Anakinra in cerebral haemorrhage to target secondary injury resulting from neuroinflammation (ACTION): Study protocol of a phase II randomised clinical trial.

BACKGROUND: Inflammation plays a vital role in the development of secondary brain injury after spontaneous intracerebral haemorrhage (ICH). Interleukin-1 beta is an early pro-inflammatory cytokine and a potential therapeutic target. AIM: To determine the effect of treatment with recombinant human interleukin-1 receptor antagonist anakinra on perihematomal oedema (PHO) formation in patients with spontaneous ICH compared to standard medical management, and investigate whether this effect is dose-dependent. METHODS: ACTION is a phase-II, prospective, randomised, three-armed (1:1:1) trial with open-label treatment and blinded end-point assessment (PROBE) at three hospitals in The Netherlands. We will include 75 patients with a supratentorial spontaneous ICH admitted within 8 h after symptom onset. Participants will receive anakinra in a high dose (loading dose 500 mg intravenously, followed by infusion with 2 mg/kg/h over 72 h; n = 25) or in a low dose (loading dose 100 mg subcutaneously, followed by 100 mg subcutaneous twice daily for 72 h; n = 25), plus standard care. The control group (n = 25) will receive standard medical management. OUTCOMES: Primary outcome is PHO, measured as oedema extension distance on MRI at day 7 ± 1. Secondary outcomes include the safety profile of anakinra, the effect of anakinra on serum inflammation markers, MRI measures of blood brain barrier integrity, and functional outcome at 90 ± 7 days. DISCUSSION: The ACTION trial will provide insight into whether targeting interleukin-1 beta in the early time window after ICH onset could ameliorate secondary brain injury. This may contribute to the development of new treatment options to improve clinical outcome after ICH.

Changes in intra- and extracranial carotid plaque calcification: a 2-year follow-up study.

Extra- and intracranial carotid plaque calcification might have plaque-stabilizing effects, yet information on changes in plaque calcification remains scarce. We evaluated changes in carotid plaque calcification over 2 years follow-up in patients with symptomatic carotid artery disease. This study is based on the PARISK-study, a multicenter cohort study, with TIA/minor stroke patients with ipsilateral mild-to-moderate carotid artery stenosis (< 70%). We included 79 patients (25% female, mean age 66 years) who underwent CTA imaging with 2 year interval. We assessed the volume of extra- and intracranial carotid artery calcification (ECAC and ICAC) and calculated the difference between baseline and follow-up ECAC and ICAC volume. We performed multivariable regression analyses to investigate the association between change of ECAC or ICAC with cardiovascular determinants. ECAC. We found increase (46.2%) and decrease (34%) in ECAC volume during 2 year follow-up, both significantly correlation with baseline ECAC volume (OR = 0.72, 95% CI 0.58-0.90 respectively OR = 2.24, 95% CI 1.60-3.13).We found significant correlation for change in ECAC volume with diabetes (ß = 0.46, 95% CI 0.03-0.89) and baseline ECAC volume (ß = 0.81, 95% CI 0.73-0.88). ICAC. We found increase (45.0%) and decrease (25.0%) in ICAC volume. The ICAC decrease was significantly correlated with baseline ICAC volume (OR = 2.17, 95% CI 1.48-3.16), age (OR = 2.00, 95% CI 1.19-3.38) and use of antihypertensive drugs (OR = 3.79, 95% CI 1.20-11.96]).The overall change of ICAC volume was also significantly correlated with diabetes (ß = 0.92, 95% CI 1.59-7.02), use of oral hypoglycemic drugs (ß = 0.86, 95% CI 0.12-1.59) and baseline ICAC volume (ß = 0.71, 95% CI 0.55-0.87). We provide novel insights into the dynamics of carotid plaque calcification in symptomatic stroke patients.

'Give me something meaningful': GPs perspectives on how to improve an audit and feedback report provided by health insurers - an exploratory qualitative study.

BACKGROUND: Audit and feedback (A&F) is a valuable quality improvement strategy, which can contribute to de-implementation of low-value care. In the Netherlands, all health insurers collaboratively provide A&F to general practitioners (GPs), the 'Primary Care Practice Report' (PCPR). Unfortunately, the use of this report by GPs is limited. This study examined the thoughts of GPs on the usability of the PCPR and GPs recommendations for improving the PCPR. METHOD: We used an interpretative qualitative design, with think-aloud tasks to uncover thoughts of GPs on the usability of the PCPR and semistructured interview questions to ask GPs' recommendations for improvement of the PCPR. Interviews were audiorecorded and transcribed ad verbatim. Data were analysed using thematic content analysis. RESULTS: We identified two main themes: 'poor usability of the PCPR', and 'minimal motivation to change based on the PCPR'. The GPs found the usability of the PCPR poor due to the feedback not being clinically meaningful, the data not being recent, individual and reliable, the performance comparators offer insufficient guidance to assess clinical performance, the results are not discussed with peers and the definitions and visuals are unclear. The GPs recommended improving these issues. The GPs motivation to change based on the PCPR was minimal. CONCLUSIONS: The GPs evaluated the PCPR as poorly usable and were minimally motivated to change. The PCPR seems developed from the perspective of the reports' commissioners, health insurers, and does not meet known criteria for effective A&F design and user-centred design. Importantly, the GPs did state that well-designed feedback could contribute to their motivation to improve clinical performance.Furthermore, the GPs stated that they receive a multitude of A&F reports, which they hardly use. Thus, we see a need for policy makers to invest in less, but more usable A&F reports.

