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Liu M, Jayaraman K, Norris AJ, Hussein A, Nelson JW, Mehla J, Diwan D, Vellimana A, Abu-Amer Y, Zipfel GJ, Athiraman U. Isoflurane Conditioning-Induced Delayed Cerebral Ischemia Protection in Subarachnoid Hemorrhage-Role of Inducible Nitric Oxide Synthase. J Am Heart Assoc 2023:e029975. [PMID: 37449587 PMCID: PMC10382105 DOI: 10.1161/jaha.123.029975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 06/20/2023] [Indexed: 07/18/2023]
Abstract
Background Recent evidence implicates inflammation as a key driver in delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage (SAH). Inducible nitric oxide synthase (iNOS) is one of the known major mediators of inflammation. We previously showed that an inhalational anesthetic, isoflurane, provides strong protection against delayed cerebral ischemia after SAH. Our current study aims to define the role of iNOS in isoflurane conditioning-induced protection against delayed cerebral ischemia in a mouse model of SAH. Methods and Results The experiments used 10- to 14-week-old male wild-type (C57BL/6) and iNOS global knockout mice. Anesthetic conditioning was initiated 1 hour after SAH with isoflurane 2% for 1 hour. Isoflurane-induced changes in iNOS expression were measured. N-(3-(aminomethyl) benzyl) acetamidine, a highly selective iNOS inhibitor, was injected intraperitoneally immediately after SAH and then daily. Vasospasm, microvessel thrombosis, and neurological assessment was performed. Data were analyzed by 1-way ANOVA and 2-way repeated measures ANOVA followed by Student Newman Keuls comparison test. Statistical significance was set at P<0.05. Isoflurane conditioning downregulated iNOS expression in naïve and SAH mice. N-(3-(aminomethyl) benzyl) acetamidine attenuated large artery vasospasm and microvessel thrombosis and improved neurological deficits in wild-type animals. iNOS knockout mice were significantly resistant to vasospasm, microvessel thrombosis, and neurological deficits induced by SAH. Combining isoflurane with N-(3-(aminomethyl) benzyl) acetamidine did not offer extra protection, nor did treating iNOS knockout mice with isoflurane. Conclusions Isoflurane conditioning-induced delayed cerebral ischemia protection appears to be mediated by downregulating iNOS. iNOS is a potential therapeutic target to improve outcomes after SAH.
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Affiliation(s)
- Meizi Liu
- Department of Anesthesiology Washington University St. Louis MO USA
| | - Keshav Jayaraman
- Department of Anesthesiology Washington University St. Louis MO USA
| | - Aaron J Norris
- Department of Anesthesiology Washington University St. Louis MO USA
| | - Ahmed Hussein
- Department of Neurological Surgery Washington University St. Louis MO USA
| | - James W Nelson
- Department of Neurological Surgery Washington University St. Louis MO USA
| | - Jogender Mehla
- Department of Neurological Surgery Washington University St. Louis MO USA
| | - Deepti Diwan
- Department of Neurological Surgery Washington University St. Louis MO USA
| | - Ananth Vellimana
- Department of Neurological Surgery Washington University St. Louis MO USA
- Department of Radiology Washington University St. Louis MO USA
- Department of Neurology Washington University St. Louis MO USA
| | - Yousef Abu-Amer
- Department of Orthopedics Washington University St. Louis MO USA
- Department of Cell Biology & Physiology Washington University St. Louis MO USA
| | - Gregory J Zipfel
- Department of Neurological Surgery Washington University St. Louis MO USA
- Department of Neurology Washington University St. Louis MO USA
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Koester SW, Catapano JS, Rumalla K, Dabrowski SJ, Benner D, Winkler EA, Cole TS, Baranoski JF, Srinivasan VM, Graffeo CS, Jha RM, Jadhav AP, Ducruet AF, Albuquerque FC, Lawton MT. Health Care Expenditures Associated with Delayed Cerebral Ischemia Following Subarachnoid Hemorrhage: A Propensity-Adjusted Analysis. World Neurosurg 2022; 167:e600-e606. [PMID: 35995358 DOI: 10.1016/j.wneu.2022.08.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/10/2022] [Accepted: 08/11/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The additional hospital costs associated with delayed cerebral ischemia (DCI) have not been well investigated in prior literature. In this study, the total hospital cost of DCI in aneurysmal subarachnoid hemmorhage (aSAH) patients treated at a single quaternary center was analyzed. METHODS All patients in the Post-Barrow Ruptured Aneurysm Trial treated for an aSAH between January 1, 2014, and July 31, 2019, were retrospectively analyzed. DCI was defined as cerebral infarction identified on computed tomography, magnetic resonance imaging, or autopsy after exclusion of procedure-related infarctions. The primary outcome was the difference in total cost (including hospital, discharge facility, and all follow-up) using a propensity-adjusted analysis. Propensity score covariate-adjusted linear regression analysis included age, sex, open versus endovascular treatment, Hunt and Hess score, and Charlson Comorbidity Index score. RESULTS Of the 391 patients included, 144 (37%) had DCI. Patients with DCI had a significantly greater cost compared to patients without DCI (mean standard deviation $112,081 [$54,022] vs. $86,159 [$38,817]; P < 0.001) and a significantly greater length of stay (21 days [11] vs. 18 days [8], P = 0.003, respectively). In propensity-adjusted linear regression analysis, both DCI (odds ratio, $13,871; 95% confidence interval, $7558-$20,185; P < 0.001) and length of stay (odds ratio, $3815 per day; 95% confidence interval, $3480-$4149 per day; P < 0.001) were found to significantly increase the cost. CONCLUSIONS The significantly higher costs associated with DCI further support the evidence that adverse effects associated with DCI in aSAH pose a significant burden to the health care system.
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Affiliation(s)
- Stefan W Koester
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kavelin Rumalla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Stephen J Dabrowski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Dimitri Benner
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Christopher S Graffeo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ruchira M Jha
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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Machado-Rivas F, Jaimes C, Scherrer B, Benson LA, Gorman MP, Warfield SK, Afacan O. Evaluation of white matter microstructure in pediatric onset multiple sclerosis with diffusion compartment imaging. J Neuroimaging 2022; 32:1098-1108. [PMID: 36036739 DOI: 10.1111/jon.13038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 07/20/2022] [Accepted: 08/05/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND PURPOSE Pediatric-onset multiple sclerosis (POMS) shows earlier axonal involvement and greater axonal loss than in adults. We aim to characterize the white matter (WM) microstructural changes in POMS using a diffusion compartment imaging (DCI) model and compare it to standard diffusion tensor imaging (DTI). METHODS Eleven patients (2 males, mean age 18.8 ± 3.9 years) with a diagnosis of relapsing and remitting POMS (mean age at disease onset 13.8 ± 2.9 years, mean duration 5.1 ± 1.9 years) and healthy controls (8 males, mean age 26.4 ± 6.5 years) were recruited and imaged at 3 T. A 90-gradient set Cube and Sphere acquisition and a novel DCI model known as DIstribution of Anisotropic MicrOstructural eNvironments with Diffusion-weighted imaging (DIAMOND) were used to calculate a single anisotropic compartment, an isotropic compartment, and a free diffusion compartment. Lesions and contralateral normal-appearing white matter (NAWM) in patients and whole brain WM for controls were labeled. RESULTS Eleven patients and 11 controls were recruited. When comparing lesions and contralateral NAWM in patients using DCI, compartmental axial diffusivity, radial diffusivity (cRD), and mean diffusivity (cMD) were higher in lesions. Conversely, compartmental fractional anisotropy (cFA) and heterogeneity index were lower in lesions. An analysis of DTI equivalents showed the same trends. In whole-brain NAWM of patients compared to controls, cRD and cMD were higher and cFA was lower in patients. CONCLUSION Lesions in POMS can be accurately characterized by a DCI model. Incipient changes in NAWM seen in DCI may not be readily observable by DTI.
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Affiliation(s)
- Fedel Machado-Rivas
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Camilo Jaimes
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Benoit Scherrer
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Leslie A Benson
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark P Gorman
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Simon K Warfield
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Onur Afacan
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Condorelli RA, Cannarella R, Crafa A, Barbagallo F, Gusmano C, Avola O, Mongioì LM, Basile L, Calogero AE, La Vignera S. Advances in non-hormonal pharmacotherapy for the treatment of male infertility: the role of inositols. Expert Opin Pharmacother 2022; 23:1081-1090. [PMID: 35348407 DOI: 10.1080/14656566.2022.2060076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Several antioxidants are available for the treatment of male infertility. Although the benefit of myo-inositol (MYO) and D-chiro-inositol (DCI) for female infertility is recognized, their role in male infertility is a matter of debate. AREAS COVERED The authors review the impact that treatment with MYO and/or DCI may have on conventional and bio-functional sperm parameters [mitochondrial membrane potential (MMP), sperm chromatin compactness, and sperm DNA fragmentation (SDF)], seminal oxidative stress (OS) and pregnancy, miscarriage, and live birth rates, and the possible mechanisms involved. Furthermore, the authors gather evidence on the effects of MYO and/or DCI on sperm function in vitro. EXPERT OPINION MYO can improve sperm count, motility, capacitation, acrosome reaction, and MMP. No data are currently available on the effects of DCI in vivo. Both MYO and DCI ameliorate sperm motility and MMP in vitro. Therefore, the use of inositols should be preferred in patients with idiopathic asthenozoospermia, especially in case of impaired sperm mitochondrial function. Due to their insulin-sensitizing action, a role for these molecules may be envisaged for the treatment of infertility caused by carbohydrate metabolism derangement.
