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Kozik V, Reuken P, Utech I, Gramlich J, Stallmach Z, Demeyere N, Rakers F, Schwab M, Stallmach A, Finke K. Characterization of neurocognitive deficits in patients with post-COVID-19 syndrome: persistence, patients' complaints, and clinical predictors. Front Psychol 2023; 14:1233144. [PMID: 37915528 PMCID: PMC10616256 DOI: 10.3389/fpsyg.2023.1233144] [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] [Received: 06/16/2023] [Accepted: 10/03/2023] [Indexed: 11/03/2023] Open
Abstract
Introduction Cognitive symptoms persisting beyond 3 months following COVID-19 present a considerable disease burden. We aimed to establish a domain-specific cognitive profile of post-COVID-19 syndrome (PCS). We examined the deficits' persistence, relationships with subjective cognitive complaints, and clinical variables, to identify the most relevant cognitive deficits and their predictors. Methods This cross-sectional study examined cognitive performance and patient-reported and clinical predictors of cognitive deficits in PCS patients (n = 282) and socio-demographically comparable healthy controls (n = 52). Results On the Oxford Cognitive Screen-Plus, the patient group scored significantly lower in delayed verbal memory, attention, and executive functioning than the healthy group. In each affected domain, 10 to 20% of patients performed more than 1.5 SD below the control mean. Delayed memory was particularly affected, with a small effect of hospitalization and age. Attention scores were predicted by hospitalization and fatigue. Discussion Thus, PCS is associated with long-term cognitive dysfunction, particularly in delayed memory, attention, and executive functioning. Memory deficits seem to be of particular relevance to patients' experience of subjective impairment. Hospitalization, fatigue, and age seem to predict cognitive deficits, while time since infection, depression, and pre-existing conditions do not.
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Affiliation(s)
- Valeska Kozik
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Philipp Reuken
- Department of Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases), Jena University Hospital, Jena, Germany
| | - Isabelle Utech
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Judith Gramlich
- Department of Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases), Jena University Hospital, Jena, Germany
| | - Zoe Stallmach
- Department of Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases), Jena University Hospital, Jena, Germany
| | - Nele Demeyere
- Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Florian Rakers
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Matthias Schwab
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Andreas Stallmach
- Department of Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases), Jena University Hospital, Jena, Germany
- Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany
| | - Kathrin Finke
- Department of Neurology, Jena University Hospital, Jena, Germany
- Department of Psychology, Ludwig-Maximilians-University, Munich, Germany
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Rakers F, Fritsch A, Herrmann A, Tannapfel A, Schwab M. Oral cladribine treatment and idiosyncratic drug-induced liver injury in multiple sclerosis. BMJ Neurol Open 2023; 5:e000481. [PMID: 37705760 PMCID: PMC10496679 DOI: 10.1136/bmjno-2023-000481] [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] [Accepted: 08/25/2023] [Indexed: 09/15/2023] Open
Abstract
Background Oral cladribine (OC) is approved for the treatment of highly active relapsing multiple sclerosis. Postmarketing safety assessments have reported rare, but occasionally severe cases of liver injury in temporal association with OC, with pathophysiologic mechanisms still unknown. In the only detailed case report on this topic, idiosyncratic drug-induced liver injury (iDILI) during OC treatment was well characterised for the first time, but occurred in the context of prior high-dose steroid exposure. Although high-dose steroids are known to induce iDILI in patients with multiple sclerosis with a delay of up to 12 weeks, OC was assumed to be the culprit agent for observed liver injury and the role of steroid exposure was not further investigated. Case Herein, we describe a case of a 35-year-old women treated with high-dose oral prednisolone during the first treatment cycle OC and subsequently developed iDILI. A causality assessment of the role of prednisolone and OC was performed using the updated Roussel Uclaf Causality Assessment Method which also included a negative re-exposure test for OC during the second OC treatment cycle 1 year later. Conclusion Our observations suggest that prednisolone or interactions between prednisolone and OC are more likely to foster development of iDILI rather than OC treatment itself.
