Additional outcomes and subgroup analyses of NXY-059 for acute ischemic stroke in the SAINT I trial

<p><b>Background and Purpose:</b> NXY-059 is a free radical-trapping neuroprotectant demonstrated to reduce disability from ischemic stroke. We conducted analyses on additional end points and sensitivity analyses to confirm our findings.</p> <p><b>Methods:</b> We randomized 1722 patients with acute ischemic stroke to a 72-hour infusion of placebo or intravenous NXY-059 within 6 hours of stroke onset. The primary outcome was disability at 90 days, as measured by the modified Rankin Scale (mRS), a 6-point scale ranging from 0 (no residual symptoms) to 5 (bed-bound, requiring constant care). Additional and exploratory analyses included mRS at 7 and 30 days; subgroup interactions with final mRS; assessments of activities of daily living by Barthel index; and National Institutes of Health Stroke Scale (NIHSS) neurological scores at 7 and 90 days.</p> <p><b>Results:</b> NXY-059 significantly improved the distribution of the mRS disability score compared with placebo at 7, 30, and 90 days (Cochran-Mantel-Haenszel test P=0.002, 0.004, 0.038, respectively; 90-day common odds ratio 1.20; 95% CI, 1.01 to 1.42). The benefit was not attributable to any specific baseline characteristic, stratification variable or subgroup interaction. Neurological scores were improved at 7 days (odds ratio [OR], 1.46; 95% CI, 1.13, 1.89; P=0.003) and the Barthel index was improved at 7 and 30 days (OR, 1.55; 95% CI, 1.22, 1.98; P<0.0001; OR, 1.27; 95% CI, 1.01, 1.59; P=0.02).</p> <p><b>Conclusions:</b> NXY-059 within 6 hours of acute ischemic stroke significantly reduced disability. Benefit on neurological scores and activities of daily living was detectable early but not significant at 90 days; however, our trial was underpowered to measure effects on the neurological examination. The benefit on disability is not confounded by interactions and is supported by other outcome measures.</p&gt

NXY-059 for the treatment of acute stroke: pooled analysis of the SAINT I and II trials

<p><b>Background and Purpose:</b> In animal models of acute ischemic stroke (AIS), the free radical-trapping agent NXY-059 showed promise as a neuroprotectant. SAINT I and II were randomized, placebo-controlled, double-blind trials to investigate the efficacy of NXY-059 in patients with AIS.</p> <p><b>Methods:</b> Patients with AIS received an infusion of intravenous NXY-059 or placebo within 6 hours from the onset of stroke symptoms. A pooled individual patient analysis was prespecified to assess the overall efficacy and to examine subgroups. The primary end point was the distribution of disability scores measured on the modified Rankin scale (mRS) at 90 days. Neurologic and activities of daily living scores were investigated as secondary end points. We also evaluated whether treatment with NXY-059 would reduce alteplase-related intracranial hemorrhages. Finally, we evaluated possible predictors of good or poor outcome.</p> <p><b>Results:</b> An intent-to-treat efficacy analysis was based on 5028 patients. Baseline parameters and prognostic factors were well balanced between treatment groups. The distribution of scores on the mRS was not different in the group treated with NXY-059 (n = 2438) compared with the placebo group (n = 2456): odds ratio for limiting disability = 1.02; 95% CI, 0.92 to 1.13 (P = 0.682, Cochran-Mantel-Haenszel test). Comparisons at each level of the mRS confirmed an absence of benefit. There was no evidence of efficacy in prespecified subgroups or from the secondary outcome analyses. Mortality was equal in the 2 groups (16.7% vs 16.5%), and adverse event rates were similar. Among patients treated with alteplase, there was no decrease in rates of symptomatic or asymptomatic hemorrhage associated with NXY-059 treatment versus placebo. Subgroup analyses identified National Institutes of Health Stroke Scale score, age, markers of inflammation, blood glucose, and right-sided infarct as predictors of poor outcome.</p> <p><b>Conclusions:</b> NXY-059 is ineffective for treatment of AIS within 6 hours of symptom onset. This is also true for subgroups and the prevention of alteplase-associated hemorrhage.</p&gt

