University of Auckland

Increasingly, adult Indigenous language learners are being identified as the “missing generation” of learners who hold great potential to contribute to the revival of Indigenous languages by acting as the middle ground between Elders, children and youth within their communities. Our research project NEȾOLṈEW̱ ‘one mind, one people’ investigated adult Indigenous language learning through the popular Mentor-Apprentice Program (MAP) method (Leanne Hinton, 2001). Over the course of 14 months, our team conducted 133 interviews with four groups of participants involved in MAP. The participants were current and past apprentices, mentors, and administrators of MAP programs in British Columbia, Canada. Our primary interest was to learn about the successes and challenges of MAP for language learning, but we also included interview questions that gave participants space to share how participating in MAP may have affected them. During thematic analysis of the interviews (Braun & Clarke, 2006, 2014) we noticed repeating comments across all four participant groups on how their involvement with MAP impacted their own and their community’s wellbeing. Six exploratory themes were identified: • Language loss negatively impacts the wellbeing of Indigenous people: “[the word] doesn’t just mean a bad, misbehaving child, it also means a poor child that has been uprooted […] and is disconnected from their culture” • The relationship between burden and wellbeing among participants in MAP: “there’s so much to be done. […] that’s the exhausting part of it. It’s trying to learn and teach at the same time” • Strengthening MAP apprentices to become future community leaders: “it brings a huge sense of pride […] and helps me be an inspiration to anyone else” • Elder’s healing through becoming language mentors: “we once again have that believe in ourselves where we can feel free” • Cultural and spiritual health and healing: “I am keeping something very precious alive by speaking my language” • Health outcomes: “it was […] the language that... pushed me to sobriety, […] it gave me... a sense of who I was”. Although studies have reported protective effects of Indigenous language use on health (Ball & Moselle, 2013; Hallett, Chandler, & Lalonde, 2007; McIvor, 2013), health-related outcomes of language revitalization efforts, including MAP, remain underexplored (Whalen, Moss, & Baldwin, 2016). In addition to discussing the six exploratory themes from our study, our paper also proposes that these themes can inform future research in the area of language revitalization and wellbeing. References Ball, J., & Moselle, K. (2013). Contributions of culture and language in aboriginal head start in urban and northern communities to children’s health outcomes: A review of theory and research. Prepared for Division of Children, Seniors & Healthy Development, Health Promotion and Chronic Disease Prevention Branch. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77–101. http://doi.org/10.1191/1478088706qp063oa Braun, V., & Clarke, V. (2014). What can “thematic analysis” offer health and wellbeing researchers? International Journal of Qualitative Studies on Health and Well-Being, 9, 26152. http://doi.org/10.3402/qhw.v9.26152 Hallett, D., Chandler, M. J., & Lalonde, C. E. (2007). Aboriginal language knowledge and youth suicide. Cognitive Development, 22(3), 392–399. http://doi.org/10.1016/j.cogdev.2007.02.001 Hinton, L. (2001). The master-apprentice language learning program. In L. Hinton & K. Hale (Eds.), The green book of language revitalization in practice (pp. 217–226). San Diego, CA: Academic Press. McIvor, O. (2013). Protective effects of language learning, use and culture on the health and well-being of Indigenous people in Canada. In Proceedings of the 17th FEL Conference, FEL XVII: Endangered Languages Beyond Boundaries: Community Connections, Collaborative Approaches and Cross-Disciplinary Research (pp. 123–131). Foundation for Endangered Languages in association with the University of Carleton. Whalen, D. H., Moss, M., & Baldwin, D. (2016). Healing through language: Positive physical health effects of indigenous language use. F1000Research, 5(852). http://doi.org/10.12688/f1000research.8656.1

