Carotid plaque hemorrhage on magnetic resonance imaging strongly predicts recurrent ischemia and stroke

Objective There is a recognized need to improve selection of patients with carotid artery stenosis for carotid endarterectomy (CEA). We assessed the value of magnetic resonance imaging (MRI)-defined carotid plaque hemorrhage (MRIPH) to predict recurrent ipsilateral cerebral ischemic events, and stroke in symptomatic carotid stenosis. Methods One hundred seventy-nine symptomatic patients with ≥50% stenosis were prospectively recruited, underwent carotid MRI, and were clinically followed up until CEA, death, or ischemic event. MRIPH was diagnosed if the plaque signal intensity was >150% that of the adjacent muscle. Event-free survival analysis was done using Kaplan–Meier plots and Cox regression models controlling for known vascular risk factors. We also undertook a meta-analysis of reported data on MRIPH and recurrent events. Results One hundred fourteen patients (63.7%) showed MRIPH, suffering 92% (57 of 62) of all recurrent ipsilateral events and all but 1 (25 of 26) future strokes. Patients without MRIPH had an estimated annual absolute stroke risk of only 0.6%. Cox multivariate regression analysis proved MRIPH as a strong predictor of recurrent ischemic events (hazard ratio [HR] = 12.0, 95% confidence interval [CI] = 4.8–30.1, p < 0.001) and stroke alone (HR = 35.0, 95% CI = 4.7–261.6, p = 0.001). Meta-analysis of published data confirmed this association between MRIPH and recurrent cerebral ischemic events in symptomatic carotid artery stenosis (odds ratio = 12.2, 95% CI = 5.5–27.1, p < 0.00001). Interpretation MRIPH independently and strongly predicts recurrent ipsilateral ischemic events, and stroke alone, in symptomatic ≥50% carotid artery stenosis. The very low stroke risk in patients without MRIPH puts into question current risk–benefit assessment for CEA in this subgroup

Magnetic resonance imaging plaque hemorrhage for risk stratification in carotid artery disease with moderate risk under current medical therapy

Background and Purpose—Magnetic resonance imaging (MRI)–defined carotid plaque hemorrhage (MRIPH) can predict recurrent cerebrovascular ischemic events in severe symptomatic carotid stenosis. It is less clear whether MRIPH can improve risk stratification despite optimized medical secondary prevention in those with moderate risk. Methods—One-hundred fifty-one symptomatic patients with 30% to 99% carotid artery stenosis (median age: 77, 60.5% men) clinically deemed to not benefit from endarterectomy were prospectively recruited to undergo MRI and clinical follow-up (mean, 22 months). The clinical carotid artery risk score could be evaluated in 88 patients. MRIPH+ve was defined as plaque intensity >150% that of adjacent muscle. Survival analyses were performed with recurrent infarction (stroke or diffusion-positive cerebral ischemia) as the main end point. Results—Fifty-five participants showed MRIPH+ve; 47 had low, 36 intermediate, and 5 high carotid artery risk scores. Cox regression showed MRIPH as a strong predictor of future infarction (hazard ratio, 5.2; 95% confidence interval, 1.64–16.34; P=0.005, corrected for degree of stenosis), also in the subgroup with 50% to 69% stenosis (hazard ratio, 4.1; 95% confidence interval, 1–16.8; P=0.049). The absolute risk of future infarction was 31.7% at 3 years in MRIPH+ve versus 1.8% in patients without (P<0.002). MRIPH increased cumulative risk difference of future infarction by 47.1% at 3 years in those with intermediate carotid artery risk score (P=0.004). Conclusions—The study confirms MRIPH to be a powerful risk marker in symptomatic carotid stenosis with added value over current risk scores. For patients undergoing current secondary prevention medication with clinically uncertain benefit from recanalization, that is, those with moderate degree stenosis and intermediate carotid artery risk scores, MRIPH offers additional risk stratification

Study 2: Predictors of socio-emotional functioning in early childhood: a longitudinal examination of the role of mother-child relationships and maternal mental health