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Affiliation(s)
- Rosita A Condorelli
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Rossella Cannarella
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Andrea Crafa
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Federica Barbagallo
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Carmelo Gusmano
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Ottavia Avola
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Laura M Mongioì
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Livia Basile
- Department of Drug and Health Sciences, University of Catania, Catania, Italy
| | - Aldo E Calogero
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Sandro La Vignera
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
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Ignacio KHD, Diestro JDB, Enriquez CAG, Pascual JSG, Medrano JMM, Omar AT, Legaspi GD. Predictive Value of Hematologic Inflammatory Markers in Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2022; 160:e296-e306. [PMID: 35017073 DOI: 10.1016/j.wneu.2022.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 01/03/2022] [Accepted: 01/04/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND OBJECTIVE Our study aimed to determine the ability of hematologic markers (neutrophil/lymphocyte ratio [NLR], platelet/lymphocyte ratio, and red cell distribution width [RDW]) in predicting delayed cerebral ischemia (DCI), modified Rankin Scale scores, and mortality in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS A retrospective observational 6-year review of medical records was conducted to identify all consecutive patients with aSAH admitted to the largest training hospital in the Philippines. Univariable and multivariable regression analyses were performed to determine the association of the biomarkers with the respective outcomes. Receiver operating characteristic curves were used to detect overall predictive accuracy. RESULTS A total of 222 patients with aSAH were included, of whom 11.71% developed DCI. Most patients with NLR ≥5.9 subsequently died (77 vs. 52%; P = 0.03). DCI was also associated with poor functional outcomes with higher modified Rankin Scale scores (3-6) on discharge (92% vs. 49%; P < 0.01), and longer duration of hospitalization (median, 20 vs. 13 days; P = 0.01). In receiver operating characteristic analyses, the value of RDW was predictive for DCI (area under the curve, 0.70; 95% confidence interval, 0.62-0.79; P < 0.01). The values of NLR (area under the curve, 0.67; 95% CI, 0.59-0.74) potentially predict functional outcome. RDW, NLR, and their combinations were poor discriminators of mortality. CONCLUSIONS Our study showed that some hematologic parameters analyzed could be of potential value as prognostic biomarkers in patients with aSAH. Hematologic biomarkers are widely available and practical parameters that may be of considerable clinical value in aSAH management, especially in lower-middle-income countries such as the Philippines.
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Affiliation(s)
- Katrina Hannah D Ignacio
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines.
| | - Jose Danilo B Diestro
- Diagnostic and Therapeutic Neuroradiology, St. Michael's Hospital, University of Toronto, Toronto, Canada; Département de radiologie, radio-oncologie et médecine nucléaire, Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Clare Angeli G Enriquez
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Juan Silvestre G Pascual
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Jose Miguel M Medrano
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Abdelsimar T Omar
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Gerardo D Legaspi
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
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Neumaier F, Weiss M, Veldeman M, Kotliar K, Wiesmann M, Schulze-Steinen H, Höllig A, Clusmann H, Schubert GA, Albanna W. Changes in endogenous daytime melatonin levels after aneurysmal subarachnoid hemorrhage - Preliminary findings from an observational cohort study. Clin Neurol Neurosurg 2021; 208:106870. [PMID: 34418701 DOI: 10.1016/j.clineuro.2021.106870] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/25/2021] [Accepted: 08/02/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Aneurysmal subarachnoid hemorrhage (aSAH) is associated with early and delayed brain injury due to several underlying and interrelated processes, which include inflammation, oxidative stress, endothelial, and neuronal apoptosis. Treatment with melatonin, a cytoprotective neurohormone with anti-inflammatory, anti-oxidant and anti-apoptotic effects, has been shown to attenuate early brain injury (EBI) and to prevent delayed cerebral vasospasm in experimental aSAH models. Less is known about the role of endogenous melatonin for aSAH outcome and how its production is altered by the pathophysiological cascades initiated during EBI. In the present observational study, we analyzed changes in melatonin levels during the first three weeks after aSAH. MATERIALS AND METHODS Daytime (from 11:00 am to 05:00 pm) melatonin levels were measured by enzyme-linked immunosorbent assay (ELISA) in serum samples obtained from 30 patients on the day of aSAH onset (d0) and in five pre-defined time intervals during the early (d1-4), critical (d5-8, d9-12, d13-15) and late (d16-21) phase. Perioperative daytime melatonin levels determined in 30 patients who underwent elective open aortic surgery served as a control for the acute effects of surgical treatment on melatonin homeostasis. RESULTS There was no difference between serum melatonin levels measured in the control patients and on the day of aSAH onset (p = 0.664). However, aSAH was associated with a sustained up-regulation that started during the critical phase (d9-12) and progressed to the late phase (d16-21), during which almost 80% of the patients reached daytime melatonin levels above 5 pg/ml. In addition, subgroup analyses revealed higher melatonin levels on d5-8 in patients with a poor clinical status on admission (p = 0.031), patients with anterior communicating artery aneurysms (p = 0.040) and patients without an external ventricular drain (p = 0.018), possibly pointing to a role of hypothalamic dysfunction. CONCLUSION Our observations in a small cohort of patients provide first evidence for a delayed up-regulation of circulatory daytime melatonin levels after aSAH and a role of aneurysm location for higher levels during the critical phase. These findings are discussed in terms of previous results about stress-induced melatonin production and the role of hypothalamic and brainstem involvement for melatonin levels after aSAH.
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Affiliation(s)
- Felix Neumaier
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany; Forschungszentrum Jülich GmbH, Institute of Neuroscience and Medicine, Nuclear Chemistry (INM-5), Jülich, Germany; University of Cologne, Faculty of Medicine and University Hospital Cologne, Institute of Radiochemistry and Experimental Molecular Imaging, Germany
| | - Miriam Weiss
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Michael Veldeman
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Konstantin Kotliar
- Department of Medical Engineering and Technomathematics, FH Aachen University of Applied Sciences, Aachen, Germany
| | - Martin Wiesmann
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany
| | - Henna Schulze-Steinen
- Department of Intensive Care and Intermediate Care, RWTH Aachen University, Aachen, Germany
| | - Anke Höllig
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany
| | | | - Walid Albanna
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany.
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Dhandapani S, Narayanan R, Dhandapani M, Bhagat H. How Safe and Effective Is Shifting from Pterional to Supraorbital Keyhole Approach for Clipping Ruptured Anterior Circulation Aneurysms? A Surgeon's Transition Phase Comparative Study. J Neurosci Rural Pract 2021; 12:512-517. [PMID: 34295105 PMCID: PMC8289527 DOI: 10.1055/s-0041-1727301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background
Comparative studies between standard pterional and supraorbital keyhole approaches for aneurysms had potential biases with the heterogeneity of patient selection, differences among surgeons, or varying expertise across the surgeon’s learning curve. This is a study of a surgeon’s transition from pterional to keyhole approach for early clipping of selected consecutive ruptured anterior circulation aneurysms.
Methods
Patients more than 18 years, presenting within 72 hours of ictus, in good clinical grades 1 to 3, no midline shift, with saccular aneurysms less than 25 mm at either communicating segment of internal carotid artery, anterior communicating artery, or middle cerebral artery segment till bifurcation were studied between the last 25 cases of pterional and first 25 cases of the keyhole, for the intraoperative and postoperative surgical outcome parameters.
Results
There was no significant difference among baseline parameters, including the location of aneurysms across both groups. While only four cases of pterional had an intraoperative ventricular puncture, the lumbar drain was electively inserted in all keyhole patients. The intraoperative parameters, such as a dural tear, adequate parent vessel exposure, temporary clipping, and intraoperative rupture, did not show any significant difference. None had immediate postoperative deficits. While delayed cerebral ischemia and wound complaints were similar in both groups, temporal hollowing and chewing difficulty were significantly more in pterional patients(
p
= 0.01).
Conclusion
A surgeon experienced in pterional approach can comfortably and safely shift to the keyhole for early clipping of selected ruptured aneurysms less than 25 mm, with a comparable surgical outcome but better cosmesis and mastication.
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Affiliation(s)
- Sivashanmugam Dhandapani
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rajasekhar Narayanan
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Manju Dhandapani
- National Institute of Nursing Education (NINE), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Hemant Bhagat
- Department of Neuroanesthesia, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Ehlert A, Starekova J, Manthei G, Ehlert-Gamm A, Flack J, Gessert M, Gerss J, Hesselmann V. Nitric Oxide-Based Treatment of Poor-Grade Patients After Severe Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2021; 32:742-754. [PMID: 31418143 PMCID: PMC7272492 DOI: 10.1007/s12028-019-00809-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Patients with aneurysmal subarachnoid hemorrhage (aSAH) require close treatment in neuro intensive care units (NICUs). The treatments available to counteract secondary deterioration and delayed ischemic events remain restricted; moreover, available neuro-monitoring of comatose patients is undependable. In comatose patients, clinical signs are hidden, and timing interventions to prevent the evolution of a perfusion disorder in response to fixed ischemic brain damage remain a challenge for NICU teams. Consequently, comatose patients often suffer secondary brain infarctions. The outcomes for long-term intubated patients w/wo pupil dilatation are the worst, with only 10% surviving. We previously added two nitroxide (NO) donors to the standard treatment: continuous intravenous administration of Molsidomine in patients with mild-to-moderate aSAH and, if required as a supplement, intraventricular boluses of sodium nitroprusside (SNP) in high-risk patients to overcome the so-called NO-sink effect, which leads to vasospasm and perfusion disorders. NO boluses were guided by clinical status and promptly reversed recurrent episodes of delayed ischemic neurological deficit. In this study, we tried to translate this concept, the initiation of intraventricular NO application on top of continuous Molsidomine infusion, from awake to comatose patients who lack neurological–clinical monitoring but are primarily monitored using frequently applied transcranial Doppler (TCD). Methods In this observational, retrospective, nonrandomized feasibility study, 18 consecutive aSAH comatose/intubated patients (Hunt and Hess IV/V with/without pupil dilatation) whose poor clinical status precluded clinical monitoring received standard neuro-intensive care, frequent TCD monitoring, continuous intravenous Molsidomine plus intraventricular SNP boluses after TCD-confirmed macrospasm during the daytime and on a fixed nighttime schedule. Results Very likely associated with the application of SNP, which is a matter of further investigation, vasospasm-related TCD findings promptly and reliably reversed or substantially weakened (p < 0.0001) afterward. Delayed cerebral ischemia (DCI) occurred only during loose, low-dose or interrupted treatment (17% vs. an estimated 65% with secondary infarctions) in 17 responders. However, despite their worse initial condition, 29.4% of the responders survived (expected 10%) and four achieved Glasgow Outcome Scale Extended (GOSE) 8–6, modified Rankin Scale (mRS) 0–1 or National Institutes of Health Stroke Scale (NIHSS) 0–2. Conclusions Even in comatose/intubated patients, TCD-guided dual-compartment administration of NO donors probably could reverse macrospasm and seems to be feasible. The number of DCI was much lower than expected in this specific subgroup, indicating that this treatment possibly provides a positive impact on outcomes. A randomized trial should verify or falsify our results.
