Statin use and outcome after intracerebral hemorrhage: case-control study and meta-analysis

OBJECTIVES

Intracerebral hemorrhage (ICH) is a highly lethal disease of the elderly. Use of statins is increasingly widespread among the elderly, and therefore common in patients who develop ICH. Accumulating data suggests that statins have neuroprotective effects, but their association with ICH outcome has been inconsistent. We therefore performed a meta-analysis of all available evidence, including unpublished data from our own institution, to determine whether statin exposure is protective for patients who develop ICH.

METHODS

In our prospectively ascertained cohort, we compared 90-day functional outcome in 238 pre-ICH statin cases and 461 statin-free ICH cases. We then meta-analyzed results from our cohort along with previously published studies using a random effects model, for a total of 698 ICH statin cases and 1,823 non-statin-exposed subjects.

RESULTS

Data from our center demonstrated an association between statin use before ICH and increased probability of favorable outcome (odds ratio [OR] = 2.08, 95% confidence interval [CI] 1.37-3.17) and reduced mortality (OR = 0.47, 95% CI 0.32-0.70) at 90 days. No compound-specific statin effect was identified. Meta-analysis of all published evidence confirmed the effect of statin use on good outcome (OR = 1.91, 95% CI 1.38-2.65) and mortality (OR = 0.55, 95% CI 0.42-0.72) after ICH.

CONCLUSION

Antecedent use of statins prior to ICH is associated with favorable outcome and reduced mortality after ICH. This phenomenon appears to be a class effect of statins. Further studies are required to clarify the biological mechanisms underlying these observations.

Contrast extravasation on CT angiography predicts hematoma expansion in intracerebral hemorrhage

BACKGROUND

Patients with acute intracerebral hemorrhage (ICH) presenting within 3 hours of symptom onset are known to be at increased risk of expansion. However, only a minority arrive within this time frame. Therefore, alternative markers for expansion risk are needed.

OBJECTIVE

To examine whether contrast extravasation on CT angiography (CTA) at presentation predicts subsequent hematoma expansion.

METHODS

Consecutive patients with primary ICH presenting to an urban tertiary care hospital were prospectively captured in a database. We retrospectively reviewed images for all patients receiving a CTA and at least one further CT scan within 48 hours.

RESULTS

Complete data were available for 104 patients. Contrast extravasation at the time of CTA was present in 56% of patients, and associated with an increased risk of hematoma expansion (22% vs 2%, p = 0.003). Patients who received a baseline CTA within 3 hours were more likely to have subsequent expansion (27%, vs 13% for those presenting later, p = 0.1). However, after multivariable analysis, contrast extravasation was the only significant predictor of hematoma expansion (OR 18, 95% CI 2.1 to 162). This effect was independent of time to presentation.

CONCLUSIONS

Contrast extravasation is independently associated with hematoma expansion. Patients presenting within the first few hours after symptom onset have traditionally been considered those at highest risk of expansion. However, for those presenting later, the presence of contrast may be a useful marker to guide therapies aimed at decreasing this risk.

Fetal body weight and the development of the control of the cardiovascular system in fetal sheep

Reduced birth weight predisposes to cardiovascular diseases in later life. We examined in fetal sheep at 0.76 (n = 18) and 0.87 (n = 17) gestation whether spontaneously occurring variations in fetal weight affect maturation of autonomic control of cardiovascular function. Fetal weights at both gestational ages were grouped statistically in low (LW) and normal weights (NW) (P < 0.01). LW fetuses were within the normal weight span showing minor growth dysproportionality at 0.76 gestation favouring heart and brain, with a primary growth of carcass between 0.76 and 0.87 gestation (P < 0.05). While twins largely contributed to LW fetuses, weight differences between singletons and twins were absent at 0.76 and modest at 0.87 gestation, underscoring the fact that twins belong to normality in fetal sheep not constituting a major malnutritive condition. Mean fetal blood pressure (FBP) of all fetuses was negatively correlated to fetal weight at 0.76 but not 0.87 gestation (P < 0.05). At this age, FBP and baroreceptor reflex sensitivity were increased in LW fetuses (P < 0.05), suggesting increased sympathetic activity and immaturity of circulatory control. Development of vagal modulation of fetal heart rate depended on fetal weight (P < 0.01). These functional associations were largely independent of twin pregnancies. We conclude, low fetal weight within the normal weight span is accompanied by a different trajectory of development of sympathetic blood pressure and vagal heart rate control. This may contribute to the development of elevated blood pressure in later life. Examination of the underlying mechanisms and consequences may contribute to the understanding of programming of cardiovascular diseases.

