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1. Assessment of smoking care by stroke specialists in patients with recent TIA and minor stroke: an international prospective registry-based cohort study

Author

Eric Vicaut, Gregory W Albers, Geoffrey A Donnan, Julien Labreuche, Gabriel Steg, Peter Rothwell, Pierre Amarenco, Hugo Charles, Philippa Lavallee, Lawrence K S Wong, Shinichiro Uchiyama, Carlos A Molina, M G HENNERICI, Louis Caplan, José Manuel Ferro, and Pierre-Jean Touboul

Subjects
Medicine
Abstract

Objectives The objectives are to assess smoking abstinence and its effects on vascular risk and to report tobacco-cessation counselling and pharmacotherapy use in patients who had a recent minor stroke or transient ischaemic attack (TIA).Design and setting The TIA registry.org project is a prospective, observational registry of patients with TIA and minor stroke that occurred in the previous 7 days with a 5-year follow-up, involving 61 sites with stroke specialists in 21 countries (Europe, Asia, Latin America and Middle East). Of those, 42 sites had 5-year follow-up data on more than 50% of their patients and were included in the present study.Participants From June 2009 through December 2011, 3847 patients were eligible for the study (80% of the initial cohort).Outcomes Tobacco counselling and smoking-cessation pharmacotherapy use in smoking patients were reported at discharge. Association between 3-month smoking status and risk of a major cardiovascular event (MACE) was analysed with multivariable Cox regression model.Results Among 3801 patients included, 835 (22%) were smokers. At discharge, only 35.2% have been advised to quit and 12.5% had smoking-cessation pharmacotherapy prescription. At 3 months, 383/835 (46.9%) baseline smokers were continuers. Living alone and alcohol abuse were associated with persistent smoking; high level of education, aphasia and dyslipidaemia with quitting. The adjusted HRs for MACE at 5 years were 1.13 (95% CI 0.90 to 1.43) in former smokers, 1.31 (95% CI 0.93 to 1.84) in quitters and 1.31 (95% CI 0.94 to 1.83) in continuers. Using time-varying analysis, current smoking at the time of MACE non-significantly increased the risk of MACE (HR 1.31 (95% CI 0.97 to 1.78); p=0.080).Conclusion In the TIAregistry.org, smoking-cessation intervention was used in a minority of patients. Surprisingly, in this population in which, at 5 years, other vascular risk factors were well controlled and antithrombotic treatment maintained, smoking cessation non-significantly decreased the risk of MACE.

Published
2024
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2. Sex Differences in Severity of Stroke in the INSTRUCT Study: a Meta‐Analysis of Individual Participant Data

Author

Hoang T. Phan, Mathew J. Reeves, Christopher L. Blizzard, Amanda G. Thrift, Dominique A. Cadilhac, Jonathan Sturm, Petr Otahal, Peter Rothwell, Yannick Bejot, Norberto L. Cabral, Peter Appelros, Janika Kõrv, Riina Vibo, Cesar Minelli, and Seana L. Gall

Subjects
epidemiology, sex difference, stroke, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract

Background Women have worse outcomes after stroke than men, and this may be partly explained by stroke severity. We examined factors contributing to sex differences in severity of acute stroke assessed by the National Institutes of Health Stroke Scale. Methods and Results We pooled individual participant data with National Institutes of Health Stroke Scale assessment (N=6343) from 8 population‐based stroke incidence studies (1996–2014), forming part of INSTRUCT (International Stroke Outcomes Study). Information on sociodemographics, stroke‐related clinical factors, comorbidities, and pre‐stroke function were obtained. Within each study, relative risk regression using log‐binominal modeling was used to estimate the female:male relative risk (RR) of more severe stroke (National Institutes of Health Stroke Scale>7) stratified by stroke type (ischemic stroke and intracerebral hemorrhage). Study‐specific unadjusted and adjusted RRs, controlling for confounding variables, were pooled using random‐effects meta‐analysis. National Institutes of Health Stroke Scale data were recorded in 5326 (96%) of 5570 cases with ischemic stroke and 773 (90%) of 855 participants with intracerebral hemorrhage. The pooled unadjusted female:male RR for severe ischemic stroke was 1.35 (95% CI 1.24–1.46). The sex difference in severity was attenuated after adjustment for age, pre‐stroke dependency, and atrial fibrillation but remained statistically significant (pooled RRadjusted 1.20, 95% CI 1.10–1.30). There was no sex difference in severity for intracerebral hemorrhage (RRcrude 1.08, 95% CI 0.97–1.21; RRadjusted 1.08, 95% CI 0.96–1.20). Conclusions Although women presented with more severe ischemic stroke than men, much although not all of the difference was explained by pre‐stroke factors. Sex differences could potentially be ameliorated by strategies to improve pre‐stroke health in the elderly, the majority of whom are women. Further research on the potential biological origin of sex differences in stroke severity may also be warranted.

Published
2019
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3. Genetics of the thrombomodulin-endothelial cell protein C receptor system and the risk of early-onset ischemic stroke.

Author

John W Cole, Huichun Xu, Kathleen Ryan, Thomas Jaworek, Nicole Dueker, Patrick McArdle, Brady Gaynor, Yu-Ching Cheng, Jeffrey O'Connell, Steve Bevan, Rainer Malik, Naveed Uddin Ahmed, Philippe Amouyel, Sheraz Anjum, Joshua C Bis, David Crosslin, John Danesh, Stefan T Engelter, Myriam Fornage, Philippe Frossard, Christian Gieger, Anne-Katrin Giese, Caspar Grond-Ginsbach, Weang Kee Ho, Elizabeth Holliday, Jemma Hopewell, M Hussain, W Iqbal, S Jabeen, Jim Jannes, Ayeesha Kamal, Yoichiro Kamatani, Sandip Kanse, Manja Kloss, Mark Lathrop, Didier Leys, Arne Lindgren, W T Longstreth, Khalid Mahmood, Christa Meisinger, Tiina M Metso, Thomas Mosley, Martina Müller-Nurasyid, Bo Norrving, Eugenio Parati, Annette Peters, Alessandro Pezzini, I Quereshi, Asif Rasheed, A Rauf, T Salam, Jess Shen, Agnieszka Słowik, Tara Stanne, Konstantin Strauch, Turgut Tatlisumak, Vincent N Thijs, Steffen Tiedt, Matthew Traylor, Melanie Waldenberger, Matthew Walters, Wei Zhao, Giorgio Boncoraglio, Stéphanie Debette, Christina Jern, Christopher Levi, Hugh Markus, James Meschia, Arndt Rolfs, Peter Rothwell, Danish Saleheen, Sudha Seshadri, Pankaj Sharma, Cathie Sudlow, Bradford Worrall, METASTROKE Consortium of the ISGC, WTCCC-2 Consortium, O Colin Stine, Steven J Kittner, and Braxton D Mitchell

Subjects
Medicine, Science
Abstract

Background and purposePolymorphisms in coagulation genes have been associated with early-onset ischemic stroke. Here we pursue an a priori hypothesis that genetic variation in the endothelial-based receptors of the thrombomodulin-protein C system (THBD and PROCR) may similarly be associated with early-onset ischemic stroke. We explored this hypothesis utilizing a multi-stage design of discovery and replication.MethodsDiscovery was performed in the Genetics-of-Early-Onset Stroke (GEOS) Study, a biracial population-based case-control study of ischemic stroke among men and women aged 15-49 including 829 cases of first ischemic stroke (42.2% African-American) and 850 age-comparable stroke-free controls (38.1% African-American). Twenty-four single-nucleotide-polymorphisms (SNPs) in THBD and 22 SNPs in PROCR were evaluated. Following LD pruning (r2≥0.8), we advanced uncorrelated SNPs forward for association analyses. Associated SNPs were evaluated for replication in an early-onset ischemic stroke population (onset-ageResultsAmong GEOS Caucasians, PROCR rs9574, which was in strong LD with 8 other SNPs, and one additional independent SNP rs2069951, were significantly associated with ischemic stroke (rs9574, OR = 1.33, p = 0.003; rs2069951, OR = 1.80, p = 0.006) using an additive-model adjusting for age, gender and population-structure. Adjusting for risk factors did not change the associations; however, associations were strengthened among those without risk factors. PROCR rs9574 also associated with early-onset ischemic stroke in the replication sample (OR = 1.08, p = 0.015), but not older-onset stroke. There were no PROCR associations in African-Americans, nor were there any THBD associations in either ethnicity.ConclusionPROCR polymorphisms are associated with early-onset ischemic stroke in Caucasians.

Published
2018
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4. Identifying sex-specific differences in the carotid revascularisation literature: findings from a scoping review

Author

Vignan Yogendrakumar, Dean A Fergusson, Dar Dowlatshahi, Jean-Louis Mas, Virginia Howard, Peter Rothwell, Olena Bereznyakova, Brian Dewar, Candyce Hamel, Sophia Gocan, Mark Fedyk, and Michel Shamy

Subjects
Neurology. Diseases of the nervous system, RC346-429
Abstract

Objective No systematic review of the literature has dedicated itself to looking at the management of symptomatic carotid stenosis in female patients. In this scoping review, we aimed to identify all randomised controlled trials (RCTs) that reported sex-specific outcomes for patients who underwent carotid revascularisation, and determine whether sufficient information is reported within these studies to assess short-term and long-term outcomes in female patients.Design, setting and participants We systematically searched Medline, Embase, Pubmed and Cochrane libraries for RCTs published between 1991 and 2020 that included female patients and compared either endarterectomy with stenting, or any revascularisation (endarterectomy or stenting) with medical therapy in patients with symptomatic high-grade (>50%) carotid stenosis.Results From 1537 references examined, 27 eligible studies were identified. Sex-specific outcomes were reported in 13 studies. Baseline patient characteristics of enrolled female patients were reported in 2 of those 13 studies. Common outcomes reported included stroke and death, however, there was significant heterogeneity in the reporting of both periprocedural and long-term outcomes. Sex-specific differences relating to the degree of stenosis and time from index event to treatment are largely limited to studies comparing endarterectomy to medical therapy. Adverse events were not reported by sex.Conclusions Only half of the previously published RCTs and systematic reviews report sex-specific outcomes. Detailed analyses on the results of carotid artery intervention for female patients with symptomatic stenosis are limited.

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6. Abstract WMP103: Associations Between Multimorbidity At Stroke/transient Ischaemic Attack Onset With All-cause Mortality Are Not Explained By Blood Biomarkers: A Population-based Study

Author

Matthew B Downer, Linxin Li, Annette I Burgess, julia M duerden, and Peter Rothwell

Subjects
Advanced and Specialized Nursing, Neurology (clinical), Cardiology and Cardiovascular Medicine
Abstract

Introduction: Multimorbidity is highly prevalent in patients with transient ischaemic attack (TIA) or stroke, and is associated with increased short- and long-term mortality thereafter. Underlying mechanisms behind this relationship are unclear, and it is unknown whether increased inflammatory or prothrombotic factors might explain increased mortality. Methods: Using the population-based Oxford Vascular Study (OXVASC), we used a panel of 16 blood biomarkers relating to inflammation (IL-6, CRP, NGAL, sTNF-R1), thrombosis/atherogenesis (TM, fibrinogen, vWF, P-Selectin, PZ, D-Dimer, Anti-PC, ADAMTS-13), and cardiac or neuronal cell damage (NT-proBNP, hFABP, NSE, BDNF). Samples were obtained at stroke/TIA onset, and patients were followed up to 10 years. Biomarker levels were log-transformed to facilitate analysis. Multimorbidity immediately prior to TIA/stroke onset was assessed using the Charlson Comorbidity Index (CCI). Partial correlations (age-adjusted) were obtained between CCI and log-biomarker levels. Crude and adjusted hazard ratios (HRs) for all-cause mortality were obtained using Cox models, censoring at 2, 5, and 10 years. Results: 1297 participants (median age 75.2, interquartile range: 65.3 - 83.2) were recruited from 2002-2012. 596 patients (46.0%) had no CCI comorbidity, 266 (20.5%) had 1, and 435 (33.5%) had 2 or more. After adjustment for age, CCI was correlated with IL-6, NGAL, sTNF-R1, TM, fibrinogen, vWF, D-Dimer, NT-proBNP, and hFABP (all p Conclusion: Multimorbidity was predictive of all-cause mortality after TIA/stroke, but the association was not explained by our panel of biomarkers. Further work is needed to explain the excess risk of mortality associated with multimorbidity in stroke/TIA patients.