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Affiliation(s)
- Florian Rakers
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Almut Fritsch
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Andreas Herrmann
- Department of Internal Medicine IV (Gastroenterology, Hepatology, and Infectious Diseases), Jena University Hospital, Jena, Germany
| | | | - Matthias Schwab
- Department of Neurology, Jena University Hospital, Jena, Germany
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Rakers F, Weise D, Hamzei F, Musleh R, Schwab M, Jacob J, Alibone M, Günther A. The Incidence and Outpatient Medical Care of Patients with Post-Stroke Spasticity. Dtsch Arztebl Int 2023; 120:284-285. [PMID: 37357701 PMCID: PMC10304005 DOI: 10.3238/arztebl.m2023.0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 10/20/2022] [Accepted: 01/11/2023] [Indexed: 06/27/2023]
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Rakers F, Schleußner E, Muth I, Hoyer D, Rupprecht S, Schiecke K, Groten T, Dreiling M, Kozik V, Schwab M, Hoyer H, Ligges C. Association between antenatal glucocorticoid exposure and the activity of the stress system, cognition, and behavior in 8- to 9-year-old children: A prospective observational study. Acta Obstet Gynecol Scand 2022; 101:996-1006. [PMID: 35652410 DOI: 10.1111/aogs.14386] [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: 02/17/2022] [Revised: 05/12/2022] [Accepted: 05/13/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Glucocorticoid (GC) -induced fetal programming of the activity of the hypothalamus-pituitary-adrenal axis (HPAA) and its associated cognitive and behavioral consequences in later life have been well characterized in several animal species. However, information on humans is scarce. In this study, we examined HPAA activity markers and associated outcomes at 8 to 9 years of age among children prenatally exposed to GC for suspected preterm birth. Our hypothesis was that antenatal exposure to the betamethasone (BM) is associated with exacerbation of HPAA activity in childhood. MATERIAL AND METHODS Prospective observational study in 31 children whose mothers received single (n = 19) or multiple (n = 12) courses of BM for threatened preterm birth but born with normal weight appropriate for the gestational age (median 37+6 weeks of gestation) compared with 38 non-exposed, age-matched children. Primary end point was the activity of the HPAA in response to the Trier Social Stress Test. Secondary end points were changes in autonomic nervous system (ANS) activity, cognitive performance (IQ), attention-deficit/hyperactivity disorder (ADHD) symptoms, and electrocortical activity (EEG). RESULTS There was no statistically significant difference in HPAA activity markers between antenatal BM exposed and unexposed groups. ANS activity in BM-exposed children shifted towards a higher parasympathetic tone reflected by a higher overall high-frequency band power of heart rate variability. IQ scores were within normal limits for both groups; however, BM-exposed children had lower IQ scores than the unexposed group. BM-exposed group had marginally more ADHD core symptoms and increased electrocortical activity in the occipital brain region compared with controls. A monotonic dose-response relationship between BM exposure and activity of the ANS and IQ was estimated in post-hoc analyses. CONCLUSIONS Antenatal exposure to BM in the context of threatened preterm birth was not associated with changes in HPAA activity in childhood. However, BM exposure may be associated with changes in ANS activity. Antenatal GC prophylaxis is a valuable and often life-saving therapy, but its prescription may warrant a well-balanced risk-benefit assessment.
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Affiliation(s)
- Florian Rakers
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | | | - Isabel Muth
- Department of Obstetrics, Jena University Hospital, Jena, Germany
| | - Dirk Hoyer
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Sven Rupprecht
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Karin Schiecke
- Institute of Medical Statistics, Computer and Data Sciences, Jena University Hospital, Jena, Germany
| | - Tanja Groten
- Department of Obstetrics, Jena University Hospital, Jena, Germany
| | - Michelle Dreiling
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Valeska Kozik
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Matthias Schwab
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Heike Hoyer
- Institute of Medical Statistics, Computer and Data Sciences, Jena University Hospital, Jena, Germany
| | - Carolin Ligges
- Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Jena University Hospital, Jena, Germany
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Kozik V, Schwab M, Thiel S, Hellwig K, Rakers F, Dreiling M. Protocol for a Cross-Sectional Study: Effects of a Multiple Sclerosis Relapse Therapy With Methylprednisolone on Offspring Neurocognitive Development and Behavior (MS-Children). Front Neurol 2022; 13:830057. [PMID: 35557615 PMCID: PMC9087857 DOI: 10.3389/fneur.2022.830057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 03/17/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction Multiple Sclerosis (MS) is the most common neuroimmunological disease in women of childbearing age. Current MS therapy consists of immunomodulatory relapse prevention with disease-modifying therapies (DMTs) and acute relapse therapy with the synthetic glucocorticoid (GC) methylprednisolone (MP). As most DMTs are not approved for use during pregnancy, treatment is usually discontinued, increasing the risk for relapses. While MP therapy during pregnancy is considered relatively save for the fetus, it may be detrimental for later cognitive and neuropsychiatric function. The underlying mechanism is thought to be an epigenetically mediated desensitization of GC receptors, the subsequent increase in stress sensitivity, and a GC-mediated impairment of brain development. The aim of this study is to investigate the associations of fetal MP exposure in the context of MS relapse therapy with later cognitive function, brain development, stress sensitivity, and behavior. Methods and Analysis Eighty children aged 8–18 years of mothers with MS will be recruited. Forty children, exposed to GC in utero will be compared to 40 children without fetal GC exposure. The intelligence quotient will serve as primary outcome. Secondary outcomes will include attention, motor development, emotional excitability, Attention-Deficit Hyperactivity Disorder-related symptoms, and behavioral difficulties. The Trier Social Stress Test will test stress sensitivity, EEG and MRI will assess functional and structural brain development. To determine underlying mechanisms, DNA methylation of the GC receptor gene and the H19/IGF2 locus and changes in the microbiome and the metabolome will be investigated. Primary and secondary outcomes will be analyzed using linear regression models. Time-variant outcomes of the stress test will be analyzed in two mixed linear models exploring overall activity and change from baseline. Ethics and Dissemination This study was approved by the participating institutions' ethics committees and results will be presented in accordance with the STROBE 2007 Statement. Trial Registration https://clinicaltrials.gov/ct2/show/NCT04832269?id=ZKSJ0130