Time-variant parametric estimation of transient quadratic phase couplings between heart rate components in healthy neonates

The heart rate variability (HRV) can be taken as an indicator of the coordination of the cardio-respiratory rhythms. Bispectral analysis using a direct (fast Fourier transform based) and time-invariant approach has shown the occurrence of a quadratic phase coupling (QPC) between a low-frequency (LF: 0.1 Hz) and a high-frequency (HF: 0.4-0.6 Hz) component of the HRV during quiet sleep in healthy neonates. The low-frequency component corresponds to the Mayer-Traube-Hering waves in blood pressure and the high-frequency component to the respiratory sinus arrhythmia (RSA). Time-variant, parametric estimation of the bispectrum provides the possibility of quantifying QPC in the time course. Therefore, the aim of this work was a parametric, time-variant bispectral analysis of the neonatal HRV in the same neonates used in the direct, time-invariant approach. For the first time rhythms in the time course of QPC between the HF component and the LF component could be shown in the neonatal HRV.

Time-variant parametric estimation of transient quadratic phase couplings during electroencephalographic burst activity

OBJECTIVES

Electroencephalographic burst activity characteristic of burst-suppression pattern (BSP) in sedated patients and of burst-interburst pattern (BIP) in the quiet sleep of healthy neonates have similar linear and non-linear signal properties. Strong interrelations between a slow frequency component and rhythmic, spindle-like activities with higher frequencies have been identified in previous studies. Time-varying characteristics of BSP and BIP prevent a definite patternrelated analysis. A continuous estimation of the bispectrum is essential to analyze these patterns. Parametric bispectral approaches provide this opportunity.

METHODS

The adaptation of an AR model leads to a parametric bispectrum by using the transfer function of the estimated AR filter. Time-variant parametric bispectral approaches require an estimation of AR parameters which consider higher order moments to preserve phase information. Accordingly, a time-variant parametric estimation of the bispectrum was introduced. Data driven simulations were performed to provide optimal parameters. BSP (12 patients) and BIP (6 neonates) were analyzed using this novel approach.

RESULTS

Significant differences in the time course of burst pattern during BSP and burst-like pattern before the onset of BSP could be shown. A rhythmic quadratic phase coupling (period 10 sec) was identified during BIP in all neonates.

CONCLUSION

Quadratic phase couplings during BSP increases in the time course depending on depth of sedation. The visually detected burst activity in BIP is only the temporarily observable EEG correlate of a hidden neural process. Time-variant bispectral approaches offer the possibility of a better characterization of underlying neural processes leading to improved diagnostic tools used in clinical routine.

On the spatio-temporal organisation of quadratic phase-couplings in ‘tracé alternant’ EEG pattern in full-term newborns

OBJECTIVE

The time courses of quadratic phase-coupling (QPC) of electroencephalographic burst and interburst patterns of the 'trace alternant' (TA) in full-term newborns have been quantified.

METHODS

Using the Gabor expansion, a fast Fourier transformation based method, biamplitude, bicoherence and phase-bicoherence time courses of both burst and interburst patterns have been determined (common average reference EEG recordings). With a frequency resolution of 0.25 Hz and a frequency grid of 1-1.5 <==> 3.5-4.5 Hz (region-of-interest), a number of 15 frequency pairs result. These pairs have been investigated.

RESULTS

The burst and the interburst patterns are characterized by temporally and topographically different QPC profiles. All differences are dominant at the electrode Fp1 followed by Fp2. There is a significant difference (combined multiple and global test strategy) in the QPC characteristics between both patterns within the time period from 0.75 to 1.5 s after the pattern onset at electrode Fp1. The maximal QPC in burst patterns (especially at Fp1) can be observed during this time period. In contrast to this finding, maximal QPC in interburst patterns (at Fp1) are reached immediately after the onset and at 3 s. Summarising all findings, a QPC-rhythm of 0.1 Hz during TA can be assumed.

CONCLUSIONS

It can be assumed that the QPC rhythm of the TA is generated by a pattern-spanning time-variant phase-locking process and there are indications for a possible correspondence between the QPC rhythm and vegetative rhythms.

SIGNIFICANCE

This study showed that advanced, time-variant analysis methods quantifying QPC rhythms are able to add new scientific information to the understanding of nature, characteristics and significance of TA in the neonatal EEG.

Cognitive rehabilitation for traumatic brain injury: A randomized trial. Defense and Veterans Head Injury Program (DVHIP) Study Group

CONTEXT

Traumatic brain injury (TBI) is a principal cause of death and disability in young adults. Rehabilitation for TBI has not received the same level of scientific scrutiny for efficacy and cost-efficiency that is expected in other medical fields.

OBJECTIVE

To evaluate the efficacy of inpatient cognitive rehabilitation for patients with TBI.

DESIGN AND SETTING

Single-center, parallel-group, randomized trial conducted from January 1992 through February 1997 at a US military medical referral center.

PATIENTS

One hundred twenty active-duty military personnel who had sustained a moderate-to-severe closed head injury, manifested by a Glasgow Coma Scale score of 13 or less, or posttraumatic amnesia lasting at least 24 hours, or focal cerebral contusion or hemorrhage on computed tomography or magnetic resonance imaging.