The thesis comprises two research papers, a systematic review and major research project. Systematic review abstract: Behavioral problems in childhood are associated with detrimental child and adolescent outcomes, including juvenile delinquency, poor academic performance, higher rates of alcohol abuse, and reduced overall quality of life. Father involvement is an important component of the father-child relationship that describes the various ways in which fathers actively participate in their children’s lives. However, evidence that higher father involvement reduces the risk of behavioral problems in children is mixed, has often been reliant on cross-sectional data, has provided limited focus on behavioral outcomes, and has often excluded older children. The current systematic review focused on longitudinal evidence regarding father involvement and subsequent behavioral outcomes in children aged 0-17 years. In addition, maternal involvement was included as a control or comparator variable. Searches were conducted across Pubmed, Scopus, Web of Science, and Embase, and 16 studies met inclusion criteria. Overall, findings provided evidence that father involvement positively contributes to children’s behavioral outcomes. The impact of father involvement appeared to be greatest in studies examining play or engagement in positive social activities. Limited use of validated father involvement measures and conceptual models are highlighted as important methodological considerations for future research. Major research project abstract: Early attachment and maternal mental health have been reliably posited as predictors of socio-emotional outcomes in children. However, there is a need for further longitudinal research to examine the influence of these variables at multiple stages throughout infancy and early childhood. The current study utilized a longitudinal design to evaluate the predictive significance of these associations from 4 months to 48 months, relative to other demographic, maternal and child factors in a community sample of mothers (N = 124). Secondary data was obtained from three previous waves of the ongoing BabySMART study. The current study recruited participants for a fourth wave of data collection using an online survey. Preliminary bivariate analyses suggested that indicators of maternal mental health and overall health-related quality of life (when children were aged 4, 18 and 48 months) and mother-child closeness and conflict (at 48 months) were significantly associated with child socio-emotional problems at 48 months. Aspects of child cognitive development (only at four months) were also significantly associated with socio-emotional problems at 48 months. Further hierarchical regression models confirmed the particular significance of mother-child relationship and maternal mental and physical health factors at four months for predicting child socio-emotional outcomes at 48 months. Clinical implications and future research in this field are discussed

Endovascular stenting of a chronic ruptured type B thoracic aortic dissection, a second chance: a case report

<p>Abstract</p> <p>Introduction</p> <p>We aim to highlight the need for awareness of late complications of endovascular thoracic aortic stenting and the need for close follow-up of patients treated by this method.</p> <p>Case presentation</p> <p>We report the first case in the English literature of an endovascular repair of a previously stented, ruptured chronic Stanford type B thoracic aortic dissection re-presenting with a type III endoleak of the original repair.</p> <p>Conclusion</p> <p>Endovascular thoracic stenting is now a widely accepted technique for the treatment of thoracic aortic dissection and its complications. Long term follow up is necessary to ensure that late complications are identified and treated appropriately. In this case of type III endoleak, although technically challenging, endovascular repair was feasible and effective.</p

Circulating Microparticles in Patients with Symptomatic Carotid Disease Are Related to Embolic Plaque Activity and Recent Cerebral Ischaemia