Influence of red alder competition on cambial phenology and latewood formation in Douglas-fir

To better understand the influence of competition on wood formation and wood quality in Douglas-fir (Pseudotsuga menziesii [Mirb.] Franco), patterns of cambial growth and latewood production were examined for one growing season in 15-year-old plantations with similar densities but differing Douglas-fir/red alder (Alnus rubra Bong.) ratios. The treatments consisted of plots having different proportions of Douglas-fir vs. red alder, different red alder planting dates, and one of two total planting densities. Cambial growth was tracked using the pinning method. Cambial activity in most trees began between May 12 and May 23, and ended between August 27 and September 10. Mean date of transition to latewood was July 6. In the treatment with the highest mean red alder basal area, Douglas-fir trees began radial growth later and ended earlier in the year than those in pure Douglas-fir stands. There was no evident effect of competition from red alder on the duration of cambial activity in treatments with intermediate to low red alder basal areas. In all treatments, the duration of radial growth was shorter in smaller-diameter trees. Early transition to latewood production was also associated with higher red alder basal area. Percent latewood was unaffected by treatment, but it was dependent on the date of a treeʼs transition to latewood production.Keywords: latewood, cambial growth, red alder, Douglas-fir, phenolog

Effect of growth ring orientation and placement of earlywood and latewood on moe and mor of very-small clear Douglas-fir beams

ASTM standard sizes for bending tests (either 50 × 50 mm or 25 × 25 mm in cross-section) are not always suitable for research purposes that characterize smaller sections of wood. Moreover, the ASTM standards specify loading the sample on the longitudinal-tangential surface. If specimens are small enough, then the effects of both growth-ring orientation and whether earlywood or latewood is on the upper and lower surfaces could affect values of modulus of elasticity (MOE) and modulus of rupture (MOR). The objectives of this study were to assess the effects of growth-ring orientation and latewood/earlywood location on bending properties of Douglas-fir specimens (10 × 10 × 150 mm). MOE did not differ with ring orientation, and MOR was about 5% higher when specimens were loaded on the radial rather than the tangential surface (MOE-LT vs. MOE-LR, respectively). The choice of growth-ring orientation did not affect the relative ranking of trees with respect to MOR or MOE. As expected, the variation of MOR and MOE was lower if the loads were applied to the longitudinal-radial surface than the longitudinal-tangential surface. Thus, rather than following the ASTM standard, within-tree variation measured on very small bending specimens can be minimized if loads are applied to the longitudinal-radial surface. When specimens were loaded on the longitudinal tangential surfaces, there was an effect on both MOE-LR and MOR-LR of whether the top and/or bottom surfaces were earlywood or latewood. The wood type had a large effect on both MOE-LR and MOR-LR when it was the compression surface rather than the tension surface. This result suggests that variance in MOE and MOR measurements in very small specimens can be reduced by tracking whether the top and bottom surfaces are earlywood or latewood.Keywords: orthotopic material, Douglas-fir, growth-ring orientation, MOE, size effect, MOR, bending, small bending specimen

Separatrix splitting at a Hamiltonian 02iω0^2 i\omega bifurcation

We discuss the splitting of a separatrix in a generic unfolding of a degenerate equilibrium in a Hamiltonian system with two degrees of freedom. We assume that the unperturbed fixed point has two purely imaginary eigenvalues and a double zero one. It is well known that an one-parametric unfolding of the corresponding Hamiltonian can be described by an integrable normal form. The normal form has a normally elliptic invariant manifold of dimension two. On this manifold, the truncated normal form has a separatrix loop. This loop shrinks to a point when the unfolding parameter vanishes. Unlike the normal form, in the original system the stable and unstable trajectories of the equilibrium do not coincide in general. The splitting of this loop is exponentially small compared to the small parameter. This phenomenon implies non-existence of single-round homoclinic orbits and divergence of series in the normal form theory. We derive an asymptotic expression for the separatrix splitting. We also discuss relations with behaviour of analytic continuation of the system in a complex neighbourhood of the equilibrium

