Blood Pressure Variability and Outcome in Acute Ischemic and Hemorrhagic Stroke: A Post-Hoc Analysis of the HeadPoST Study

The Head Positioning in Acute Stroke Trial (HeadPoST) is a pragmatic, international, cluster crossover randomized trial of 11,093 patients with acute stroke assigned to a lying-flat (0o) or sitting-up (head elevated ≥30o) position. This post-hoc analysis aimed to determine the association between BPV and outcomes for patients from a wide range of international clinical settings and how the association was modified by randomized head position. BPV was defined according to standard criteria with the key parameter considered the coefficient of variation (CV) of systolic BP (SBP) over 24 hours. Outcome was ordinal 90-day modified Rankin Scale (mRS) score. The association was analyzed by ordinal, logistic regression, hierarchical, mixed models with fixed intervention (lying-flat vs. sitting-up), and fixed period, random cluster, and random cluster-period, effects. 9,156 (8,324 AIS and 817 ICH; mean age 68.1 years; 39.2% women) were included in the analysis. CV of SBP had a significant linear association with unfavorable shift of mRS at 90 days (adjusted odds ratio [OR] 1.06, 95% confidence interval [CI] 1.02-1.11; P=0.01). There was no heterogeneity of the association by randomized head positioning. In addition, CV of diastolic BP (DBP) (1.08, 1.03-1.12; P=0.001) over 24 hours post stroke, was significantly associated with 3-month poor outcome. The association was more apparent in sitting-up position (1.12, 1.06-1.19) compared with lying-flat position (1.03, 0.98-1.09) (P interaction = 0.005). BPV was associated with adverse stroke outcome, the magnitude of the association was greater with sitting-up head positioning in terms of DBP variability

Illuminating dark networks: A social network analysis of an Australian drug trafficking syndicate

A small but growing number of analysts of criminal activity have used social network analysis (SNA) to characterise criminal organisations and produce valuable insights into the operation of illicit markets. The successful conduct of SNA requires data that informs about links or relationships between pairs of individuals within the group. To date analyses have been undertaken with data extracted from offender databases, transcripts of physical or electronic surveillance, written summaries of police interrogations, and transcripts of court proceedings. These data can be expensive, time-consuming and complicated to access and analyse. This paper presents findings from a study which aimed to determine the feasibility and utility of conducting SNA using a novel source of data: judges' sentencing comments. Free of charge, publically accessible without the need for ethics clearance, available at the completion of sentencing and summary in nature, this data offers a more accessible and less expensive alternative to the usual forms of data used. The judges' sentencing comments were drawn from a series of Australian court cases involving members of a criminal group involved in the manufacture and distribution of methamphetamine during the 1990s. Feasibility is evaluated in terms of the ability to produce a network map and generate the types of quantitative measures produced in studies using alternate data sources. The utility of the findings is judged in relation to the insights they provide into the structure and operation of criminal groups in Australia's methamphetamine market. © 2011 Springer Science+Business Media B.V

The role of off-licence outlets in binge drinking: A survey of drinking practices last Saturday night among young adults in Australia

Introduction and Aims.: To examine where young adults purchase their alcohol on Saturday nights and how this relates to binge drinking. Design and Methods.: This study used an online survey of a non-probability-based quota sample of 2013 Australians aged 18-30 years who had consumed alcohol in the past year. Participants who purchased alcohol from off-licence outlets the Saturday night before answering the survey were compared with participants who purchased only from on-licence outlets with regard to how much they drank (binge drinking was defined as five or more drinks), how much they spent on alcohol, where they drank, their risk of an alcohol use disorder and other demographic factors. Results.: Of participants who drank the previous Saturday night (n=1106), 46% bought alcohol only from off-licence outlets (e.g. bottle shops), 19% bought from both off-licence and on-licence outlets (e.g. clubs, bars), and 23% bought only from on-licence outlets. Participants who bought alcohol from off-licence outlets were equally likely to binge-drink as participants who bought only from on-licence outlets (B=-0.02, P=0.912), but they drank more cheaply and usually drank at home. Participants who bought alcohol from both off-licence and on-licence outlets were more likely to binge-drink (B=1.39, P<0.001), drank both at home and in public places, were at higher risk of an alcohol use disorder and were more likely to have used stimulants the previous Saturday night. Discussion and Conclusions.: Off-licence outlets were a major source of alcohol in this sample of young Australian adults, many of whom binge-drank in private homes. © 2013 Australasian Professional Society on Alcohol and other Drugs