Background and Purpose: In order to assess the association of microparticles derived from activated platelets (PMP) or endothelial cells (EMP) with risk markers for recurrent embolic events in patients with symptomatic carotid artery disease, we studied the associations between PMP/EMP and three risk markers: plaque haemorrhage (PH), micro-embolic signals and cerebral diffusion abnormalities. Methods: Patients with recently symptomatic high-grade carotid artery stenosis (60–99%, 42 patients, 31 men; mean age 75 ± 8 years) and 30 healthy volunteers (HV, 11 men; mean age 56 ± 12 years) were prospectively recruited. Patients were characterised by carotid magnetic resonance imaging (presence of PH [MRI PH]), brain diffusion MRI (cerebral ischaemia [DWI+]) and transcranial Doppler ultrasound (micro-embolic signals [MES+]). PMP and EMP were classified by flow cytometry and expressed as log-transformed counts per microlitre. Results: MES+ patients (n = 18) had elevated PMP (MES+ 9.61 ± 0.57) compared to HV (8.80 ± 0.73; p &#x3c; 0.0001) and to MES– patients (8.55 ± 0.85; p &#x3c; 0.0001). Stroke patients had elevated PMP (9.49 ± 0.64) and EMP (6.13 ± 1.0) compared to non-stroke patients (PMP 8.81 ± 0.73, p = 0.026, EMP 5.52 ± 0.65, p = 0.011) and HV (PMP 8.80 ± 0.73, p = 0.007, and EMP 5.44 ± 0.47, p = 0.006). DWI+ patients (n = 16) showed elevated PMP (DWI+ 9.53 ± 0.64; vs. HV, p = 0.002) and EMP (DWI+ 5.91 ± 0.99 vs. HV 5.44 ± 0.47; p = 0.037). Only PMP but not EMP were higher in DWI+ versus DWI– patients (8.67 ± 0.90; p = 0.002). No association was found between PMP and EMP with MRI PH. Conclusions: PMP and EMP were associated with stroke and recent cerebrovascular events (DWI+) but only PMP were also associated with ongoing (MES+) thrombo-embolic activity suggesting a differential biomarker potential for EMP to index cerebral ischaemia while PMP may predict on-going thrombo-embolic activity

Endovascular strategy or open repair for ruptured abdominal aortic aneurysm: one-year outcomes from the IMPROVE randomized trial.

AIMS: To report the longer term outcomes following either a strategy of endovascular repair first or open repair of ruptured abdominal aortic aneurysm, which are necessary for both patient and clinical decision-making. METHODS AND RESULTS: This pragmatic multicentre (29 UK and 1 Canada) trial randomized 613 patients with a clinical diagnosis of ruptured aneurysm; 316 to an endovascular first strategy (if aortic morphology is suitable, open repair if not) and 297 to open repair. The principal 1-year outcome was mortality; secondary outcomes were re-interventions, hospital discharge, health-related quality-of-life (QoL) (EQ-5D), costs, Quality-Adjusted-Life-Years (QALYs), and cost-effectiveness [incremental net benefit (INB)]. At 1 year, all-cause mortality was 41.1% for the endovascular strategy group and 45.1% for the open repair group, odds ratio 0.85 [95% confidence interval (CI) 0.62, 1.17], P = 0.325, with similar re-intervention rates in each group. The endovascular strategy group and open repair groups had average total hospital stays of 17 and 26 days, respectively, P < 0.001. Patients surviving rupture had higher average EQ-5D utility scores in the endovascular strategy vs. open repair groups, mean differences 0.087 (95% CI 0.017, 0.158), 0.068 (95% CI -0.004, 0.140) at 3 and 12 months, respectively. There were indications that QALYs were higher and costs lower for the endovascular first strategy, combining to give an INB of £3877 (95% CI £253, £7408) or €4356 (95% CI €284, €8323). CONCLUSION: An endovascular first strategy for management of ruptured aneurysms does not offer a survival benefit over 1 year but offers patients faster discharge with better QoL and is cost-effective. CLINICAL TRIAL REGISTRATION: ISRCTN 48334791

The effects of a video-presentation on attitudes towards Mental Health

A cross-sectional and longitudinal design was used in order to establish the effects an intervention in the form of a video presentation may have on attitudes towards mental health. Three variables were combined in order to provide an overall measure of attitudes towards mental health. These measures included attitude towards mental illness, attitude towards seeking professional help and empathy. A total of 74 participants took part in the study. Pre and post-intervention effects were measured in one group (n=37) while a separate control group (n=37) did not engage with the intervention. The repeated measures analysis found that there was no significant difference between pre-intervention scores and post-intervention scores. There was a significant difference between both conditions for each measure when the variables were compared individually. Additionally, the between group analysis indicated that there was a positive significant difference between the post-intervention group and the non-intervention (control) group. Author Keywords: Mental Health, Attitudes, Intervention, Mental Illness, Professional Help, Empath

Urgent need to update NICE guidelines on imaging for transient ischaemic attack

Available to read on the publisher's website here: https://doi.org/10.1016/S0140-6736(22)01281-8.https://doi.org/10.1016/S0140-6736(22)01281-