Published
2022
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7. Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy

Author

Alison Halliday, Richard Bulbulia, Leo H Bonati, Johanna Chester, Andrea Cradduck-Bamford, Richard Peto, Hongchao Pan, John Potter, Hans Henning Eckstein, Barbara Farrell, Marcus Flather, Averil Mansfield, Boby Mihaylova, Kazim Rahimi, David Simpson, Dafydd Thomas, Peter Sandercock, Richard Gray, Andrew Molyneux, Cliff P Shearman, Peter Rothwell, Anna Belli, Will Herrington, Parminder Judge, Peter Leopold, Marion Mafham, Michael Gough, Piergiorgio Cao, Sumaira MacDonald, Vasha Bari, Clive Berry, S Bradshaw, Wojciech Brudlo, Alison Clarke, Robin Cox, Susan Fathers, Kamran Gaba, Mo Gray, Elizabeth Hayter, Constance Holliday, Rijo Kurien, Michael Lay, Steffi le Conte, Jessica McManus, Zahra Madgwick, Dylan Morris, Andrew Munday, Sandra Pickworth, Wiktor Ostasz, Michiel Poorthuis, Sue Richards, Louisa Teixeira, Sergey Tochlin, Lynda Tully, Carol Wallis, Monique Willet, Alan Young, Renato Casana, Chiara Malloggi, Andrea Odero Jr, Vincenzo Silani, Gianfranco Parati, Giuseppe Malchiodi, Giovanni Malferrari, Francesco Strozzi, Nicola Tusini, Enrico Vecchiati, Gioacchino Coppi, Antonio Lauricella, Roberto Moratto, Roberto Silingardi, Jessica Veronesi, Andrea Zini, Emanuele Ferrero, Michelangelo Ferri, Andrea Gaggiano, Carmelo Labate, Franco Nessi, Daniele Psacharopulo, Andrea Viazzo, Giovanni Malacrida, Daniela Mazzaccaro, Giovanni Meola, Alfredo Modafferi, Giovanni Nano, Maria Teresa Occhiuto, Paolo Righini, Silvia Stegher, Stefano Chiarandini, Filippo Griselli, Sandro Lepidi, Fabio Pozzi Mucelli, Marcello Naccarato, Mario D'Oria, Barbara Ziani, Andrea Stella, Mortalla Dieng, Gianluca Faggioli, Mauro Gargiulo, Sergio Palermo, Rodolfo Pini, Giovanni Maria Puddu, Andrea Vacirca, Domenico Angiletta, Claudio Desantis, Davide Marinazzo, Giovanni Mastrangelo, Guido Regina, Raffaele Pulli, Paolo Bianchi, Lea Cireni, Elisabetta Coppi, Rocco Pizzirusso, Filippo Scalise, Giovanni Sorropago, Valerio Tolva, Valeria Caso, Enrico Cieri, Paola DeRango, Luca Farchioni, Giacomo Isernia, Massimo Lenti, Gian Battista Parlani, Guglielmo Pupo, Grazia Pula, Gioele Simonte, Fabio Verzini, Federico Carimati, Maria Luisa Delodovici, Federico Fontana, Gabriele Piffaretti, Matteo Tozzi, Efrem Civilini, Giorgio Poletto, Bernhard Reimers, Barbara Praquin, Sonia Ronchey, Laura Capoccia, Wassim Mansour, Enrico Sbarigia, Francesco Speziale, Pasqualino Sirignano, Danilo Toni, Roberto Galeotti, Vincenzo Gasbarro, Francesco Mascoli, Tiberio Rocca, Elpiniki Tsolaki, Giulia Bernardini, Ester DeMarco, Alessia Giaquinta, Francesco Patti, Massimiliano Veroux, Pierfrancesco Veroux, Carla Virgilio, Nicola Mangialardi, Matteo Orrico, Vincenzo Di Lazzaro, Nunzio Montelione, Francesco Spinelli, Francesco Stilo, Carlo Cernetti, Sandro Irsara, Giuseppe Maccarrone, Diego Tonello, Adriana Visonà, Beniamino Zalunardo, Emiliano Chisci, Stefano Michelagnoli, Nicola Troisi, Maela Masato, Massimo Dei Negri, Andrea Pacchioni, Salvatore Saccà, Giovanni Amatucci, Alfredo Cannizzaro, Federico Accrocca, Cesare Ambrogi, Renzo Barbazza, Giustino Marcucci, Andrea Siani, Guido Bajardi, Giovanni Savettieri, Angelo Argentieri, Riccardo Corbetta, Attilio Odero, Pietro Quaretti, Federico Z Thyrion, Alessandro Cappelli, Domenico Benevento, Gianmarco De Donato, Maria Agnese Mele, Giancarlo Palasciano, Daniela Pieragalli, Alessandro Rossi, Carlo Setacci, Francesco Setacci, Domenico Palombo, Maria Cecilia Perfumo, Edoardo Martelli, Aldo Paolucci, Santi Trimarchi, Viviana Grassi, Luigi Grimaldi, Giuliana La Rosa, Domenico Mirabella, Matteo Scialabba, Leonildo Sichel, Costantino L D'Angelo, Gian Franco Fadda, Holta Kasemi, Mario Marino, Francesco Burzotta, Francesco Alberto Codispoti, Angela Ferrante, Giovanni Tinelli, Yamume Tshomba, Claudio Vincenzoni, Deborah Amis, Dawn Anderson, Martin Catterson, Mike Clarke, Michelle Davis, Anand Dixit, Alexander Dyker, Gary Ford, Ralph Jackson, Sreevalsan Kappadath, David Lambert, Tim Lees, Stephen Louw, James McCaslin, Noala Parr, Rebecca Robson, Gerard Stansby, Lucy Wales, Vera Wealleans, Lesley Wilson, Michael Wyatt, Hardeep Baht, Ibrahim Balogun, Ilse Burger, Tracy Cosier, Linda Cowie, Gunaratnam Gunathilagan, David Hargroves, Robert Insall, Sally Jones, Hannah Rudenko, Natasha Schumacher, Jawaharlal Senaratne, George Thomas, Audrey Thomson, Tom Webb, Ellen Brown, Bernard Esisi, Ali Mehrzad, Shane MacSweeney, Norman McConachie, Alison Southam, Wayne Sunman, Ahmed Abdul-Hamiq, Jenny Bryce, Ian Chetter, Duncan Ettles, Raghuram Lakshminarayan, Kim Mitchelson, Christopher Rhymes, Graham Robinson, Paul Scott, Alison Vickers, Ray Ashleigh, Stephen Butterfield, Ed Gamble, Jonathan Ghosh, Charles N McCollum, Mark Welch, Sarah Welsh, Leszek Wolowczyk, Mary Donnelly, Stephen D'Souza, Anselm A Egun, Bindu Gregary, Thomas Joseph, Christine Kelly, Shuja Punekar, M Asad Rahi, Sonia Raj, Dare Seriki, George Thomson, James Brown, Ragunath Durairajan, Iris Grunwald, Paul Guyler, Paula Harman, Matthew Jakeways, Christopher Khuoge, Ashish Kundu, Thayalini Loganathan, Nisha Menon, Raji O Prabakaran, Devesh Sinha, Vicky Thompson, Sharon Tysoe, Dennis Briley, Chris Darby, Linda Hands, Dominic Howard, Wilhelm Kuker, Ursula Schulz, Rachel Teal, David Barer, Andrew Brown, Susan Crawford, Paul Dunlop, Ramesh Krishnamurthy, Nikhil Majmudar, Duncan Mitchell, Min P Myint, Richard O'Brien, Janice O'Connell, Naweed Sattar, Shanmugam Vetrivel, Jonathan Beard, Trevor Cleveland, Peter Gaines, John Humphreys, Alison Jenkins, Craig King, Daniel Kusuma, Ralph Lindert, Robbie Lonsdale, Raj Nair, Shah Nawaz, Faith Okhuoya, Douglas Turner, Graham Venables, Paul Dorman, Andrea Hughes, Deborah Jones, David Mendelow, Helen Rodgers, Aidas Raudoniitis, Peter Enevoldson, Hans Nahser, Imelda O'Brien, Francesco Torella, Dave Watling, Richard White, Pauline Brown, Dipankar Dutta, Lorraine Emerson, Paula Hilltout, Sachin Kulkarni, Jackie Morrison, Keith Poskitt, Fiona Slim, Sarah Smith, Amanda Tyler, Joanne Waldron, Mark Whyman, Milda Bajoriene, Lucy Baker, Amanda Colston, Bekky Eliot-Jones, Gita Gramizadeh, Catherine Lewis-Clarke, Laura McCafferty, Deborah Oliver, Debbie Palmer, Abhijeet Patil, Suzannah Pegler, Gopi Ramadurai, Aisling Roberts, Tracey Sargent, Shivaprasad Siddegowda, Ravi Singh-Ranger, Akintunde Williams, Lucy Williams, Steve Windebank, Tadas Zuromskis, Lanka Alwis, Jane Angus, Asaipillai Asokanathan, Caroline Fornolles, Diana Hardy, Sophy Hunte, Frances Justin, Duke Phiri, Marie Mitabouana-Kibou, Lakshmanan Sekaran, Sakthivel Sethuraman, Margaret L Tate, Joyce Akyea-Mensah, Stephen Ball, Angela Chrisopoulou, Elizabeth Keene, Alison Phair, Steven Rogers, John V Smyth, Colin Bicknell, Jeremy Chataway, Nicholas Cheshire, Andrew Clifton, Caroline Eley, Richard Gibbs, Mohammad Hamady, Beth Hazel, Alex James, Michael Jenkins, Nyma Khanom, Austin Lacey, Maz Mireskandari, Joanna O'Reilly, Antony Pereira, Tina Sachs, John Wolfe, Philip Davey, Gill Rogers, Gemma Smith, Gareth Tervit, Ian Nichol, Andrew Parry, Gavin Young, Simon Ashley, James Barwell, Francis Dix, Azlisham M Nor, Chris Parry, Angela Birt, Paul Davies, Jim George, Anne Graham, Leon Jonker, Nicci Kelsall, Caroline Potts, Toni Wilson, Jamie Crinnion, Larissa Cuenoud, Nikola Aleksic, Srdan Babic, Nenad Ilijevski, Đorde Radak, Dragan Sagic, Slobodan Tanaskovic, Momcilo Colic, Vladimir Cvetic, Lazar Davidovic, Dejana R Jovanovic, Igor Koncar, Perica Mutavdžic, Miloš Sladojevic, Ivan Tomic, Eike S Debus, Ulrich Grzyska, Dagmar Otto, Götz Thomalla, Jessica Barlinn, Johannes Gerber, Kathrin Haase, Christian Hartmann, Stefan Ludwig, Volker Pütz, Christian Reeps, Christine Schmidt, Norbert Weiss, Sebastian Werth, Simon Winzer, Janine Gemper, Albrecht Günther, Bianka Heiling, Elisabeth Jochmann, Panagiota Karvouniari, Carsten Klingner, Thomas Mayer, Julia Schubert, Friederike Schulze-Hartung, Jürgen Zanow, Yvonne Bausback, Franka Borger, Spiridon Botsios, Daniela Branzan, Sven Bräunlich, Henryk Hölzer, Janin Lenzer, Christopher Piorkowski, Nadine Richter, Johannes Schuster, Dierk Scheinert, Andrej Schmidt, Holger Staab, Matthias Ulrich, Martin Werner, Hermann Berger, Gábor Biró, Hans-Henning Eckstein, Michael Kallmayer, Kornelia Kreiser, Alexander Zimmermann, Bärbel Berekoven, Klaus Frerker, Vera Gordon, Giovanni Torsello, Sebastian Arnold, Cora Dienel, Martin Storck, Bernhard Biermaier, Hans Martin Gissler, Christof Klötzsch, Tomas Pfeiffer, Ralph Schneider, Leander Söhl, Michael Wennrich, Angelika Alonso, Michael Keese, Christoph Groden, Andreas Cöster, Andreas Engelhardt, Christoph-Maria Ratusinski, Bengt Berg, Martin Delle, Johan Formgren, Peter Gillgren, Lotta Jarl, Torbjörn B Kall, Peter Konrad, Niklas Nyman, Claes Skiöldebrand, Johnny Steuer, Rabbe Takolander, Jonas Malmstedt, Stefan