli Zhang, Xiaowei Tao, Pingshun An, Ranran Tang, Xu Qin, Yingling Wang, Wenjun Zhang, Rong Ma, Xiaoqiong Huang, Yonglin Liu, Yazhi Wang, Ping Fan, Hailan Yang, Lianyuan Feng, Jianxia Zhi, Jiewen Zhang, Yao Zhou, Danhong Wu, Haiyan He, Xiaohong Chen, Yongge Hou, Xiaohui Su, Siyuan Fan, Luis Suárez, Juan de Dios Polanco, Patricio Sotomayor, Ricardo Urzúa, Daniela Urrutia, Nathalie Conejan, Arturo Escobar, Monica Gonzalez, Danisa Vargas, Angel Constante, Erika Vásquez, Elizabeth Godoy, Christian Figueroa, Vanesa San Martin, Nataly Vidal, Madeleyn Muñoz, María Spencer, Juan Almeida, Ignacio Acosta, Rodrigo Guerrero, Prudencio Lozano, Camila Aguayo, Jimena Pizarro, Alvaro Soto, Flor Bonilla, Pía García, Carolina Del Castillo, Marcela Grandjean, Alexis Von Johnn, Ignacio Gutierrez, Francisca Rivero, Ignacio López, Federico Silva, Marlen Pachón, José Mendoza, Alexander Pabón, Mahesh Kate, Naushad Akhtar, Gibbsdeep S. Narang, Ashish Deepak, Vikram Huded, Romnesh De Sowza, Alben Sigamani, Karthikeyan Rajendran, Anisha Vishwanath, Anusha K, Somasundaram Kumaravelu, Syed Rahamath, Sandeep Kannneganti, Dheeraj Khurana, Cheena Katoch, Taranpreet Kaur, Ummer Karadan, Anu Kuriakose, Jaison John, Mumthaz Basheer, Harsha Hemal Gunasekara, Gamlath Chandima Udeni De Silva, Peetagam Harshi Lakmali Ubeywickrama, Kavisha Chathumali Silva, Eshani Anuradha De Silva, Udaya Ranawaka, Chamila Mettananda, Yamuna Nanayakkara, Tharini Mendis, Gayathri Fernando, Ahamed Imthikab, Kandula Pieris, Saman B. Gunatilake, Pamuditha M. W. Madanayake, Shiran A. Paranavitane, Bimsara Senanayake, Vaidhehi Vishwanathan, Maathury Sivapalan, Ruwangi U. Murage, Uthpala Chandradeva, Yao‐Hua Liu, Chih‐Lung Lin, Hsiu‐Fen Lin, Kuan‐Ting Liu, Chien‐Fu Chen, Meng‐Ni Wu, Su‐Hua Tsai, Chi‐Ching Chen, Lan‐Yi Chen, Chien‐Hung Chang, Yeu‐Jhy Chang, Kuo‐Lun Huang, Ting‐Yu Chang, Chi‐Hung Liu, Chen‐June Seak, Yu‐Li Lin, Jia‐Yi Luo, Hsiao‐Ying Yang, Ching‐Yi Wang, Lung Chan, Chaur‐Jong Hu, Nai‐Fang Chi, Dean Wu, Yao‐Hsien Huang, Yi‐Chun Kuan, Chien‐Tai Hong, Yi‐Chun Chen, Yu Sun, Cheng‐Huai Lin, Chien‐Jung Lu, Hai‐Jui Chu, Yi‐Chia Lo, Wen‐Hui Chang, Wan‐Jung Lin, Hui‐Chen Su, Tien‐Yu Lin, Chi‐Hsuan Cho, Shu‐Lan Lu, Ya‐Fang Hsueh, Ching‐Yi Lai, David Jarrett, Claire James, Stacey Valentine, Clare Whistler, Rebecca Butler, Simone Browning, Caroline Watchurst, Renuka Erande, Emma Elliott, Krishna Patel, Maria Brezitski, Caroline Hogan, Asra Banaras, Lucinda Crook, Rashidat Ahmed, Lindsay Potter, Rosie Laird, Natasha Clarke, Alison Loosemore, J. Godber, Sara Gawned, K. A. Hamilton, Rachael Jones, Paul Guyler, Sharon Tysoe, Raji Prabakaran, Sweni Shah, Joanne Calver, Laszlo K. Sztriha, Maria Fitzpatrick, Stephanie Drysdale, John Aeron‐Thomas, Emma McKenzie, Belinda Chitando, Paul Willcoxson, Elizabeth