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Affiliation(s)
- Angelika Ehlert
- Department of Neurosurgery, Asklepios Hospital St. Georg, Lohmühlenstr. 5, 20099, Hamburg, Germany.
| | - Jitka Starekova
- Department of Radiology, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany
| | - Gerd Manthei
- Department of Neurosurgery, Asklepios Hospital St. Georg, Lohmühlenstr. 5, 20099, Hamburg, Germany
| | | | - Joachim Flack
- Doctor's Office, Breitenfelderstr. 7, 20251, Hamburg, Germany
| | - Marie Gessert
- Department of Neurology, Asklepios Hospital St. Georg, Lohmühlenstr. 5, 20099, Hamburg, Germany
| | - Joachim Gerss
- Institute of Biostatistics and Clinical Research, University Hospital Münster, Schmeddingstr. 56, 48149, Münster, Germany
| | - Volker Hesselmann
- Department of Neuroradiology, Asklepios Hospital Nord, Tangstedter Landstr. 400, 22417, Hamburg, Germany
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Albanna W, Weiss M, Veldeman M, Conzen C, Schmidt T, Blume C, Zayat R, Clusmann H, Stoppe C, Schubert GA. Urea-Creatinine Ratio (UCR) After Aneurysmal Subarachnoid Hemorrhage: Association of Protein Catabolism with Complication Rate and Outcome. World Neurosurg 2021; 151:e961-e971. [PMID: 34020058 DOI: 10.1016/j.wneu.2021.05.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 05/09/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The urea-creatinine ratio (UCR) has been proposed as potential biomarker for critical illness-associated catabolism. Its role in the context of aneurysmal subarachnoid hemorrhage (aSAH) remains to be elucidated, which was the aim of the present study. METHODS We enrolled 66 patients with aSAH with normal renal function and 36 patients undergoing elective cardiac surgery as a control group for the effects of surgery. In patients with aSAH, the predictive or diagnostic value of early (day 0-2) and critical (day 5-7) UCRs was assessed with regard to delayed cerebral ischemia (DCI), DCI-related infarction, and clinical outcome after 12 months. RESULTS Preoperatively, UCR was similar both groups. Within 2 days postoperatively, UCRs increased significantly in patients in the elective cardiac surgery group (P < 0.001) but decreased back to baseline on day 5-7 (P = 0.245), whereas UCRs in patients with aSAH increased to significantly greater levels on day 5-7 (P = 0.028). Greater early or critical UCRs were associated with poor clinical outcomes (P = 0.015) or DCI (P = 0.011), DCI-related infarction (P = 0.006), and poor clinical outcomes (P < 0.001) respectively. In multivariate analysis, there was an independent association between greater early UCRs and poor clinical outcomes (P = 0.026). CONCLUSIONS In this exploratory study of UCR in the context of aSAH, greater early values were predictive for a poor clinical outcome after 12 months, whereas greater critical values were associated with DCI, DCI-related infarctions, and poor clinical outcomes. The clinical implications as well as the pathophysiologic relevance of protein catabolism should be explored further in the context of aSAH.
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Affiliation(s)
- Walid Albanna
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany.
| | - Miriam Weiss
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Michael Veldeman
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Catharina Conzen
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Tobias Schmidt
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Christian Blume
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Rachad Zayat
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Christian Stoppe
- Department of Intensive Care Medicine and Intermediate Care, RWTH Aachen University, Aachen, Germany
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Douilly C, Lepoix E, Azzouz B, Morel A, Trenque T. [DRESS syndrome to phenobarbital: A hypersensitivity reaction to drugs known but forgotten by prescribers-A case report]. Therapie 2021; 77:493-495. [PMID: 34088496 DOI: 10.1016/j.therap.2021.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 04/30/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Camille Douilly
- Département de pharmacovigilance et pharmaco-épidemiologie, centre hospitalo-universitaire de Reims, avenue du Général Koening, 51092 Reims, France
| | - Elise Lepoix
- Département de pharmacovigilance et pharmaco-épidemiologie, centre hospitalo-universitaire de Reims, avenue du Général Koening, 51092 Reims, France.
| | - Brahim Azzouz
- Département de pharmacovigilance et pharmaco-épidemiologie, centre hospitalo-universitaire de Reims, avenue du Général Koening, 51092 Reims, France; EA 3797, faculté de médecine, université de Reims Champagne-Ardenne, 51100 Reims, France
| | - Aurore Morel
- Département de pharmacovigilance et pharmaco-épidemiologie, centre hospitalo-universitaire de Reims, avenue du Général Koening, 51092 Reims, France
| | - Thierry Trenque
- Département de pharmacovigilance et pharmaco-épidemiologie, centre hospitalo-universitaire de Reims, avenue du Général Koening, 51092 Reims, France; EA 3797, faculté de médecine, université de Reims Champagne-Ardenne, 51100 Reims, France
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11
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Simon M, Grote A. Interleukin 6 and Aneurysmal Subarachnoid Hemorrhage. A Narrative Review. Int J Mol Sci 2021; 22:4133. [PMID: 33923626 DOI: 10.3390/ijms22084133] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 02/07/2023] Open
Abstract
Interleukin 6 (IL-6) is a prominent proinflammatory cytokine. Neuroinflammation in general, and IL-6 signaling in particular, appear to play a major role in the pathobiology and pathophysiology of aneurysm formation and aneurysmal subarachnoid hemorrhage (SAH). Most importantly, elevated IL-6 CSF (rather than serum) levels appear to correlate with delayed cerebral ischemia (DCI, “vasospasm”) and secondary (“vasospastic”) infarctions. IL-6 CSF levels may also reflect other forms of injury to the brain following SAH, i.e., early brain damage and septic complications of SAH and aneurysm treatment. This would explain why many researchers have found an association between IL-6 levels and patient outcomes. These findings clearly suggest CSF IL-6 as a candidate biomarker in SAH patients. However, at this point, discrepant findings in variable study settings, as well as timing and other issues, e.g., defining proper clinical endpoints (i.e., secondary clinical deterioration vs. angiographic vasospasm vs. secondary vasospastic infarct) do not allow for its routine use. It is also tempting to speculate about potential therapeutic measures targeting elevated IL-6 CSF levels and neuroinflammation in SAH patients. Corticosteroids and anti-platelet drugs are indeed used in many SAH cases (not necessarily with the intention to interfere with detrimental inflammatory signaling), however, no convincing benefit has been demonstrated yet. The lack of a robust clinical perspective against the background of a relatively large body of data linking IL-6 and neuroinflammation with the pathophysiology of SAH is somewhat disappointing. One underlying reason might be that most relevant studies only report correlative data. The specific molecular pathways behind elevated IL-6 levels in SAH patients and their various interactions still remain to be delineated. We are optimistic that future research in this field will result in a better understanding of the role of neuroinflammation in the pathophysiology of SAH, which in turn, will translate into the identification of suitable biomarkers and even potential therapeutic targets.
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12
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Athiraman U, Dhar R, Jayaraman K, Karanikolas M, Helsten D, Yuan J, Lele AV, Rath GP, Tempelhoff R, Roth S, Zipfel GJ. Conditioning Effect of Inhalational Anesthetics on Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2021; 88:394-401. [PMID: 32860066 DOI: 10.1093/neuros/nyaa356] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 06/19/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (SAH) has been identified as an independent predictor of poor outcome in numerous studies. OBJECTIVE To investigate the potential protective role of inhalational anesthetics against angiographic vasospasm, DCI, and neurologic outcome in SAH patients. METHODS After Institutional Review Board approval, data were collected retrospectively for SAH patients who received general anesthesia for aneurysm repair between January 1st, 2010 and May 31st, 2018. Primary outcomes were angiographic vasospasm, DCI, and neurologic outcome as measured by modified Rankin scale at hospital discharge. Univariate and logistic regression analysis were performed to identify independent predictors of these outcomes. RESULTS The cohort included 390 SAH patients with an average age of 56 ± 15 (mean ± SD). Multivariate logistic regression analysis identified inhalational anesthetic only technique, Hunt-Hess grade, age, anterior circulation aneurysm and average intraoperative mean blood pressure as independent predictors of angiographic vasospasm. Inhalational anesthetic only technique and modified Fishers grade were identified as independent predictors of DCI. No impact on neurological outcome at time of discharge was noted. CONCLUSION Our data provide additional evidence that inhalational anesthetic conditioning in SAH patients affords protection against angiographic vasospasm and new evidence that it exerts a protective effect against DCI. When coupled with similar results from preclinical studies, our data suggest further investigation into the impact of inhalational anesthetic conditioning on SAH patients, including elucidating the most effective dosing regimen, defining the therapeutic window, determining whether a similar protective effect against early brain injury, and on long-term neurological outcome exists.