Acosta, Katarina Björses, Kerstin Brandt, Nuno Dias, Anders Gottsäter, Jan Holst, Thorarinn Kristmundsson, Tobias Kühme, Tilo Kölbel, Bengt Lindblad, Mats Lindh, Martin Malina, Tomas Ohrlander, Tim Resch, Viola Rönnle, Björn Sonesson, Margareta Warvsten, Zbigniew Zdanowski, Erik Campbell, Per Kjellin, Hans Lindgren, Johan Nyberg, Björn Petersen, Gunnar Plate, Håkan Pärsson, Peter Qvarfordt, Pavel Ignatenko, Andrey Karpenko, Vladimir Starodubtsev, Mikhail A Chernyavsky, Maria S Golovkova, Boris B Komakha, Nikolay N Zherdev, Andrey Belyasnik, Pavel Chechulov, Dmitry Kandyba, Igor Stepanishchev, Csaba Csobay-Novák, Edit Dósa, László Entz, Balázs Nemes, Zoltán Szeberin, Pál Barzó, Mihaly Bodosi, Eniko Fákó, Béla Fülöp, Tamás Németh, Szilárd Pazdernyik, Krisztina Skoba, Erika Vörös, Eleni Chatzinikou, Athanasios Giannoukas, Christos Karathanos, Stylianos Koutsias, Georgios Kouvelos, Miltiadis Matsagkas, Styliani Ralli, Christos Rountas, Nikolaos Rousas, Konstantinos Spanos, Elias Brountzos, John D Kakisis, Andreas Lazaris, Konstantinos G Moulakakis, Leonidas Stefanis, Georgios Tsivgoulis, Spyros Vasdekis, Constantine N Antonopoulos, Ion Bellenis, Dimitrios Maras, Antonios Polydorou, Victoria Polydorou, Antonios Tavernarakis, Nikolaos Ioannou, Maria Terzoudi, Miltos Lazarides, Michalis Mantatzis, Kostas Vadikolias, Lukasz Dzieciuchowicz, Marcin Gabriel, Zbigniew Krasinski, Grzegorz Oszkinis, Fryderyk Pukacki, Maciej Slowinski, Michal-Goran Stanišic, Ryszard Staniszewski, Jolanta Tomczak, Maciej Zielinski, Piotr Myrcha, Dorota Rózanski, Stanislaw Drelichowski, Wojciech Iwanowski, Katarzyna Koncewicz, Pawel Bialek, Zbigniew Biejat, Wojciech Czepel, Anna Czlonkowska, Anatol Dowzenko, Julia Jedrzejewska, Adam Kobayashi, Jerzy Leszczynski, Andrzej Malek, Jerzy Polanski, Robert Proczka, Maciej Skorski, Mieczyslaw Szostek, Piotr Andziak, Maciej Dratwicki, Robert Gil, Miroslaw Nowicki, Jaroslaw Pniewski, Jaroslaw Rzezak, Piotr Seweryniak, Pawel Dabek, Michal Juszynski, Grzegorz Madycki, Bartosz Pacewski, Witold Raciborski, Piotr Slowinski, Walerian Staszkiewicz, Martin Bombic, Vladimír Chlouba, Jirí Fiedler, Karel Hes, Petr Koštál, Jindrich Sova, Zdenek Kríž, Mojmír Prívara, Michal Reif, Robert Staffa, Robert Vlachovský, Bohuslav Vojtíšek, Tomáš Hrbác, Martin Kuliha, Václav Procházka, Martin Roubec, David Školoudík, David Netuka, Anna Šteklácová, Vladimír Beneš III, Pavel Buchvald, Ladislav Endrych, Miroslav Šercl, Walter Campos Jr, Ivan B Casella, Nelson de Luccia, André E V Estenssoro, Calógero Presti, Pedro Puech-Leão, Celso R B Neves, Erasmo S da Silva, Cid J Sitrângulo Jr, José A T Monteiro, Gisela Tinone, Marcelo Bellini Dalio, Edwaldo E Joviliano, Octávio M Pontes Neto, Mauricio Serra Ribeiro, Patrick Cras, Jeroen M H Hendriks, Mieke Hoppenbrouwers, Patrick Lauwers, Caroline Loos, Laetitia Yperzeele, Mia Geenens, Dimitri Hemelsoet, Isabelle van Herzeele, Frank Vermassen, Parla Astarci, Frank Hammer, Valérie Lacroix, André Peeters, Robert Verhelst, Silvana Cirelli, Pol Dormal, Annelies Grimonprez, Bart Lambrecht, Philipe Lerut, Eddy Thues, Guy De Koster, Quentin Desiron, Alain Maertens de Noordhout, Danielle Malmendier, Mireille Massoz, Georges Saad, Marc Bosiers, Joren Callaert, Koen Deloose, Estrella Blanco Cañibano, Beatriz García Fresnillo, Mercedes Guerra Requena, Pilar C Morata Barrado, Miguel Muela Méndez, Antonio Yusta Izquierdo, Fernando Aparici Robles, Paula Blanes Orti, Luis García Dominguez, Rafael Martínez López, Manuel Miralles Hernández, José I Tembl Ferrairo, Ángel Chamorro, Juan Macho, Víctor Obach, Vincent Riambau, Luis San Román, Frank J Ahlhelm, Kristine Blackham, Stefan Engelter, Thomas Eugster, Henrik Gensicke, Lorenz Gürke, Philippe Lyrer, Luigi Mariani, Marina Maurer, Edin Mujagic, Mandy Müller, Marios Psychogios, Peter Stierli, Christoph Stippich, Christopher Traenka, Thomas Wolff, Benjamin Wagner, Martina M Wiegert, Sandra Clarke, Michael Diepers, Ernst Gröchenig, Philipp Gruber, Andrej Isaak, Timo Kahles, Regula Marti, Krassen Nedeltchev, Luca Remonda, Nadir Tissira, Martina Valença Falcão, Gert J de Borst, Rob H Lo, Frans L Moll, Raechel Toorop, Bart H van der Worp, Evert J Vonken, Jaap L Kappelle, Ommid Jahrome, Floris Vos, Wouter Schuiling, Hendrik van Overhagen, Rudolf W M Keunen, Bob Knippenberg, Jan J Wever, Jan W Lardenoije, Michel Reijnen, Luuk Smeets, Steven van Sterkenburg, Gustav Fraedrich, Elke Gizewski, Ingrid Gruber, Michael Knoflach, Stefan Kiechl, Barbara Rantner, Timur Abdulamit, Patrice Bergeron, Raymond Padovani, Jean-Christophe Trastour, Jean-Marie Cardon, Anne Le Gallou-Wittenberg, Eric Allaire, Jean-Pierre Becquemin, Frédéric Cochennec-Paliwoda, Pascal Desgranges, Hassan Hosseini, Hicham Kobeiter, Jean Marzelle, Mohammed A Almekhlafi, Simerpreet Bal, Phillip A Barber, Shelagh B Coutts, Andrew M Demchuk, Muneer Eesa, Michelle Gillies, Mayank Goyal, Michael D Hill, Mark E Hudon, Anitha Jambula, Carol Kenney, Gary Klein, Marie McClelland, Alim Mitha, Bijoy K Menon, William F Morrish, Steven Peters, Karla J Ryckborst, Greg Samis, Supriya Save, Eric E Smith, Peter Stys, Suresh Subramaniam, Garnette R Sutherland, Tim Watson, John H Wong, L Zimmel, Vojko Flis, Jože Matela, Kazimir Miksic, Franko Milotic, Božidar Mrdja, Barbara Stirn, Erih Tetickovic, Mladen Gasparini, Anton Grad, Ingrid Kompara, Zoren Miloševic, Veronika Palmiste, Toomas Toomsoo, Balzhan Aidashova, Nursultan Kospanov, Roman Lyssenko, Daulet Mussagaliev, Rafi Beyar, Aaron Hoffman, Tony Karram, Arthur Kerner, Eugenia Nikolsky, Samy Nitecki, Silva Andonova, Chavdar Bachvarov, Vesko Petrov, Ivan Cvjetko, Vinko Vidjak, Damir Halužan, Mladen Petrunic, Bao Liu, Chang-Wei Liu, Daniel Bartko, Peter Beno, František Rusnák, Kamil Zelenák, Masayuki Ezura, Takashi Inoue, Naoto Kimura, Ryushi Kondo, Yasushi Matsumoto, Hiroaki Shimizu, Hidenori Endo, Eisuke Furui, Søren Bakke, Kristen Krohg-Sørensen, Terje Nome, Mona Skjelland, Bjørn Tennøe, João Albuquerque e Castro, Gonçalo Alves, Frederico Bastos Gonçalves, José de Aragão Morais, Ana C Garcia, Hugo Valentim, Leonor Vasconcelos, Fernando Belcastro, Fernando Cura, Patricio Zaefferer, Foad Abd-Allah, Mohamed H Eldessoki, Hussein Heshmat Kassem, Haytham Soliman Gharieb, Mary P Colgan, Syed N Haider, Joe Harbison, Prakash Madhavan, Dermot Moore, Gregor Shanik, Viviane Kazan, Munier Nazzal, Vicki Ramsey-Williams, ACST-2 Collaborative Group, Group, ACST-2 Collaborative, Halliday A., Bulbulia R., Bonati L.H., Chester J., Cradduck-Bamford A., Peto R., Pan H., Potter J., Henning Eckstein H., Farrell B., Flather M., Mansfield A., Mihaylova B., Rahimi K., Simpson D., Thomas D., Sandercock P., Gray R., Molyneux A., Shearman C.P., Rothwell P., Belli A., Herrington W., Judge P., Leopold P., Mafham M., Gough M., Cao P., MacDonald S., Bari V., Berry C., Bradshaw S., Brudlo W., Clarke A., Cox R., Fathers S., Gaba K., Gray M., Hayter E., Holliday C., Kurien R., Lay M., le Conte S., McManus J., Madgwick Z., Morris D., Munday A., Pickworth S., Ostasz W., Poorthuis M., Richards S., Teixeira L., Tochlin S., Tully L., Wallis C., Willet M., Young A., Casana R., Malloggi C., Odero A., Silani V., Parati G., Malchiodi G., Malferrari G., Strozzi F., Tusini N., Vecchiati E., Coppi G., Lauricella A., Moratto R., Silingardi R., Veronesi J., Zini A., Ferrero E., Ferri M., Gaggiano A., Labate C., Nessi F., Psacharopulo D., Viazzo A., Malacrida G., Mazzaccaro D., Meola G., Modafferi A., Nano G., Occhiuto M.T., Righini P., Stegher S., Chiarandini S., Griselli F., Lepidi S., Pozzi Mucelli F., Naccarato M., D'Oria M., Ziani B., Stella A., Dieng M., Faggioli G., Gargiulo M., Palermo S., Pini R., Puddu G.M., Vacirca A., Angiletta D., Desantis C., Marinazzo D., Mastrangelo G., Regina G., Pulli R., Bianchi P., Cireni L., Coppi E., Pizzirusso R., Scalise F., Sorropago G., Tolva V., Caso V., Cieri E., DeRango P., Farchioni L., Isernia G., Lenti M., Parlani G.B., Pupo G., Pula G., Simonte G., Verzini F., Carimati F., Delodovici M.L., Fontana F., Piffaretti G., Tozzi M., Civilini E., Poletto G., Reimers B., Praquin B., Ronchey S., Capoccia L., Mansour W., Sbarigia E., Speziale F., Sirignano P., Toni D., Galeotti R., Gasbarro V., Mascoli F., Rocca T., Tsolaki E., Bernardini G., DeMarco E., Giaquinta A., Patti F., Veroux M., Veroux P., Virgilio C., Mangialardi N., Orrico M., Di Lazzaro V., Montelione N., Spinelli F., Stilo F., Cernetti C., Irsara S., Maccarrone G., Tonello D., Visona A., Zalunardo B., Chisci E., Michelagnoli S., Troisi N., Masato M., Dei Negri M., Pacchioni A., Sacca S., Amatucci G., Cannizzaro A., Accrocca F., Ambrogi C., Barbazza R., Marcucci G., Siani A., Bajardi G., Savettieri G., Argentieri A., Corbetta R., Quaretti P., Thyrion F.Z., Cappelli A., Benevento D., De Donato G., Mele M.A., Palasciano G., Pieragalli D., Rossi A., Setacci C., Setacci F., Palombo D., Perfumo