Typologies of alcohol consumption on a saturday night among young adults

Background: Alcohol policies and interventions seek to curtail risky single-occasion drinking (RSOD) and the negative health and public order consequences. Yet RSOD behaviors are not easily defined since people can drink excessively at a variety of locations and drink a range of products. The current study examines the presence and correlates of different typologies or classes of drinking behavior on 1 Saturday night to facilitate a nuanced policy response to harmful drinking. Methods: Data from 1,883 adults aged 18 to 30 were collected using an online survey. Latent class analysis was used to categorize respondents into mutually exclusive classes based on the quantity, type, and unit cost of alcohol consumed plus location of alcohol consumption on the past Saturday night. Significant correlates and predictors of latent class membership were then identified using regression analysis. Results: Seven distinct classes were identified that represent qualitatively distinct profiles of Saturday night drinking behavior among young adults. Multivariate analyses indicated that alcohol risk (measured using the Alcohol Use Disorder Identification Test), age, and recent (past 12 months) stimulant use were strong predictors of heavier drinking. The heaviest drinkers also consumed some of the cheapest alcohol and consumed alcohol at multiple locations over the course of the night. Conclusions: Given the large degree of heterogeneity among drinking behaviors, policy makers need to be cognizant that alcohol type and drinking location-specific policies may be less effective in targeting some groups of the population. © 2014 by the Research Society on Alcoholism

Recreational drug use and binge drinking: Stimulant but not cannabis intoxication is associated with excessive alcohol consumption

Abstract: Introduction and Aims: Binge drinking is elevated among recreational drug users, but it is not clear whether this elevation is related to intoxication with recreational drugs. We examined whether stimulant intoxication and cannabis intoxication were associated with binge drinking among young adults. Design and Methods: An online survey of 18- to 30-year-old Australians who had drunk alcohol in the past year (n=1994) were quota sampled for: (i) past year ecstasy use (n=497); (ii) past year cannabis (but not ecstasy) use (n=688); and (iii) no ecstasy or cannabis use in the past year (alcohol-only group, n=809). Binge drinking last Saturday night (five or more drinks) was compared for participants who took stimulants (ecstasy, cocaine, amphetamine or methamphetamine) or cannabis last Saturday night. Results: Ecstasy users who were intoxicated with stimulants (n=91) were more likely to binge drink than ecstasy users who were not (n=406) (89% vs. 67%), after adjusting for demographics, poly-drug use and intoxication with cannabis and energy drinks (adjusted odds ratio 3.1, P=0.007), drinking a median of 20 drinks (cf. 10 drinks among other ecstasy users). Cannabis intoxication was not associated with binge drinking among cannabis users (57% vs. 55%) or ecstasy users (73% vs. 71%). Binge drinking was more common in all of these groups than in the alcohol-only group (34%). Discussion and Conclusions: Stimulant intoxication, but not cannabis intoxication, is associated with binge drinking among young adults, compounding already high rates of binge drinking among people who use these drugs. © 2014 Australasian Professional Society on Alcohol and other Drugs

Examining supply changes in Australia's cocaine market

Introduction and Aims. Media attention to cocaine use and supply has increased following some of the largest cocaine seizures in Australia's history. Whether there has been an expansion in supply remains unclear. This paper examines the evidence behind assertions of increased supply in Australia and the scale and nature of any apparent increase, using proxy indicators of cocaine importation, distribution and use. Design and Methods. Eight proxies of cocaine importation, distribution and use were adopted, including amount of importation, mode of importation and supply flows to Australia. Each proxy indicator was sourced using publicly available and Australia-wide data, including information on the total weight of border seizures, mode of detection and country of embarkation of individual seizures. Data permitting, trends were examined for up to a 12year period (1997-1998 to 2009-2010). Results. Since 2006-2007 there was evidence of increased cocaine importation, albeit less than between 1998-1999 and 2001-2002. There were further signs that the 2006-2007 expansion coincided with a diversification of trafficking routes to and through Australia (beyond the traditional site of entry-Sydney) and shifts in the geographic distribution of use. Discussion and Conclusions. The congruity between indicators suggests that there has been a recent expansion in cocaine supply to and distribution within Australia, but that the more notable shift has concerned the nature of supply, with an apparent growth in importation and distribution beyond New South Wales. The diversification of cocaine supply routes may increase risks of market entrenchment and organised crime throughout Australia. © 2011 Australasian Professional Society on Alcohol and other Drugs

Kaplan-Meier plot of survival following admission for AMI, Scotland 2001–2003, by ethnic group and sex

<p><b>Copyright information:</b></p><p>Taken from "Record linked retrospective cohort study of 4.6 million people exploring ethnic variations in disease: myocardial infarction in South Asians"</p><p>http://www.biomedcentral.com/1471-2458/7/142</p><p>BMC Public Health 2007;7():142-142.</p><p>Published online 5 Jul 2007</p><p>PMCID:PMC1965474.</p><p></p

Low- Versus Standard-Dose Alteplase in Patients on Prior Antiplatelet Therapy: The ENCHANTED Trial (Enhanced Control of Hypertension and Thrombolysis Stroke Study)

