Development of a decision support tool to facilitate primary care management of patients with abnormal liver function tests without clinically apparent liver disease [HTA03/38/02]. Abnormal Liver Function Investigations Evaluation (ALFIE)

Liver function tests (LFTs) are routinely performed in primary care, and are often the gateway to further invasive and/or expensive investigations. Little is known of the consequences in people with an initial abnormal liver function (ALF) test in primary care and with no obvious liver disease. Further investigations may be dangerous for the patient and expensive for Health Services. The aims of this study are to determine the natural history of abnormalities in LFTs before overt liver disease presents in the population and identify those who require minimal further investigations with the potential for reduction in NHS costs

Mitochondrial haplotypes reveal low diversity and restricted connectivity in the critically endangered batoid population of a Marine Protected Area

ACKNOWLEDGEMENTS This study was supported by NatureScot, Scottish Government project SP02B, a Heredity Fieldwork Grant of the Genetics Society, and Save Our Seas Foundation project SOSF 470. We would like to thank Leigh Taylor, Ronnie Campbell and Roger Eaton for skippering the sampling charters in the Marine Protected Area and all anglers who provided skate recapture data. Thanks to Fenella Wood and Danielle Sloan for assisting on charter trips. Further, thanks go to Marine Scotland Science (Francis Neat), the Centre for Environment Fisheries and Aquaculture Science (Vicky Bendall and Stewart Hetherington), and the University of St Andrews for providing tissue samples and Lauren Smith and Dan Wise for contributing samples of egg cases.Peer reviewedPublisher PD

Reprint: Good laboratory practice: preventing introduction of bias at the bench

As a research community, we have failed to show that drugs, which show substantial efficacy in animal models of cerebral ischemia, can also improve outcome in human stroke. Accumulating evidence suggests this may be due, at least in part, to problems in the design, conduct, and reporting of animal experiments which create a systematic bias resulting in the overstatement of neuroprotective efficacy. Here, we set out a series of measures to reduce bias in the design, conduct and reporting of animal experiments modeling human stroke

Longitudinal stroke recovery associated with dysregulation of complement system - A proteomics pathway analysis

Currently the longitudinal proteomic profile of post-ischemic stroke recovery is relativelyunknown with few well-accepted biomarkers or understanding of the biological systemsthat underpin recovery. We aimed to characterize plasma derived biological pathwaysassociated with recovery during the first year post event using a discovery proteomicsworkflow coupled with a topological pathway systems biology approach. Blood samples(n = 180, ethylenediaminetetraacetic acid plasma) were collected from a subgroup of60 first episode stroke survivors from the Australian START study at 3 timepoints: 3–7days (T1), 3-months (T2) and 12-months (T3) post-stroke. Samples were analyzed byliquid chromatography mass spectrometry using label-free quantification (data availableat ProteomeXchange with identifier PXD015006). Differential expression analysis revealedthat 29 proteins between T1 and T2, and 33 proteins between T1 and T3 weresignificantly different, with 18 proteins commonly differentially expressed across thetwo time periods. Pathway analysis was conducted using Gene Graph EnrichmentAnalysis on both the Kyoto Encyclopedia of Genes and Genomes and Reactomedatabases. Pathway analysis revealed that the significantly differentiated proteinsbetween T1 and T2 were consistently found to belong to the complement pathway.Further correlational analyses utilized to examine the changes in regulatory effects ofproteins over time identified significant inhibitory regulation of clusterin on complementcomponent 9. Longitudinal post-stroke blood proteomics profiles suggest that thealternative pathway of complement activation remains in a state of higher activation from3-7 days to 3 months post-stroke, while simultaneously being regulated by clusterin andvitronectin. These findings also suggest that post-stroke induced sterile inflammation andimmunosuppression could inhibit recovery within the 3-month window post-stroke

Should patients with abnormal liver function tests in primary care be tested for chronic viral hepatitis: cost minimisation analysis based on a comprehensively tested cohort