Iveson, Peter Wanklyn, Natasha Dyer, Michael Keeling, Romina Rodriguez, Kerry Elliott, Mia Porteous, Mark O'Neill, Sheridan Orme, Carla Richardson, Janet Tomlinson, Suzanne Hawkins, Delia Bester, Carol Jeffs, Joanne Howard, Pauline Brown, Deborah Ward, Jennifer Turfrey, Leanne Raybould, Allison Bates, Sue O'Connell, Margaret O'Connor, Samantha Williams, Hedley C. A. Emsley, Alison McLoughlin, Sonia Raj, Bindu Gregary, Donna Doyle, G. M. Courtauld, C. Schofield, L. Lucas, A. Lydon, A. James, Kari Saastamoinen, Laura Howaniec, Premchand Daboo, Ali N. Ali, Emma Richards, Joanne Howe, Christine Kamara, Kathy Stocks, Ralf Lindert, Diana J. Day, Sarah Finlay, Joanne McGee, Jennifer Mitchell, Elaine Amis, Rosemary Macey, Suzanne Tauro, Lauren Henry, Sarah Cuddy, Andrew Steele, Kerry Mullen, Sarah Kirker, Murudappa Bhattad, Michael Carpenter, Prabal Datta, Ann Needle, Linda Jackson, Julie Ball, Rosie Beckitt, Nicola Chivers, Angela Bowring, Sara Eddy, Kevin Thorpe, Samantha Keenan, Alison Griffin, Stuart Maguire, Chris Patterson, Hawraman Ramadan, Ruth Bellfield, Michaela Hooley, Kelvin Stewart, Lucy Williams, Cara Gurney, Deborah Oliver, Maria Gardiner, Sarah Grayland, Mohit Bhandari, David M. Collas, Tolu Adesina, Saul Sundayi, Ruth Harvey, Emma Pope, Audrey Lam, Elaine Walker, Colin Merrill, Soma Banerjee, Kirsten Hannah Harvey, Sheila Mashate, Peter Wilding, Linda Johnson, Robert Namushi, Patricia Jacob, Sreeman Andole, Karen Dunne, Naveen Gadapa, Sam King, Sonata Siliuzaite, Sharon Dealing, Karen Attwood, Annette Woods, Banher Sandhu, Maam Mamun, Afzal Mahmood, June Jones, Abimbola Ojo, Denise Carter‐Evans, Royal Liverpool, Aravind Manoj, Glyn Fletcher, Paula Lopez, Jill Greig, Matthew Robinson, Sarah Jones, Lorinda Jones, Claire West, Helen Tench, Rachel Gascoyne, Amanda Whileman, Emily Hall, Stephanie Wright, Julie Toms, Duke Phiri, Sakthivel Sethuraman, Niaz Mohammed, Frances Justin, Margaret Louise Tate, Meena Chauhan, Syed I. Haider, Arumugam Nallasivan, Tim Webster, Sandra Leason, Samantha Seagrave, Peterborough City Hospital, Peter Owksu‐Agyei, Natalie Temple, Nicola Butterworth‐Cowin, Frederick Magezi, Leicester Royal Infirmary, Shagufta Khan, Claire Stephens, Amit Mistri, Aidan Murphy, Manda Lam, Paul Underwood, Catherine Thompson, Clare Buckley, Diane Wood, Sarah Board, Linda Howard, Ashraf Ahmed, Bethany Oates, Sara Leonard, Royal Bournemouth Hospital, Royal Bournemouth, Kamy Thavanesan, Michelle Dharmasiri, Sathyabama Logianathan, Catherine Ovington, Gail Hann, Chantel Cox, Craigavon Area Hospital, Southern Health, Social Care Trust, Catherine Douglas, Michael Goggin, Patricia Fearon, Sara Gilpin, Margaret O'Hagan, Pilgrim Hospital, Anne Hardwick, Kimberley Netherton, Judith Quinn, Tulu Bozkaplan, Josin Jose, Univ New South Wales, Ctr