UNLABELLED: The two main functions of bioinformatics are the organization and analysis of biological data using computational resources. Geneious Basic has been designed to be an easy-to-use and flexible desktop software application framework for the organization and analysis of biological data, with a focus on molecular sequences and related data types. It integrates numerous industry-standard discovery analysis tools, with interactive visualizations to generate publication-ready images. One key contribution to researchers in the life sciences is the Geneious public application programming interface (API) that affords the ability to leverage the existing framework of the Geneious Basic software platform for virtually unlimited extension and customization. The result is an increase in the speed and quality of development of computation tools for the life sciences, due to the functionality and graphical user interface available to the developer through the public API. Geneious Basic represents an ideal platform for the bioinformatics community to leverage existing components and to integrate their own specific requirements for the discovery, analysis and visualization of biological data. AVAILABILITY AND IMPLEMENTATION: Binaries and public API freely available for download at http://www.geneious.com/basic, implemented in Java and supported on Linux, Apple OSX and MS Windows. The software is also available from the Bio-Linux package repository at http://nebc.nerc.ac.uk/news/geneiousonbl.

PhyML is a phylogeny software based on the maximum-likelihood principle. Early PhyML versions used a fast algorithm performing nearest neighbor interchanges to improve a reasonable starting tree topology. Since the original publication (Guindon S., Gascuel O. 2003. A simple, fast and accurate algorithm to estimate large phylogenies by maximum likelihood. Syst. Biol. 52:696-704), PhyML has been widely used (>2500 citations in ISI Web of Science) because of its simplicity and a fair compromise between accuracy and speed. In the meantime, research around PhyML has continued, and this article describes the new algorithms and methods implemented in the program. First, we introduce a new algorithm to search the tree space with user-defined intensity using subtree pruning and regrafting topological moves. The parsimony criterion is used here to filter out the least promising topology modifications with respect to the likelihood function. The analysis of a large collection of real nucleotide and amino acid data sets of various sizes demonstrates the good performance of this method. Second, we describe a new test to assess the support of the data for internal branches of a phylogeny. This approach extends the recently proposed approximate likelihood-ratio test and relies on a nonparametric, Shimodaira-Hasegawa-like procedure. A detailed analysis of real alignments sheds light on the links between this new approach and the more classical nonparametric bootstrap method. Overall, our tests show that the last version (3.0) of PhyML is fast, accurate, stable, and ready to use. A Web server and binary files are available from http://www.atgc-montpellier.fr/phyml/.

Since initially writing on thematic analysis in 2006, the popularity of the method we outlined has exploded, the variety of TA approaches have expanded, and, not least, our thinking has developed and shifted. In this reflexive commentary, we look back at some of the unspoken assumptions that informed how we wrote our 2006 paper. We connect some of these un-identified assumptions, and developments in the method over the years, with some conceptual mismatches and confusions we see in published TA studies. In order to facilitate better TA practice, we reflect on how our thinking has evolved – and in some cases sedimented – since the publication of our 2006 paper, and clarify and revise some of the ways we phrased or conceptualised TA, and the elements of, and processes around, a method we now prefer to call reflexive TA.

Abstract Hypothesis‐testing methods for multivariate data are needed to make rigorous probability statements about the effects of factors and their interactions in experiments. Analysis of variance is particularly powerful for the analysis of univariate data. The traditional multivariate analogues, however, are too stringent in their assumptions for most ecological multivariate data sets. Non‐parametric methods, based on permutation tests, are preferable. This paper describes a new non‐parametric method for multivariate analysis of variance, after McArdle and Anderson (in press). It is given here, with several applications in ecology, to provide an alternative and perhaps more intuitive formulation for ANOVA (based on sums of squared distances) to complement the description provided by McArdle and Anderson (in press) for the analysis of any linear model. It is an improvement on previous non‐parametric methods because it allows a direct additive partitioning of variation for complex models. It does this while maintaining the flexibility and lack of formal assumptions of other non‐parametric methods. The test‐statistic is a multivariate analogue to Fisher’s F ‐ratio and is calculated directly from any symmetric distance or dissimilarity matrix. P ‐values are then obtained using permutations. Some examples of the method are given for tests involving several factors, including factorial and hierarchical (nested) designs and tests of interactions.