M.C., Martelli E., Paolucci A., Trimarchi S., Grassi V., Grimaldi L., La Rosa G., Mirabella D., Scialabba M., Sichel L., D'Angelo C.L., Fadda G.F., Kasemi H., Marino M., Burzotta F., Codispoti F.A., Ferrante A., Tinelli G., Tshomba Y., Vincenzoni C., Amis D., Anderson D., Catterson M., Clarke M., Davis M., Dixit A., Dyker A., Ford G., Jackson R., Kappadath S., Lambert D., Lees T., Louw S., McCaslin J., Parr N., Robson R., Stansby G., Wales L., Wealleans V., Wilson L., Wyatt M., Baht H., Balogun I., Burger I., Cosier T., Cowie L., Gunathilagan G., Hargroves D., Insall R., Jones S., Rudenko H., Schumacher N., Senaratne J., Thomas G., Thomson A., Webb T., Brown E., Esisi B., Mehrzad A., MacSweeney S., McConachie N., Southam A., Sunman W., Abdul-Hamiq A., Bryce J., Chetter I., Ettles D., Lakshminarayan R., Mitchelson K., Rhymes C., Robinson G., Scott P., Vickers A., Ashleigh R., Butterfield S., Gamble E., Ghosh J., McCollum C.N., Welch M., Welsh S., Wolowczyk L., Donnelly M., D'Souza S., Egun A.A., Gregary B., Joseph T., Kelly C., Punekar S., Rahi M.A., Raj S., Seriki D., Thomson G., Brown J., Durairajan R., Grunwald I., Guyler P., Harman P., Jakeways M., Khuoge C., Kundu A., Loganathan T., Menon N., Prabakaran R.O., Sinha D., Thompson V., Tysoe S., Briley D., Darby C., Hands L., Howard D., Kuker W., Schulz U., Teal R., Barer D., Brown A., Crawford S., Dunlop P., Krishnamurthy R., Majmudar N., Mitchell D., Myint M.P., O'Brien R., O'Connell J., Sattar N., Vetrivel S., Beard J., Cleveland T., Gaines P., Humphreys J., Jenkins A., King C., Kusuma D., Lindert R., Lonsdale R., Nair R., Nawaz S., Okhuoya F., Turner D., Venables G., Dorman P., Hughes A., Jones D., Mendelow D., Rodgers H., Raudoniitis A., Enevoldson P., Nahser H., O'Brien I., Torella F., Watling D., White R., Brown P., Dutta D., Emerson L., Hilltout P., Kulkarni S., Morrison J., Poskitt K., Slim F., Smith S., Tyler A., Waldron J., Whyman M., Bajoriene M., Baker L., Colston A., Eliot-Jones B., Gramizadeh G., Lewis-Clarke C., McCafferty L., Oliver D., Palmer D., Patil A., Pegler S., Ramadurai G., Roberts A., Sargent T., Siddegowda S., Singh-Ranger R., Williams A., Williams L., Windebank S., Zuromskis T., Alwis L., Angus J., Asokanathan A., Fornolles C., Hardy D., Hunte S., Justin F., Phiri D., Mitabouana-Kibou M., Sekaran L., Sethuraman S., Tate M.L., Akyea-Mensah J., Ball S., Chrisopoulou A., Keene E., Phair A., Rogers S., Smyth J.V., Bicknell C., Chataway J., Cheshire N., Clifton A., Eley C., Gibbs R., Hamady M., Hazel B., James A., Jenkins M., Khanom N., Lacey A., Mireskandari M., O'Reilly J., Pereira A., Sachs T., Wolfe J., Davey P., Rogers G., Smith G., Tervit G., Nichol I., Parry A., Young G., Ashley S., Barwell J., Dix F., Nor A.M., Parry C., Birt A., Davies P., George J., Graham A., Jonker L., Kelsall N., Potts C., Wilson T., Crinnion J., Cuenoud L., Aleksic N., Babic S., Ilijevski N., Radak, Sagic D., Tanaskovic S., Colic M., Cvetic V., Davidovic L., Jovanovic D.R., Koncar I., Mutavdzic P., Sladojevic M., Tomic I., Debus E.S., Grzyska U., Otto D., Thomalla G., Barlinn J., Gerber J., Haase K., Hartmann C., Ludwig S., Putz V., Reeps C., Schmidt C., Weiss N., Werth S., Winzer S., Gemper J., Gunther A., Heiling B., Jochmann E., Karvouniari P., Klingner C., Mayer T., Schubert J., Schulze-Hartung F., Zanow J., Bausback Y., Borger F., Botsios S., Branzan D., Braunlich S., Holzer H., Lenzer J., Piorkowski C., Richter N., Schuster J., Scheinert D., Schmidt A., Staab H., Ulrich M., Werner M., Berger H., Biro G., Eckstein H.-H., Kallmayer M., Kreiser K., Zimmermann A., Berekoven B., Frerker K., Gordon V., Torsello G., Arnold S., Dienel C., Storck M., Biermaier B., Gissler H.M., Klotzsch C., Pfeiffer T., Schneider R., Sohl L., Wennrich M., Alonso A., Keese M., Groden C., Coster A., Engelhardt A., Ratusinski C.-M., Berg B., Delle M., Formgren J., Gillgren P., Jarl L., Kall T.B., Konrad P., Nyman N., Skioldebrand C., Steuer J., Takolander R., Malmstedt J., Acosta S., Bjorses K., Brandt K., Dias N., Gottsater A., Holst J., Kristmundsson T., Kuhme T., Kolbel T., Lindblad B., Lindh M., Malina M., Ohrlander T., Resch T., Ronnle V., Sonesson B., Warvsten M., Zdanowski Z., Campbell E., Kjellin P., Lindgren H., Nyberg J., Petersen B., Plate G., Parsson H., Qvarfordt P., Ignatenko P., Karpenko A., Starodubtsev V., Chernyavsky M.A., Golovkova M.S., Komakha B.B., Zherdev N.N., Belyasnik A., Chechulov P., Kandyba D., Stepanishchev I., Csobay-Novak C., Dosa E., Entz L., Nemes B., Szeberin Z., Barzo P., Bodosi M., Fako E., Fulop B., Nemeth T., Pazdernyik S., Skoba K., Voros E., Chatzinikou E., Giannoukas A., Karathanos C., Koutsias S., Kouvelos G., Matsagkas M., Ralli S., Rountas C., Rousas N., Spanos K., Brountzos E., Kakisis J.D., Lazaris A., Moulakakis K.G., Stefanis L., Tsivgoulis G., Vasdekis S., Antonopoulos C.N., Bellenis I., Maras D., Polydorou A., Polydorou V., Tavernarakis A., Ioannou N., Terzoudi M., Lazarides M., Mantatzis M., Vadikolias K., Dzieciuchowicz L., Gabriel M., Krasinski Z., Oszkinis G., Pukacki F., Slowinski M., Stanisic M.-G., Staniszewski R., Tomczak J., Zielinski M., Myrcha P., Rozanski D., Drelichowski S., Iwanowski W., Koncewicz K., Bialek P., Biejat Z., Czepel W., Czlonkowska A., Dowzenko A., Jedrzejewska J., Kobayashi A., Leszczynski J., Malek A., Polanski J., Proczka R., Skorski M., Szostek M., Andziak P., Dratwicki M., Gil R., Nowicki M., Pniewski J., Rzezak J., Seweryniak P., Dabek P., Juszynski M., Madycki G., Pacewski B., Raciborski W., Slowinski P., Staszkiewicz W., Bombic M., Chlouba V., Fiedler J., Hes K., Kostal P., Sova J., Kriz Z., Privara M., Reif M., Staffa R., Vlachovsky R., Vojtisek B., Hrbac T., Kuliha M., Prochazka V., Roubec M., Skoloudik D., Netuka D., Steklacova A., Benes III V., Buchvald P., Endrych L., Sercl M., Campos W., Casella I.B., de Luccia N., Estenssoro A.E.V., Presti C., Puech-Leao P., Neves C.R.B., da Silva E.S., Sitrangulo C.J., Monteiro J.A.T., Tinone G., Bellini Dalio M., Joviliano E.E., Pontes Neto O.M., Serra Ribeiro M., Cras P., Hendriks J.M.H., Hoppenbrouwers M., Lauwers P., Loos C., Yperzeele L., Geenens M., Hemelsoet D., van Herzeele I., Vermassen F., Astarci P., Hammer F., Lacroix V., Peeters A., Verhelst R., Cirelli S., Dormal P., Grimonprez A., Lambrecht B., Lerut P., Thues E., De Koster G., Desiron Q., Maertens de Noordhout A., Malmendier D., Massoz M., Saad G., Bosiers M., Callaert J., Deloose K., Blanco Canibano E., Garcia Fresnillo B., Guerra Requena M., Morata Barrado P.C., Muela Mendez M., Yusta Izquierdo A., Aparici Robles F., Blanes Orti P., Garcia Dominguez L., Martinez Lopez R., Miralles Hernandez M., Tembl Ferrairo J.I., Chamorro A., Macho J., Obach V., Riambau V., San Roman L., Ahlhelm F.J., Blackham K., Engelter S., Eugster T., Gensicke H., Gurke L., Lyrer P., Mariani L., Maurer M., Mujagic E., Muller M., Psychogios M., Stierli P., Stippich C., Traenka C., Wolff T., Wagner B., Wiegert M.M., Clarke S., Diepers M., Grochenig E., Gruber P., Isaak A., Kahles T., Marti R., Nedeltchev K., Remonda L., Tissira N., Valenca Falcao M., de Borst G.J., Lo R.H., Moll F.L., Toorop R., van der Worp B.H., Vonken E.J., Kappelle J.L., Jahrome O., Vos F., Schuiling W., van Overhagen H., Keunen R.W.M., Knippenberg B., Wever J.J., Lardenoije J.W., Reijnen M., Smeets L., van Sterkenburg S., Fraedrich G., Gizewski E., Gruber I., Knoflach M., Kiechl S., Rantner B., Abdulamit T., Bergeron P., Padovani R., Trastour J.-C., Cardon J.-M., Le Gallou-Wittenberg A., Allaire E., Becquemin J.-P., Cochennec-Paliwoda F., Desgranges P., Hosseini H., Kobeiter H., Marzelle J., Almekhlafi M.A., Bal S., Barber P.A., Coutts S.B., Demchuk A.M., Eesa M., Gillies M., Goyal M., Hill M.D., Hudon M.E., Jambula A., Kenney C., Klein G., McClelland M., Mitha A., Menon B.K., Morrish W.F., Peters S., Ryckborst K.J., Samis G., Save S., Smith E.E., Stys P., Subramaniam S., Sutherland G.R., Watson T., Wong J.H., Zimmel L., Flis V., Matela J., Miksic K., Milotic F., Mrdja B., Stirn B., Tetickovic E., Gasparini M., Grad A., Kompara I., Milosevic Z., Palmiste V., Toomsoo T., Aidashova B., Kospanov N., Lyssenko R., Mussagaliev D., Beyar R., Hoffman A., Karram T., Kerner A., Nikolsky E., Nitecki S., Andonova S., Bachvarov C., Petrov V., Cvjetko I., Vidjak V., Haluzan D., Petrunic M., Liu B., Liu C.-W., Bartko D., Beno P., Rusnak F., Zelenak K., Ezura M., Inoue T., Kimura N., Kondo R., Matsumoto Y., Shimizu H., Endo H., Furui E., Bakke S., Krohg-Sorensen K., Nome T., Skjelland M., Tennoe B., Albuquerque e Castro J., Alves G., Bastos Goncalves F., de Aragao Morais J., Garcia A.C., Valentim H., Vasconcelos L., Belcastro F., Cura F., Zaefferer P., Abd-Allah F., Eldessoki M.H., Heshmat Kassem H., Soliman Gharieb H., Colgan M.P., Haider S.N., Harbison J., Madhavan P., Moore D., Shanik G., Kazan V., Nazzal M., Ramsey-Williams V., and Gargiulo M