Estudios Clin, Clin Alemana Univ Desarrollo, Peking Univ, Australian Catholic Univ, Univ Cent Lancashire, Univ Chile, Universidade de São Paulo (USP), Fukuoka Univ, Univ Leicester, Univ Edinburgh, George Inst Global Hlth, Univ Desarrollo, St Vincents Hlth Australia Sydney, Univ Kelaniya, Christian Med Coll & Hosp, Kaohsiung Med Univ & Hosp, Linkou Chang Gung Mem Hosp, Peking Union Med Coll Hosp, Monash Univ, Natl Univ Singapore, Bradford Royal Infirm, Christian Med College, RemediumOne Pvt Ltd, Kaohsiung Med Univ, Calvary Publ Hosp Bruce, Royal North Shore Hosp, Royal Prince Alfred Hosp, Concord Repatriat Gen Hosp, Fiona Stanley Hosp, Macquarie Base Hosp, Hosp Governador Celso Ramos, Universidade Estadual Paulista (Unesp), Yangquan Coalmine Grp Gen Hosp, Nanjing Med Univ, 85 Hosp Peoples Liberat Army, Chifeng Univ, Beijing Pinggu Hosp, Wenzhou Med Univ, Soochow Univ, Hebei Med Univ, Capital Med Univ, Jining Med Univ, Third Peoples Hosp Huizhou, Second Cangzhou Cent Hosp, Shanghai Jiao Tong Univ, Baogang Hosp, Harbin Med Univ, Shanghai Jiao Tong Univ Sch, Guangzhou Med Univ, Second Hosp Nanchang, Bethune Int Peace Hosp, Hua Henan Prov Peoples Hosp, Shijiazhuang Cent Hosp, Hosp Base San Jos de Osorno, Unit Narayana Hrudayalaya Ltd, Dr Ramesh Cardiac & Multispecial Hosp Pvt Ltd, Post Grad Inst Med Educ & Res, Baby Mem Hosp Ltd, Sree Chitra Tirunal Inst Med Sci & Technol, Sri Jayawardenepura Gen Hosp, Colombo North Teaching Hosp, Colombo South Coching Hosp, Taipei Med Univ, En Chu Kong Hosp, Natl Cheng Kung Univ Hosp, Queen Alexandra Hosp, Portsmouth Hosp NHS Natl Hlth Serv iTrust, Univ Coll London Hosp NHS Fdn Trust, Univ Hosp Birmingham NHS Fdn Trust, Southend Univ Hosp NHS Fdn Trust, Kings Coll Hosp London, York Teaching Hosp NHS Fdn Trust, Nottingham Univ Hosp NHS Trust, Blackpool Teaching Hosp NHS Fdn Trust, Gloucestershire Hosp NHS Fdn Trust, Teaching Hospi NHS Fdn Trust, Royal Cornwall Hosp NHS Trust, Royal London Hosp, Sheffield Teaching Hosp NHS Fdn Trust, Cambridge Univ Hosp NHS Fdn Trust, Royal Victoria Hosp, Pinderfields Gen Hosp, Royal Devon & Exeter NHS Fdn Trust, Bradford Teaching Hosp NHS Fdn Trust, Great Western Hosp NHS Fdn Trust, Watford Dist Gen Hosp, Imperial Coll Healthcare NHS Trust, Medway NHS Fdn Trust, Royal Liverpool & Broadgreen Univ NHS Trust, Calderdale & Huddersfield NHS Fdn Trust, Hywel Dda Univ Hlth Board, Chesterfield Royal Hosp NHS Fdn Trust, Luton & Dunstable Univ Hosp NHS Fdn Trust, Countess Chester Hosp NHS Fdn Trust, Peterborough City Hosp, Univ Hosp Leicester NHS Trust, Dist Hosp NHS Fdn Trust, Barnsley Hosp NHS Fdn Trust, Dorset Cty Hosp NHS Fdn Trust, Royal Bournemouth & Christchurch Hosp NHS Fdn Tru, Southern Hlth & Social Care Trust, United Lincolnshire Hosp NHS Trust, and Bedford Hosp NHS Trust