BACKGROUND: The evolutionary analysis of molecular sequence variation is a statistical enterprise. This is reflected in the increased use of probabilistic models for phylogenetic inference, multiple sequence alignment, and molecular population genetics. Here we present BEAST: a fast, flexible software architecture for Bayesian analysis of molecular sequences related by an evolutionary tree. A large number of popular stochastic models of sequence evolution are provided and tree-based models suitable for both within- and between-species sequence data are implemented. RESULTS: BEAST version 1.4.6 consists of 81000 lines of Java source code, 779 classes and 81 packages. It provides models for DNA and protein sequence evolution, highly parametric coalescent analysis, relaxed clock phylogenetics, non-contemporaneous sequence data, statistical alignment and a wide range of options for prior distributions. BEAST source code is object-oriented, modular in design and freely available at http://beast-mcmc.googlecode.com/ under the GNU LGPL license. CONCLUSION: BEAST is a powerful and flexible evolutionary analysis package for molecular sequence variation. It also provides a resource for the further development of new models and statistical methods of evolutionary analysis.

Feedback is one of the most powerful influences on learning and achievement, but this impact can be either positive or negative. Its power is frequently mentioned in articles about learning and teaching, but surprisingly few recent studies have systematically investigated its meaning. This article provides a conceptual analysis of feedback and reviews the evidence related to its impact on learning and achievement. This evidence shows that although feedback is among the major influences, the type of feedback and the way it is given can be differentially effective. A model of feedback is then proposed that identifies the particular properties and circumstances that make it effective, and some typically thorny issues are discussed, including the timing of feedback and the effects of positive and negative feedback. Finally, this analysis is used to suggest ways in which feedback can be used to enhance its effectiveness in classrooms.

Bayesian inference of phylogeny using Markov chain Monte Carlo (MCMC) plays a central role in understanding evolutionary history from molecular sequence data. Visualizing and analyzing the MCMC-generated samples from the posterior distribution is a key step in any non-trivial Bayesian inference. We present the software package Tracer (version 1.7) for visualizing and analyzing the MCMC trace files generated through Bayesian phylogenetic inference. Tracer provides kernel density estimation, multivariate visualization, demographic trajectory reconstruction, conditional posterior distribution summary, and more. Tracer is open-source and available at http://beast.community/tracer.

The last decade has seen a sharp increase in the number of scientific publications describing physiological and pathological functions of extracellular vesicles (EVs), a collective term covering various subtypes of cell-released, membranous structures, called exosomes, microvesicles, microparticles, ectosomes, oncosomes, apoptotic bodies, and many other names. However, specific issues arise when working with these entities, whose size and amount often make them difficult to obtain as relatively pure preparations, and to characterize properly. The International Society for Extracellular Vesicles (ISEV) proposed Minimal Information for Studies of Extracellular Vesicles ("MISEV") guidelines for the field in 2014. We now update these "MISEV2014" guidelines based on evolution of the collective knowledge in the last four years. An important point to consider is that ascribing a specific function to EVs in general, or to subtypes of EVs, requires reporting of specific information beyond mere description of function in a crude, potentially contaminated, and heterogeneous preparation. For example, claims that exosomes are endowed with exquisite and specific activities remain difficult to support experimentally, given our still limited knowledge of their specific molecular machineries of biogenesis and release, as compared with other biophysically similar EVs. The MISEV2018 guidelines include tables and outlines of suggested protocols and steps to follow to document specific EV-associated functional activities. Finally, a checklist is provided with summaries of key points.

A general inductive approach for analysis of qualitative evaluation data is described. The purposes for using an inductive approach are to (a) condense raw textual data into a brief, summary format; (b) establish clear links between the evaluation or research objectives and the summary findings derived from the raw data; and (c) develop a framework of the underlying structure of experiences or processes that are evident in the raw data. The general inductive approach provides an easily used and systematic set of procedures for analyzing qualitative data that can produce reliable and valid findings. Although the general inductive approach is not as strong as some other analytic strategies for theory or model development, it does provide a simple, straightforward approach for deriving findings in the context of focused evaluation questions. Many evaluators are likely to find using a general inductive approach less complicated than using other approaches to qualitative data analysis.