Subjects
Male, medicine.medical_specialty, Time Factors, Time Factor, medicine.medical_treatment, Carotid Stenosi, MEDLINE, Carotid endarterectomy, Rate ratio, Risk Assessment, Asymptomatic, law.invention, Randomized controlled trial, law, Risk Factors, carotid artery stenting (CAS), carotid endarterectomy (CEA), Stent, medicine, Humans, Carotid Stenosis, Stroke, Endarterectomy, Aged, Endarterectomy, Carotid, business.industry, carotid artery, Risk Factor, Articles, General Medicine, trial, medicine.disease, Settore MED/22 - CHIRURGIA VASCOLARE, Surgery, Stenosis, Treatment Outcome, Settore MED/11 - MALATTIE DELL'APPARATO CARDIOVASCOLARE, Female, Stents, Human medicine, medicine.symptom, business, Human
Abstract

Summary Background Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence. Methods ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362. Findings Between Jan 15, 2008, and Dec 31, 2020, 3625 patients in 130 centres were randomly allocated, 1811 to CAS and 1814 to CEA, with good compliance, good medical therapy and a mean 5 years of follow-up. Overall, 1% had disabling stroke or death procedurally (15 allocated to CAS and 18 to CEA) and 2% had non-disabling procedural stroke (48 allocated to CAS and 29 to CEA). Kaplan-Meier estimates of 5-year non-procedural stroke were 2·5% in each group for fatal or disabling stroke, and 5·3% with CAS versus 4·5% with CEA for any stroke (rate ratio [RR] 1·16, 95% CI 0·86–1·57; p=0·33). Combining RRs for any non-procedural stroke in all CAS versus CEA trials, the RR was similar in symptomatic and asymptomatic patients (overall RR 1·11, 95% CI 0·91–1·32; p=0·21). Interpretation Serious complications are similarly uncommon after competent CAS and CEA, and the long-term effects of these two carotid artery procedures on fatal or disabling stroke are comparable. Funding UK Medical Research Council and Health Technology Assessment Programme.

Published
2021

8. 134 Apathy in cerebrovascular small vessel disease is characterised by distinct white matter tract changes

Author

Youssuf Saleh, Campbell le Heron, Michele Veldsman, Daniel Drew, Olivia Plant, Ursula Schulz, Arjune Sen, Sanjay Manohar, Peter Rothwell, and Masud Husain

Subjects
Psychiatry and Mental health, Surgery, Neurology (clinical)
Abstract

IntroductionClinical apathy is a poorly understood neuropsychiatric syndrome characterised by a sig- nificant decrease in goal-directed, motivated behaviour. It occurs in ~30% of patients with cerebrovas- cular small vessel disease (SVD). With the aim of improving our mechanistic understanding of apathy, we conducted a multimodal investigation combining validated behavioural paradigms and magnetic resonance imaging (MRI) techniques.Methods83 patients with MRI evidence of SVD were recruited from the Oxford Vascular Study (OXVASC) and Oxford neurology clinics. They were investigated using a novel effort-based decision making task and the Apathy Evaluation Scale (AES). Structural and diffusion weighted MRI was conducted to measure white matter lesion load (WMLL) and tract integrity, indexed by Fractional anisotropy (FA).ResultsPatients with apathy demonstrated a significant reduction in motivated behaviour and were sig- nificantly less incentivised by low levels of reward. Diffusion weighted imaging demonstrated that apathy was characterised by focal changes to limbic association tracts, including the uncinate fasciculus and cingulum bundle, as well as fronto-striatal white matter tracts. Importantly, global measures of disease severity did not independently associate with apathy.DiscussionReduced incentivisation by low reward characterised apathy in SVD, as previously reported in Parkinson’s disease, suggesting a common mechanism underlying apathy across neurological diseases. The association of apathy with focal white matter tract changes is consistent with disruption to key frontal and fronto-striatal circuits which have been previously implicated in effort-based decision-making for rewards.youssuf.saleh@ndcn.ox.ac.uk

Published
2022
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9. An observational study showed that explaining randomization using gambling-related metaphors and computer-agency descriptions impeded randomized clinical trial recruitment

Author

Marcus Jepson, Daisy Elliott, Carmel Conefrey, Julia Wade, Leila Rooshenas, Caroline Wilson, David Beard, Jane M. Blazeby, Alison Birtle, Alison Halliday, Rob Stein, Jenny L. Donovan, Andrew Carr, Jonathan Cook, Cushla Cooper, Benjamin Dean, Alastair Gray, Stephen Gwilym, Andrew Judge, Naomi Merritt, Jane Moser, Jonathan Rees, Ines Rombach, Julian Savulescu, Irene Tracey, Karolina Wartolowska, Paul Barham, Sara T. Brookes, Tom Crosby, Stephen J. Falk, S. Michael Griffin, William Hollingworth, Andrew D. Hollowood, Richard Krysztopik, Wyn Lewis, Jo Nicklin, Christopher Streets, Sean Strong, Dan Titcomb, Geraint Williams, Rik Bryan, James Catto, John Chester, Ann French, Emma Hall, Chris Harris, Mark Johnson, Rob Jones, Francis Keeley, Tony Kirkbank, Roger Kockelbergh, Rebecca Lewis, Michelle Newton, Thomas Powles, Rachel Waters, Andrew Winterbottom, Jean-Pierre Becquemin, Anna Belli, Marc Bosiers, Piergiorgio Cao, Christina Davies, Michael Gough, Elizabeth Hayter, Peter Leopold, Sumaira McDonald, Jonathan Michaels, Borislava Mihaylova, Richard Peto, Steven Robertson, Peter Rothwell, Rachael Scott, Dafydd Thomas, Frank Vermassen, John Bartlett, David Cameron, Amy Campbell, Peter Canney, Janet Dunn, Helena Earl, Mary Falzon, Adele Francis, Peter Hall, Victoria Harmer, Helen Higgins, Louise Hiller, Luke Hughes-Davies, Claire Hulme, Iain Macpherson, Andreas Makris, Andrea Marshall, Christopher McCabe, Adrienne Morgan, Sarah Pinder, Christopher Poole, Daniel Rea, and Nigel Stallard

Subjects
Randomization, Psychotherapist, Epidemiology, Article, law.invention, 03 medical and health sciences, Random Allocation, 0302 clinical medicine, Randomized controlled trial, Patient Education as Topic, law, Qualitative research, Agency (sociology), Journal Article, Humans, 030212 general & internal medicine, Decision Making, Computer-Assisted, Randomized Controlled Trials as Topic, Random allocation, Patient Selection, United Kingdom, 3. Good health, Comprehension, Patient information, Centre for Surgical Research, 030220 oncology & carcinogenesis, Gambling, CLARITY, Randomized controlled trials, Recruitment to RCTs, Metaphor, Observational study, Recruitment, Psychology
Abstract

Objectives To explore how the concept of randomization is described by clinicians and understood by patients in randomized controlled trials (RCTs) and how it contributes to patient understanding and recruitment. Study Design and Setting Qualitative analysis of 73 audio recordings of recruitment consultations from five, multicenter, UK-based RCTs with identified or anticipated recruitment difficulties. Results One in 10 appointments did not include any mention of randomization. Most included a description of the method or process of allocation. Descriptions often made reference to gambling-related metaphors or similes, or referred to allocation by a computer. Where reference was made to a computer, some patients assumed that they would receive the treatment that was “best for them”. Descriptions of the rationale for randomization were rarely present and often only came about as a consequence of patients questioning the reason for a random allocation. Conclusions The methods and processes of randomization were usually described by recruiters, but often without clarity, which could lead to patient misunderstanding. The rationale for randomization was rarely mentioned. Recruiters should avoid problematic gambling metaphors and illusions of agency in their explanations and instead focus on clearer descriptions of the rationale and method of randomization to ensure patients are better informed about randomization and RCT participation., Highlights • Practices commonly used to describe randomisation in RCT recruitment could confuse patients. • Patients found it difficult to comprehend gambling-related metaphors of randomisation. • Computer-agency descriptions led to patients believing they would receive the best treatment.