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Affiliation(s)
| | - Rajat Dhar
- Department of Neurology, Washington University, St. Louis, Missouri
| | - Keshav Jayaraman
- Department of Neurological surgery, Washington University, St. Louis, Missouri
| | | | - Daniel Helsten
- Department of Anesthesiology , Washington University, St. Louis, Missouri
| | - Jane Yuan
- Department of Neurological surgery, Washington University, St. Louis, Missouri
| | - Abhijit V Lele
- Neurocritical Care Service, Harborview Medical Center, Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Girija Prasad Rath
- Department of Neuroanaesthesiology & Critical Care, Neurosciences Centre, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Rene Tempelhoff
- Department of Anesthesiology , Washington University, St. Louis, Missouri.,Department of Neurological surgery, Washington University, St. Louis, Missouri
| | - Steven Roth
- Department of Anesthesiology; Ophthalmology and Visual Sciences, College of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Gregory J Zipfel
- Department of Neurology, Washington University, St. Louis, Missouri.,Department of Neurological surgery, Washington University, St. Louis, Missouri
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Athiraman U, Liu M, Jayaraman K, Yuan J, Mehla J, Zipfel GJ. Anesthetic and subanesthetic doses of isoflurane conditioning provides strong protection against delayed cerebral ischemia in a mouse model of subarachnoid hemorrhage. Brain Res 2020; 1750:147169. [PMID: 33132166 DOI: 10.1016/j.brainres.2020.147169] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/16/2020] [Accepted: 10/17/2020] [Indexed: 12/23/2022]
Abstract
Delayed cerebral ischemia (DCI) is identified as one of the significant contributors to poor patient outcome after aneurysmal subarachnoid hemorrhage (SAH). We previously reported that a supratherapeutic dose of isoflurane conditioning (2%) provided robust protection against SAH-induced DCI. The aim of our current study is to compare the efficacy of the supratherapeutic dose of isoflurane to that typically used to establish general anesthesia or sedation. After IRB approval for animal studies, ten to fourteen-week-old wild-type male mice (C57BL/6) were divided into five groups - sham, SAH alone, or SAH with isoflurane conditioning (0.5%, 1%, and 2%). Conditioning was performed with one-hour of isoflurane initiated one-hour after induction of SAH via endovascular perforation technique. Vasospasm measurement in the middle cerebral artery was assessed 72 h after SAH. Neurological assessment was performed at baseline and for next three days after SAH. It was identified that all tested doses of isoflurane conditioning (0.5%, 1%, and 2%) significantly attenuated large artery vasospasm and markedly improved neurological deficits following SAH. No significant differences in neurovascular outcome were noted between the three doses of isoflurane conditioning. Our data show that isoflurane dosing typically used for general anesthesia (1%) or sedation (0.5%) provide similar levels of DCI protection in SAH as that provided by a supratherapeutic dose (2%). This result has important implications for future translational studies. Additional studies examining the therapeutic potential of anesthetic conditioning for SAH are therefore warranted.
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Affiliation(s)
- Umeshkumar Athiraman
- Department of Anesthesiology, Washington University, St. Louis, MO 63110, United States.
| | - Meizi Liu
- Department of Anesthesiology, Washington University, St. Louis, MO 63110, United States
| | - Keshav Jayaraman
- Department of Neurological Surgery, Washington University, St. Louis, MO 63110, United States
| | - Jane Yuan
- Department of Anesthesiology, Washington University, St. Louis, MO 63110, United States
| | - Jogender Mehla
- Department of Neurological Surgery, Washington University, St. Louis, MO 63110, United States
| | - Gregory J Zipfel
- Departments of Neurological Surgery and Neurology, Washington University, St. Louis, MO 63110, United States
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Nishikawa N, Iwaki H, Shiraishi T, Mukai Y, Takahashi Y, Murata M. Female, aging, difference formulations of DCI, or lower body weight increases AUC 4hr of levodopa in patients with Parkinson's disease. Parkinsonism Relat Disord 2020; 76:16-20. [PMID: 32554330 DOI: 10.1016/j.parkreldis.2020.05.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 05/09/2020] [Accepted: 05/19/2020] [Indexed: 11/21/2022]
Abstract
INTRODUCTION There is considerable intra- and inter-individual variability in the pharmacokinetics (PK) of levodopa after oral administration. Inter-individual variability in levodopa PK has also been demonstrated in fasting single-dose studies. We examined the factors that affect levodopa PK in patients with Parkinson's disease (PD) and quantified the intensity of their respective effects. METHODS We studied 220 patients who underwent PK assessment after administration of 1 tablet of levodopa/DOPA decarboxylase inhibitor (DCI) combination, which contained 10 mg carbidopa/100 mg levodopa or 25 mg benserazide/100 mg levodopa. PK was evaluated using non-compartmental analysis. RESULTS In total, 220 PD patients (including 112 men) were studied. The mean age (±standard deviation) and mean disease duration was 68.1 ± 8.9 and 7.7 ± 5.8 years, respectively. The Cmax of levodopa was 9.0 ± 4.0 ng/mL, Tmax was 41.4 ± 40.2 min, and area under the blood concentration-time curve up to 4 h (AUC4hr) was 12.3 ± 3.7 ng/mL*4hr. Factors affecting AUC4hr were analyzed using multiple linear regression models. Age (1.1 ± 0.23 per +10 years, p = 3.1E-8), sex (2.2 ± 0.5 for female, p = 1.9E-5), DCI (1.4 ± 0.4 for benserazide, p = 0.0028), and body weight (-0.77 ± 0.22 per +10 kg, p = 5.4E-4) were significantly related to AUC4hr, while disease duration, dyskinesia status, and eGFR were not related to AUC4hr and Cmax. CONCLUSION Female, aging, difference formulations of DCI, or lower body weight independently contributes to increased AUC4hr of levodopa in Japanese patients with PD in this study.
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15
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Mohme M, Sauvigny T, Mader MM, Schweingruber N, Maire CL, Rünger A, Ricklefs F, Regelsberger J, Schmidt NO, Westphal M, Lamszus K, Tolosa E, Czorlich P. Immune Characterization in Aneurysmal Subarachnoid Hemorrhage Reveals Distinct Monocytic Activation and Chemokine Patterns. Transl Stroke Res 2020; 11:1348-61. [PMID: 31858408 DOI: 10.1007/s12975-019-00764-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 11/08/2019] [Accepted: 12/04/2019] [Indexed: 10/25/2022]
Abstract
The pathophysiology of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH) is incompletely understood. Intrathecal activation of inflammatory immune cells is suspected to play a major role for the induction of DCI. The aim of this study is to identify immune cell subsets and mediators involved in the pathogenesis of DCI. We prospectively collected blood and CSF from 25 patients with aSAH at early and late time points. We performed multicolor flow cytometry of peripheral blood and CSF, analyzing immune cell activation and pro-inflammatory cyto- and chemokines. In addition to the primary immune analysis, we retrospectively analyzed immune cell dynamics in the CSF of all our SAH patients. Our results show an increased monocyte infiltration secondary to aneurysm rupture in patients with DCI. Infiltrating monocytes are defined by a non-classical (CD14dim CD16+) phenotype at early stages. The infiltration is most likely triggered by the intrathecal immune activation. Here, high levels of pro-inflammatory chemokines, such as CXCL1, CXCL9, CXCL10, and CXCL11, are detected. The intrathecal cellular activation profile of monocytes was defined by upregulation of CD163 and CD86 on monocytes and a presumable later differentiation into antigen-presenting plasmacytoid dendritic cells (pDCs) and hemosiderophages. Peripheral immune activation was reflected by CD69 upregulation on T cells. Analysis of DCI prevalence, Hunt and Hess grade, and clinical outcome correlated with the degree of immune activation. We demonstrate that monocytes and T cells are activated intrathecally after aSAH and mediate a local inflammatory response which is presumably driven by chemokines. Our data shows that the distinct pattern of immune activation correlates with the prevalence of DCI, indicating a pathophysiological connection to the incidence of vasospasm.
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16
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Athiraman U, Aum D, Vellimana AK, Osbun JW, Dhar R, Tempelhoff R, Zipfel GJ. Evidence for a conditioning effect of inhalational anesthetics on angiographic vasospasm after aneurysmal subarachnoid hemorrhage. J Neurosurg 2019; 133:1-7. [PMID: 31200380 DOI: 10.3171/2019.3.jns183512] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 03/24/2019] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (SAH) is characterized by large-artery vasospasm, distal autoregulatory dysfunction, cortical spreading depression, and microvessel thrombi. Large-artery vasospasm has been identified as an independent predictor of poor outcome in numerous studies. Recently, several animal studies have identified a strong protective role for inhalational anesthetics against secondary brain injury after SAH including DCI-a phenomenon referred to as anesthetic conditioning. The aim of the present study was to assess the potential role of inhalational anesthetics against cerebral vasospasm and DCI in patients suffering from an SAH. METHODS After IRB approval, data were collected retrospectively for all SAH patients admitted to the authors' hospital between January 1, 2010, and December 31, 2013, who received general anesthesia with either inhalational anesthetics only (sevoflurane or desflurane) or combined inhalational (sevoflurane or desflurane) and intravenous (propofol) anesthetics during aneurysm treatment. The primary outcomes were development of angiographic vasospasm and development of DCI during hospitalization. Univariate and logistic regression analyses were performed to identify independent predictors of these endpoints. RESULTS The cohort included 157 SAH patients whose mean age was 56 ± 14 (± SD). An inhalational anesthetic-only technique was employed in 119 patients (76%), while a combination of inhalational and intravenous anesthetics was employed in 34 patients (22%). As expected, patients in the inhalational anesthetic-only group were exposed to significantly more inhalational agent than patients in the combination anesthetic group (p < 0.05). Multivariate logistic regression analysis identified inhalational anesthetic-only technique (OR 0.35, 95% CI 0.14-0.89), Hunt and Hess grade (OR 1.51, 95% CI 1.03-2.22), and diabetes (OR 0.19, 95% CI 0.06-0.55) as significant predictors of angiographic vasospasm. In contradistinction, the inhalational anesthetic-only technique had no significant impact on the incidence of DCI or functional outcome at discharge, though greater exposure to desflurane (as measured by end-tidal concentration) was associated with a lower incidence of DCI. CONCLUSIONS These data represent the first evidence in humans that inhalational anesthetics may exert a conditioning protective effect against angiographic vasospasm in SAH patients. Future studies will be needed to determine whether optimized inhalational anesthetic paradigms produce definitive protection against angiographic vasospasm; whether they protect against other events leading to secondary brain injury after SAH, including microvascular thrombi, autoregulatory dysfunction, blood-brain barrier breakdown, neuroinflammation, and neuronal cell death; and, if so, whether this protection ultimately improves patient outcome.