Abstract In this article we discuss our experience designing and implementing a statistical computing language. In developing this new language, we sought to combine what we felt were useful features from two existing computer languages. We feel that the new language provides advantages in the areas of portability, computational efficiency, memory management, and scoping.

Computational evolutionary biology, statistical phylogenetics and coalescent-based population genetics are becoming increasingly central to the analysis and understanding of molecular sequence data. We present the Bayesian Evolutionary Analysis by Sampling Trees (BEAST) software package version 1.7, which implements a family of Markov chain Monte Carlo (MCMC) algorithms for Bayesian phylogenetic inference, divergence time dating, coalescent analysis, phylogeography and related molecular evolutionary analyses. This package includes an enhanced graphical user interface program called Bayesian Evolutionary Analysis Utility (BEAUti) that enables access to advanced models for molecular sequence and phenotypic trait evolution that were previously available to developers only. The package also provides new tools for visualizing and summarizing multispecies coalescent and phylogeographic analyses. BEAUti and BEAST 1.7 are open source under the GNU lesser general public license and available at http://beast-mcmc.googlecode.com and http://beast.bio.ed.ac.uk.

Developing a universal quality standard for thematic analysis (TA) is complicated by the existence of numerous iterations of TA that differ paradigmatically, philosophically and procedurally. This plurality in TA is often not recognised by editors, reviewers or authors, who promote ‘coding reliability measures’ as universal requirements of quality TA. Focusing particularly on our reflexive TA approach, we discuss quality in TA with reference to ten common problems we have identified in published TA research that cites or claims to follow our guidance. Many of the common problems are underpinned by an assumption of homogeneity in TA. We end by outlining guidelines for reviewers and editors – in the form of twenty critical questions – to support them in promoting high(er) standards in TA research, and more deliberative and reflexive engagement with TA as method and practice.