Published
2018
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10. No surgical innovation without evaluation: the IDEAL recommendations

Author

Peter, McCulloch, Douglas G, Altman, W Bruce, Campbell, David R, Flum, Paul, Glasziou, John C, Marshall, Jon, Nicholl, Jeffrey K, Aronson, Jeffrey S, Barkun, Jane M, Blazeby, Isabell C, Boutron, Pierre-Alain, Clavien, Jonathan A, Cook, Patrick L, Ergina, Liane S, Feldman, Guy J, Maddern, Bournaby C, Reeves, Christoph M, Seiler, Steven M, Strasberg, Jonathan L, Meakins, Deborah, Ashby, Nick, Black, John, Bunker, Martin, Burton, Marion, Campbell, Kalipso, Chalkidou, Iain, Chalmers, Marc, de Leval, Jon, Deeks, Adrian, Grant, Muir, Gray, Roger, Greenhalgh, Milos, Jenicek, Sean, Kehoe, Richard, Lilford, Peter, Littlejohns, Yoon, Loke, Rajan, Madhock, Kim, McPherson, Jonathan, Meakins, Peter, Rothwell, Bill, Summerskill, David, Taggart, Parris, Tekkis, Matthew, Thompson, Tom, Treasure, Ulrich, Trohler, Jan, Vandenbroucke, and University of Zurich

Subjects
Research design, medicine.medical_specialty, Biomedical Research, media_common.quotation_subject, 610 Medicine & health, 2700 General Medicine, Intervention (counseling), Research Support as Topic, Health care, Medicine, Humans, Medical physics, Quality (business), media_common, Randomized Controlled Trials as Topic, 10217 Clinic for Visceral and Transplantation Surgery, Clinical Trials as Topic, business.industry, General Medicine, Surgery, Clinical trial, Treatment Outcome, 10022 Division of Surgical Research, Development studies, Learning curve, Evaluation Studies as Topic, Research Design, Surgical Procedures, Operative, Professional association, business, Editorial Policies
Abstract

Surgery and other invasive therapies are complex interventions, the assessment of which is challenged by factors that depend on operator, team, and setting, such as learning curves, quality variations, and perception of equipoise. We propose recommendations for the assessment of surgery based on a five-stage description of the surgical development process. We also encourage the widespread use of prospective databases and registries. Reports of new techniques should be registered as a professional duty, anonymously if necessary when outcomes are adverse. Case series studies should be replaced by prospective development studies for early technical modifications and by prospective research databases for later pre-trial evaluation. Protocols for these studies should be registered publicly. Statistical process control techniques can be useful in both early and late assessment. Randomised trials should be used whenever possible to investigate efficacy, but adequate pre-trial data are essential to allow power calculations, clarify the definition and indications of the intervention, and develop quality measures. Difficulties in doing randomised clinical trials should be addressed by measures to evaluate learning curves and alleviate equipoise problems. Alternative prospective designs, such as interrupted time series studies, should be used when randomised trials are not feasible. Established procedures should be monitored with prospective databases to analyse outcome variations and to identify late and rare events. Achievement of improved design, conduct, and reporting of surgical research will need concerted action by editors, funders of health care and research, regulatory bodies, and professional societies. © 2009 Elsevier Ltd. All rights reserved.

Published
2016

12. Prevention is paramount if we are to overcome stroke

Author

Peter Rothwell

Subjects
03 medical and health sciences, medicine.medical_specialty, 0302 clinical medicine, Physical medicine and rehabilitation, business.industry, medicine, 030212 general & internal medicine, Neurology (clinical), 030204 cardiovascular system & hematology, medicine.disease, business, Stroke, General Nursing
Published
2016
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13. Cerebrovascular diseases

Author

Peter Rothwell

Subjects
genetic structures, sense organs, cardiovascular diseases, eye diseases
Abstract

This chapter is concerned with those diseases of the cerebral and ocular circulation that cause ischaemia or infarction of the brain and eye or spontaneous haemorrhage into or around the brain. The main clinical manifestations of these diseases are transient ischaemic attack and stroke.

Published
2011
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14. Investigations

Author

David Chadwick, Alastair Compston, Michael Donaghy, Nicholas Fletcher, Robert Grant, David Hilton-Jones, Martin Rossor, Peter Rothwell, and Neil Scolding

Abstract

This chapter describes the many methods that can be used to investigate neurological disorders. The application and suitability for specific disorder types are outlined, as are contraindications for use. Methods of imaging the central nervous system include computed tomography (CT) imaging, several magnetic resonance (MR) scanning methods, Single photon emission computed tomography (SPECT) and Positron Emission Tomography (PET). Invasive (angiography) and non-invasive methods of imaging the cerebral circulation are also outlined.The standard method of recording electrical activity of the brain is the electroencephalogram (EEG), which is heavily used in epilepsy to investigate regions of epileptogenesis.Other investigations described include evoked potentials, nerve conduction and electromyography studies, the examination of cerebrospinal fluid and the diagnostic use of neurological autoantibodies. Finally, neurogenetics, neuropsychological assessment and the assessment of treatments by randomized trials are discussed.

Published
2011
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15. Evaluation and stages of surgical innovations

Author

Jeffrey S, Barkun, Jeffrey K, Aronson, Liane S, Feldman, Guy J, Maddern, Steven M, Strasberg, Douglas G, Altman, Jane M, Blazeby, Isabell C, Boutron, W Bruce, Campbell, Pierre-Alain, Clavien, Jonathan A, Cook, Patrick L, Ergina, David R, Flum, Paul, Glasziou, John C, Marshall, Peter, McCulloch, Jon, Nicholl, Bournaby C, Reeves, Christoph M, Seiler, Jonathan L, Meakins, Deborah, Ashby, Nick, Black, John, Bunker, Martin, Burton, Marion, Campbell, Kalipso, Chalkidou, Iain, Chalmers, Marc, de Leval, Jon, Deeks, Adrian, Grant, Muir, Gray, Roger, Greenhalgh, Milos, Jenicek, Sean, Kehoe, Richard, Lilford, Peter, Littlejohns, Yoon, Loke, Rajan, Madhock, Kim, McPherson, Peter, Rothwell, Bill, Summerskill, David, Taggart, Parris, Tekkis, Matthew, Thompson, Tom, Treasure, Ulrich, Trohler, Jan, Vandenbroucke, University of Zurich, and Barkun, J S

Subjects
medicine.medical_specialty, Biomedical Research, Evidence-Based Medicine, Technology Assessment, Biomedical, business.industry, MEDLINE, 610 Medicine & health, 2700 General Medicine, General Medicine, Evidence-based medicine, Technology assessment, Surgical procedures, Trial and error, Surgery, 10022 Division of Surgical Research, Evaluation Studies as Topic, Surgical Procedures, Operative, medicine, Humans, Medical physics, Diffusion of Innovation, business, 10217 Clinic for Visceral and Transplantation Surgery
Abstract

Surgical innovation is an important part of surgical practice. Its assessment is complex because of idiosyncrasies related to surgical practice, but necessary so that introduction and adoption of surgical innovations can derive from evidence-based principles rather than trial and error. A regulatory framework is also desirable to protect patients against the potential harms of any novel procedure. In this first of three Series papers on surgical innovation and evaluation, we propose a five-stage paradigm to describe the development of innovative surgical procedures.

Published
2009

16. Bleeding risk analysis in stroke imaging before thromboLysis (BRASIL): pooled analysis of T2*-weighted magnetic resonance imaging data from 570 patients

Author

Jens, Fiehler, Gregory W, Albers, Jean-Martin, Boulanger, Laurent, Derex, Achim, Gass, Niels, Hjort, Jong S, Kim, David S, Liebeskind, Tobias, Neumann-Haefelin, Salvador, Pedraza, Joachim, Rother, Peter, Rothwell, Alex, Rovira, Peter D, Schellinger, and Johannes, Trenkler

Subjects
Male, Middle Aged, Prognosis, Magnetic Resonance Imaging, Brain Ischemia, Stroke, Predictive Value of Tests, Risk Factors, Humans, Female, Thrombolytic Therapy, Aged, Cerebral Hemorrhage, Follow-Up Studies
Abstract

There has been speculation that the risk of secondary symptomatic intracranial hemorrhage (SICH) may be increased after thrombolytic therapy in ischemic stroke patients who have cerebral microbleeds (CMBs) on T2*-weighted magnetic resonance imaging. Because of this concern, some centers withhold potentially beneficial thrombolytic therapy from these patients.We analyzed magnetic resonance imaging data acquired within 6 hours after symptom onset from 570 ischemic stroke patients treated with intravenous tissue plasminogen activator in 13 centers in Europe, North America, and Asia. Baseline T2*-weighted magnetic resonance images were evaluated for the presence of CMBs. The primary end point was SICH, defined as clinical deterioration with an increase in the National Institutes of Health Stroke Scale score byor=4 points, temporally related to a parenchymal hematoma on follow-up-imaging.A total of 242 CMBs were detected in 86 of 570 patients (15.1%). The number of CMBs ranged from 1 to 77 in the individual patient, withor=5 CMBs in 6 of 570 patients (1.1%). Proportions of patients with SICH were 5.8% (95% CI, 1.9 to 13.0) in the presence of CMBs and 2.7% (95% CI, 1.4 to 4.5) in patients without CMBs (P=0.170, Fisher's exact test), resulting in no significant absolute increase in the risk of SICH of 3.1% (95% CI, -2.0 to 8.3).The data suggest that if there is any increased risk of SICH attributable to CMBs, it is likely to be small and unlikely to exceed the benefits of thrombolytic therapy. No reliable conclusion regarding risk in the rare patient with multiple CMBs can be reached.

Published
2007

17. Stroke prevention

Author

Gregory Y H, Lip, Peter, Rothwell, and Cathie, Sudlow

Subjects
Stroke, Endarterectomy, Carotid, Aspirin, Atrial Fibrillation, Hypercholesterolemia, Hypertension, Anticoagulants, Humans, Drug Therapy, Combination, Angioplasty, Balloon, Antihypertensive Agents, Platelet Aggregation Inhibitors
Published
2005

18. Stroke prevention

Author

Bethan, Freestone, Gregory Y H, Lip, Peter, Rothwell, and Cathie, Sudlow

Subjects
Stroke, Aspirin, Atrial Fibrillation, Hypercholesterolemia, Hypertension, Anticoagulants, Humans, Angioplasty, Balloon, Antihypertensive Agents, Platelet Aggregation Inhibitors
Published
2004

19. Risk factors for specific subtypes of ischaemic stroke

Author

Schulz, Ursula Gabriele Renate., Rothwell, Peter M., and Peter Rothwell

Subjects
Diffusion magnetic resonance imaging, cardiovascular diseases, Cerebral ischemia, Cerebrovascular disease
Abstract

Ischaemic stroke is a complex disorder with many different aetiologies, but previous studies of stroke often did not differentiate aetiological subtypes of ischaemic stroke. However, different stroke subtypes may have different risk factors, and to target preventive treatments more effectively, we need to understand these associations. I studied the association of established vascular risk factors with different aetiological stroke subtypes in population-based cohorts of stroke patients. I studied Diffusion Weighted Magnetic Resonance Imaging (DWI) in patients with subacute minor stroke and TIA to determine whether DWI may be a useful addition to the management of such patients, and whether it may be a useful tool in future epidemiological studies of stroke. To determine whether carotid anatomy may be a risk factor for large vessel atheroma I studied angiographical data from the European Carotid Surgery Trial. My main findings are that the prevalence of risk factors differs between stroke subtypes. It also differs between hospitalised and non-hospitalised patients, highlighting that risk factor studies should be performed in population-based cohorts. Analysis of family history data suggests that future genetic studies may best be targeted at non-cardioembolic stroke and at younger patients, and that genetic studies of hypertension may help to unravel some of the genetic factors contributing to stroke risk. DWI is sensitive in subacute minor stroke, and inter- and intra-observer reproducibility are high. DWI frequently adds useful information and may influence patient management. More widespread use of DWI in patients with subacute stroke and TIA should be considered, and DWI may also be a useful tool in future epidemiological studies of stroke. Carotid anatomy varies considerably between individuals, is very asymmetrical within individuals, and it differs between men and women. These findings may partly explain differences in plaque development between individuals, asymmetrical plaque formation within individuals, and sex differences in the distribution of carotid plaque and in the prevalence of carotid atheroma in the general population. Carotid anatomy may be a risk factor for local plaque development. Although not amenable to treatment, knowing which anatomical configuration is associated with atheroma formation could help to identify high-risk individuals in whom other risk factors should be treated aggressively.