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Affiliation(s)
| | | | | | | | - Rajat Dhar
- 3Neurology, Washington University, St. Louis, Missouri
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Mehaffey JH, Hawkins RB, Charles EJ, Sahli ZT, Schirmer BD, Hallowell PT. Socioeconomically Distressed Communities Associated With Long-term Mortality After Bariatric Surgery. J Surg Res 2019; 243:8-13. [PMID: 31146087 DOI: 10.1016/j.jss.2019.04.081] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/14/2019] [Accepted: 04/26/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Surgical outcomes are affected by socioeconomic status, yet these factors are poorly accounted for in clinical databases. We sought to determine if the Distressed Communities Index (DCI), a composite ranking by zip code that quantifies socioeconomic risk, was associated with long-term survival after bariatric surgery. METHODS All patients undergoing Roux-en-Y gastric bypass (1985-2004) at a single institution were paired with DCI. Scores range from 0 (no distress) to 100 (severe distress) and account for unemployment, education, poverty, median income, housing vacancies, job growth, and business establishment growth. Distressed communities, defined as DCI ≥75, were compared with all other patients. Regression modeling was used to evaluate the effect of DCI on 10-year bariatric outcomes, whereas Cox Proportional Hazards and Kaplan-Meier analysis examined long-term survival. RESULTS Gastric bypass patients (n = 681) come from more distressed communities compared with the general public (DCI 60.5 ± 23.8 versus 50 ± 10; P < 0.0001). A total of 221 (32.3%) patients came from distressed communities (DCI ≥75). These patients had similar preoperative characteristics, including BMI (51.5 versus 51.7 kg/m2; P = 0.63). Socioeconomic status did not affect 10-year bariatric outcomes, including percent reduction in excess body mass index (57% versus 58%; P = 0.93). However, patients from distressed communities had decreased risk-adjusted long-term survival (hazard ratio, 1.38; P = 0.043). CONCLUSIONS Patients with low socioeconomic status, as determined by the DCI, have equivalent outcomes after bariatric surgery despite worse long-term survival. Future quality improvement efforts should focus on these persistent disparities in health care.
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Affiliation(s)
- J Hunter Mehaffey
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Robert B Hawkins
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Eric J Charles
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Zeyad T Sahli
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Bruce D Schirmer
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Peter T Hallowell
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia.
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Jabbarli R, Pierscianek D, Darkwah Oppong M, Sato T, Dammann P, Wrede KH, Kaier K, Köhrmann M, Forsting M, Kleinschnitz C, Roos A, Sure U. Laboratory biomarkers of delayed cerebral ischemia after subarachnoid hemorrhage: a systematic review. Neurosurg Rev 2018; 43:825-833. [PMID: 30306357 DOI: 10.1007/s10143-018-1037-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 09/19/2018] [Accepted: 09/21/2018] [Indexed: 01/25/2023]
Abstract
Delayed cerebral ischemia (DCI) is a severe complication of subarachnoid hemorrhage (SAH). Clinical and radiographic features of SAH may be helpful in identification of individuals prone to DCI. The aim of this systematic review was to analyze the present evidence on predictive value of blood and cerebrospinal fluid (CSF) biomarkers of DCI after SAH. We systematically searched in PubMed, Scopus, Web of Science, and Cochrane Library databases for publications before July 15, 2018, reporting correlations between blood/CSF biomarkers and occurrence of DCI and/or vasospasm in SAH patients. Included studies underwent quality assessment according to QUIPS and STARD guidelines. Level of evidence (I-IV) for each of tested biomarkers was assessed according to GRADE guidelines. Of 2181 unique records identified in four databases, 270 original articles and 5 meta-analyses were included to this review. Of 257 blood and CSF parameters analyzed in 16.914 SAH patients, there was no biomarker with positive association with DCI/vasospasm showing level I evidence. Twenty-one biomarkers achieved level II evidence and could be confirmed as predictive biomarkers. In this review, six single nucleotide polymorphisms (for EET metabolic pathways, COMT, HMGB1, ACE, PAI-1 promoter, and Hp genes) and 15 non-genetic biomarkers (pNF-H, ADAMTS13, NPY, Copeptin, HMGB1, GFAP, periostin, Tau, BNP, NT pro-BNP, hs-TnT, PA-TEGMA, MPV:PLT, NLR, and PLR) were selected as predictive DCI biomarkers. We propose that a panel analysis of the selected genetic and protein biomarker candidates would be needed for further validation in a large SAH cohort.
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Affiliation(s)
- Ramazan Jabbarli
- Department of Neurosurgery, University Hospital of Essen, D-45147, Essen, Germany.
| | - Daniela Pierscianek
- Department of Neurosurgery, University Hospital of Essen, D-45147, Essen, Germany
| | | | - Tako Sato
- Department of Neurosurgery, University Hospital of Essen, D-45147, Essen, Germany
| | - Philipp Dammann
- Department of Neurosurgery, University Hospital of Essen, D-45147, Essen, Germany
| | - Karsten H Wrede
- Department of Neurosurgery, University Hospital of Essen, D-45147, Essen, Germany
| | - Klaus Kaier
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Martin Köhrmann
- Clinic for Neurology, University Hospital of Essen, Essen, Germany
| | - Michael Forsting
- Institute for Diagnostic and Interventional Radiology, University Hospital of Essen, Essen, Germany
| | | | - Andreas Roos
- Leibniz Institute for Analytical Sciences - ISAS - e.V., Dortmund, Germany
| | - Ulrich Sure
- Department of Neurosurgery, University Hospital of Essen, D-45147, Essen, Germany
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Luo W, Wang H, Hu J. Increased concentration of serum periostin is associated with poor outcome of patients with aneurysmal subarachnoid hemorrhage. J Clin Lab Anal 2018; 32:e22389. [PMID: 29498090 DOI: 10.1002/jcla.22389] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 12/27/2017] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To explore the role of serum periostin in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHOD We conducted a retrospective study and 124 aSAH patients treated in Shenzhen People's hospital during March 1st 2015 to December 30th 2016 were included. Baseline information, neurological status and clinical outcome were recorded. Blood samples on admission were collected and enzyme linked immunosorbent assay (ELISA) kits were used to detect the serum level of periostin. Spearman's Correlation Analysis was used to analyze the correlation between periostin and clinical severity. Receiver operating characteristic (ROC) curve was performed to investigate variables' prognostic value in patients with aSAH. RESULTS The average age of patients included was 57.23 years old. Preliminary analysis revealed that serum periostin was significantly correlated with clinical severity. Patients with poor outcome at 12 months had higher level of periostin than patients with good outcome. Multivariate logistic regression analysis showed elevated level of periostin was significantly associated with poor outcome and the AUC was 0.85 for periostin in predicting poor outcome of patient with aSAH. CONCLUSION Elevated serum periostin concentrations are significantly associated with clinical severity and poor outcome of aSAH patients, which indicate serum periostin can be used as a prognostic biomarker in patients with aSAH.
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Affiliation(s)
- Weijian Luo
- Department of Neurosurgery, Shenzhen People's Hospital, Second Clinical Medical College of Jinan University, Shenzhen, China
| | - Hao Wang
- Department of Neurosurgery, Shenzhen People's Hospital, Second Clinical Medical College of Jinan University, Shenzhen, China
| | - Jiliang Hu
- Department of Neurosurgery, Shenzhen People's Hospital, Second Clinical Medical College of Jinan University, Shenzhen, China
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Westermaier T, Stetter C, Kunze E, Willner N, Holzmeier J, Weiland J, Koehler S, Lotz C, Kilgenstein C, Ernestus RI, Roewer N, Muellenbach RM. Controlled Hypercapnia Enhances Cerebral Blood Flow and Brain Tissue Oxygenation After Aneurysmal Subarachnoid Hemorrhage: Results of a Phase 1 Study. Neurocrit Care 2017; 25:205-14. [PMID: 26886010 DOI: 10.1007/s12028-016-0246-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND This study investigated if cerebral blood flow (CBF) regulation by changes of the arterial partial pressure of carbon dioxide (PaCO2) can be used therapeutically to increase CBF and improve neurological outcome after subarachnoid hemorrhage (SAH). METHODS In 12 mechanically ventilated poor-grade SAH-patients, a daily trial intervention was performed between day 4 and 14. During this intervention, PaCO2 was decreased to 30 mmHg and then gradually increased to 40, 50, and 60 mmHg in 15-min intervals by modifications of the respiratory minute volume. CBF and brain tissue oxygen saturation (StiO2) were the primary and secondary endpoints. Intracranial pressure was controlled by an external ventricular drainage. RESULTS CBF reproducibly decreased during hyperventilation and increased to a maximum of 141 ± 53 % of baseline during hypercapnia (PaCO2 60 mmHg) on all days between day 4 and 14 after SAH. Similarly, StiO2 increased during hypercapnia. CBF remained elevated within the first hour after resetting ventilation to baseline parameters and no rebound effect was observed within this time-span. PaCO2-reactivities of CBF and StiO2 were highest between 30 and 50 mmHg and slightly decreased at higher levels. CONCLUSION CBF and StiO2 reproducibly increased by controlled hypercapnia of up to 60 mmHg even during the period of the maximum expected vasospasm. The absence of a rebound effect within the first hour after hypercapnia indicates that an improvement of the protocol is possible. The intervention may yield a therapeutic potential to prevent ischemic deficits after aneurysmal SAH.