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Affiliation(s)
- Valeska Kozik
- Department of Neurology, Jena University Hospital, Jena, Germany
- *Correspondence: Valeska Kozik
| | - Matthias Schwab
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Sandra Thiel
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Kerstin Hellwig
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Florian Rakers
- Department of Neurology, Jena University Hospital, Jena, Germany
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Werner C, Loudovici-Krug D, Derlien S, Rakers F, Smolenski UC, Lehmann T, Best N, Günther A. Study protocol: multimodal physiotherapy as an add-on treatment to botulinum neurotoxin type A therapy for patients with cervical dystonia: DysPT-multi-a prospective, multicentre, single-blind, randomized, controlled study. Trials 2021; 22:740. [PMID: 34696821 PMCID: PMC8547107 DOI: 10.1186/s13063-021-05705-8] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 10/08/2021] [Indexed: 11/14/2022] Open
Abstract
Background Botulinum neurotoxin (BoNT) is currently the best therapeutic option in the treatment for cervical dystonia (CD). Additional treatments like physiotherapy (PT) may even improve the results of the BoNT injection with type A (BoNT-A), but there are no definite recommendations. In the last few years, some studies showed tendencies for PT as an adjuvant therapy to benefit. However, high-quality studies are required. Methods This study is a multicentre, randomized, single-blind, controlled trial to demonstrate the effectiveness of a multimodal PT program compared to a nonspecific cupping therapy, additionally to the BoNT-A therapy. Two hundred participants will be assigned into the multimodal PT plus BoNT intervention arm or the BoNT plus cupping arm using randomization. Primary endpoint is the total Score of Toronto Western Spasmodic Rating Scale (TWSTRS). Secondary endpoints are the mobility of the cervical spine (range of motion, ROM), the TWSTRS subscales, and the quality of life (measured by questionnaires: CDQ-24 and SF-36). Patients will be single-blind assessed every 3 months according to their BoNT injection treatment over a period of 9 months. Discussion The study aims to determine the effectiveness and therefore potential benefit of an additional multimodal physiotherapy for standardized treatment with BoNT-A in patients with CD, towards the BoNT-therapy alone. This largest randomized controlled trial in this field to date is intended to generate missing evidence for therapy guidelines. Trial registration The study was registered in the German Clinical Study Register before the start of the patient recruitment (DRKS00020411; date: 21.01.2020).
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Affiliation(s)
- Christian Werner
- Department of Neurology, St. Georg Klinikum Eisenach, Eisenach, Germany
| | | | - Steffen Derlien
- Institute for Physiotherapy, Jena University Hospital, Jena, Germany
| | - Florian Rakers
- Hans-Berger-Department of Neurology, Jena University Hospital, Jena, Germany
| | | | - Thomas Lehmann
- Institute of Medical Statistics, Jena University Hospital, Jena, Germany
| | - Norman Best
- Institute for Physiotherapy, Jena University Hospital, Jena, Germany
| | - Albrecht Günther
- Hans-Berger-Department of Neurology, Jena University Hospital, Jena, Germany
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Kockler M, Schlattmann P, Walther M, Hagemann G, Becker PN, Rosahl S, Witte OW, Schwab M, Rakers F. Weather conditions associated with subarachnoid hemorrhage: a multicenter case-crossover study. BMC Neurol 2021; 21:283. [PMID: 34281522 PMCID: PMC8287714 DOI: 10.1186/s12883-021-02312-7] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 06/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Most spontaneous subarachnoid hemorrhages (SAH) occur unexpectedly and independently of classical risk factors. In the light of increasing climate variability and change, we investigated weather and rapid weather changes as possible short-term risk factors for SAH. METHODS Seven hundred ninety one patients admitted to three major hospitals in Germany for non-traumatic SAH with a determinable onset of SAH symptoms were included in this hospital-based, case-crossover study. The effects of atmospheric pressure, relative air humidity, and ambient temperature and their 24 h changes on the onset of SAH under temperate climate conditions were estimated. RESULTS There was no association between the risk of SAH and 24 h weather changes, mean daily temperature or mean relative air humidity in the overall population. For every 11.5 hPa higher mean daily atmospheric pressure, the risk of SAH increased by 15% (OR 1.15, 95% confidence interval (CI) 1.01-1.30) in the entire study population with a lag time of three days. CONCLUSION Our results suggest no relevant association between 24 h-weather changes or absolute values of ambient temperature and relative humidity and the risk of SAH. The medical significance of the statistically weak increase in SAH risk three days after exposure to high atmospheric pressure is unclear. However, as the occurrence of stable high-pressure systems will increase with global warming and potentially affect SAH risk, we call for confirming studies in different geographical regions to verify our observations.
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Affiliation(s)
- Michael Kockler
- Hans-Berger Department of Neurology, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Peter Schlattmann
- Institute of Medical Statistics, Computer Sciences and Documentation, Jena University Hospital, 07747, Jena, Germany
| | - Mario Walther
- Department of Fundamental Sciences, Ernst Abbe University of Applied Sciences, 07745, Jena, Germany
| | - Georg Hagemann
- Department of Neurology, HELIOS Hospital Berlin-Buch, 13125, Berlin, Germany
| | - Philipp Nils Becker
- Department of Neurology, HELIOS Hospital Berlin-Buch, 13125, Berlin, Germany
| | - Steffen Rosahl
- Department of Neurosurgery, HELIOS Hospital Erfurt, 99089, Erfurt, Germany
| | - Otto W Witte
- Hans-Berger Department of Neurology, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Matthias Schwab
- Hans-Berger Department of Neurology, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Florian Rakers
- Hans-Berger Department of Neurology, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany. .,Department of Neurology, HELIOS Hospital Berlin-Buch, 13125, Berlin, Germany.