BACKGROUND: The Global Burden of Diseases, Injuries, and Risk Factors Study 2015 provides an up-to-date synthesis of the evidence for risk factor exposure and the attributable burden of disease. By providing national and subnational assessments spanning the past 25 years, this study can inform debates on the importance of addressing risks in context. METHODS: We used the comparative risk assessment framework developed for previous iterations of the Global Burden of Disease Study to estimate attributable deaths, disability-adjusted life-years (DALYs), and trends in exposure by age group, sex, year, and geography for 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks from 1990 to 2015. This study included 388 risk-outcome pairs that met World Cancer Research Fund-defined criteria for convincing or probable evidence. We extracted relative risk and exposure estimates from randomised controlled trials, cohorts, pooled cohorts, household surveys, census data, satellite data, and other sources. We used statistical models to pool data, adjust for bias, and incorporate covariates. We developed a metric that allows comparisons of exposure across risk factors-the summary exposure value. Using the counterfactual scenario of theoretical minimum risk level, we estimated the portion of deaths and DALYs that could be attributed to a given risk. We decomposed trends in attributable burden into contributions from population growth, population age structure, risk exposure, and risk-deleted cause-specific DALY rates. We characterised risk exposure in relation to a Socio-demographic Index (SDI). FINDINGS: Between 1990 and 2015, global exposure to unsafe sanitation, household air pollution, childhood underweight, childhood stunting, and smoking each decreased by more than 25%. Global exposure for several occupational risks, high body-mass index (BMI), and drug use increased by more than 25% over the same period. All risks jointly evaluated in 2015 accounted for 57·8% (95% CI 56·6-58·8) of global deaths and 41·2% (39·8-42·8) of DALYs. In 2015, the ten largest contributors to global DALYs among Level 3 risks were high systolic blood pressure (211·8 million [192·7 million to 231·1 million] global DALYs), smoking (148·6 million [134·2 million to 163·1 million]), high fasting plasma glucose (143·1 million [125·1 million to 163·5 million]), high BMI (120·1 million [83·8 million to 158·4 million]), childhood undernutrition (113·3 million [103·9 million to 123·4 million]), ambient particulate matter (103·1 million [90·8 million to 115·1 million]), high total cholesterol (88·7 million [74·6 million to 105·7 million]), household air pollution (85·6 million [66·7 million to 106·1 million]), alcohol use (85·0 million [77·2 million to 93·0 million]), and diets high in sodium (83·0 million [49·3 million to 127·5 million]). From 1990 to 2015, attributable DALYs declined for micronutrient deficiencies, childhood undernutrition, unsafe sanitation and water, and household air pollution; reductions in risk-deleted DALY rates rather than reductions in exposure drove these declines. Rising exposure contributed to notable increases in attributable DALYs from high BMI, high fasting plasma glucose, occupational carcinogens, and drug use. Environmental risks and childhood undernutrition declined steadily with SDI; low physical activity, high BMI, and high fasting plasma glucose increased with SDI. In 119 countries, metabolic risks, such as high BMI and fasting plasma glucose, contributed the most attributable DALYs in 2015. Regionally, smoking still ranked among the leading five risk factors for attributable DALYs in 109 countries; childhood underweight and unsafe sex remained primary drivers of early death and disability in much of sub-Saharan Africa. INTERPRETATION: Declines in some key environmental risks have contributed to declines in critical infectious diseases. Some risks appear to be invariant to SDI. Increasing risks, including high BMI, high fasting plasma glucose, drug use, and some occupational exposures, contribute to rising burden from some conditions, but also provide opportunities for intervention. Some highly preventable risks, such as smoking, remain major causes of attributable DALYs, even as exposure is declining. Public policy makers need to pay attention to the risks that are increasingly major contributors to global burden. FUNDING: Bill & Melinda Gates Foundation.

BACKGROUND: In patients with type 2 diabetes, the effects of intensive glucose control on vascular outcomes remain uncertain. METHODS: We randomly assigned 11,140 patients with type 2 diabetes to undergo either standard glucose control or intensive glucose control, defined as the use of gliclazide (modified release) plus other drugs as required to achieve a glycated hemoglobin value of 6.5% or less. Primary end points were composites of major macrovascular events (death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke) and major microvascular events (new or worsening nephropathy or retinopathy), assessed both jointly and separately. RESULTS: After a median of 5 years of follow-up, the mean glycated hemoglobin level was lower in the intensive-control group (6.5%) than in the standard-control group (7.3%). Intensive control reduced the incidence of combined major macrovascular and microvascular events (18.1%, vs. 20.0% with standard control; hazard ratio, 0.90; 95% confidence interval [CI], 0.82 to 0.98; P=0.01), as well as that of major microvascular events (9.4% vs. 10.9%; hazard ratio, 0.86; 95% CI, 0.77 to 0.97; P=0.01), primarily because of a reduction in the incidence of nephropathy (4.1% vs. 5.2%; hazard ratio, 0.79; 95% CI, 0.66 to 0.93; P=0.006), with no significant effect on retinopathy (P=0.50). There were no significant effects of the type of glucose control on major macrovascular events (hazard ratio with intensive control, 0.94; 95% CI, 0.84 to 1.06; P=0.32), death from cardiovascular causes (hazard ratio with intensive control, 0.88; 95% CI, 0.74 to 1.04; P=0.12), or death from any cause (hazard ratio with intensive control, 0.93; 95% CI, 0.83 to 1.06; P=0.28). Severe hypoglycemia, although uncommon, was more common in the intensive-control group (2.7%, vs. 1.5% in the standard-control group; hazard ratio, 1.86; 95% CI, 1.42 to 2.40; P<0.001). CONCLUSIONS: A strategy of intensive glucose control, involving gliclazide (modified release) and other drugs as required, that lowered the glycated hemoglobin value to 6.5% yielded a 10% relative reduction in the combined outcome of major macrovascular and microvascular events, primarily as a consequence of a 21% relative reduction in nephropathy. (ClinicalTrials.gov number, NCT00145925.)

