Conclusion:Rates of recurrent stroke are similar in patients with stroke treated with aspirin and extended release dipyridamole vs those treated with clopidogrel.Summary: Surviving patients with ischemic stroke are at risk for recurrent stroke. Multiple trials have proven the efficacy of antiplatelet agents in prevention of recurrent stroke after non-cardioembolic stroke. Which particular antiplatelet therapy may work best in the prevention of recurrent stroke is unknown. This trial studied the relative efficacy and safety of aspirin plus extended-release dipyridamole (ERDP) for prevention of recurrent stroke compared with patients treated with clopidogrel. This is a double-blind, two-by-two factorial trial. Patients were randomly assigned to receive 75 mg of aspirin plus 200 mg of ERDP twice daily, or to receive 75 mg of clopidogrel daily. The primary outcome was first recurrence of stroke. The secondary end point was a composite of myocardial infarction, stroke, or death from cardiovascular cause. The trial was designed as a noninferiority trial with sequential statistic testing of noninferiority, followed by superiority testing. A total of 20,332 patients were followed up worldwide, with a mean follow-up of 2.5 years. In patients receiving aspirin and ERDP, recurrent stroke occurred in 916 (9%). In patients receiving clopidogrel, recurrent stroke occurred in 898 (8.8%), with a hazard ratio (HR) of 1.01 (95% confidence interval [CI], 0.92-1.11). The secondary composite outcome occurred in 13.1% of patients in each group (HR for aspirin/ERDP, 0.99; 95% CI, 0.92-1.07). Patients treated with aspirin/ERDP had 4.1% (n ϭ 419) major hemorrhagic events compared with 3.6% (n ϭ 365) in patients treated with clopidogrel (HR, 1.15; 95% CI, 1.00-1.32) and had more intracranial hemorrhage (HR, 1.42; 95% CI, 1.11-1.83). The net risk of a major hemorrhagic event or recurrent stroke was similar in the two groups, 11.7% in the aspirin/ERDP group vs 11.4% in the clopidogrel group (HR, 1.03; 95% CI, 1.95-1.11).Comments: The study indicates no significant difference between the use of aspirin/ERDP vs clopidogrel in preventing recurrent stroke. This was a huge study with high patient numbers and international representation from 35 countries or regions. The results of the study, therefore, should be generalizable worldwide. Although the study failed to identify a superior treatment to prevent recurrent stroke, we now know the expected risk of recurrent stroke in patients treated according to the study protocol. The study has also provided us safety and efficacy data for physicians concerning individual treatment decisions for their patients with ischemic stroke.

Residual vein thrombosis (RVT) indicates

Outpatient treatment of deep vein thrombosis (DVT) has become a common practice in uncomplicated patients. Few data are still present in patients with comorbidity (such as cancer) or concomitant symptomatic pulmonary embolism. Cancer patients with DVT are often excluded from home treatment because they have a higher risk of both bleeding and recurrent DVT. We tested the feasibility and safety of the Home Treatment (HT) program for acute DVT a PE in cancer patients. Patients were treated as outpatients unless they required admission for other medical problems, were actively bleeding or had pain that requires parenteral narcotics. Outpatient treatment was with low molecular weight heparin (LMWH) followed by warfarin or with LMWH alone. An educational program for patients was implemented. Two-hundred and seven patients with cancer were evaluated, 36 (17.4%) of whom had metastatic disease. Treatment with LMWH and warfarin was prescribed to 106 (51.2%) and LMWH alone to 102 (48.8%). One hundred and twenty-seven patients (61.3%) were entirely treated at home. There were no differences between patients treated at home and hospitalized patients with regard to gender, mean age, site of cancer, presence of metastases, and treatment. After 6 months, recurrent thrombo-embolism occurred in 8.7% of patients treated at home and in 5.6% of hospitalized patients (P=0.58); major bleeding in 2.0% and 1.5%, respectively (P=0.06). Twenty-seven patients (33%) in the hospitalized, and 33 (26%) in the home-treatment group, died after a follow-up of 6 months. These results indicate that, regarding cancer patients with acute DVT and/or PE, there is no difference between hospitalised and home-treated patients in terms of major outcomes.

Objectives To conduct a pilot study to evaluate the predictive value of the Montreal Cognitive Assessment test (MoCA) and a brief test of multiple object tracking (MOT) relative to other tests of cognition and attention in identifying at-risk older drivers, and to determine which combination of tests provided the best overall prediction. Methods Forty-seven currently-licensed drivers (58 to 95 years), primarily from a clinical driving evaluation program, participated. Their performance was measured on: (1) a screening test battery, comprising MoCA, MOT, MiniMental State Examination (MMSE), Trail-Making Test, visual acuity, contrast sensitivity, and Useful Field of View (UFOV); and (2) a standardized road test. Results Eighteen participants were rated at-risk on the road test. UFOV subtest 2 was the best single predictor with an area under the curve (AUC) of .84. Neither MoCA nor MOT was a better predictor of the at-risk outcome than either MMSE or UFOV, respectively. The best four-test combination (MMSE, UFOV subtest 2, visual acuity and contrast sensitivity) was able to identify at-risk drivers with 95% specificity and 80% sensitivity (.91 AUC). Conclusions Although the best four-test combination was much better than a single test in identifying at-risk drivers, there is still much work to do in this field to establish test batteries that have both high sensitivity and specificity.