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Affiliation(s)
- Thomas Westermaier
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany.
| | - Christian Stetter
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
| | - Ekkehard Kunze
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
| | - Nadine Willner
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
| | - Judith Holzmeier
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
| | - Judith Weiland
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
| | - Stefan Koehler
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
| | - Christopher Lotz
- Department of Anesthesia and Critical Care, University Hospital Wuerzburg, 97080, Würzburg, Germany
| | - Christian Kilgenstein
- Department of Anesthesia and Critical Care, University Hospital Wuerzburg, 97080, Würzburg, Germany
| | - Ralf-Ingo Ernestus
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
| | - Norbert Roewer
- Department of Anesthesia and Critical Care, University Hospital Wuerzburg, 97080, Würzburg, Germany
| | - Ralf Michael Muellenbach
- Department of Anesthesia and Critical Care, University Hospital Wuerzburg, 97080, Würzburg, Germany
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Sun J, Hu J, Zhu G, Zhang D, Zhu Y, Chen Z, Li J, Zhang H, Tang J, Nie J, Zhang S. PCDD/Fs distribution characteristics and health risk assessment in fly ash discharged from MSWIs in China. Ecotoxicol Environ Saf 2017; 139:83-88. [PMID: 28113115 DOI: 10.1016/j.ecoenv.2017.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 12/25/2016] [Accepted: 01/06/2017] [Indexed: 06/06/2023]
Abstract
This study provided distribution and health risk information of polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD/Fs) in fly ash from 4 municipal solid waste incinerators (MSWIs) in four seasons from four sites, including Zhengzhou City in Henan Province, Chuzhou City in Anhui Province, Jilin City in Jilin Province and Zibo City in Shandong Province. The toxic equivalent concentration (I-TEQ) values of PCDD/Fs ranged from 0.0707 to 0.7742ng I-TEQ/g, and no identical sequence occurred during four seasons in different sampling sites. The stabilization process might efficiently reduce the content and toxicology of PCDD/Fs in fly ash. The value of PCDD/PCDF in fly ash ranged from 0.145 to 0.787 after solidification. The characteristic index (DCI) of 2,3,4,7,8-P5CDF was 0.803 with 6.6% under 95% probability for fly ash samples discharged from MSWIs. The 95th percentile carcinogenic risks (CRs) for onsite workers were lower than the threshold value (10-5), suggesting that the cancer risk levels of PCDD/Fs in fly ash for onsite workers were acceptable. The 95th percentile non-carcinogenic risks (non-CRs) for onsite workers were lower than 1, suggesting no obvious non-carcinogenic effect was developed for onsite workers. This paper provide an overview information on the distribution of PCDD/Fs in fly ash during four seasons, and it could be used as an important fingerprint to distinguish the fly ash sources. Thus, the research could provide basic information for fly ash management in environment.
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Affiliation(s)
- Jie Sun
- Jiangsu Levei Testing Company Limited, Wuxi 214000, China
| | - Juan Hu
- Jiangsu Levei Testing Company Limited, Wuxi 214000, China
| | - Gengzheng Zhu
- Jiangsu Levei Testing Company Limited, Wuxi 214000, China
| | - Dadang Zhang
- Jiangsu Levei Testing Company Limited, Wuxi 214000, China
| | - Yuyi Zhu
- Jiangsu Levei Testing Company Limited, Wuxi 214000, China
| | - Zhihai Chen
- Jiangsu Levei Testing Company Limited, Wuxi 214000, China.
| | - Jiafu Li
- Jiangsu Levei Testing Company Limited, Wuxi 214000, China.
| | - Hongjian Zhang
- Jiangsu Levei Testing Company Limited, Wuxi 214000, China
| | - Jinshun Tang
- Jiangsu Levei Testing Company Limited, Wuxi 214000, China
| | - Jihua Nie
- School of Public Health Medical College of Soochow university, Suzhou 215000, China
| | - Shuyu Zhang
- School of Public Health Medical College of Soochow university, Suzhou 215000, China
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Chin W, Joo E, Ninokawa S, Popa DA, Covington DB. Efficacy of the U.S. Navy Treatment Tables in treating DCS in 103 recreational scuba divers. Undersea Hyperb Med 2017; 44:399-405. [PMID: 29116694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Despite the fact that current decompression schedules reduce the risk of decompression sickness (DCS), recreational scuba divers continue to experience DCS. Therapy outcomes in these divers are difficult to track. Our study aims to understand the efficacy of the United States Navy (USN) Treatment Tables (5, 6, 6A, 9) in providing symptomatic relief among recreational scuba divers. We conducted a single-center retrospective review of recreational divers treated from 2003 to 2013. A total of 187 divers were identified: 84 divers were excluded, and the charts of the remaining 103 divers were independently reviewed by three clinicians. For these 103 divers, the response variable, therapy outcome, was categorized as no relief, partial relief, or complete relief of symptoms. In a population of 76 males and 27 females with an average of three dives and three treatments, 53 patients achieved complete symptomatic relief, 45 patients had partial relief, and five patients reported no relief at the end of all recompression treatments. Among the patients who achieved complete symptomatic relief, 28 (53%) needed only one recompression treatment. The depth of the diver's first dive and the change in symptoms within the first 20 minutes of the first recompression treatment were found to be explanatory variables of the treatment outcome.
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Affiliation(s)
- Walter Chin
- UCLA Radiation Oncology, Los Angeles, California U.S
| | - Ellie Joo
- UCLA Radiation Oncology, Los Angeles, California U.S
| | | | - Daniel A Popa
- UCLA Radiation Oncology, Los Angeles, California U.S
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23
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Ofir D, Yanir Y, Abramovich A, Bar R, Arieli Y. Evaluating the risk of decompression sickness for a yo-yo dive using a rat model. Undersea Hyperb Med 2016; 43:405-410. [PMID: 28763169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
PURPOSE The frequent ascents made during yo-yo diving may contribute to gas bubble clearance but paradoxically may also increase the risk of central nervous system decompression illness (DCI). We evaluated the risk of DCI due to yo-yo dives with very short surface intervals, using a controlled animal model. METHODS Dives were conducted on air to a depth of 90 meters (10 atmospheres absolute) for 32 minutes of bottom time, at a descent/ascent rate of 10 meters/ minute. Sprague-Dawley rats weighing ~ 300 grams were divided randomly into three groups. Group A performed a square dive protocol without any surface intervals, Group B conducted a protocol that included two surface intervals during the dive, and Group C performed a protocol with three surface intervals. Ascent/descent rate for surface intervals, each lasting one minute, was also 10 meters/minute. RESULTS Manifestations of DCI were observed in 13 of 16 animals in Group A (81.3%), six of 12 in Group B (58.3%), and two of 12 in Group C (16.7%). Mortality rates were similar in all groups. CONCLUSIONS Surface intervals during dives breathing air significantly reduced DCI risk in the rat. Further studies are required using a larger animal model to reinforce the results of the present investigation.
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Affiliation(s)
- Dror Ofir
- Israel Naval Medical Institute, IDF Medical Corps, Haifa, Israel
| | - Yoav Yanir
- Israel Naval Medical Institute, IDF Medical Corps, Haifa, Israel
| | - Amir Abramovich
- Israel Naval Medical Institute, IDF Medical Corps, Haifa, Israel
| | - Ronen Bar
- Israel Naval Medical Institute, IDF Medical Corps, Haifa, Israel
| | - Yehuda Arieli
- Israel Naval Medical Institute, IDF Medical Corps, Haifa, Israel
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Cialoni D, Pieri M, Giunchi G, Sponsiello N, Lanzone AM, Torcello L, Boaretto G, Marroni A. Detection of venous gas emboli after repetitive breath-hold dives: case report. Undersea Hyperb Med 2016; 43:449-455. [PMID: 28763174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Neurological symptoms after breathhold (BH) diving are often referred to as "Taravana" and considered a form of decompression sickness. However, the presence of "high" gas embolism after BH diving has never been clearly shown. This study showed high bubble formation after BH diving. MATERIALS AND METHODS We performed transthoracic echocardiography on a 53-year-old male spearfishing diver (180 cm; 80 kg; BMI 24.7) 15 minutes before diving and at 15-minute intervals for 90 minutes after diving in a 42-meter-deep pool. Number of dives, bottom time and surface intervals were freely determined by the diver. Dive profiles were digitally recorded for depth, time and surface interval, using a freediving computer. Relative surface interval (surface interval/diving time) and gradient factor were calculated. REULTS High bubble grades were found in all the recorded echocardiograms. From the first to third recording (45 minutes), Grade 4 Eftedal-Brubakk (EB) bubbles were observed. The 60-, 75- and 90-minute recordings showed a reduction to Grades 3, 2 and 1 EB. Mean calculated GF for every BH dive was 0.22; maximum GF after the last dive was 0.33. CONCLUSIONS High bubble grades can occur in BH diving, as confirmed by echocardiographic investigation. Ordinary methods to predict inert gas supersaturation may not able to predict Taravana cases.
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Affiliation(s)
- D Cialoni
- DAN Europe Research Division, Roseto degli Abruzzi, Italy
- Apnea Academy Research, Padua, Italy
| | - M Pieri
- DAN Europe Research Division, Roseto degli Abruzzi, Italy
| | - G Giunchi
- DAN Europe Research Division, Roseto degli Abruzzi, Italy
| | - N Sponsiello
- DAN Europe Research Division, Roseto degli Abruzzi, Italy
- Apnea Academy Research, Padua, Italy
| | - A M Lanzone
- UU.OO. di Cardiologia e Cardiochirurgia; Istituto Clinico San Rocco, Ome (Bs), Lombardy, Italy
| | - L Torcello
- Habilita, Hyperbaric Department; Zingonia (BG), Lombardy, Italy
| | - G Boaretto
- Swimming pool Y-40 research coordinator, Padua, Italy
| | - A Marroni
- DAN Europe Research Division, Roseto degli Abruzzi, Italy
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Ehlert A, Manthei G, Hesselmann V, Mathias K, Bein B, Pluta R. A Case of Hyperacute Onset of Vasospasm After Aneurysmal Subarachnoid Hemorrhage and Refractory Vasospasm Treated with Intravenous and Intraventricular Nitric Oxide: A Mini Review. World Neurosurg 2016; 91:673.e11-8. [PMID: 27109628 DOI: 10.1016/j.wneu.2016.04.047] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 04/13/2016] [Accepted: 04/14/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND A case of hyperacute vasospasm, indicating a poor prognosis after aneurysmal subarachnoid hemorrhage (SAH), is reported, and a review is presented of the literature addressing use of nitric oxide (NO) donors in cases of refractory vasospasm and recurrent delayed cortical ischemias (DCI). CASE DESCRIPTION A 65-year-old woman was admitted within 1 hour after aneurysmal SAH (Hunt and Hess grade III, Fisher modified by Frontera grade IV). A hyperacute vasospasm had been confirmed arteriographically, the right middle cerebral artery (MCA) aneurysm was immediately coiled and a standard antivasospastic therapy was started. Within 48 hours, the patient developed cerebral vasospasm with DCI. Because the standard therapy failed to control clinical symptoms and to address severe vasospasm, an individualized rescue treatment with NO donors was initiated. A continuous intravenous molsidomine infusion was started and clinical stabilization was achieved for a week (Hunt and Hess grade I; World Federation of Neurological Surgeons grade I; Glasgow Coma Scale score, 15) after which vasospasm and DCI recurred. During a subsequent DCI, we escalated NO donor therapy by adding intraventricular boluses of sodium nitroprusside (SNP). Over the course of the following 22 days, 7 transient DCIs (Glasgow Coma Scale score, 8) were treated with boluses of SNP during continued molsidomine therapy and each time vasospasm and DCI were completely reversed. Despite initial poor prognosis, the clinical outcome was excellent; at 3, 6, and 12 months follow-up the patient's modified National Institutes of Health-Stroke Scale and modified Rankin Scale scores were 0, with no cognitive deficits. CONCLUSIONS The review of the literature suggested that combined intravenous molsidomine with intraventricular SNP treatment reversed refractory, recurrent vasospasm and DCIs probably by addressing the hemoglobin NO sink effect, NO depletion, and decreased NO availability after aneurysmal SAH.