INTERVENTIONS

Patients were randomly assigned to an intensive, standardized, 8-week, in-hospital cognitive rehabilitation program (n=67) or a limited home rehabilitation program with weekly telephone support from a psychiatric nurse (n=53).

MAIN OUTCOME MEASURES

Return to gainful employment and fitness for military duty at 1-year follow-up, compared by intervention group.

RESULTS

At 1-year follow-up, there was no significant difference between patients who had received the intensive in-hospital cognitive rehabilitation program vs the limited home rehabilitation program in return to employment (90% vs 94%, respectively; P=.51; difference, 4% [95% confidence interval ¿CI¿, -5% to 14%]) or fitness for duty (73% vs 66%, respectively; P=. 43; difference, 7% [95% CI, -10% to 24%]). There also were no significant differences in cognitive, behavioral, or quality-of-life measures. In a post-hoc subset analysis of patients who were unconscious for more than 1 hour (n = 75) following TBI, the in-hospital group had a greater return-to-duty rate (80% vs 58%; P=. 05).

CONCLUSIONS

In this study, the overall benefit of in-hospital cognitive rehabilitation for patients with moderate-to-severe TBI was similar to that of home rehabilitation. These findings emphasize the importance of conducting randomized trials to evaluate TBI rehabilitation interventions. JAMA. 2000;283:3075-3081

A novel Ggamma isolated from Drosophila constitutes a visual G protein gamma subunit of the fly compound eye

Visual transduction in the compound eye of flies is a well established model system for the study of G protein-coupled transduction pathways. To characterize key components of the phototransduction cascade we performed substractive hybridization screening. We cloned the cDNA coding for the visual Ggamma (Ggamma(e)) subunit from Drosophila which had so far eluded identification at the molecular level. Northern blot analysis revealed the presence of a major, 1.4-kilobase(kb) Ggamma(e) transcript and two minor transcripts of 1.8 and 6 kb in size. The major 1.4-kb mRNA is expressed preferentially in the eye. The spatial expression pattern determined for Ggamma(e) as well as co-immunoprecipitation experiments demonstrated that Ggamma(e) dimerizes with Gbeta(e) to form the heterodimeric Gbetagamma subunit which functions in visual transduction in the Drosophila compound eye. Ggamma(e) shares common characteristics with the visual Ggamma subunits of human rod and cone photoreceptors although different classes of Galpha subunits are employed in vertebrate and invertebrate phototransduction. By the molecular cloning and characterization of the visual gamma subunit of Drosophila one of the few missing links in the well studied Drosophila phototransduction cascade has been characterized to complete our knowledge about the Drosophila visual transduction pathway.

Patterning of the R7 and R8 photoreceptor cells of Drosophila: evidence for induced and default cell-fate specification

Opsin gene expression in the R7 and R8 photoreceptor cells of the Drosophila compound eye is highly coordinated. We have found that the R8 cell specific Rh5 and Rh6 opsins are expressed in non-overlapping sets of R8 cells, in a precise pairwise fashion with Rh3 and Rh4 in the R7 cells of individual ommatidia. Removal of the R7 cells in sevenless, boss or sina mutants, disrupts Rh5 expression and dramatically increases the number of Rh6-expressing R8 cells. This suggests that the expression of Rh5 may be induced by an Rh3-expressing R7 cell, whereas Rh6 expression is most likely a default state of the R8 cell. We found that the paired expression of opsin genes in the R7 and R8 cells occurs in a sevenless and boss independent manner. Furthermore, we found that the generation of both Rh3- and Rh4-expressing R7 cells can occur in the absence of an R8 cell. These results suggest that the specification of opsin expression in the R7 cells may occur autonomously, whereas the R7 photoreceptor cell may be responsible for regulating a binary developmental switch between induced and default cell-fates in the R8 cell.

Motivation for traumatic brain injury rehabilitation questionnaire (MOT-Q): reliability, factor analysis, and relationship to MMPI-2 variables

A Likert scale questionnaire was developed to assess motivation for postacute rehabilitation by traumatic brain injury patients. Items were designed to reflect head-injured individuals' statements about their attitudes toward head injury rehabilitation. Factors such as denial of illness, anger, compliance with treatment, and medical information seeking behavior were used to assess unfavorable and favorable components of motivation. Reliability was assessed using Cronbach's Alpha, which was found to be 0.91 for the total scale. Four factor analysis derived subscales were identified: Lack of Denial, Interest in Rehabilitation, Lack of Anger, and Reliance on Professional Help. Correlation and multiple regression analyses demonstrated moderate relationships between MOT-Q and several MMPI-2 variables largely related to indicators of somatic distress, depression and capacity for self-sufficiency. Lack of Denial subscale showed the strongest relationship to MMPI-2 of all MOT-Q variables, while Interest in Rehabilitation showed the best correlation to the MOT-Q total.