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Franke K, Van den Bergh BRH, de Rooij SR, Kroegel N, Nathanielsz PW, Rakers F, Roseboom TJ, Witte OW, Schwab M. Effects of maternal stress and nutrient restriction during gestation on offspring neuroanatomy in humans. Neurosci Biobehav Rev 2020; 117:5-25. [PMID: 32001273 PMCID: PMC8207653 DOI: 10.1016/j.neubiorev.2020.01.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 01/23/2020] [Accepted: 01/24/2020] [Indexed: 01/06/2023]
Abstract
Cognitive and mental health are major determinants of quality of life, allowing integration into society at all ages. Human epidemiological and animal studies indicate that in addition to genetic factors and lifestyle, prenatal environmental influences may program neuropsychiatric disorders in later life. While several human studies have examined the effects of prenatal stress and nutrient restriction on brain function and mental health in later life, potentially mediating effects of prenatal stress and nutrient restriction on offspring neuroanatomy in humans have been studied only in recent years. Based on neuroimaging and anatomical data, we comprehensively review the studies in this emerging field. We relate prenatal environmental influences to neuroanatomical abnormalities in the offspring, measured in utero and throughout life. We also assess the relationship between neuroanatomical abnormalities and cognitive and mental disorders. Timing- and gender-specific effects are considered, if reported. Our review provides evidence for adverse effects of an unfavorable prenatal environment on structural brain development that may contribute to the risk for cognitive, behavioral and mental health problems throughout life.
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Affiliation(s)
- Katja Franke
- Department of Neurology, Jena University Hospital, Jena, Germany.
| | - Bea R H Van den Bergh
- Research Group on Health Psychology, Faculty of Psychology and Educational Sciences, KU Leuven, Leuven, Belgium; Department for Welfare, Public Health and Family, Flemish Government, Brussels, Belgium
| | - Susanne R de Rooij
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam University Medical Centres, University of Amsterdam, The Netherlands
| | - Nasim Kroegel
- Department of Neurology, Jena University Hospital, Jena, Germany; acatech - National Academy of Science and Engineering, Berlin, Germany
| | - Peter W Nathanielsz
- Texas Pregnancy & Life Course Health Research Center, Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, TX, United States; Dept. of Animal Science, University of Wyoming, Laramie, WY, United States
| | - Florian Rakers
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Tessa J Roseboom
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam University Medical Centres, University of Amsterdam, The Netherlands; Department of Obstetrics and Gynaecology, Amsterdam University Medical Centres, University of Amsterdam, The Netherlands
| | - Otto W Witte
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Matthias Schwab
- Department of Neurology, Jena University Hospital, Jena, Germany
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Huschmann A, Rasche M, Schlattmann P, Witte OW, Schwab M, Schulze PC, Rakers F. A case-crossover study on the effect of short-term exposure to moderate levels of air pollution on the risk of heart failure. ESC Heart Fail 2020; 7:3851-3858. [PMID: 32924321 PMCID: PMC7754969 DOI: 10.1002/ehf2.12977] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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] [Received: 05/19/2020] [Revised: 08/03/2020] [Accepted: 08/10/2020] [Indexed: 01/06/2023] Open
Abstract
Aims Exposure to high levels of air pollution in industrialized urban areas is associated with an increased risk of heart failure (HF). On most days, the majority of European cities are only moderately affected by air pollution. The aim of this study was to evaluate the association between short‐term exposure to moderate levels of air pollution with the risk of HF in a city with good air quality. Methods and results We recruited 576 patients (median age 82 years; 58.2% men) admitted to a large university hospital in Central Germany for HF to participate in a hospital‐based, bidirectional, case‐crossover study. Diagnosis of HF and symptom onset were verified individually. The effect of short‐term exposure to nitrogen dioxide (NO2), particulate matter (PM10), and ozone (O3) on the risk of HF was estimated using linear and non‐linear (categorized) multivariate analyses for three different lag times (1, 2, and 3 days before HF onset). Air pollution variables were adjusted to the date of HF symptom onset. During the study period, the average daily concentration of air pollutants was only moderate and reflects the average European background air pollution. In particular, the concentration of air pollutants ranged from 2 to 63.39 μg/m3 (median = 17.46 μg/m3) for NO2, from 2 to 125.88 μg/m3 (median = 44.61 μg/m3) for O3, and from 2.21 to 166.79 μg/m3 (median = 18.67 μg/m3) for PM10. We did not find a linear or non‐linear association between short‐term exposure to NO2, O3, or PM10 and risk for HF at all lag times in the overall population and subgroups. Conclusions In an area with only moderate air pollution, short‐term exposure to major air pollutants does not increase the risk for HF. Future studies should focus on a potential threshold effect of air pollution on HF risk as a basis for evidence‐based development of statutory limits in highly polluted areas.