Subjects
Male, Stroke care, Brain Ischemia, 0302 clinical medicine, Atrial Fibrillation, Clinical Studies, Thrombolytic Therapy, 030212 general & internal medicine, Acute ischemic stroke, Stroke, Thrombectomy, Original Research, Aged, 80 and over, Evidence-Based Medicine, Quality and Outcomes, Multilevel model, Middle Aged, 16. Peace & justice, 3. Good health, Outcome and Process Assessment, Health Care, quality, outcome, Female, multilevel analysis, Cardiology and Cardiovascular Medicine, China, medicine.medical_specialty, Evidence-based practice, Taiwan, India, Patient Positioning, 03 medical and health sciences, medicine, Humans, Intensive care medicine, Antihypertensive Agents, Physical Therapy Modalities, Aged, Sri Lanka, Ischemic Stroke, business.industry, Australia, Anticoagulants, South America, A300, Process of care, medicine.disease, United Kingdom, Logistic Models, acute stroke care, Cerebrovascular Disease/Stroke, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Deglutition Disorders, business, Platelet Aggregation Inhibitors, 030217 neurology & neurosurgery
Abstract

Made available in DSpace on 2019-10-04T12:41:37Z (GMT). No. of bitstreams: 0 Previous issue date: 2019-07-02 National Health and Medical Research Council of Australia Background-The uptake of proven stroke treatments varies widely. We aimed to determine the association of evidence-based processes of care for acute ischemic stroke (AIS) and clinical outcome of patients who participated in the HEADPOST (Head Positioning in Acute Stroke Trial), a multicenter cluster crossover trial of lying flat versus sitting up, head positioning in acute stroke. Methods and Results-Use of 8 AIS processes of care were considered: reperfusion therapy in eligible patients; acute stroke unit care; antihypertensive, antiplatelet, statin, and anticoagulation for atrial fibrillation; dysphagia assessment; and physiotherapist review. Hierarchical, mixed, logistic regression models were performed to determine associations with good outcome (modified Rankin Scale scores 0-2) at 90 days, adjusted for patient and hospital variables. Among 9485 patients with AIS, implementation of all processes of care in eligible patients, or defect-free care, was associated with improved outcome (odds ratio, 1.40; 95% CI, 1.18-1.65) and better survival (odds ratio, 2.23; 95% CI, 1.62-3.09). Defect-free stroke care was also significantly associated with excellent outcome (modified Rankin Scale score 0-1) (odds ratio, 1.22; 95% CI, 1.04-1.43). No hospital characteristic was independently predictive of outcome. Only 1445 (15%) of eligible patients with AIS received all processes of care, with significant regional variations in overall and individual rates. Conclusions-Use of evidence-based care is associated with improved clinical outcome in AIS. Strategies are required to address regional variation in the use of proven AIS treatments. Univ New South Wales, Fac Med, George Inst Global Hlth, Sydney, NSW, Australia Ctr Estudios Clin, Inst Ciencias & Innovac Med, Santiago, Chile Clin Alemana Univ Desarrollo, Fac Med, Serv Neurol, Dept Neurol & Psiquiatria, Santiago, Chile Peking Univ, Hlth Sci Ctr, George Inst Global Hlth, Beijing, Peoples R China Australian Catholic Univ, Nursing Res Inst, St Vincents Hlth Australia Sydney, Sydney, NSW, Australia Univ Cent Lancashire, Fac Hlth & Wellbeing, Preston, Lancs, England Univ Chile, Fac Med, Dept Ciencias Neurol, Santiago, Chile