MRI Vessel Wall Imaging after Intra-Arterial Treatment for Acute Ischemic Stroke.

BACKGROUND AND PURPOSE: Vessel wall imaging is increasingly performed in the diagnostic work-up of patients with ischemic stroke. The aim of this study was to compare vessel wall enhancement after intra-arterial thrombosuction with that in patients not treated with thrombosuction. MATERIALS AND METHODS: From 2009 to 2017, forty-nine patients with an ischemic stroke underwent 7T MR imaging within 3 months after symptom onset as part of a prospective intracranial vessel wall imaging study. Fourteen of these patients underwent intra-arterial treatment using thrombosuction (intra-arterial treatment group). In the intra-arterial treatment group, vessel walls were evaluated for major vessel wall changes. All patients underwent pre- and postcontrast vessel wall imaging to assess enhancing foci of the vessel wall using coregistered subtraction images. A Wilcoxon signed rank test was performed to test for differences. RESULTS: In the intra-arterial treatment group, 11 of 14 patients (79%) showed vessel wall enhancement compared with 17 of 35 patients without intra-arterial treatment (49%). In the intra-arterial treatment group, more enhancing foci were detected on the ipsilateral side (n = 18.5) compared with the contralateral side (n = 3, P = .005). Enhancement was more often concentric on the ipsilateral side (n = 8) compared with contralateral side (n = 0, P = .01). No differences were found in the group without intra-arterial treatment between the number and configuration of ipsilateral and contralateral enhancing foci. CONCLUSIONS: Patients with intra-arterial treatment by means of thrombosuction showed more (concentric) enhancing foci of the vessel wall ipsilateral compared with contralateral to the treated artery than the patients without intra-arterial treatment, suggesting reactive changes of the vessel wall. This finding should be taken into account when assessing vessel wall MR images in patients with stroke.

Intracranial Atherosclerotic Burden on 7T MRI Is Associated with Markers of Extracranial Atherosclerosis: The SMART-MR Study.

BACKGROUND AND PURPOSE: Intracranial atherosclerosis, a major risk factor for ischemic stroke, is thought to have different atherogenic mechanisms than extracranial atherosclerosis. Studies investigating their relationship in vivo are sparse and report inconsistent results. We studied the relationship between intracranial atherosclerosis and extracranial atherosclerosis in a cohort of patients with a history of vascular disease. MATERIALS AND METHODS: Within the Second Manifestations of ARTerial disease-Magnetic Resonance (SMART) study, cross-sectional analyses were performed in 130 patients (mean age, 68 ± 9 years) with a history of vascular disease and with assessable 7T intracranial vessel wall MR imaging data. Intracranial atherosclerosis burden was defined as the number of intracranial vessel wall lesions in the circle of Willis and its major branches. Age- and sex-adjusted unstandardized regression coefficients (b-value) were calculated with intracranial atherosclerosis burden as the dependent variable and extracranial atherosclerosis markers as independent variables. RESULTS: Ninety-six percent of patients had ≥1 vessel wall lesion, with a mean intracranial atherosclerosis burden of 8.5 ± 5.7 lesions. Significant associations were observed between higher intracranial atherosclerosis burden and carotid intima-media thickness (b = 0.53 lesions per +0.1 mm; 95% CI, 0.1-1.0 lesions), 50%-100% carotid stenosis versus no stenosis (b = 6.6 lesions; 95% CI, 2.3-10.9 lesions), ankle-brachial index ≤ 0.9 versus >0.9 (b = 4.9 lesions; 95% CI, 1.7-8.0 lesions), and estimated glomerular filtration rate (b = -0.77 lesions per +10 mL/min; 95% CI, -1.50 to -0.03 lesions). No significant differences in intracranial atherosclerosis burden were found among different categories of vascular disease. CONCLUSIONS: Intracranial atherosclerosis was associated with various extracranial markers of atherosclerosis, not supporting a different etiology.

Biologic treatment sequences for plaque psoriasis: a cost-utility analysis based on 10 years of Dutch real-world evidence from BioCAPTURE.

