To investigate whether the location and extent of the CT hyperdense artery sign (HAS) at presentation affects response to IV alteplase in the randomized controlled Third International Stroke Trial (IST-3).
Methods:
All prerandomization and follow-up (24–48 hours) CT brain scans in IST-3 were assessed for HAS presence, location, and extent by masked raters. We assessed whether HAS grew, persisted, shrank, or disappeared at follow-up, the association with 6-month functional outcome, and effect of alteplase. IST-3 is registered (ISRCTN25765518).
Results:
HAS presence (vs absence) independently predicted poor 6-month outcome (increased Oxford Handicap Scale [OHS]) on adjusted ordinal regression analysis (odds ratio [OR] 0.66, p < 0.001). Outcome was worse in patients with more (vs less) extensive HAS (OR 0.61, p = 0.027) but not in proximal (vs distal) HAS (p = 0.420). Increasing age was associated with more HAS growth at follow-up (OR 1.01, p = 0.013). Treatment with alteplase increased HAS shrinkage/disappearance at follow-up (OR 0.77, p = 0.006). There was no significant difference in HAS shrinkage with alteplase in proximal (vs distal) or more (vs less) extensive HAS (p = 0.516 and p = 0.580, respectively). There was no interaction between presence vs absence of HAS and benefit of alteplase on 6-month OHS (p = 0.167).
Conclusions:
IV alteplase promotes measurable reduction in HAS regardless of HAS location or extent. Alteplase increased independence at 6 months in patients with and without HAS.
Classification of evidence:
This study provides Class I evidence that for patients within 6 hours of ischemic stroke with a CT hyperdense artery sign, IV alteplase reduced intra-arterial hyperdense thrombus.
Abstract To increase the effectiveness of agri‐environmental schemes, innovative approaches that focus on the landscape scale beyond individual fields and farms are widely discussed and tested. Central to these approaches is collaboration between several farmers and other actors in agricultural landscapes. The effectiveness of collaborative agri‐environmental initiatives is strongly related to the motivation of actors. Administrative and social issues might hamper actor decisions to join an initiative. Based on our experience in implementing a participatory landscape‐scale project in Germany, we raise the question in which ways actors can be motivated and empowered to participate in such initiatives and how collaborative approaches can stimulate and maintain the exchange of participants. We find that establishing bridging structures (for an equal exchange of ideas and experiences), identifying and involving regional facilitators (to promote the participation of farmers and other actors) and addressing the expectations of actors (e.g. regarding administrative burden) can jointly support the establishment of collaborative initiatives in agriculture. This is particularly relevant when local actors have little experience with joint measure implementation and institutional framework conditions for collaborative governance are limited or not provided. Read the free Plain Language Summary for this article on the Journal blog.
Within the past 10 years, heart transplantation has become established as a standard procedure in heart surgery. Improvements in immunosuppressive therapy and diagnosis of graft rejection have been crucial. The criteria for transplantation have been broadened for recipients as well as for donors. Newborns, pediatric patients, diabetics, and patients with impaired renal function will no longer be excluded from transplantation due to improved postoperative therapy. Furthermore, progress has been made with assisted circulation. Patients with acute heart failure can now be bridged to transplantation.
Approximately one third of brain-dead organ donors are above the age of 35 years. These donors have been used routinely for heart transplantation because the risks of compromised early graft function and potentially accelerated graft atherosclerosis remained nuclear. The increasing length of the waiting list and a 30% death rate of those on the waiting list for donor organs in our heart transplant program led to acceptance of donor hearts up to 54 years of age. Of a total number of 233 donor hearts, 74 were between 36 and 54 years old (group 2). These hearts were compared for early and chronic graft function with a group of 159 patients who received hearts from donors aged 1-35 years (group 1). All but three group 2 hearts were accepted without coronary angiography. Early postoperative graft function was sufficient in all 72 group 2 patients, whereas in group 1, early graft failure in nine (5.7%) patients led to death or required retransplantation. Forty-one patients in group 2 and 79 patients in group 1 were restudied at annual intervals between 1 and 4 years postoperatively by complete cardiac angiography. Mean late postoperative left and right ventricular ejection fractions were normal in both groups. Graft atherosclerosis was found in seven (8.9%) patients in group 1 and in four (9.8%) patients in group 2.(ABSTRACT TRUNCATED AT 250 WORDS)
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