Antiplatelet therapy with aspirin, clopidogrel, and dipyridamole versus clopidogrel alone or aspirin and dipyridamole in patients with acute cerebral ischaemia (TARDIS): a randomised, open-label, phase 3 superiority trial

Background: Intensive antiplatelet therapy with three agents might be more effective than guideline treatment for preventing recurrent events in patients with acute cerebral ischaemia. We aimed to compare the safety and efficacy of intensive antiplatelet therapy (combined aspirin, clopidogrel, and dipyridamole) with that of guideline-based antiplatelet therapy. Methods: We did an international, prospective, randomised, open-label, blinded-endpoint trial in adult participants with ischaemic stroke or transient ischaemic attack (TIA) within 48 h of onset. Participants were assigned in a 1:1 ratio using computer randomisation to receive loading doses and then 30 days of intensive antiplatelet therapy (combined aspirin 75 mg, clopidogrel 75 mg, and dipyridamole 200 mg twice daily) or guideline-based therapy (comprising either clopidogrel alone or combined aspirin and dipyridamole). Randomisation was stratified by country and index event, and minimised with prognostic baseline factors, medication use, time to randomisation, stroke-related factors, and thrombolysis. The ordinal primary outcome was the combined incidence and severity of any recurrent stroke (ischaemic or haemorrhagic; assessed using the modified Rankin Scale) or TIA within 90 days, as assessed by central telephone follow-up with masking to treatment assignment, and analysed by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN47823388. Findings: 3096 participants (1556 in the intensive antiplatelet therapy group, 1540 in the guideline antiplatelet therapy group) were recruited from 106 hospitals in four countries between April 7, 2009, and March 18, 2016. The trial was stopped early on the recommendation of the data monitoring committee. The incidence and severity of recurrent stroke or TIA did not differ between intensive and guideline therapy (93 [6%] participants vs 105 [7%]; adjusted common odds ratio [cOR] 0·90, 95% CI 0·67–1·20, p=0·47). By contrast, intensive antiplatelet therapy was associated with more, and more severe, bleeding (adjusted cOR 2·54, 95% CI 2·05–3·16, p<0·0001). Interpretation: Among patients with recent cerebral ischaemia, intensive antiplatelet therapy did not reduce the incidence and severity of recurrent stroke or TIA, but did significantly increase the risk of major bleeding. Triple antiplatelet therapy should not be used in routine clinical practice

Antiplatelet therapy with aspirin, clopidogrel, and dipyridamole versus clopidogrel alone or aspirin and dipyridamole in patients with acute cerebral ischaemia (TARDIS): a randomised, open-label, phase 3 superiority trial

Background: Intensive antiplatelet therapy with three agents might be more effective than guideline treatment for preventing recurrent events in patients with acute cerebral ischaemia. We aimed to compare the safety and efficacy of intensive antiplatelet therapy (combined aspirin, clopidogrel, and dipyridamole) with that of guideline-based antiplatelet therapy.Methods: We did an international, prospective, randomised, open-label, blinded-endpoint trial in adult participants with ischaemic stroke or transient ischaemic attack (TIA) within 48 h of onset. Participants were assigned in a 1:1 ratio using computer randomisation to receive loading doses and then 30 days of intensive antiplatelet therapy (combined aspirin 75 mg, clopidogrel 75 mg, and dipyridamole 200 mg twice daily) or guideline-based therapy (comprising either clopidogrel alone or combined aspirin and dipyridamole). Randomisation was stratified by country and index event, and minimised with prognostic baseline factors, medication use, time to randomisation, stroke-related factors, and thrombolysis. The ordinal primary outcome was the combined incidence and severity of any recurrent stroke (ischaemic or haemorrhagic; assessed using the modified Rankin Scale) or TIA within 90 days, as assessed by central telephone follow-up with masking to treatment assignment, and analysed by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN47823388.Findings: 3096 participants (1556 in the intensive antiplatelet therapy group, 1540 in the guideline antiplatelet therapy group) were recruited from 106 hospitals in four countries between April 7, 2009, and March 18, 2016. The trial was stopped early on the recommendation of the data monitoring committee. The incidence and severity of recurrent stroke or TIA did not differ between intensive and guideline therapy (93 [6%] participants vs 105 [7%]; adjusted common odds ratio [cOR] 0·90, 95% CI 0·67–1·20, p=0·47). By contrast, intensive antiplatelet therapy was associated with more, and more severe, bleeding (adjusted cOR 2·54, 95% CI 2·05–3·16,

Controlling Oxygen Defect Formation and Its Effect on Reversible Symmetry Lowering and Disorder-to-Order Phase Transformations in Nonstoichiometric Ternary Uranium Oxides

In situ synchrotron powder X-ray diffraction measurements have demonstrated that the isostructural AUO4–x (A = alkaline earth metal cation) oxides CaUO4–x and α-Sr0.4Ca0.6UO4–x undergo a reversible phase transformation under reducing conditions at high temperatures associated with the ordering of in-plane oxygen vacancies resulting in the lowering of symmetry. When rhombohedral (space group R3̅m) CaUO4–x and α-Sr0.4Ca0.6UO4–x are heated to 450 and 400 °C, respectively, in a hydrogen atmosphere, they undergo a first-order phase transformation to a single phase structure which can be refined against a triclinic model in space group P1̅, δ-CaUO4–x and δ-Sr0.4Ca0.6UO4–x, where the oxygen vacancies are disordered initially. Continued heating results in the appearance of superlattice reflections, indicating the ordering of in-plane oxygen vacancies. Cooling ordered δ-CaUO4–x and δ-Sr0.4Ca0.6UO4–x to near room temperature results in the reformation of the disordered rhombohedral phases. Essential to the transformation is the generation of a critical amount of oxygen vacancies. Once these are formed, the transformation can be accessed continuously through thermal cycling, showing that the transformations are purely thermodynamic in origin. Stoichiometric structures of both oxides can be recovered by heating oxygen deficient CaUO4–x and α-Sr0.4Ca0.6UO4–x under pure oxygen to high temperatures. When heated in air, the amount of oxygen vacancy defects that form in CaUO4–x and α-Sr0.4Ca0.6UO4–x are found to correlate with the A site composition. The inclusion of the larger Sr2+ cation on the A site reduces defect–defect interactions, which increases the amount of defects that can form and lowers their formation temperature. The relative difference in the amount of defects that form can be understood on the basis of oxygen vacancy and U5+ disordering as shown by both ab initio calculations and estimated oxygen vacancy formation energies based on thermodynamic considerations. This difference in defect–defect interactions consequently introduces variations in the long-range ordered anionic lattice of the δ phases despite the isostructural relationship of the α structures of CaUO4–x and Sr0.4Ca0.6UO4–x. These results are discussed with respect to the influence the A site cation has upon anion defect formation and ordering and are also compared to δ-SrUO4–x, the only other material known to be able to undergo a reversible symmetry lowering and disorder-to-order transformation with increasing temperatur