Univ Sao Paulo, Ribeirao Preto Med Sch, Stroke Serv Neurol Div, Ribeirao Preto, Brazil Fukuoka Univ, Fac Med, Dept Prevent Med & Publ Hlth, Fukuoka, Fukuoka, Japan Univ Leicester, Dept Cardiovasc Sci, Leicester Biomed Res Ctr, Leicester, Leics, England Univ Leicester, Natl Inst Hlth Res, Leicester Biomed Res Ctr, Leicester, Leics, England Univ Edinburgh, Ctr Clin Brain Sci, Edinburgh, Midlothian, Scotland George Inst Global Hlth, Sydney, NSW, Australia Univ Desarrollo, Serv Neurol, Dept Neurol & Psiquiatria Clin Alemana Santiago, Santiago, Chile St Vincents Hlth Australia Sydney, Sydney, NSW, Australia Australian Catholic Univ, Sydney, NSW, Australia Univ Cent Lancashire, Stroke Practice Res Unit, Sch Hlth, Lancashire Clin Trials Unit, Preston, Lancs, England Univ Leicester, Dept Cardiovasc Sci, Cardiovasc Res Ctr, British Heart Fdn, Leicester, Leics, England Univ Kelaniya, Dept Pharmacol, Fac Med, Colombo, Sri Lanka Christian Med Coll & Hosp, Dept Neurol, Ludhiana, India Kaohsiung Med Univ & Hosp, Dept Neurol, Kaohsiung, Taiwan Linkou Chang Gung Mem Hosp, Dept Neurol, Taipei, Taiwan Peking Union Med Coll Hosp, Beijing, Peoples R China Univ Sao Paulo, Ribeirao Preto Sch Med, Ribeirao Preto, Brazil Monash Univ, Dept Epidemiol & Prevent Med, Melbourne, Vic, Australia Univ Cent Lancashire, Sch Hlth Sci, Coll Hlth & Wellbeing, Preston, Lancs, England Univ Desarrollo, Santiago, Chile Univ New South Wales, Neurosci Res Australia, Sydney, NSW, Australia Natl Univ Singapore, Dept Pharmacol, Singapore, Singapore Bradford Royal Infirm, Bradford Inst Hlth Res, Leeds, W Yorkshire, England Christian Med College, Ludhiana, Punjab, India RemediumOne Pvt Ltd, Kandy, Sri Lanka Kaohsiung Med Univ, Chung Ho Mem Hosp, Kaohsiung, Taiwan Calvary Publ Hosp Bruce, Bruce, Australia Royal North Shore Hosp, St Leonards, NSW, Australia Royal Prince Alfred Hosp, Camperdown, NSW, Australia Concord Repatriat Gen Hosp, Camperdown, NSW, Australia Fiona Stanley Hosp, Camperdown, NSW, Australia Macquarie Base Hosp, Melbourne, Vic, Australia Univ Sao Paulo, Fac Med Ribeirao Preto, Hosp Clin, Sao Paulo, Brazil Hosp Governador Celso Ramos, Florianopolis, SC, Brazil Sao Paulo State Univ, Hosp Fac Med Botucatu, UNESP, Sao Paulo, Brazil Yangquan Coalmine Grp Gen Hosp, Yangquan, Peoples R China Nanjing Med Univ, Nanjing Hosp 1, Nanjing, Jiangsu, Peoples R China 85 Hosp Peoples Liberat Army, Beijing, Peoples R China Chifeng Univ, Affiliated Hosp, Chifeng, Peoples R China Beijing Pinggu Hosp, Beijing, Peoples R China Wenzhou Med Univ, Affiliated Hosp 1, Wenzhou, Peoples R China Soochow Univ, Affiliated Hosp 2, Suzhou, Peoples R China Hebei Med Univ, Hosp 3, Shijiazhuang, Hebei, Peoples R China Capital Med Univ, Xuanwu Hosp, Beijing, Peoples R China Jining Med Univ, Affiliated Hosp, Jining, Peoples R China Third Peoples Hosp Huizhou, Huizhou, Peoples R China Second Cangzhou Cent Hosp, Cangzhou, Peoples R China Shanghai Jiao Tong Univ, Hosp Affiliated, Sch Med, Shanghai, Peoples R China Baogang Hosp, Baotou, Peoples R China Harbin Med Univ, Affiliated Hosp 1, Harbin, Heilongjiang, Peoples R China Shanghai Jiao Tong Univ Sch, Tong Ren Hosp, Peoples Hosp Hejian City, Shanghai, Peoples R China Peking Univ, Shougang Hosp, Beijing, Peoples R China Guangzhou Med Univ, Affiliated Hosp 3, Guangzhou, Guangdong, Peoples R China Second Hosp Nanchang, Nanchang, Jiangxi, Peoples R China Bethune Int Peace Hosp, Beijing, Peoples R China Hua