Published
2004

20. Stroke : Practical Management

Author

Charles P. Warlow, Jan van Gijn, Martin S. Dennis, Joanna M. Wardlaw, John M. Bamford, Graeme J. Hankey, Peter A. G. Sandercock, Gabriel Rinkel, Peter Langhorne, Cathie Sudlow, Peter Rothwell, Charles P. Warlow, Jan van Gijn, Martin S. Dennis, Joanna M. Wardlaw, John M. Bamford, Graeme J. Hankey, Peter A. G. Sandercock, Gabriel Rinkel, Peter Langhorne, Cathie Sudlow, and Peter Rothwell

Subjects
Cerebrovascular disease, Cerebrovascular disease--Treatment
Abstract

Completely updated edition, written by a close-knit author team Presents a unique approach to stroke - integrated clinical management that weaves together causation, presentation, diagnosis, management and rehabilitation Includes increased coverage of the statins due to clearer evidence of their effectiveness in preventing stroke Features important new evidence on the preventive effect of lowering blood pressure Contains a completely revised section on imaging Covers new advances in interventional radiology

Published
2008

23. Effect of MDMA-assisted therapy on mood and anxiety symptoms in advanced-stage cancer (EMMAC): study protocol for a double-blind, randomised controlled trial.

Author

Bhagavan C, Glue P, Evans W, Reynolds L, Turner T, King C, Russell BR, Morunga E, Mills JL, Layton G, and Menkes DB

Subjects
Humans, Double-Blind Method, Treatment Outcome, Depression psychology, Depression therapy, Depression drug therapy, Quality of Life, Methylphenidate therapeutic use, Methylphenidate adverse effects, Methylphenidate administration & dosage, Time Factors, Male, Neoplasm Staging, N-Methyl-3,4-methylenedioxyamphetamine adverse effects, N-Methyl-3,4-methylenedioxyamphetamine administration & dosage, Neoplasms psychology, Neoplasms complications, Anxiety psychology, Randomized Controlled Trials as Topic, Affect drug effects, Hallucinogens administration & dosage, Hallucinogens adverse effects, Hallucinogens therapeutic use
Abstract

Background: Symptoms of anxiety and depression are common in patients with terminal illness and multiple challenges exist with timely and effective care in this population. Several centres have reported that one dose of the serotonergic psychedelic psilocybin, combined with therapeutic support, improves these symptoms for up to 6 months in this patient group. Drawing upon related therapeutic mechanisms, 3,4-methylenedioxymethamphetamine (MDMA)-assisted therapy may have the potential to achieve similar, positive mental health outcomes in this group. Preliminary evidence also supports the tolerability of MDMA-assisted therapy for anxiety and depression in advanced-stage cancer., Methods: Up to 32 participants with advanced-stage cancer and associated depression and anxiety will be randomised in a 1:1 ratio into one of two blinded parallel treatment arms. The intervention group will receive 120 mg (+ 60 mg optional supplemental dose) MDMA-assisted therapy. The psychoactive control group will receive 20 mg oral (+ 10 mg optional supplemental dose) methylphenidate-assisted therapy. For each medication-assisted therapy session, participants will undergo two 90-min therapeutic support sessions in the week preceding, and one 90-min support session the day after the experimental session. A battery of measures (mood, anxiety, quality of life, mystical experience, spiritual wellbeing, attitudes towards death, personality traits, holistic health and wellbeing, connectedness, demoralisation, expectations, qualitative data and safety measures) will be assessed at baseline and through to the end of the protocol. Participants will be followed up until either 12 months post-randomisation or death, whichever occurs first., Discussion: This study will examine the effect of MDMA-assisted therapy on symptoms of anxiety and depression in advanced-stage cancer. Potential therapeutic implications include establishing the safety and effectiveness of a novel treatment that may relieve mental suffering in patients with life-threatening illness., Trial Registration: Trial registered on Australian New Zealand Clinical Trials Registry., Registration Number: ACTRN12619001334190p. Date registered: 30/09/2019. URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378153&showOriginal=true&isReview=true., (© 2024. The Author(s).)

Published
2024
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24. Outcomes of Postoperative Overnight High-Acuity Care in Medium-Risk Patients Undergoing Elective and Unplanned Noncardiac Surgery.

Author

Ludbrook G, Grocott MPW, Heyman K, Clarke-Errey S, Royse C, Sleigh J, and Solomon LB

Subjects
Adult, Humans, Male, Aged, Female, Postoperative Care, Cohort Studies, Incidence, Length of Stay, Postoperative Complications epidemiology, Patient Discharge
Abstract

Importance: Postoperative complications are increasing, risking patients' health and health care sustainability. High-acuity postoperative units may benefit outcomes, but existing data are very limited., Objective: To evaluate whether a new high-acuity postoperative unit, advanced recovery room care (ARRC), reduces complications and health care utilization compared with usual ward care (UC)., Design, Setting, and Participants: In this observational cohort study, adults who were undergoing noncardiac surgery at a single-center tertiary adult hospital, anticipated to stay in hospital for 2 or more nights, were scheduled for postoperative ward care, and at medium risk (defined as predicted 30-day mortality of 0.7% to 5% by the National Safety Quality Improvement Program risk calculator) were included. Allocation to ARRC was based on bed availability. From 2405 patients assessed for eligibility with National Safety Quality Improvement Program risk scoring, 452 went to ARRC and 419 to UC, with 8 lost to 30-day follow-up. Propensity scoring identified 696 patients with matched pairs. Patients were treated between March and November 2021, and data were analyzed from January to September 2022., Interventions: ARRC is an extended postanesthesia care unit (PACU), staffed by anesthesiologists and nurses (1 nurse to 2 patients) collaboratively with surgeons, with capacity for invasive monitoring and vasoactive infusions. ARRC patients were treated until the morning after surgery, then transferred to surgical wards. UC patients were transferred to surgical wards after usual PACU care., Main Outcome and Measures: The primary end point was days at home at 30 days. Secondary end points were health facility utilization, medical emergency response (MER)-level complications, and mortality. Analyses compared groups before and after propensity scoring matching., Results: Of 854 included patients, 457 (53.5%) were male, and the mean (SD) age was 70.0 (14.4) years. Days at home at 30 days was greater with ARRC compared with UC (mean [SD] time, 17 [11] vs 15 [11] days; P = .04). During the first 24 hours, more patients were identified with MER-level complications in ARRC (43 [12.4%] vs 13 [3.7%]; P < .001), but after return to the ward, these were less frequent from days 2 to 9 (9 [2.6%] vs 22 [6.3%]; P = .03). Length of hospital stay, hospital readmissions, emergency department visits, and mortality were similar., Conclusions and Relevance: For medium-risk patients, brief high-acuity care with ARRC allowed enhanced detection and management of early MER-level complications, which was followed by a decreased incidence of subsequent MER-level complications after discharge to the ward and by increased days at home at 30 days.

Published
2023
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25. Clinical utility of cardiac magnetic resonance imaging to assess the left atrium before catheter ablation for atrial fibrillation - A systematic review and meta-analysis.

Author

Ghafouri K, Franke KB, Foo FS, and Stiles MK

Subjects
Heart Atria diagnostic imaging, Heart Atria surgery, Humans, Magnetic Resonance Imaging, Recurrence, Treatment Outcome, Atrial Fibrillation diagnostic imaging, Atrial Fibrillation surgery, Catheter Ablation
Abstract

Aims: This systematic review and meta-analysis aims to clarify the role of pre-procedural cardiac magnetic resonance imaging (MRI) in identifying the association between left atrial (LA) characteristics and post-ablation atrial fibrillation (AF) recurrence. These characteristics include LA fibrosis, emptying function, sphericity, volume, volume index, peak strain and post-contrast T1 relaxation time., Methods: PubMed, EMBASE, and Cochrane were searched up to July 2020 for English language articles reporting the use of cardiac MRI in catheter ablation for AF. Studies reporting the prognostic value of pre-ablation cardiac MRI were included. All references and citations were filtered for relevant manuscripts., Results: Twenty-four publications were identified. Every 10% increase in LA fibrosis was associated with a 1.54-fold increase in post-ablation AF recurrence (95%CI: 1.39-1.70, I 2  = 50.1%). Every 10 ml increase in LA volume resulted in a hazard ratio of 1.07 (95%CI:1.03-1.12; I 2  = 41.4%) for post-ablation AF recurrence. For LA sphericity, there was no significant association with post-ablation AF recurrence (HR: 1.032 [95%CI: 0.962-1.103, I 2  = 49.6%). Egger's test was non-significant for publication bias in all meta-analyses. LA volume index, emptying function, peak strain and post-contrast LA T1 relaxation time had insufficient compatible publications to conduct a meta-analysis., Conclusion: LA fibrosis quantified by cardiac MRI is associated with risk of AF recurrence after AF ablation, while increased LA volume is associated with AF recurrence to a lesser extent. There remains insufficient evidence to support the routine measurement of LA sphericity, LA volume index, LA emptying function, peak strain and LA T1 relaxation time to predict AF recurrence after AF ablation., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Published
2021
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28. MDLSD: study protocol for a randomised, double-masked, placebo-controlled trial of repeated microdoses of LSD in healthy volunteers.

Author

Murphy RJ, Sumner RL, Evans W, Menkes D, Lambrecht I, Ponton R, Sundram F, Hoeh N, Ram S, Reynolds L, and Muthukumaraswamy S

Subjects
Cognition, Double-Blind Method, Healthy Volunteers, Humans, Male, Personality, Randomized Controlled Trials as Topic, Hallucinogens adverse effects, Lysergic Acid Diethylamide adverse effects
Abstract

Background: Regular ingestion of sub-hallucinogenic doses of psychedelics, referred to as "microdosing", has gained increasing popularity and attention in the press and in online forums, with reported benefits across multiple cognitive and emotional domains. Rigorously controlled studies to date, however, have been limited in scope and have failed to produce results comparable to those reported in the grey literature., Methods: Eighty healthy male participants will receive 14 doses of placebo or 10 μg lysergic acid diethylamide orally every 3rd day over a 6-week treatment protocol. A battery of personality, creativity, mood, cognition, and EEG plasticity measures, as well as resting-state fMRI imaging, will be administered at baseline and at the end of the protocol. Creativity, mood, and plasticity measures will additionally be assessed in the acute phase of the first dose. Daily functioning will be monitored with questionnaires and a wearable sleep and activity tracker., Discussion: This study will rigorously examine the claims presented in the microdosing grey literature by pairing a comparable dosing protocol with objective measures. Potential therapeutic implications include future clinical trials to investigate microdosed psychedelics as a standalone treatment or as an augmentation of psychotherapy in the treatment of depression, addiction, eating disorders, obsessive-compulsive disorders, and palliative care., Trial Registration: ACTRN12621000436875 . Registered on 19 February 2021.

Published
2021
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29. Expanding the emergency nurse role to meet demand: nurse and physician perspectives.