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Affiliation(s)
- Angelika Ehlert
- Department of Neurosurgery, Asklepios Klinik St. Georg, Hamburg, Germany.
| | - Gerd Manthei
- Department of Neurosurgery, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Volker Hesselmann
- Department of Neuroradiology, Asklepios Clinic North, Hamburg, Germany
| | - Klaus Mathias
- Department of Neuroradiology, Asklepios Clinic, St. Georg, Hamburg, Germany
| | - Berthold Bein
- Department of Anesthesiology, Asklepios Clinic, St. Georg, Hamburg, Germany
| | - Ryszard Pluta
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institute of Health, Bethesda, Maryland, USA
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Srinivasan A, Aggarwal A, Gaudihalli S, Mohanty M, Dhandapani M, Singh H, Mukherjee KK, Dhandapani S. Impact of Early Leukocytosis and Elevated High-Sensitivity C-Reactive Protein on Delayed Cerebral Ischemia and Neurologic Outcome After Subarachnoid Hemorrhage. World Neurosurg 2016; 90:91-95. [PMID: 26898490 DOI: 10.1016/j.wneu.2016.02.049] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 02/06/2016] [Accepted: 02/09/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND The role of inflammatory response in the pathophysiology of subarachnoid hemorrhage (SAH) is being increasingly recognized. This study analyzed the impact of cellular and biochemical markers of early inflammatory response to ictus on outcome after SAH. METHODS Patients with SAH were prospectively studied for markers of early cellular, biochemical, and cytotoxic inflammatory response, including total leukocyte count (TLC), high-sensitivity C-reactive protein (hs-CRP), and lactate dehydrogenase. The relationship of these markers to delayed cerebral ischemia (DCI), new infarct, and Glasgow Outcome Scale (GOS) score at 3 months was studied. RESULTS The study comprised 246 patients. Of patients, 94 who developed DCI had a significantly higher TLC [± SD] (11.2 × 10(3)/mm(3) [± 4.0] vs. 9.4 × 10(3)/mm(3) [± 2.9], P = 0.001) and 62 with new infarct had significantly higher TLC (11.0 × 10(3)/mm(3) [± 3.6] vs. 9.8 × 10(3)/mm(3) [± 3.4], P = 0.05). GOS score had a significant inverse relationship to TLC at admission. The mean TLC [± SD] was 12.7 × 10(3)/mm(3) [± 4.2], 11.7 × 10(3)/mm(3) [± 3.1], 10.2 × 10(3)/mm(3) [± 3.4], and 9.3 × 10(3)/mm(3) [± 2.8] among patients with GOS scores of 1, 3, 4, and 5 (P < 0.001). hs-CRP showed a trend of an inverse relationship to GOS score in univariate analysis. Lactate dehydrogenase had no relationship with any outcome parameter. In multivariate analysis, higher admission TLC had a significant association with DCI (P = 0.01) and poorer GOS score (P < 0.001), and higher hs-CRP had a significant association with poorer GOS score (P = 0.05). CONCLUSIONS A leukocytosis response to ictus seems to have a significant independent association with both DCI and poor GOS score, and hs-CRP level had a significant independent association with poor GOS score, indicating preeminence of early cellular response in SAH pathophysiology.
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Affiliation(s)
- Anirudh Srinivasan
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Aggarwal
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sachin Gaudihalli
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manju Mohanty
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manju Dhandapani
- National Institute of Nursing Education, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harminder Singh
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Kanchan K Mukherjee
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sivashanmugam Dhandapani
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
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Hockel K, Diedler J, Steiner J, Birkenhauer U, Danz S, Ernemann U, Schuhmann MU. Long-Term, Continuous Intra-Arterial Nimodipine Treatment of Severe Vasospasm After Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2015; 88:104-112. [PMID: 26732964 DOI: 10.1016/j.wneu.2015.11.081] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 11/23/2015] [Accepted: 11/24/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Secondary vasospasm and disturbances in cerebrovascular autoregulation are associated with the development of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. An intra-arterial application of nimodipine has been shown to increase the vessel diameter, although this effect is transient. The feasibility of long-term, continuous, intra-arterial nimodipine treatment and its effects on macrovasospasm, autoregulation parameters, and outcome were evaluated in patients with refractory severe macrovasospasm. METHODS Ten patients were included with refractory macrovasospasm despite bolus nimodipine application (n = 4) or with primary severe vasospasm (n = 6). The patients were assessed with continuous multimodal neuromonitoring (mean arterial pressure, intraceranial pressure, cerebral perfusion pressure, brain tissue oxygen tension probe), daily transcranial Doppler examinations, and computed tomography angiography/perfusion. Autoregulation indices, the pressure reactivity index, and oxygen reactivity index were calculated. Indwelling microcatheters were placed in the extracranial internal carotid arteries and 0.4 mg nimodipine was continuously infused at 50 mL/hour. RESULTS The duration of continuous, intra-arterial nimodipine ranged from 9 to 15 days. During treatment intracranial pressure remained stable, transcranial Doppler flow velocity decreased, and brain tissue oxygen tension improved by 37%. Macrovasospasm, as assessed via computed tomography angiography, had improved (n = 5) or disappeared (n = 5) at the end of treatment. Cerebrovascular autoregulation according to the pressure reactivity index and oxygen reactivity index significantly worsened during treatment. All patients showed a favorable outcome (median Glasgow Outcome Scale 5) at 3 months. CONCLUSIONS In well-selected patients with prolonged severe macrovasospasm, continuous intra-arterial nimodipine treatment can be applied as a rescue therapy with relative safety for more than 2 weeks to prevent secondary cerebral ischemia. The induced impairment of cerebrovascular autoregulation during treatment seems to have no negative effects.
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Affiliation(s)
- Konstantin Hockel
- Department of Neurosurgery, University Hospital Tübingen, University of Tübingen, Germany.
| | - Jennifer Diedler
- Department of Neurosurgery, University Hospital Tübingen, University of Tübingen, Germany
| | - Jochen Steiner
- Department of Neurosurgery, University Hospital Tübingen, University of Tübingen, Germany
| | - Ulrich Birkenhauer
- Department of Neurosurgery, University Hospital Tübingen, University of Tübingen, Germany
| | - Sören Danz
- Diagnostic and Interventional Neuroradiology, Department of Radiology, University Hospital Tübingen, University of Tübingen, Germany
| | - Ulrike Ernemann
- Diagnostic and Interventional Neuroradiology, Department of Radiology, University Hospital Tübingen, University of Tübingen, Germany
| | - Martin U Schuhmann
- Department of Neurosurgery, University Hospital Tübingen, University of Tübingen, Germany
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Choudhury PR, Choudhury MD, Ningthoujam SS, Mitra A, Nath D, Talukdar AD. Plant utilization against digestive system disorder in Southern Assam, India. J Ethnopharmacol 2015; 175:192-197. [PMID: 26387738 DOI: 10.1016/j.jep.2015.09.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 09/14/2015] [Accepted: 09/15/2015] [Indexed: 06/05/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Being one of the most common types of life threatening diseases in Southern Assam, India, the digestive system disorders (DSD) have gained much attention in recent decades. Traditional beliefs and inadequate income of mass population result in the use of alternative phytotherapies to treat the diseases. AIM OF THE STUDY The present paper documents the medicinal knowledge and utilization of plants for treatment of digestive system disorders in Southern Assam, India by Disease Consensus Index (DCI). It also determines the most suitable plant species used to treat digestive system disorders in the study area. MATERIALS AND METHODS The study was based on ethnomedicinal field survey covering a period of 1 year from 2014-2015. The ethnomedicinal information was collected by using semi-structured questionnaires from different traditional Bengali people having knowledge on medicinal plants. Collected data were analyzed by calculating DCI. RESULTS During the survey, 29 informants were interviewed and a total of 49 plants under 46 genera belonging to 33 families were listed. Data analysis revealed that Litsea glutinosa, Momordica charantia, Andrographis paniculata, Lawsonia inermis, Cleome viscosa, Psidium guajava, Ageratum conyzoides, Cuscuta reflexa, Cynodon dactylon and Carica papaya are the most prominent plants among the people of Southern Assam for treating DSD. CONCLUSION This explorative survey emphasizes the need to preserve and document the traditional healing practices for managing DSD inviting for more imminent scientific research on the plants to determine their efficacy as well as safety. With the help of statistical analysis (DCI), we propose 10 priority plants for DSD in present work. Systematic pharmacological study with these plants may contribute significant result.