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Affiliation(s)
- Ariane Huschmann
- Hans Berger Department of Neurology, Jena University Hospital, Jena, 07747, Germany
| | - Marius Rasche
- Department of Pediatrics, Jena University Hospital, Jena, 07747, Germany
| | - Peter Schlattmann
- Institute of Medical Statistics, Computer Sciences and Documentation, Jena University Hospital, Jena, 07747, Germany
| | - Otto W Witte
- Hans Berger Department of Neurology, Jena University Hospital, Jena, 07747, Germany
| | - Matthias Schwab
- Hans Berger Department of Neurology, Jena University Hospital, Jena, 07747, Germany
| | - P Christian Schulze
- Department of Internal Medicine I, Jena University Hospital, Jena, 07747, Germany
| | - Florian Rakers
- Hans Berger Department of Neurology, Jena University Hospital, Jena, 07747, Germany
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Hermes M, Antonow-Schlorke I, Hollstein D, Kuehnel S, Rakers F, Frauendorf V, Dreiling M, Rupprecht S, Schubert H, Witte OW, Schwab M. Maternal psychosocial stress during early gestation impairs fetal structural brain development in sheep. Stress 2020; 23:233-242. [PMID: 31469022 DOI: 10.1080/10253890.2019.1652266] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Maternal stress, especially during early pregnancy, predisposes offspring to neuropsychiatric disorders. We hypothesized that maternal psychosocial stress (MPS) during pregnancy affects fetal structural neurodevelopment depending on the gestational age of exposure. Fetal sheep brains were harvested at 130 days gestation (dG, term 150 dG) from ewes frequently isolated from flock-mates during early gestation (first and second trimester; n = 10) or late gestation (third trimester; n = 10), or from control flock-mates (n = 8). Immunohistochemistry for formation of neuronal processes, myelination, synaptic density, cell proliferation and programed cell death was performed on brain tissue sections. Sections of the cortical gray matter, the hippocampal CA3 region and the superficial, subcortical and deep white matter were examined morphometrically. Stress effects depended on the brain region and time of exposure. Stress during early gestation but not during late gestation reduced the amount of neuronal processes in the cerebral cortex and hippocampus by 36.9 ± 10.1% (p < 0.05, mean ± SEM) and 36.9 ± 15.8% (p < 0.05), respectively, accompanied by a decrease in synaptic density in the cerebral cortex and hippocampus by 39.8 ± 23.1% (p < 0.05) and 32.9 ± 13.4% (p < 0.01). Myelination was decreased in white matter layers on average by 44.8 ± 11.7% (p < 0.05) accompanied by reduced (glial) cell proliferation in the deep white matter by 83.6 ± 12.4% (p < 0.05). In contrast, stress during the third trimester had no effect in any brain region. Chronic MPS during the first and second trimester induced prolonged effects on neuronal network and myelin formation which might contribute to disturbed neurobehavioral, cognitive and motor development in offspring of stressed mothers.Lay summaryMany women are exposed to stressful events during pregnancy. Maternal stress especially during early pregnancy predisposes for offspring's neuropsychiatric disorders. In our sheep study, we show that disturbance of fetal brain development is a potential mechanism and is worst during 1st and 2nd trimester.
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Affiliation(s)
- Markus Hermes
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | | | - Dorothea Hollstein
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Sarah Kuehnel
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Florian Rakers
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Vilmar Frauendorf
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Michelle Dreiling
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Sven Rupprecht
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
- Else Kröner-Forschungskolleg AntiAge, Bad Homburg, Germany
| | - Harald Schubert
- Institute of Lab Animal Sciences and Welfare, Jena University Hospital, Jena, Germany
| | - Otto W Witte
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Matthias Schwab
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
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Kuramatsu JB, Sembill JA, Gerner ST, Sprügel MI, Hagen M, Roeder SS, Endres M, Haeusler KG, Sobesky J, Schurig J, Zweynert S, Bauer M, Vajkoczy P, Ringleb PA, Purrucker J, Rizos T, Volkmann J, Müllges W, Kraft P, Schubert AL, Erbguth F, Nueckel M, Schellinger PD, Glahn J, Knappe UJ, Fink GR, Dohmen C, Stetefeld H, Fisse AL, Minnerup J, Hagemann G, Rakers F, Reichmann H, Schneider H, Wöpking S, Ludolph AC, Stösser S, Neugebauer H, Röther J, Michels P, Schwarz M, Reimann G, Bäzner H, Schwert H, Claßen J, Michalski D, Grau A, Palm F, Urbanek C, Wöhrle JC, Alshammari F, Horn M, Bahner D, Witte OW, Günther A, Hamann GF, Lücking H, Dörfler A, Achenbach S, Schwab S, Huttner HB. Management of therapeutic anticoagulation in patients with intracerebral haemorrhage and mechanical heart valves. Eur Heart J 2019. [PMID: 29529259 PMCID: PMC5950928 DOI: 10.1093/eurheartj/ehy056] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Aims Evidence is lacking regarding acute anticoagulation management in patients after intracerebral haemorrhage (ICH) with implanted mechanical heart valves (MHVs). Our objective was to investigate anticoagulation reversal and resumption strategies by evaluating incidences of haemorrhagic and thromboembolic complications, thereby defining an optimal time-window when to restart therapeutic anticoagulation (TA) in patients with MHV and ICH. Methods and results We pooled individual patient-data (n = 2504) from a nationwide multicentre cohort-study (RETRACE, conducted at 22 German centres) and eventually identified MHV-patients (n = 137) with anticoagulation-associated ICH for outcome analyses. The primary outcome consisted of major haemorrhagic complications analysed during hospital stay according to treatment exposure (restarted TA vs. no-TA). Secondary outcomes comprised thromboembolic complications, the composite outcome (haemorrhagic and thromboembolic complications), timing of TA, and mortality. Adjusted analyses involved propensity-score matching and multivariable cox-regressions to identify optimal timing of TA. In 66/137 (48%) of patients TA was restarted, being associated with increased haemorrhagic (TA = 17/66 (26%) vs. no-TA = 4/71 (6%); P < 0.01) and a trend to decreased thromboembolic complications (TA = 1/66 (2%) vs. no-TA = 7/71 (10%); P = 0.06). Controlling treatment crossovers provided an incidence rate-ratio [hazard ratio (HR) 10.31, 95% confidence interval (CI) 3.67–35.70; P < 0.01] in disadvantage of TA for haemorrhagic complications. Analyses of TA-timing displayed significant harm until Day 13 after ICH (HR 7.06, 95% CI 2.33–21.37; P < 0.01). The hazard for the composite—balancing both complications, was increased for restarted TA until Day 6 (HR 2.51, 95% CI 1.10–5.70; P = 0.03). Conclusion Restarting TA within less than 2 weeks after ICH in patients with MHV was associated with increased haemorrhagic complications. Optimal weighing—between least risks for thromboembolic and haemorrhagic complications—provided an earliest starting point of TA at Day 6, reserved only for patients at high thromboembolic risk. ![]()
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Affiliation(s)
- Joji B Kuramatsu
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Jochen A Sembill
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Stefan T Gerner
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Maximilian I Sprügel
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Manuel Hagen
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Sebastian S Roeder
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Matthias Endres
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, Berlin 10117, Germany.,Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin 10117, Germany.,German Centre for Cardiovascular Research (DZHK), Oudenarder Straße 16, Berlin 13347, Germany.,German Center for Neurodegenerative Diseases (DZNE), partner site Berlin, Charitéplatz 1, Berlin 10117, Germany
| | - Karl Georg Haeusler
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, Berlin 10117, Germany.,Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin 10117, Germany
| | - Jan Sobesky
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, Berlin 10117, Germany.,Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin 10117, Germany
| | - Johannes Schurig
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin 10117, Germany
| | - Sarah Zweynert
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, Berlin 10117, Germany
| | - Miriam Bauer
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin 10117, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, Berlin 13353, Germany
| | - Peter A Ringleb
- Department of Neurology, Heidelberg University Hospital, INF 400, Heidelberg 69120, Germany
| | - Jan Purrucker
- Department of Neurology, Heidelberg University Hospital, INF 400, Heidelberg 69120, Germany
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University Hospital, INF 400, Heidelberg 69120, Germany
| | - Jens Volkmann
- Department of Neurology, University of Würzburg, Josef-Schneider-Straße 11, Würzburg 97080, Germany
| | - Wolfgang Müllges
- Department of Neurology, University of Würzburg, Josef-Schneider-Straße 11, Würzburg 97080, Germany
| | - Peter Kraft
- Department of Neurology, University of Würzburg, Josef-Schneider-Straße 11, Würzburg 97080, Germany
| | - Anna-Lena Schubert
- Department of Neurology, University of Würzburg, Josef-Schneider-Straße 11, Würzburg 97080, Germany
| | - Frank Erbguth
- Department of Neurology, Community Hospital Nuremberg, Breslauer Str. 201, Nuremberg 90471, Germany
| | - Martin Nueckel
- Department of Neurology, Community Hospital Nuremberg, Breslauer Str. 201, Nuremberg 90471, Germany
| | - Peter D Schellinger
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, UK RUB, Hans-Nolte-Str. 1, Minden 32429, Germany
| | - Jörg Glahn
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, UK RUB, Hans-Nolte-Str. 1, Minden 32429, Germany
| | - Ulrich J Knappe
- Department of Neurosurgery, Johannes Wesling Medical Center Minden, UK RUB, Hans-Nolte-Str. 1, Minden 32429, Germany
| | - Gereon R Fink
- Department of Neurology, University of Cologne, Kerpener Str. 62, Cologne 50937, Germany
| | - Christian Dohmen
- Department of Neurology, University of Cologne, Kerpener Str. 62, Cologne 50937, Germany
| | - Henning Stetefeld
- Department of Neurology, University of Cologne, Kerpener Str. 62, Cologne 50937, Germany
| | - Anna Lena Fisse
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster 48149, Germany
| | - Jens Minnerup
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster 48149, Germany
| | - Georg Hagemann
- Department of Neurology, Community Hospital Helios Klinikum Berlin-Buch, Schwanebecker Chaussee 50, Berlin 13125, Germany
| | - Florian Rakers
- Department of Neurology, Community Hospital Helios Klinikum Berlin-Buch, Schwanebecker Chaussee 50, Berlin 13125, Germany
| | - Heinz Reichmann
- Department of Neurology, University of Dresden, Fetscherstr. 74, Dresden 01307, Germany
| | - Hauke Schneider
- Department of Neurology, University of Dresden, Fetscherstr. 74, Dresden 01307, Germany
| | - Sigrid Wöpking
- Department of Neurology, University of Dresden, Fetscherstr. 74, Dresden 01307, Germany
| | | | - Sebastian Stösser
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, Ulm 89081, Germany
| | - Hermann Neugebauer
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, Ulm 89081, Germany
| | - Joachim Röther
- Department of Neurology, Community Hospital Asklepios Klinik Hamburg Altona, Paul Ehrlich-Strasse 1, Hamburg 22763, Germany
| | - Peter Michels
- Department of Neurology, Community Hospital Asklepios Klinik Hamburg Altona, Paul Ehrlich-Strasse 1, Hamburg 22763, Germany
| | - Michael Schwarz
- Department of Neurology, Community Hospital Klinikum Dortmund, Beurhausstraße 40, Dortmund 44137, Germany
| | - Gernot Reimann
- Department of Neurology, Community Hospital Klinikum Dortmund, Beurhausstraße 40, Dortmund 44137, Germany