BACKGROUND: Treatment with biologics may be indicated for patients with moderate-to-severe plaque psoriasis, but comparative evidence on cost-effectiveness is limited. Switching of biologics is common, but it is unclear what the effect is of differences in sequences of biologics. OBJECTIVES: To evaluate the cost-effectiveness of different biologic treatment sequences for psoriasis based on real-world evidence. PATIENTS AND METHODS: A sequence model was developed to evaluate the costs and health effects of three consecutive lines of biologic treatments [for example adalimumab-etanercept-ustekinumab (Ada-Eta-Ust) vs. Eta-Ust-Ada] over a 10-year time horizon in the Netherlands. The model was populated with data from the Dutch BioCAPTURE registry and scientific literature. Analyses were conducted of cost per quality-adjusted life year (QALY) and uncertainty was addressed by probabilistic as well as scenario analyses. RESULTS: Treatment of psoriasis with biologics for a 10-year period was estimated to be associated with a cost of €141 962 to €148 442 per patient depending on the treatment sequence used. Cumulative health effects ranged from 7·79 to 8·03 QALYs. Starting with Ada or Ust seems favourable concerning cost and utilities compared with strategies starting with Eta, although credible intervals were partly overlapping. CONCLUSIONS: The order in which biologics are used influences treatment cost-effectiveness, both in terms of costs and health effects. Initiation of a biologic treatment sequence for psoriasis might best be done with Ada or Ust; Eta seems less optimal from a health-economic perspective.

Quantitative Intracranial Atherosclerotic Plaque Characterization at 7T MRI: An Ex Vivo Study with Histologic Validation.

BACKGROUND AND PURPOSE: In recent years, several high-resolution vessel wall MR imaging techniques have emerged for the characterization of intracranial atherosclerotic vessel wall lesions in vivo. However, a thorough validation of MR imaging results of intracranial plaques with histopathology is still lacking. The aim of this study was to characterize atherosclerotic plaque components in a quantitative manner by obtaining the MR signal characteristics (T1, T2, T2*, and proton density) at 7T in ex vivo circle of Willis specimens and using histopathology for validation. MATERIALS AND METHODS: A multiparametric ultra-high-resolution quantitative MR imaging protocol was performed at 7T to identify the MR signal characteristics of different intracranial atherosclerotic plaque components, and using histopathology for validation. In total, 38 advanced plaques were matched between MR imaging and histology, and ROI analysis was performed on the identified tissue components. RESULTS: Mean T1, T2, and T2* relaxation times and proton density values were significantly different between different tissue components. The quantitative T1 map showed the most differences among individual tissue components of intracranial plaques with significant differences in T1 values between lipid accumulation (T1 = 838 ± 167 ms), fibrous tissue (T1 = 583 ± 161 ms), fibrous cap (T1 = 481 ± 98 ms), calcifications (T1 = 314 ± 39 ms), and the intracranial arterial vessel wall (T1 = 436 ± 122 ms). CONCLUSIONS: Different tissue components of advanced intracranial plaques have distinguishable imaging characteristics with ultra-high-resolution quantitative MR imaging at 7T. Based on this study, the most promising method for distinguishing intracranial plaque components is T1-weighted imaging.

[Cost-effectiveness in Dutch mental health care: future because of ROM?]. / Doelmatigheid in de ggz: toekomst dankzij ROM?

BACKGROUND: The document reporting Dutch mental health care negotiations for 2014-2017 calls for a cost decrease based on cost-effectiveness. Thanks to ROM, the Dutch mental health care seems well prepared for cost-effectiveness research. AIM: Evaluate how valid cost-effectiveness research should be established in mental health care and the role of rom therein. METHOD: Evaluation of requirements of cost-effectiveness research, trends, and a translation to Dutch mental health care. RESULTS: Valid cost-effectiveness research in mental health care requires the application of a societal perspective, a long time-horizon and an adequate evaluation of quality of life of patients. Healthcare consumption, outcome of care and characterisation of the patient population should be measured systematically and continuously. Currently, rom-data are not suitable to serve as a basis for cost-effectiveness research, although a proper basis is present. Further development of rom could lead to a situation in which mental health care is purchased on the basis of cost-effectiveness. However, cost-effectiveness will only really be improved if quality of care is rewarded, rather than rewarding activities that are not always related to outcome of care. CONCLUSION: Cost-effectiveness research in mental health care should focus on societal costs and benefits, quality of life and a long time-horizon. If developed further, rom has the potential to be a basis for cost-effectiveness research in the future.

Imaging the intracranial atherosclerotic vessel wall using 7T MRI: initial comparison with histopathology.