Author

Cameron M and Shaw V

Subjects
Adult, Career Mobility, Female, Humans, Interviews as Topic, Male, New Zealand, Organizational Innovation, Quality Assurance, Health Care, Surveys and Questionnaires, Clinical Competence, Emergency Nursing, Emergency Service, Hospital organization & administration, Nurse's Role, Personnel Delegation, Physicians psychology
Abstract

Background: Emergency departments (EDs) in New Zealand are experiencing growing demand because of rising attendances, and this is having a negative effect on patients, staff and organisations. The expansion of traditional nursing roles is one solution that has been explored internationally to ameliorate the adverse effects of increasing patient attendances., Aim: To explore the attitudes of registered nurses and physicians employed in emergency medicine towards an expanded role for registered nurses in the ED setting., Method: A mixed-methods approach was adopted, in which data were collected in two phases, using interviews and questionnaires. Semi-structured, face-to-face interviews were held with clinical and non-clinical staff employed in emergency medicine, and questionnaires were distributed to 140 physicians and nurses employed in one ED. The data were analysed to identify themes and to determine the differences between nurse and physician respondents., Findings: Ten ED staff were interviewed, including non-clinical managers (n=4), physicians (n=2) and nurses (n=4). Analysis of the interviews identified five themes: driving change; expanded nurse role; optimal environment; facilitating change; and optimising outcomes for patients. A total of 70 questionnaires were returned, with 63 from nurses and seven from physicians. Nurse respondents were more supportive than their physician colleagues of the need to expand the nursing role in the ED., Conclusion: The existing New Zealand nursing scope of practice has the capacity to develop roles, with nurses supporting this change more than physicians. If role expansion is undertaken, serious consideration needs to be given to developing clear professional boundaries to maintain patient safety and department flow., Competing Interests: None declared, (© 2020 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

Published
2020
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30. Sentinel node biopsy for melanoma: New Zealand indication guidelines in practice ✰ .

Author

Brian T, McEwan W, and Jameson MB

Subjects
Adult, Aged, Aged, 80 and over, Female, Guideline Adherence, Humans, Male, Middle Aged, New Zealand, Practice Patterns, Physicians' statistics & numerical data, Referral and Consultation, Retrospective Studies, Sentinel Lymph Node Biopsy statistics & numerical data, Melanoma pathology, Practice Guidelines as Topic, Skin Neoplasms pathology
Published
2019
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31. Nga Whenu Raranga/Weaving Strands in the Alcohol and Other Drug Treatment Court of Aotearoa/New Zealand.

Author

Thom K and Black S

Subjects
Anthropology, Cultural, Humans, Jurisprudence, New Zealand, Substance-Related Disorders therapy
Abstract

This article reports findings from an ethnographic study that explored the meaning of therapeutic in the Alcohol and Other Drug Treatment (AODT) Court in New Zealand. Descriptions are provided of the therapeutic framework called ngā whenu raranga/weaving strands that resulted from interviews with court team members (n = 25), courtroom observations (200 hours), and document analysis. This includes the details of four strands; Law, United States Best Practice, Recovery and Lore that compose the framework. We argue that the therapeutic framework is simultaneously a philosophical and practical accomplishment and we provide brief examples of how the four strands are woven together, with each strand shaping the other, as the court team, participants and wider community interact together. The article concludes by considering the implications of the study's findings, focusing on challenges that come with the widening of therapeutic discourse in the AODT Court.

Published
2018

32. The patient perspective on a first raised PSA test.

Author

Brown C, Hodgson F, Obertova Z, Holmes M, and Lawrenson R

Subjects
Aged, Digital Rectal Examination, Humans, Male, Middle Aged, New Zealand, Prostatic Neoplasms ethnology, Early Detection of Cancer psychology, Early Detection of Cancer statistics & numerical data, General Practice statistics & numerical data, Prostate-Specific Antigen, Prostatic Neoplasms diagnosis, Prostatic Neoplasms psychology
Abstract

Introduction: Approximately 350 000 prostate-specific antigen (PSA) tests are undertaken in New Zealand on a quarter of a million men each year. A number of studies have looked at PSA testing done by general practitioners (GPs) and subsequent outcomes. Few have looked at the patient perspective after a raised PSA result., Aim: To explore patient experiences up to and following a raised PSA test., Methods: Thirty-one general practices within the Midland region were recruited. Community laboratory databases were used to identify all men with a first raised PSA test during 2010. Questionnaires were sent to these men., Results: One hundred and ninety-four (63%) eligible responses were received from 307 eligible men delivered questionnaires. For 54% of men this was their first PSA test. Most men (66%) identified that their PSA test was initiated by their GP. Forty-three percent of men identified having symptoms at the time of their first raised PSA test. A digital rectal examination (DRE) was performed on 73% of men at the time of the test. Fifty-eight percent of men were referred to see a specialist. Maori men were less likely to be referred after a raised PSA. Of all men referred, 61% received a biopsy., Discussion: PSA testing is predominantly initiated by GPs. We found the care pathway is variable for men after an elevated PSA result. Standardisation of the pathway prior to and post diagnosis would assist patients in knowing what to expect and would aid in GP management of men being investigated for prostate cancer.

Published
2015

33. Treatment modalities for Māori and New Zealand European men with localised prostate cancer.

Author

Obertová Z, Lawrenson R, Scott N, Holmes M, Brown C, Lao C, Tyrie L, and Gilling P

Subjects
Adult, Aged, Aged, 80 and over, Healthcare Disparities statistics & numerical data, Humans, Male, Middle Aged, New Zealand epidemiology, Prostatic Neoplasms epidemiology, Prostatic Neoplasms ethnology, Random Allocation, Registries, Retrospective Studies, White People, Healthcare Disparities ethnology, Prostatic Neoplasms therapy
Abstract

Objectives: To examine diagnostic and treatment pathways for Māori (the indigenous people of New Zealand [NZ]) and NZ European men with prostate cancer in order to identify causes of higher mortality rates for Māori men., Methods: All Māori men (150) diagnosed with prostate cancer in the Midland Cancer Network region between 2007 and 2010 were identified from the NZ Cancer Registry and frequency age-matched with three randomly sampled NZ European men. Clinical records of these men were searched for information on clinical stage at diagnosis, comorbidities, and type of treatment for localised disease., Results: The final cohort included 136 Māori and 400 NZ European men, of whom 97 Māori and 311 NZ European were diagnosed with localised prostate cancer. Māori men were twice as likely to be diagnosed with distant metastases compared with NZ European men (19.1 vs 9.8 %). Māori men with localised disease were less likely to be treated with radical prostatectomy compared with NZ European men [RR 0.66 (95 % CI 0.48, 0.90)]. Multivariate regression analysis adjusted for age, D'Amico risk strata, comorbidities, and socioeconomic deprivation showed that Māori men were more likely to be managed expectantly [RR 1.74 (95 % CI 1.06, 2.57)]., Conclusion: Differences between Māori and NZ European men observed in the management of localised prostate cancer cannot be readily explained by patient characteristics, such as comorbidities or risk assessment at diagnosis. Poorer outcomes for Māori men may not only be related to later stage at diagnosis but differences in treatment modalities may also be a factor.

Published
2015
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35. Palliative care patients' use of emergency departments.

Author

Lawrenson R, Waetford J, Gibbons V, Kirk P, Haggar S, and Reddy R

Subjects
Adult, Aged, Aged, 80 and over, Female, Genital Neoplasms, Female, Health Services Needs and Demand, Humans, Male, Middle Aged, Multivariate Analysis, Neoplasms, New Zealand, Odds Ratio, Pain, Palliative Care methods, Risk Factors, Rural Population, Sex Distribution, Young Adult, Emergency Service, Hospital statistics & numerical data, Palliative Care statistics & numerical data
Abstract

Aim: To compare attendances of Maori with non-Maori palliative care patients at Emergency Departments (ED) and the outcome of their visits., Method: This was an observational study using record linkage. The study population was Waikato palliative care patients registered in a 12-month period, aged over 20 years. For each patient we recorded from the hospital records their age, gender, ethnicity, domicile (Hamilton or other), hospital visited and number of visits to the emergency department in the study period. We compared likelihood of attendance at ED and also looked at reasons for the visits and the outcome--including admit to hospital or place of discharge, Results: 1185 palliative care patients were identified from the palliative care register. There were 645 men (54.4%), 197 Maori (16.6%) and 18 Pacific (1.5%). The mean age overall was 70.8 years and mean length of time on the register during the year of interest was 120.7 (median 66) days. 449 (37.9%) of the study population visited ED at least once. A multivariate analysis revealed that men visited ED more than women (Odds Ratios [OR] 1.6, p=0.001) and women with a gynaecological cancer visited ED more often than other palliative care conditions (OR 3.3, p<0.001). No other factor including ethnicity was associated with the risk of visiting ED., Conclusion: This study has helped quantify the characteristics of palliative care patients utilising ED in a relatively rural population with a high proportion of Maori. It has shown that a significant proportion of palliative care patients will attend ED, that men with palliative care needs are more likely to attend ED but Maori are not more likely to utilise the services. We believe that New Zealand hospitals should consider the role of their ED in the management of palliative care patients.

Published
2013

36. Frederic John Mouat (1816-97), MD FRCS LLD of the Indian Medical Service.

Author

Lawrenson R

Subjects
General Surgery education, History, 19th Century, Humans, India, Prisoners history, Education, Medical history, General Surgery history, Prisons history
Abstract

Frederic John Mouat trained at University College London, qualifying Member of the Royal College of Surgeons in 1838. He was a distinguished surgeon in the Indian Civil Medical Service who became Professor of Medicine in the Bengal Medical College. After 30 years in India, where he was a leading figure in the field of education and prison reform, he retired to the UK in 1870. Then he started a new career as an Inspector for the Local Government Board. He was also an active member of the Royal Statistical Society, becoming its President in 1890. He died in 1897 leaving a widow and four stepchildren.

Published
2007
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37. The use of amino-terminal fraction brain natriuretic peptide (NT-proBNP) assays in general practices in Waikato, New Zealand.

Author

Gibbons V, Devlin G, Speed J, and Lawrenson R

Subjects
Aged, Aged, 80 and over, Diagnostic Tests, Routine statistics & numerical data, Female, Heart Failure blood, Humans, Male, Medical Audit, Middle Aged, New Zealand, Sensitivity and Specificity, Family Practice statistics & numerical data, Heart Failure diagnosis, Natriuretic Peptide, Brain blood, Peptide Fragments blood, Practice Patterns, Physicians' statistics & numerical data
Abstract

Aims: To assess the use of the amino-terminal fraction brain natriuretic peptide (NT-proBNP) assay in the management of patients with suspected heart failure in general practice in Waikato District Health Board (DHB)., Methods: We undertook an audit of all BNP requests to Waikato Health Laboratory from 1 March 2005 to 28 February 2006 inclusive. Data were analysed for age, gender, test result, and requesting general practitioner (GP). Crude incidence rate of BNP test by age group, sex, and by district was obtained. Second tests were analysed to ascertain numbers of patients re-tested in primary care., Results: 1553 tests were ordered on 1327 patients; 1182 (89%) of patients had only one test in primary care; 680 (51.2%) of first tests were <40 pmol/L, 409 (30.8%) were between 40-220 pmol/L; and 238 (17.9%) were >220 pmol/L. Of the estimated 250 GPs in Waikato DHB, 75% (189) of GPs had requested one or more BNP tests. 27% (51/189) of GPs requested a repeat test on one or more patient. 27% of patients with result >220 pmol/L had a further BNP test in general practice., Conclusions: The majority of Waikato GPs have experience with BNP testing in primary care. It appears to be used appropriately as a tool to rule out the diagnosis of heart failure by most GPs. A small number of doctors appear to use BNP more frequently, possibly to monitor treatment or change in condition (an indication for which it is not currently recommended). The use of BNP varies by district.

Published
2007

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