Henan Prov Peoples Hosp, Beijing, Peoples R China Hua Henan Prov Peoples Hosp, Zhengzhou, Henan, Peoples R China Shanghai Jiao Tong Univ, Sch Med, Shanghai Ninth Peoples Hosp, Shanghai, Peoples R China Shijiazhuang Cent Hosp, Shijiazhuang, Hebei, Peoples R China Hosp Base San Jos de Osorno, Osorno, Chile Christian Med Coll & Hosp, Ludhiana, Punjab, India Unit Narayana Hrudayalaya Ltd, Mazumdar Shaw Med Ctr, Bangalore, Karnataka, India Dr Ramesh Cardiac & Multispecial Hosp Pvt Ltd, Guntur, India Post Grad Inst Med Educ & Res, Chandigarh, India Baby Mem Hosp Ltd, Calicut, Kerala, India Sree Chitra Tirunal Inst Med Sci & Technol, Thiruvananthapuram, Kerala, India Sri Jayawardenepura Gen Hosp, Sri Jayawardenepura Kott, Sri Lanka Colombo North Teaching Hosp, Colombo, Sri Lanka Colombo South Coching Hosp, Colombo, Sri Lanka Linkou Chang Gung Mem Hosp, Taoyuan, Taiwan Taipei Med Univ, Shuang Ho Hosp, Taipei, Taiwan En Chu Kong Hosp, New Taipei, Taiwan Natl Cheng Kung Univ Hosp, Tainan, Taiwan Queen Alexandra Hosp, Portsmouth, Hants, England Portsmouth Hosp NHS Natl Hlth Serv iTrust, Portsmouth, Hants, England Univ Coll London Hosp NHS Fdn Trust, London, England Univ Hosp Birmingham NHS Fdn Trust, Queen Elizabeth Hosp Birmingham, Birmingham, W Midlands, England Southend Univ Hosp NHS Fdn Trust, Southend On Sea, England Kings Coll Hosp London, London, England York Teaching Hosp NHS Fdn Trust, York, N Yorkshire, England Nottingham Univ Hosp NHS Trust, Nottingham, England Blackpool Teaching Hosp NHS Fdn Trust, Blackpool, England Gloucestershire Hosp NHS Fdn Trust, Gloucestershire Royal Hosp, Gloucester, England Teaching Hospi NHS Fdn Trust, London, England Royal Cornwall Hosp NHS Trust, Truro, England Royal London Hosp, Barts Hlth NHS Trust, London, England Sheffield Teaching Hosp NHS Fdn Trust, Sheffield, S Yorkshire, England Cambridge Univ Hosp NHS Fdn Trust, Addenbrookes Hosp, Cambridge, England Royal Victoria Hosp, Belfast Hlth & Social Care Trust, London, England Pinderfields Gen Hosp, Mid Yorkshire Hosp NHS Trust, Wakefield, England Royal Devon & Exeter NHS Fdn Trust, London, England Bradford Teaching Hosp NHS Fdn Trust, Bradford, W Yorkshire, England Great Western Hosp NHS Fdn Trust, Swindon, Wilts, England Watford Dist Gen Hosp, Watford, England Imperial Coll Healthcare NHS Trust, London, England Medway NHS Fdn Trust, Gillingham, England Royal Liverpool & Broadgreen Univ NHS Trust, Liverpool, Merseyside, England Calderdale & Huddersfield NHS Fdn Trust, Huddersfield, W Yorkshire, England Hywel Dda Univ Hlth Board, Haverfordwest, Wales Chesterfield Royal Hosp NHS Fdn Trust, Calow, England Luton & Dunstable Univ Hosp NHS Fdn Trust, Luton, Beds, England Countess Chester Hosp NHS Fdn Trust, Chester, Cheshire, England Peterborough City Hosp, Peterborough, Cambs, England Univ Hosp Leicester NHS Trust, Leicester Royal Infirm, Leicester, Leics, England Dist Hosp NHS Fdn Trust, London, England Barnsley Hosp NHS Fdn Trust, Barnsley, England Dorset Cty Hosp NHS Fdn Trust, Dorchester, England Royal Bournemouth & Christchurch Hosp NHS Fdn Tru, Royal Bournemouth Hosp, Bournemouth, Dorset, England Southern Hlth & Social Care Trust, Craigavon Area Hosp, Portadown, England United Lincolnshire Hosp NHS Trust, Pilgrim Hosp, Lincoln, England Bedford Hosp NHS Trust, Bedford, England Sao Paulo State Univ, Hosp Fac Med Botucatu, UNESP, Sao Paulo, Brazil National Health and Medical Research Council of Australia: 1066966