BACKGROUND AND PURPOSE: Several studies have attempted to characterize intracranial atherosclerotic plaques by using MR imaging sequences. However, dedicated validation of these sequences with histology has not yet been performed. The current study assessed the ability of ultra-high-resolution 7T MR imaging sequences with different image contrast weightings to image plaque components, by using histology as criterion standard. MATERIALS AND METHODS: Five specimens of the circle of Wills were imaged at 7T with 0.11 × 0.11 mm in-plane-resolution proton attenuation-, T1-, T2-, and T2*-weighted sequences (through-plane resolution, 0.11-1 mm). Tissue samples from 13 fiducial-marked locations (per specimen) on MR imaging underwent histologic processing and atherosclerotic plaque classification. Reconstructed MR images were matched with histologic sections at corresponding locations. RESULTS: Forty-four samples were available for subsequent evaluation of agreement or disagreement between plaque components and image contrast differences. Of samples, 52.3% (n = 23) showed no image contrast heterogeneity; this group comprised solely no lesions or early lesions. Of samples, 25.0% (n = 11, mostly advanced lesions) showed good correlation between the spatial organization of MR imaging heterogeneities and plaque components. Areas of foamy macrophages were generally seen as proton attenuation-, T2-, and T2*- hypointense areas, while areas of increased collagen content showed more ambiguous signal intensities. Five samples showed image-contrast heterogeneity without corresponding plaque components on histology; 5 other samples showed contrast heterogeneity based on intima-media artifacts. CONCLUSIONS: MR imaging at 7T has the image contrast capable of identifying both focal intracranial vessel wall thickening and distinguishing areas of different signal intensities spatially corresponding to plaque components within more advanced atherosclerotic plaques.

Plaque At RISK (PARISK): prospective multicenter study to improve diagnosis of high-risk carotid plaques.

BACKGROUND: Patients with symptomatic carotid artery stenosis are at high risk for recurrent stroke. To date, the decision to perform carotid endarterectomy in patients with a recent cerebrovascular event is mainly based on degree of stenosis of the ipsilateral carotid artery. However, additional atherosclerotic plaque characteristics might be better predictors of stroke, allowing for more precise selection of patients for carotid endarterectomy. AIMS AND HYPOTHESIS: We investigate the hypothesis that the assessment of carotid plaque characteristics with magnetic resonance imaging, multidetector-row computed tomography angiography, ultrasonography, and transcranial Doppler, either alone or in combination, may improve identification of a subgroup of patients with < 70% carotid artery stenosis with an increased risk of recurrent stroke. METHODS: The Plaque At RISK (PARISK) study is a prospective multicenter cohort study of patients with recent (<3 months) neurological symptoms due to ischemia in the territory of the carotid artery and < 70% ipsilateral carotid artery stenosis who are not scheduled for carotid endarterectomy or stenting. At baseline, 300 patients will undergo magnetic resonance imaging, multidetector-row computed tomography angiography, and ultrasonography examination of the carotid arteries. In addition, magnetic resonance imaging of the brain, ambulatory transcranial Doppler recording of the middle cerebral artery and blood withdrawal will be performed. After two-years, imaging will be repeated in 150 patients. All patients undergo a follow-up brain magnetic resonance imaging, and there will be regular clinical follow-up until the end of the study. STUDY OUTCOMES: The combined primary end-point contains ipsilateral recurrent ischemic stroke or transient ischemic attack or new ipsilateral ischemic brain lesions on follow-up brain magnetic resonance imaging.

Prevalence and clinical consequences of carotid artery residual defects following endarterectomy: a prospective CT angiography evaluation study.

OBJECTIVES: It is still unclear whether residual defects seen after carotid endarterectomy (CEA) have clinical consequences. We investigated prevalence of residual defects in the carotid artery and their possible impact on clinical and Duplex ultrasound (DUS) follow-up. MATERIALS AND METHODS: Sixty-five patients who had undergone CEA were prospectively examined with 1-3 month postoperative computed tomographic angiography (CTA), clinical and DUS follow-up. Defects in common (CCA), external (ECA) and internal carotid artery (ICA) were scored as clamp marks, intimal step or flap, mural thrombus, kink, microdehiscence suture or residual stenosis. RESULTS: Fifty-eight patients (89.2%) had residual defects in CCA, ECA or ICA (143 defects). Intimal steps (n = 39) and residual stenosis (n = 17) were most noted defects. Only residual defects in ECA were significantly associated with significant higher PSV values both at short-term and long-term follow-up (1990 vs. 1400 mm s(-1) at 1 year and 2000 vs. 1230 mm s(-1) at 2 years, P-values 0.031 and 0.016). CONCLUSION: Carotid artery residual defects on CTA after CEA are very common, simple fingerprints of the operative procedure, have no clear consequence. When CTA is performed clinically after CEA, knowledge of high prevalence and type of defects detected on CTA may be of importance for radiologists and clinicians.