Translational Stroke Research Using a Rabbit Embolic Stroke Model: A Correlative Analysis Hypothesis for Novel Therapy Development

Alteplase (tissue plasminogen activator, tPA) is currently the only FDA-approved treatment that can be given to acute ischemic stroke (AIS) patients if patients present within 3 h of an ischemic stroke. After 14 years of alteplase clinical research, evidence now suggests that the therapeutic treatment window can be expanded 4.5 h, but this is not formally approved by the FDA. Even though there remains a significant risk of intracerebral hemorrhage associated with alteplase administration, there is an increased chance of favorable outcome with tPA treatment. Over the last 30 years, the use of preclinical models has assisted with the search for new effective treatments for stroke, but there has been difficulty with the translation of efficacy from animals to humans. Current research focuses on the development of new and potentially useful thrombolytics, neuroprotective agents, and devices which are also being tested for efficacy in preclinical and clinical trials. One model in particular, the rabbit small clot embolic stroke model (RSCEM) which was developed to test tPA for efficacy, remains the only preclinical model used to gain FDA approval of a therapeutic for stroke. Correlative analyses from existing preclinical translational studies and clinical trials indicate that there is a therapeutic window ratio (ARR) of 2.43-3 between the RSCEM and AIS patients. In conclusion, the RSCEM can be used as an effective translational tool to gauge the clinical potential of new treatments

Granulocyte-colony stimulating factor for stroke treatment: mechanisms of action and efficacy in preclinical studies

G-CSF is widely employed for the treatment of chemotherapy-induced neutropenia. Recently, neuroprotective effects of G-CSF in animal stroke models were discovered including infarct size reduction and enhancement of functional recovery. The underlying mechanisms of action of G-CSF in ischemia appear to be a direct anti-apoptotic activity in neurons and a neurogenesis inducing capacity. Additional effects may be based on the stimulation of new blood-vessel formation, the stimulation of immunocompetence and -modulation as well as on bone marrow mobilization. In addition to a discussion of these mechanisms, we will review the available preclinical studies and analyze their impact on the overall efficacy of G-CSF in experimental stroke

Animal models of focal brain ischemia

Stroke is a leading cause of disability and death in many countries. Understanding the pathophysiology of ischemic injury and developing therapies is an important endeavor that requires much additional research. Animal stroke models provide an important mechanism for these activities. A large number of stroke models have been developed and are currently used in laboratories around the world. These models are overviewed as are approaches for measuring infarct size and functional outcome

Antihypertensives for combating dementia? A perspective on candidate molecular mechanisms and population-based prevention

Age-related increases in prevalent dementia over the next 30–40 years risk collapsing medical resources or radically altering the way we treat patients. Better prevention of dementia therefore needs to be one of our highest medical priorities. We propose a perspective on the pathological basis of dementia based on a cerebrovascular-Alzheimer disease spectrum that provides a more powerful explanatory framework when considering the impact of possible public health interventions. With this in mind, a synthesis of evidence from basic, clinical and epidemiological studies indeed suggests that the enhanced treatment of hypertension could be effective for the primary prevention of dementia of either Alzheimer or vascular etiology. In particular, we focus on candidate preventative mechanisms, including reduced cerebrovascular disease, disruption of hypoxia-dependent amyloidogenesis and the potential neuroprotective properties of calcium channel blockers. Following the successful translation of large, long-term and resource-intense trials in cardiology into improved vascular health outcomes in many countries, new multinational prevention trials with dementia-related primary outcomes are now urgently required