BACKGROUND AND PURPOSE: Many patients receiving thrombolysis for acute ischemic stroke are on prior antiplatelet therapy (APT), which may increase symptomatic intracerebral hemorrhage risk. In a prespecified subgroup analysis, we report comparative effects of different doses of intravenous alteplase according to prior APT use among participants of the international multicenter ENCHANTED study (Enhanced Control of Hypertension and Thrombolysis Stroke Study). METHODS: Among 3285 alteplase-treated patients (mean age, 66.6 years; 38% women) randomly assigned to low-dose (0.6 mg/kg) or standard-dose (0.9 mg/kg) intravenous alteplase within 4.5 hours of symptom onset, 752 (22.9%) reported prior APT use. Primary outcome at 90 days was the combined end point of death or disability (modified Rankin Scale [mRS] scores, 2-6). Other outcomes included mRS scores 3 to 6, ordinal mRS shift, and symptomatic intracerebral hemorrhage by various standard criteria. RESULTS: There were no significant differences in outcome between patients with and without prior APT after adjustment for baseline characteristics and management factors during the first week; defined by mRS scores 2 to 6 (adjusted odds ratio [OR], 1.01; 95% confidence interval [CI], 0.81-1.26; P=0.953), 3 to 6 (OR, 0.95; 95% CI, 0.75-1.20; P=0.662), or ordinal mRS shift (OR, 1.03; 95% CI, 0.87-1.21; P=0.770). Alteplase-treated patients on prior APT had higher symptomatic intracerebral hemorrhage (OR, 1.82; 95% CI, 1.00-3.30; P=0.051) according to the safe implementation of thrombolysis in stroke-monitoring study definition. Although not significant (P-trend, 0.053), low-dose alteplase tended to have better outcomes than standard-dose alteplase in those on prior APT compared with those not using APT (mRS scores of 2-6; OR, 0.84; 95% CI, 0.62-1.12 versus OR, 1.16; 95% CI, 0.99-1.36). CONCLUSIONS: Low-dose alteplase may improve outcomes in thrombolysis-treated acute ischemic stroke patients on prior APT, but this requires further evaluation in a randomized controlled trial. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01422616

Intensive blood pressure reduction with intravenous thrombolysis therapy for acute ischaemic stroke (ENCHANTED): an international, randomised, open-label, blinded-endpoint, phase 3 trial

BACKGROUND: Systolic blood pressure of more than 185 mm Hg is a contraindication to thrombolytic treatment with intravenous alteplase in patients with acute ischaemic stroke, but the target systolic blood pressure for optimal outcome is uncertain. We assessed intensive blood pressure lowering compared with guideline-recommended blood pressure lowering in patients treated with alteplase for acute ischaemic stroke. METHODS: We did an international, partial-factorial, open-label, blinded-endpoint trial of thrombolysis-eligible patients (age ≥18 years) with acute ischaemic stroke and systolic blood pressure 150 mm Hg or more, who were screened at 110 sites in 15 countries. Eligible patients were randomly assigned (1:1, by means of a central, web-based program) within 6 h of stroke onset to receive intensive (target systolic blood pressure 130-140 mm Hg within 1 h) or guideline (target systolic blood pressure <180 mm Hg) blood pressure lowering treatment over 72 h. The primary outcome was functional status at 90 days measured by shift in modified Rankin scale scores, analysed with unadjusted ordinal logistic regression. The key safety outcome was any intracranial haemorrhage. Primary and safety outcome assessments were done in a blinded manner. Analyses were done on intention-to-treat basis. This trial is registered with ClinicalTrials.gov, number NCT01422616. FINDINGS: Between March 3, 2012, and April 30, 2018, 2227 patients were randomly allocated to treatment groups. After exclusion of 31 patients because of missing consent or mistaken or duplicate randomisation, 2196 alteplase-eligible patients with acute ischaemic stroke were included: 1081 in the intensive group and 1115 in the guideline group, with 1466 (67·4%) administered a standard dose among the 2175 actually given intravenous alteplase. Median time from stroke onset to randomisation was 3·3 h (IQR 2·6-4·1). Mean systolic blood pressure over 24 h was 144·3 mm Hg (SD 10·2) in the intensive group and 149·8 mm Hg (12·0) in the guideline group (p<0·0001). Primary outcome data were available for 1072 patients in the intensive group and 1108 in the guideline group. Functional status (mRS score distribution) at 90 days did not differ between groups (unadjusted odds ratio [OR] 1·01, 95% CI 0·87-1·17, p=0·8702). Fewer patients in the intensive group (160 [14·8%] of 1081) than in the guideline group (209 [18·7%] of 1115) had any intracranial haemorrhage (OR 0·75, 0·60-0·94, p=0·0137). The number of patients with any serious adverse event did not differ significantly between the intensive group (210 [19·4%] of 1081) and the guideline group (245 [22·0%] of 1115; OR 0·86, 0·70-1·05, p=0·1412). There was no evidence of an interaction of intensive blood pressure lowering with dose (low vs standard) of alteplase with regard to the primary outcome. INTERPRETATION: Although intensive blood pressure lowering is safe, the observed reduction in intracranial haemorrhage did not lead to improved clinical outcome compared with guideline treatment. These results might not support a major shift towards this treatment being applied in those receiving alteplase for mild-to-moderate acute ischaemic stroke. Further research is required to define the underlying mechanisms of benefit and harm resulting from early intensive blood pressure lowering in this patient group