| | - Hansjörg Bäzner
- Department of Neurology, Community Hospital Klinikum Stuttgart, Kriegsbergstrasse 60, Stuttgart 70174, Germany
| | - Henning Schwert
- Department of Neurology, Community Hospital Klinikum Stuttgart, Kriegsbergstrasse 60, Stuttgart 70174, Germany
| | - Joseph Claßen
- Department of Neurology, University of Leipzig, Liebigstr. 20, Leipzig 04103, Germany
| | - Dominik Michalski
- Department of Neurology, University of Leipzig, Liebigstr. 20, Leipzig 04103, Germany
| | - Armin Grau
- Department of Neurology, Community Hospital Klinikum der Stadt Ludwigshafen am Rhein, Bremserstraße 79, Ludwigshafen 67063, Germany
| | - Frederick Palm
- Department of Neurology, Community Hospital Klinikum der Stadt Ludwigshafen am Rhein, Bremserstraße 79, Ludwigshafen 67063, Germany
| | - Christian Urbanek
- Department of Neurology, Community Hospital Klinikum der Stadt Ludwigshafen am Rhein, Bremserstraße 79, Ludwigshafen 67063, Germany
| | - Johannes C Wöhrle
- Department of Neurology, Community Hospital Klinikum Koblenz, Kardinal-Krementz-Str. 1-5, Koblenz 56073, Germany
| | - Fahid Alshammari
- Department of Neurology, Community Hospital Klinikum Koblenz, Kardinal-Krementz-Str. 1-5, Koblenz 56073, Germany
| | - Markus Horn
- Department of Neurology, Community Hospital Bad Hersfeld, Seilerweg 29, Bad Hersfeld 36251, Germany
| | - Dirk Bahner
- Department of Neurology, Community Hospital Bad Hersfeld, Seilerweg 29, Bad Hersfeld 36251, Germany
| | - Otto W Witte
- Department of Neurology, University of Jena, Erlanger Allee 101, Jena 07747, Germany
| | - Albrecht Günther
- Department of Neurology, University of Jena, Erlanger Allee 101, Jena 07747, Germany
| | - Gerhard F Hamann
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Günzburg, Ludwig-Heilmeyer-Straße 2, 89312 Günzburg, Germany
| | - Hannes Lücking
- Department of Neuroradiology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Arnd Dörfler
- Department of Neuroradiology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Stephan Achenbach
- Department of Cardiology, University of Erlangen-Nuremberg, Ulmenweg 18, Erlangen 91054, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Hagen B Huttner
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
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12
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Kuramatsu JB, Biffi A, Gerner ST, Sembill JA, Sprügel MI, Leasure A, Sansing L, Matouk C, Falcone GJ, Endres M, Haeusler KG, Sobesky J, Schurig J, Zweynert S, Bauer M, Vajkoczy P, Ringleb PA, Purrucker J, Rizos T, Volkmann J, Müllges W, Kraft P, Schubert AL, Erbguth F, Nueckel M, Schellinger PD, Glahn J, Knappe UJ, Fink GR, Dohmen C, Stetefeld H, Fisse AL, Minnerup J, Hagemann G, Rakers F, Reichmann H, Schneider H, Rahmig J, Ludolph AC, Stösser S, Neugebauer H, Röther J, Michels P, Schwarz M, Reimann G, Bäzner H, Schwert H, Claßen J, Michalski D, Grau A, Palm F, Urbanek C, Wöhrle JC, Alshammari F, Horn M, Bahner D, Witte OW, Günther A, Hamann GF, Hagen M, Roeder SS, Lücking H, Dörfler A, Testai FD, Woo D, Schwab S, Sheth KN, Huttner HB. Association of Surgical Hematoma Evacuation vs Conservative Treatment With Functional Outcome in Patients With Cerebellar Intracerebral Hemorrhage. JAMA 2019; 322:1392-1403. [PMID: 31593272 PMCID: PMC6784768 DOI: 10.1001/jama.2019.13014] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 08/07/2019] [Indexed: 01/05/2023]
Abstract
Importance The association of surgical hematoma evacuation with clinical outcomes in patients with cerebellar intracerebral hemorrhage (ICH) has not been established. Objective To determine the association of surgical hematoma evacuation with clinical outcomes in cerebellar ICH. Design, Setting, and Participants Individual participant data (IPD) meta-analysis of 4 observational ICH studies incorporating 6580 patients treated at 64 hospitals across the United States and Germany (2006-2015). Exposure Surgical hematoma evacuation vs conservative treatment. Main Outcomes and Measures The primary outcome was functional disability evaluated by the modified Rankin Scale ([mRS] score range: 0, no functional deficit to 6, death) at 3 months; favorable (mRS, 0-3) vs unfavorable (mRS, 4-6). Secondary outcomes included survival at 3 months and at 12 months. Analyses included propensity score matching and covariate adjustment, and predicted probabilities were used to identify treatment-related cutoff values for cerebellar ICH. Results Among 578 patients with cerebellar ICH, propensity score-matched groups included 152 patients with surgical hematoma evacuation vs 152 patients with conservative treatment (age, 68.9 vs 69.2 years; men, 55.9% vs 51.3%; prior anticoagulation, 60.5% vs 63.8%; and median ICH volume, 20.5 cm3 vs 18.8 cm3). After adjustment, surgical hematoma evacuation vs conservative treatment was not significantly associated with likelihood of better functional disability at 3 months (30.9% vs 35.5%; adjusted odds ratio [AOR], 0.94 [95% CI, 0.81 to 1.09], P = .43; adjusted risk difference [ARD], -3.7% [95% CI, -8.7% to 1.2%]) but was significantly associated with greater probability of survival at 3 months (78.3% vs 61.2%; AOR, 1.25 [95% CI, 1.07 to 1.45], P = .005; ARD, 18.5% [95% CI, 13.8% to 23.2%]) and at 12 months (71.7% vs 57.2%; AOR, 1.21 [95% CI, 1.03 to 1.42], P = .02; ARD, 17.0% [95% CI, 11.5% to 22.6%]). A volume range of 12 to 15 cm3 was identified; below this level, surgical hematoma evacuation was associated with lower likelihood of favorable functional outcome (volume ≤12 cm3, 30.6% vs 62.3% [P = .003]; ARD, -34.7% [-38.8% to -30.6%]; P value for interaction, .01), and above, it was associated with greater likelihood of survival (volume ≥15 cm3, 74.5% vs 45.1% [P < .001]; ARD, 28.2% [95% CI, 24.6% to 31.8%]; P value for interaction, .02). Conclusions and Relevance Among patients with cerebellar ICH, surgical hematoma evacuation, compared with conservative treatment, was not associated with improved functional outcome. Given the null primary outcome, investigation is necessary to establish whether there are differing associations based on hematoma volume.