Published
2019

3. Cytomegalovirus proctitis mimicking rectal cancer in an immunocompetent elderly patient: a case report

Author

Tolu Adesina, Sathyavani Subbarao, Adam Gwozdz, Anthony O’Sullivan, Giovanni Satta, and Julia Rees

Subjects
Male, Radiography, Abdominal, medicine.medical_specialty, Colorectal cancer, Population, Congenital cytomegalovirus infection, Cytomegalovirus, Case Report, Disease, General Biochemistry, Genetics and Molecular Biology, Diagnosis, Differential, medicine, Humans, Proctitis, Intensive care medicine, education, Stroke, Aged, Medicine(all), education.field_of_study, Rectal Neoplasms, Biochemistry, Genetics and Molecular Biology(all), business.industry, CMV, General Medicine, Colitis, medicine.disease, Surgery, Chronic infection, Cytomegalovirus Infections, Cell-mediated immunity, Differential diagnosis, Tomography, X-Ray Computed, business, Immunocompetence
Abstract

Background Cytomegalovirus infection is associated with significant morbidity and mortality in immunocompromised patients, but its impact on immunocompetent patients is still poorly understood. Furthermore, there is increasing evidence implying that chronic infection may contribute to a heightened cardiovascular risk. Case presentation We describe the case of incidental diagnosis of Cytomegalovirus proctitis in an immune-competent white British elderly gentleman, admitted following a stroke and investigated for rectal cancer following the development of bloody diarrhoea and persistent systemic inflammatory response. Conclusion This raised some several interesting points; firstly that we must revise our approach to investigating the immunocompetent elderly patient, secondly, could chronic Cytomegalovirus infection have contributed to the presentation of stroke in this patient and lastly what are the existing evidence for treatment in this population? We use this opportunity to try and address some of these questions and feel that this would be of benefit to the wider audience. We discuss the risk factors for disease in immune-competent patients and also a brief overview of the benefits of treatment in this population.

Published
2014
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4. Capsular warning syndrome

Author

Tolu Adesina and Vivek Nadarajan

Subjects
Male, Weakness, medicine.medical_specialty, Pediatrics, Neurology, business.industry, Treatment options, Infarction, Syndrome, General Medicine, medicine.disease, Article, Surgery, Neuroimaging, Ischemic Attack, Transient, Humans, Medicine, cardiovascular diseases, medicine.symptom, business, Completed stroke, Stroke, Aged, Sudden onset
Abstract

We present a case of a 72-year-old man who presented with fluctuating right-sided weakness and numbness. This was characterised by episodic sudden onset weakness with resolution of symptoms in between. His symptoms and signs were becoming persistent despite the addition of dual antiplatelet therapy. The history we describe is classical of capsular warning syndrome. The patient went on to have further definitive neuroimaging which revealed a pontine infarct, rather than the expected capsular infarct. We discuss the importance of capsular warning syndrome, the proposed pathophysiological mechanisms and different locations of infarction in previous cases of capsular warning syndrome. We also discuss the lack of consensus (within the literature) in treatment options which are used to try and prevent a completed stroke occurring in cases of capsular warning syndrome.

Published
2013
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