Variant Musculo-tendinous Slip between Teres major and Triceps brachii

A variation of the muscles of the scapular region is a very rare finding. During the routine dissection for the undergraduates, a variant short musculo-tendinous slip in between the teres major and the long head of triceps brachii muscles was seen. This slip could cause compression of the underlying brachial vessels and the cords of brachial plexus. Therefore this type of variation is worthy of being noted by the surgeons

Statistical analysis plan for the ‘Efficacy of Nitric Oxide in Stroke’ (ENOS) trial

High blood pressure is common during the acute phase of stroke and is associated with a poor outcome. However, the management of high blood pressure remains unclear. The ‘Efficacy of Nitric Oxide in Stroke’ trial tested whether transdermal glyceryl trinitrate, a nitric oxide donor that lowers blood pressure, is safe and effective in improving outcome after acute stroke. Efficacy of Nitric Oxide in Stroke is an international multicenter, prospective, randomized, single-blind, blinded endpoint trial, with funding from the UK Medical Research Council. Patients with acute ischemic stroke or intracerebral hemorrhage and systolic blood pressure 140–220 mmHg were randomized to glyceryl trinitrate or no glyceryl trinitrate and, where relevant, to continue or stop prestrike antihypertensive therapy. The primary outcome is shift in modified Rankin Scale at three-months. Patients or relatives gave written informed (proxy) consent, and all sites had research ethics approval. Analyses will be done by intention to treat. This paper and attachment describe the trial’s statistical analysis plan, developed prior to unblinding of date. The statistical analysis plan contains design and methods for analyses, and unpopulated tables and figures for the two primary publications and some secondary publications. The database will be locked in late February 2014 in preparation for presentation of the results in May 2014. The data from the trial will improve the precision of the estimates of the overall treatment effects (efficacy and safety) of results from completed trials of blood pressure management in acute stroke, and provide the first large-scale randomized evidence on transdermal glyceryl trinitrate, and of continuing (vs. stopping) prestroke antihypertensive medications, in acute stroke

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

Background Findings from the RESTART trial suggest that starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. Brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases (such as cerebral microbleeds) are associated with greater risks of recurrent intracerebral haemorrhage. We did subgroup analyses of the RESTART trial to explore whether these brain imaging features modify the effects of antiplatelet therapy

Prehospital transdermal glyceryl trinitrate in patients with ultra-acute presumed stroke (RIGHT-2): an ambulance-based, randomised, sham-controlled, blinded, phase 3 trial

Background High blood pressure is common in acute stroke and is a predictor of poor outcome; however, large trials oflowering blood pressure have given variable results, and the management of high blood pressure in ultra-acute strokeremains unclear. We investigated whether transdermal glyceryl trinitrate (GTN; also known as nitroglycerin), a nitricoxide donor, might improve outcome when administered very early after stroke onset.Methods We did a multicentre, paramedic-delivered, ambulance-based, prospective, randomised, sham-controlled,blinded-endpoint, phase 3 trial in adults with presumed stroke within 4 h of onset, face-arm-speech-time score of 2or 3, and systolic blood pressure 120 mm Hg or higher. Participants were randomly assigned (1:1) to receivetransdermal GTN (5 mg once daily for 4 days; the GTN group) or a similar sham dressing (the sham group) in UKbasedambulances by paramedics, with treatment continued in hospital. Paramedics were unmasked to treatment,whereas participants were masked. The primary outcome was the 7-level modified Rankin Scale (mRS; a measure offunctional outcome) at 90 days, assessed by central telephone follow-up with masking to treatment. Analysis washierarchical, first in participants with a confirmed stroke or transient ischaemic attack (cohort 1), and then in allparticipants who were randomly assigned (intention to treat, cohort 2) according to the statistical analysis plan. Thistrial is registered with ISRCTN, number ISRCTN26986053.Findings Between Oct 22, 2015, and May 23, 2018, 516 paramedics from eight UK ambulance services recruited1149 participants (n=568 in the GTN group, n=581 in the sham group). The median time to randomisation was 71 min(IQR 45–116). 597 (52%) patients had ischaemic stroke, 145 (13%) had intracerebral haemorrhage, 109 (9%) hadtransient ischaemic attack, and 297 (26%) had a non-stroke mimic at the final diagnosis of the index event. In the GTNgroup, participants’ systolic blood pressure was lowered by 5·8 mm Hg compared with the sham group (p<0·0001),and diastolic blood pressure was lowered by 2·6 mm Hg (p=0·0026) at hospital admission. We found no difference inmRS between the groups in participants with a final diagnosis of stroke or transient ischaemic stroke (cohort 1):3 (IQR 2–5; n=420) in the GTN group versus 3 (2–5; n=408) in the sham group, adjusted common odds ratio for pooroutcome 1·25 (95% CI 0·97–1·60; p=0·083); we also found no difference in mRS between all patients (cohort 2:3 [2–5]; n=544, in the GTN group vs 3 [2–5]; n=558, in the sham group; 1·04 [0·84–1·29]; p=0·69). We found nodifference in secondary outcomes, death (treatment-related deaths: 36 in the GTN group vs 23 in the sham group[p=0·091]), or serious adverse events (188 in the GTN group vs 170 in the sham group [p=0·16]) between treatmentgroups. Interpretation Prehospital treatment with transdermal GTN does not seem to improve functional outcome in patientswith presumed stroke. It is feasible for UK paramedics to obtain consent and treat patients with stroke in the ultra acute prehospital settin

Protocol for a prospective collaborative systematic review and meta-analysis of individual patient data from randomised controlled trials of vasoactive drugs in acute stroke: the Blood pressure in Acute Stroke Collaboration, stage-3 (BASC-3)

Rationale Despite several large clinical trials assessing blood pressure lowering in acute stroke, equipoise remains, particularly for ischaemic stroke. The ‘Blood pressure in Acute Stroke Collaboration’ (BASC) commenced in the mid 1990s focusing on systematic reviews and meta-analysis of blood pressure lowering in acute stroke. From the start, BASC planned to assess safety and efficacy of blood pressure lowering in acute stroke using individual patient data. Aims To determine the optimal management of blood pressure in patients with acute stroke, encompassing both intracerebral haemorrhage and ischaemic stroke. Secondary aims are to assess which clinical and therapeutic factors may alter the optimal management of high blood pressure in patients with acute stroke and to assess the effect of vasoactive treatments on haemodynamic variables. Methods and design Individual patient data from randomised controlled trials of blood pressure management in participants with ischaemic stroke and/or intracerebral haemorrhage enrolled during the ultra-acute (pre-hospital), hyper-acute (<6 hours), acute (<48 hours) and sub-acute (<168 hours) phases of stroke. Study outcomes The primary effect variable will be functional outcome defined by the ordinal distribution of the modified Rankin Scale; analyses will also be carried out in prespecified subgroups to assess the modifying effects of stroke-related and pre-stroke patient characteristics. Key secondary variables will include clinical, haemodynamic and neuroradiological variables; safety variables will comprise death and serious adverse events. Discussion Study questions will be addressed in stages, according to the protocol, before integrating these into a final overreaching analysis. We invite eligible trials to join the collaboration

3-level service composition and Cashew: a model for orchestration and choreography in semantic web services

There are two types of behavioural model in the WSMO semantic description of services: an orchestration and a choreography, together called the interface. While an orchestration defines a service’s behaviour as a composition of existing parts, a choreography is intended to document the conversation of messages exchanged with a single client. In this paper we present a three-level model for behavioural descriptions, and how the Cashew workflow model fits into this, building on existing work in, and establishing connections with, semantic web services, workflow, and software engineering design