The paper motivates, presents, demonstrates in use, and evaluates a methodology for conducting design science (DS) research in information systems (IS). DS is of importance in a discipline oriented to the creation of successful artifacts. Several researchers have pioneered DS research in IS, yet over the past 15 years, little DS research has been done within the discipline. The lack of a methodology to serve as a commonly accepted framework for DS research and of a template for its presentation may have contributed to its slow adoption. The design science research methodology (DSRM) presented here incorporates principles, practices, and procedures required to carry out such research and meets three objectives: it is consistent with prior literature, it provides a nominal process model for doing DS research, and it provides a mental model for presenting and evaluating DS research in IS. The DS process includes six steps: problem identification and motivation, definition of the objectives for a solution, design and development, demonstration, evaluation, and communication. We demonstrate and evaluate the methodology by presenting four case studies in terms of the DSRM, including cases that present the design of a database to support health assessment methods, a software reuse measure, an Internet video telephony application, and an IS planning method. The designed methodology effectively satisfies the three objectives and has the potential to help aid the acceptance of DS research in the IS discipline.

We present a new open source, extensible and flexible software platform for Bayesian evolutionary analysis called BEAST 2. This software platform is a re-design of the popular BEAST 1 platform to correct structural deficiencies that became evident as the BEAST 1 software evolved. Key among those deficiencies was the lack of post-deployment extensibility. BEAST 2 now has a fully developed package management system that allows third party developers to write additional functionality that can be directly installed to the BEAST 2 analysis platform via a package manager without requiring a new software release of the platform. This package architecture is showcased with a number of recently published new models encompassing birth-death-sampling tree priors, phylodynamics and model averaging for substitution models and site partitioning. A second major improvement is the ability to read/write the entire state of the MCMC chain to/from disk allowing it to be easily shared between multiple instances of the BEAST software. This facilitates checkpointing and better support for multi-processor and high-end computing extensions. Finally, the functionality in new packages can be easily added to the user interface (BEAUti 2) by a simple XML template-based mechanism because BEAST 2 has been re-designed to provide greater integration between the analysis engine and the user interface so that, for example BEAST and BEAUti use exactly the same XML file format.

Biotic invaders are species that establish a new range in which they proliferate, spread, and persist to the detriment of the environment. They are the most important ecological outcomes from the unprecedented alterations in the distribution of the earth's biota brought about largely through human transport and commerce. In a world without borders, few if any areas remain sheltered from these immigrations. The fate of immigrants is decidedly mixed. Few survive the hazards of chronic and stochastic forces, and only a small fraction become naturalized. In turn, some naturalized species do become invasive. There are several potential reasons why some immigrant species prosper: some escape from the constraints of their native predators or parasites; others are aided by human-caused disturbance that disrupts native communities. Ironically, many biotic invasions are apparently facilitated by cultivation and husbandry, unintentional actions that foster immigrant populations until they are self-perpetuating and uncontrollable. Whatever the cause, biotic invaders can in many cases inflict enormous environmental damage: (1) Animal invaders can cause extinctions of vulnerable native species through predation, grazing, competition, and habitat alteration. (2) Plant invaders can completely alter the fire regime, nutrient cycling, hydrology, and energy budgets in a native ecosystem and can greatly diminish the abundance or survival of native species. (3) In agriculture, the principal pests of temperate crops are nonindigenous, and the combined expenses of pest control and crop losses constitute an onerous “tax” on food, fiber, and forage production. (4) The global cost of virulent plant and animal diseases caused by parasites transported to new ranges and presented with susceptible new hosts is currently incalculable. Identifying future invaders and taking effective steps to prevent their dispersal and establishment constitutes an enormous challenge to both conservation and international commerce. Detection and management when exclusion fails have proved daunting for varied reasons: (1) Efforts to identify general attributes of future invaders have often been inconclusive. (2) Predicting susceptible locales for future invasions seems even more problematic, given the enormous differences in the rates of arrival among potential invaders. (3) Eradication of an established invader is rare, and control efforts vary enormously in their efficacy. Successful control, however, depends more on commitment and continuing diligence than on the efficacy of specific tools themselves. (4) Control of biotic invasions is most effective when it employs a long-term, ecosystem-wide strategy rather than a tactical approach focused on battling individual invaders. (5) Prevention of invasions is much less costly than post-entry control. Revamping national and international quarantine laws by adopting a “guilty until proven innocent” approach would be a productive first step. Failure to address the issue of biotic invasions could effectively result in severe global consequences, including wholesale loss of agricultural, forestry, and fishery resources in some regions, disruption of the ecological processes that supply natural services on which human enterprise depends, and the creation of homogeneous, impoverished ecosystems composed of cosmopolitan species. Given their current scale, biotic invasions have taken their place alongside human-driven atmospheric and oceanic alterations as major agents of global change. Left unchecked, they will influence these other forces in profound but still unpredictable ways.