Background Liver function tests (LFTs) are ordered in large numbers in primary care, and the Birmingham and Lambeth Liver Evaluation Testing Strategies (BALLETS) study was set up to assess their usefulness in patients with no pre-existing or self-evident liver disease. All patients were tested for chronic viral hepatitis thereby providing an opportunity to compare various strategies for detection of this serious treatable disease. Methods This study uses data from the BALLETS cohort to compare various testing strategies for viral hepatitis in patients who had received an abnormal LFT result. The aim was to inform a strategy for identification of patients with chronic viral hepatitis. We used a cost-minimisation analysis to define a base case and then calculated the incremental cost per case detected to inform a strategy that could guide testing for chronic viral hepatitis. Results Of the 1,236 study patients with an abnormal LFT, 13 had chronic viral hepatitis (nine hepatitis B and four hepatitis C). The strategy advocated by the current guidelines (repeating the LFT with a view to testing for specific disease if it remained abnormal) was less efficient (more expensive per case detected) than a simple policy of testing all patients for viral hepatitis without repeating LFTs. A more selective strategy of viral testing all patients for viral hepatitis if they were born in countries where viral hepatitis was prevalent provided high efficiency with little loss of sensitivity. A notably high alanine aminotransferase (ALT) level (greater than twice the upper limit of normal) on the initial ALT test had high predictive value, but was insensitive, missing half the cases of viral infection. Conclusions Based on this analysis and on widely accepted clinical principles, a "fast and frugal" heuristic was produced to guide general practitioners with respect to diagnosing cases of viral hepatitis in asymptomatic patients with abnormal LFTs. It recommends testing all patients where a clear clinical indication of infection is present (e.g. evidence of intravenous drug use), followed by testing all patients who originated from countries where viral hepatitis is prevalent, and finally testing those who have a notably raised ALT level (more than twice the upper limit of normal). Patients not picked up by this efficient algorithm had a risk of chronic viral hepatitis that is lower than the general population

Where Will the Next Generation of Stroke Treatments Come From?

Remarkable progress has occurred over the last two decades in stroke interventions. Many have been developed on the basis of their efficacy in other disorders. This "inheritance" approach should continue, but two areas where completely novel therapeutic targets might emerge are the stimulation of neuroplasticity and unraveling the genetic code of stroke heterogeneity (Table 2). For the former, the next steps are to identify small-molecule, nontoxic compounds that most effectively enhance plasticity in animal models, and then subject them to clinical trial in humans. For the latter, more and larger-scale cooperative GWASs in carefully phenotyped stroke populations are required to better understand the polygenic nature of cerebrovascular disease. Then, the physiological relevance of genetic abnormalities can be determined in in vitro and in vivo systems before candidate compounds are developed

Recruitment to trials of late thrombolysis: Lessons from the EXTEND study

To increase the percentage of acute stroke patients benefiting from thrombolysis, the utility of expanding the time window of treatment beyond 4.5 hours after stroke onset needs to be investigated. We aimed to identify the target population and the challenges of recruitment of patients for the time window beyond 4.5 hours. Extending the time for Thrombolysis in Emergency Neurological Deficits (EXTEND), a multicentre randomised controlled trial testing the efficacy of thrombolytic therapy in patients with clinically significant ischaemic penumbra between 4.5 to 9 hours after stroke onset, was used as a model to evaluate inclusion and exclusion criteria for late thrombolysis trials. Data from all stroke patients admitted to Austin Health over a 1 year period were retrospectively analysed. Case notes were examined to determine potential trial eligibility. Of 556 patients assessed, 95 (17%) presented during the EXTEND time window. Sixty-seven of these (70.5%) were wake-up strokes (WUS) and 28 (29.5%) arrived between 4.5 and 9 hours after symptoms onset. At least one exclusion criterion was found for 78 (82%) of them. Hence, 17 (3%) patients arrived within an appropriate time frame for the study without any exclusion criteria. Most of these (13) arrived outside routine MRI hours. The number of patients recruited would have increased more than three-fold if imaging had been available 24 hours, 7 days a week. A significant proportion (17%) of ischaemic stroke patients presented between 4.5 and 9 hours after stroke onset. The majority of these were WUS. The major challenge identified for patient recruitment was imaging availability