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Affiliation(s)
- Prakash Roy Choudhury
- Department of Life Science & Bioinformatics, Assam University, Silchar, Assam, India
| | | | | | - Abhijit Mitra
- Department of Life Science & Bioinformatics, Assam University, Silchar, Assam, India
| | - Deepa Nath
- Department of Botany & Biotechnology, Karimganj College, Karimganj, Assam, India
| | - Anupam Das Talukdar
- Department of Life Science & Bioinformatics, Assam University, Silchar, Assam, India.
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Khashab MA, Saxena P, Kumbhari V, Nandwani M, Roland BC, Stein E, Clarke JO, Stavropoulos S, Inoue H, Pasricha PJ. Peroral endoscopic myotomy as a platform for the treatment of spastic esophageal disorders refractory to medical therapy (with video). Gastrointest Endosc 2014; 79:136-9. [PMID: 24342590 DOI: 10.1016/j.gie.2013.08.021] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2013] [Accepted: 08/15/2013] [Indexed: 12/12/2022]
Affiliation(s)
- Mouen A Khashab
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Payal Saxena
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Monica Nandwani
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Bani Chander Roland
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Ellen Stein
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - John O Clarke
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Stavros Stavropoulos
- Department of Medicine and Division of Gastroenterology, Winthrop University Hospital, Meneola, New York, USA
| | - Haruhiro Inoue
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Pankaj J Pasricha
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Stucky BD, Edelen MO, Vaughan CA, Tucker JS, Butler J. The psychometric development and initial validation of the DCI-A short form for adolescent therapeutic community treatment process. J Subst Abuse Treat 2014; 46:516-21. [PMID: 24462245 DOI: 10.1016/j.jsat.2013.12.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 12/06/2013] [Accepted: 12/09/2013] [Indexed: 11/24/2022]
Abstract
The 5-factor client-report Dimensions of Change in Therapeutic Communities Treatment Instrument-Adolescent (DCI-A) was developed to assess adolescent substance abuse treatment process in the therapeutic community (TC). The goal of this study was to use bifactor modeling to derive a unidimensional DCI-A short-form (DCI-A-SF) that would represent content from the original DCI-A factors. Data are from 442 adolescents receiving treatment at one of seven residential TC programs. Bifactor analyses suggested selection of seven DCI-A items to comprise the short form. Three items are from the treatment motivation factor, and one item was selected from each of the remaining four factors. Confirmatory factor analysis suggested that the 7-item DCI-A-SF is strongly unidimensional, and unidimensional IRT analysis of the items indicated good internal consistency. A structural equation model that demonstrates the mediating relationship of DCI-A-SF with other measures, including demographic and pre-treatment characteristics, and subsequent treatment completion, provides preliminary evidence of internal validity.
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Mahan CE, Fisher MD, Mills RM, Fields LE, Stephenson JJ, Fu AC, Spyropoulos AC. Thromboprophylaxis patterns, risk factors, and outcomes of care in the medically ill patient population. Thromb Res 2013; 132:520-6. [DOI: 10.1016/j.thromres.2013.08.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 08/12/2013] [Accepted: 08/13/2013] [Indexed: 12/19/2022]
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Ribeiro S, Furtado C, Pereira J. Association between cardiovascular disease and socioeconomic level in Portugal. Rev Port Cardiol 2013; 32:847-54. [PMID: 24119864 DOI: 10.1016/j.repc.2013.01.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Accepted: 01/19/2013] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Cardiovascular disease is the leading cause of morbidity, mortality and disability in Portugal. Socioeconomic level is known to influence health status but there is scant evidence on socioeconomic inequalities in cardiovascular disease in Portugal. AIM To analyze the distribution of cardiovascular disease in the Portuguese population according to socioeconomic status. METHODS We conducted a cross-sectional study using data from the fourth National Health Survey on a representative sample of the Portuguese population. Socioeconomic inequalities in cardiovascular disease, risk factors and number of medical visits were analyzed using odds ratios according to socioeconomic status (household equivalent income) in the adult population (35-74 years). Comparisons focused on the top and bottom 50% and 10% of household income distribution. RESULTS Of the 21 807 individuals included, 53.3% were female, and mean age was 54 ± 11 years. Cardiovascular disease, stroke, ischemic heart disease, hypertension, diabetes, obesity and physical inactivity were associated with lower socioeconomic status, while smoking was associated with higher status; number of medical visits and psychological distress showed no association. When present, inequality was greater at the extremes of income distribution. CONCLUSIONS The results reveal an association between morbidity, lifestyle and socioeconomic status. They also suggest that besides improved access to effective medical intervention, there is a need for a comprehensive strategy for health promotion and disease prevention that takes account of individual, cultural and socioeconomic characteristics.
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Affiliation(s)
- Sónia Ribeiro
- Escola Nacional de Saúde Pública, Universidade Nova de Lisboa, Lisboa, Portugal; Hospital de Santa Maria, Centro Académico de Medicina de Lisboa, Serviço de Cardiologia I, CCUL, Lisboa, Portugal.
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Vanuytsel T, Bisschops R, Farré R, Pauwels A, Holvoet L, Arts J, Caenepeel P, De Wulf D, Mimidis K, Rommel N, Tack J. Botulinum toxin reduces Dysphagia in patients with nonachalasia primary esophageal motility disorders. Clin Gastroenterol Hepatol 2013; 11:1115-1121.e2. [PMID: 23591282 DOI: 10.1016/j.cgh.2013.03.021] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Revised: 02/21/2013] [Accepted: 03/01/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endoscopic injection of botulinum toxin (BTX) has shown benefits for patients with diffuse esophageal spasm (DES) and nutcracker esophagus (NE) in small uncontrolled trials. We investigated the effect of BTX on symptoms of patients with DES or NE and assessed manometry findings in a prospective, double-blind, randomized, controlled study. METHODS We assessed 22 patients with dysphagia-predominant, manometry-confirmed DES or NE (6 men; age, 63 ± 2 y) at a tertiary care medical center. Patients were given injections of BTX (8 × 12.5 U) or saline (8 × 0.5 mL) in 4 quadrants, at 2 and 7 cm above the esophagogastric junction. After 1 month, patients crossed over between groups and received endoscopic injections of BTX or saline. When the study began and 4 weeks after each injection, the patients were assessed by esophageal manometry and completed a symptom questionnaire (to determine solid and liquid dysphagia, chest pain, and regurgitation and heartburn; all scored 0-4). Responders were defined based on modified Vantrappen criteria for achalasia. RESULTS After BTX injections, patients had significant decreases in total symptom scores (sum of solid and liquid dysphagia and chest pain; from 7.6 ± 0.7 to 4.8 ± 0.8; P = .01); this decrease was not observed in patients who received saline injections. Moreover, BTX injection stabilized unintentional weight loss (weight gain of 0.3 ± 0.3 after BTX injection vs further weight loss of 1.6 ± 0.5 kg after saline injection; P = .01). Fifty percent of patients had a response 1 month after BTX injection, compared with 10% after saline injection (P = .04); 30% still had a response 1 year after BTX injection. BTX injection also caused a significant decrease in the mean esophagogastric junction pressure, compared with baseline (15.8 ± 1.7 vs 24.0 ± 2.8 mm Hg; P = .02). CONCLUSIONS In a prospective controlled study of patients with DES and NE, injections of BTX reduced symptoms and stabilized unintentional weight loss. TRIAL REGISTRY http://www.targid.eu, ML2669, ML6294.
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Affiliation(s)
- Tim Vanuytsel
- Translational Research Center for Gastrointestinal Disorders, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
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Coutinho MF, Bourbon M, Prata MJ, Alves S. Sortilin and the risk of cardiovascular disease. Rev Port Cardiol 2013; 32:793-9. [PMID: 23910371 DOI: 10.1016/j.repc.2013.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Revised: 02/06/2013] [Accepted: 02/21/2013] [Indexed: 11/24/2022] Open
Abstract
Plasma low-density lipoprotein cholesterol (LDL-C) levels are a key determinant of the risk of cardiovascular disease, which is why many studies have attempted to elucidate the pathways that regulate its metabolism. Novel latest-generation sequencing techniques have identified a strong association between the 1p13 locus and the risk of cardiovascular disease caused by changes in plasma LDL-C levels. As expected for a complex phenotype, the effects of variation in this locus are only moderate. Even so, knowledge of the association is of major importance, since it has unveiled a new metabolic pathway regulating plasma cholesterol levels. Crucial to this discovery was the work of three independent teams seeking to clarify the biological basis of this association, who succeeded in proving that SORT1, encoding sortilin, was the gene in the 1p13 locus involved in LDL metabolism. SORT1 was the first gene identified as determining plasma LDL levels to be mechanistically evaluated and, although the three teams used different, though appropriate, experimental methods, their results were in some ways contradictory. Here we review all the experiments that led to the identification of the new pathway connecting sortilin with plasma LDL levels and risk of myocardial infarction. The regulatory mechanism underlying this association remains unclear, but its discovery has paved the way for considering previously unsuspected therapeutic targets and approaches.
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Abstract
Several inositol isomers and in particular myo-inositol (MI) and D-chiro-inositol (DCI), were shown to possess insulin-mimetic properties and to be efficient in lowering post-prandial blood glucose. In addition, abnormalities in inositol metabolism are associated with insulin resistance and with long term microvascular complications of diabetes, supporting a role of inositol or its derivatives in glucose metabolism. The aim of this review is to focus on the potential benefits of a dietary supplement of myo-inositol, by far the most common inositol isomer in foodstuffs, in human disorders associated with insulin resistance (polycystic ovary syndrome, gestational diabetes mellitus or metabolic syndrome) or in prevention or treatment of some diabetic complications (neuropathy, nephropathy, cataract). The relevance of such a nutritional strategy will be discussed for each context on the basis of the clinical and/or animal studies. The dietary sources of myo-inositol and its metabolism from its dietary uptake to its renal excretion will be also covered in this review. Finally, the actual insights into inositol insulin-sensitizing effects will be addressed and in particular the possible role of inositol glycans as insulin second messengers.
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Affiliation(s)
- Marine L Croze
- Université de Lyon, INSA de Lyon, CarMeN, INSERM U1060, Univ Lyon-1, F-69621 Villeurbanne, France.
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