We present SeaView version 4, a multiplatform program designed to facilitate multiple alignment and phylogenetic tree building from molecular sequence data through the use of a graphical user interface. SeaView version 4 combines all the functions of the widely used programs SeaView (in its previous versions) and Phylo_win, and expands them by adding network access to sequence databases, alignment with arbitrary algorithm, maximum-likelihood tree building with PhyML, and display, printing, and copy-to-clipboard of rooted or unrooted, binary or multifurcating phylogenetic trees. In relation to the wide present offer of tools and algorithms for phylogenetic analyses, SeaView is especially useful for teaching and for occasional users of such software. SeaView is freely available at http://pbil.univ-lyon1.fr/software/seaview.

BACKGROUND: Trials of endovascular therapy for ischemic stroke have produced variable results. We conducted this study to test whether more advanced imaging selection, recently developed devices, and earlier intervention improve outcomes. METHODS: We randomly assigned patients with ischemic stroke who were receiving 0.9 mg of alteplase per kilogram of body weight less than 4.5 hours after the onset of ischemic stroke either to undergo endovascular thrombectomy with the Solitaire FR (Flow Restoration) stent retriever or to continue receiving alteplase alone. All the patients had occlusion of the internal carotid or middle cerebral artery and evidence of salvageable brain tissue and ischemic core of less than 70 ml on computed tomographic (CT) perfusion imaging. The coprimary outcomes were reperfusion at 24 hours and early neurologic improvement (≥8-point reduction on the National Institutes of Health Stroke Scale or a score of 0 or 1 at day 3). Secondary outcomes included the functional score on the modified Rankin scale at 90 days. RESULTS: The trial was stopped early because of efficacy after 70 patients had undergone randomization (35 patients in each group). The percentage of ischemic territory that had undergone reperfusion at 24 hours was greater in the endovascular-therapy group than in the alteplase-only group (median, 100% vs. 37%; P<0.001). Endovascular therapy, initiated at a median of 210 minutes after the onset of stroke, increased early neurologic improvement at 3 days (80% vs. 37%, P=0.002) and improved the functional outcome at 90 days, with more patients achieving functional independence (score of 0 to 2 on the modified Rankin scale, 71% vs. 40%; P=0.01). There were no significant differences in rates of death or symptomatic intracerebral hemorrhage. CONCLUSIONS: In patients with ischemic stroke with a proximal cerebral arterial occlusion and salvageable tissue on CT perfusion imaging, early thrombectomy with the Solitaire FR stent retriever, as compared with alteplase alone, improved reperfusion, early neurologic recovery, and functional outcome. (Funded by the Australian National Health and Medical Research Council and others; EXTEND-IA ClinicalTrials.gov number, NCT01492725, and Australian New Zealand Clinical Trials Registry number, ACTRN12611000969965.).