Summary Background Antiplatelet therapy reduces the risk of major vascular events for people with occlusive vascular disease, although it might increase the risk of intracranial haemorrhage. Patients surviving the commonest subtype of intracranial haemorrhage, intracerebral haemorrhage, are at risk of both haemorrhagic and occlusive vascular events, but whether antiplatelet therapy can be used safely is unclear. We aimed to estimate the relative and absolute effects of antiplatelet therapy on recurrent intracerebral haemorrhage and whether this risk might exceed any reduction of occlusive vascular events. Methods The REstart or STop Antithrombotics Randomised Trial (RESTART) was a prospective, randomised, open-label, blinded endpoint, parallel-group trial at 122 hospitals in the UK. We recruited adults (≥18 years) who were taking antithrombotic (antiplatelet or anticoagulant) therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage, discontinued antithrombotic therapy, and survived for 24 h. Computerised randomisation incorporating minimisation allocated participants (1:1) to start or avoid antiplatelet therapy. We followed participants for the primary outcome (recurrent symptomatic intracerebral haemorrhage) for up to 5 years. We analysed data from all randomised participants using Cox proportional hazards regression, adjusted for minimisation covariates. This trial is registered with ISRCTN (number ISRCTN71907627). Findings Between May 22, 2013, and May 31, 2018, 537 participants were recruited a median of 76 days (IQR 29–146) after intracerebral haemorrhage onset: 268 were assigned to start and 269 (one withdrew) to avoid antiplatelet therapy. Participants were followed for a median of 2·0 years (IQR [1·0– 3·0]; completeness 99·3%). 12 (4%) of 268 participants allocated to antiplatelet therapy had recurrence of intracerebral haemorrhage compared with 23 (9%) of 268 participants allocated to avoid antiplatelet therapy (adjusted hazard ratio 0·51 [95% CI 0·25–1·03]; p=0·060). 18 (7%) participants allocated to antiplatelet therapy experienced major haemorrhagic events compared with 25 (9%) participants allocated to avoid antiplatelet therapy (0·71 [0·39–1·30]; p=0·27), and 39 [15%] participants allocated to antiplatelet therapy had major occlusive vascular events compared with 38 [14%] allocated to avoid antiplatelet therapy (1·02 [0·65–1·60]; p=0·92). Interpretation These results exclude all but a very modest increase in the risk of recurrent intracerebral haemorrhage with antiplatelet therapy for patients on antithrombotic therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage. The risk of recurrent intracerebral haemorrhage is probably too small to exceed the established benefits of antiplatelet therapy for secondary prevention. Funding British Heart Foundation.

Background Findings from the RESTART trial suggest that starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. Brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases (such as cerebral microbleeds) are associated with greater risks of recurrent intracerebral haemorrhage. We did subgroup analyses of the RESTART trial to explore whether these brain imaging features modify the effects of antiplatelet therapy. Methods RESTART was a prospective, randomised, open-label, blinded-endpoint, parallel-group trial at 122 hospitals in the UK that assessed whether starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. For this prespecified subgroup analysis, consultant neuroradiologists masked to treatment allocation reviewed brain CT or MRI scans performed before randomisation to confirm participant eligibility and rate features of the intracerebral haemorrhage and surrounding brain. We followed participants for primary (recurrent symptomatic intracerebral haemorrhage) and secondary (ischaemic stroke) outcomes for up to 5 years (reported elsewhere). For this report, we analysed eligible participants with intracerebral haemorrhage according to their treatment allocation in primary subgroup analyses of cerebral microbleeds on MRI and in exploratory subgroup analyses of other features on CT or MRI. The trial is registered with the ISRCTN registry, number ISRCTN71907627.

Arch Dis Child 2012;97(Suppl 2):A1-A539 A125 AbstractsAcinetobacter and Klebsiella pneumoniae were the most common identified pathogens. Conclusion Hospital-acquired pneumonia adversely affects patients outcome in our setting. Moreover, m-PCR permits simultaneous detection of several bacterial pathogens in a single reaction which can optimize the emergency diagnosis of HAP and can improve etiology-directed clinical management of bacterial pneumonia. Background and Aims Ventilator-associated pneumonia (VAP) is a common nosocomial infection in PICU patients, defined as nosocomial pneumonia in patients in mechanical ventilation≥48 hours. We conducted a retrospective study to determine the incidence of VAP and its impact on outcomes in PICU patients. Methods The medical records of PICU patients admitted to PICU of a tertiary-care hospital from January 2011 to December 2011 were reviewed. Outcomes measures were length of mechanical ventilation and PICU stay, hospital cost and mortality. Results 127 patients, mean age 4.48±4.25 years, 58.3% boys were enrolled. 27 admissions resulted in development of 31 episodes of VAP, accounting for a VAP rate of 15.33 per 1000 ventilator days. Mean time to diagnosis for the first VAP episode was 14.30±18.58 days from initiation of mechanical ventilation. 4 patients developed 2 nd VAP episode at 21.40±17.91 day of mechanical ventilation. Age, sex, presence of comorbidity and PRISM III score at admission did not differ between patients with VAP and those without VAP. Patients with VAP had significantly longer PICU length of stay (46.04±43.68 days vs. 9.10±9.25, P<0,001), greater needs for mechanical ventilation(42.26±43.56 days vs. 6.90±7.75, P<0,001), and higher hospital costs for PICU bed excluding treatment cost (9207.40±8737.80 vs. 1820.00±1850.47, P<0,001), than those without VAP. Patients with VAP presented increased mortality (25.9% vs. 15%), but the difference didn't reach statistical significance. Conclusions VAP in critically ill children is associated with prolonged mechanical ventilation, longer PICU stay and increased hospital cost, emerging the need for effective prevention strategies. VENTILATOR-ASSOCIATED

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We report a case of conus medullaris syndrome presenting with lower limb and bladder symptoms. MR imaging showed an abnormality in the lowest part of the spinal cord as a first presentation of myelin oligodendrocyte glycoprotein (MOG)-associated disease. While such cord swelling can mimic a tumour, these patients respond well to corticosteroids, with good outcomes. MOG-associated disease is an immune-mediated syndrome distinct from aquaporin 4 antibody positive neuromyelitis optica syndrome and is now considered an independent entity. Although there can be overlapping phenotypes, there are also differences, and MOG-associated disease generally has a much better prognosis compared with aquaporin 4 antibody-positive neuromyelitis optica syndrome.