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Affiliation(s)
- Joji B. Kuramatsu
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Alessandro Biffi
- Department of Neurology, Massachusetts General Hospital, Boston
- Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center, Boston, Massachusetts
| | - Stefan T. Gerner
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Jochen A. Sembill
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | | | - Audrey Leasure
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Lauren Sansing
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Charles Matouk
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Guido J. Falcone
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Matthias Endres
- Department of Neurology, Charité—Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), partner site Berlin, Berlin, Germany
| | - Karl Georg Haeusler
- Department of Neurology, Charité—Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | - Jan Sobesky
- Department of Neurology, Charité—Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Johannes Schurig
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Sarah Zweynert
- Department of Neurology, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Miriam Bauer
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Peter A. Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jan Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Alfried Krupp Krankenhaus Essen, Essen, Germany
| | - Jens Volkmann
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | - Wolfgang Müllges
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | - Peter Kraft
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | | | - Frank Erbguth
- Department of Neurology, Community Hospital Nuremberg, Nuremberg, Germany
| | - Martin Nueckel
- Department of Neurology, Community Hospital Nuremberg, Nuremberg, Germany
| | - Peter D. Schellinger
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, UK RUB, Minden, Germany
| | - Jörg Glahn
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, UK RUB, Minden, Germany
| | - Ulrich J. Knappe
- Department of Neurosurgery, Johannes Wesling Medical Center Minden, UK RUB, Minden, Germany
| | - Gereon R. Fink
- Department of Neurology, University of Cologne, Cologne, Germany
| | - Christian Dohmen
- Department of Neurology, University of Cologne, Cologne, Germany
| | | | - Anna Lena Fisse
- Department of Neurology, University of Münster, Münster, Germany
| | - Jens Minnerup
- Department of Neurology, University of Münster, Münster, Germany
| | - Georg Hagemann
- Department of Neurology, Community Hospital Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Florian Rakers
- Department of Neurology, Community Hospital Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Heinz Reichmann
- Department of Neurology, University of Dresden, Dresden, Germany
| | - Hauke Schneider
- Department of Neurology, University of Dresden, Dresden, Germany
- Department of Neurology, Klinikum Augsburg, Augsburg, Germany
| | - Jan Rahmig
- Department of Neurology, University of Dresden, Dresden, Germany
| | | | | | - Hermann Neugebauer
- Department of Neurology, University of Würzburg, Würzburg, Germany
- Department of Neurology, University of Ulm, Ulm, Germany
| | - Joachim Röther
- Department of Neurology, Community Hospital Asklepios Klinik Hamburg Altona, Hamburg, Germany
| | - Peter Michels
- Department of Neurology, Community Hospital Asklepios Klinik Hamburg Altona, Hamburg, Germany
| | - Michael Schwarz
- Department of Neurology, Community Hospital Klinikum Dortmund, Dortmund, Germany
| | - Gernot Reimann
- Department of Neurology, Community Hospital Klinikum Dortmund, Dortmund, Germany
| | - Hansjörg Bäzner
- Department of Neurology, Community Hospital Klinikum Stuttgart, Stuttgart, Germany
| | - Henning Schwert
- Department of Neurology, Community Hospital Klinikum Stuttgart, Stuttgart, Germany
| | - Joseph Claßen
- Department of Neurology, University of Leipzig, Leipzig, Germany
| | | | - Armin Grau
- Department of Neurology, Community Hospital Klinikum der Stadt Ludwigshafen am Rhein, Ludwigshafen, Germany
| | - Frederick Palm
- Department of Neurology, Community Hospital Klinikum der Stadt Ludwigshafen am Rhein, Ludwigshafen, Germany
| | - Christian Urbanek
- Department of Neurology, Community Hospital Klinikum der Stadt Ludwigshafen am Rhein, Ludwigshafen, Germany
| | - Johannes C. Wöhrle
- Department of Neurology, Community Hospital Klinikum Koblenz, Koblenz, Germany
| | - Fahid Alshammari
- Department of Neurology, Community Hospital Klinikum Koblenz, Koblenz, Germany
| | - Markus Horn
- Department of Neurology, Community Hospital Bad Hersfeld, Bad Hersfeld, Germany
| | - Dirk Bahner
- Department of Neurology, Community Hospital Bad Hersfeld, Bad Hersfeld, Germany
| | - Otto W. Witte
- Department of Neurology, University of Jena, Jena, Germany
| | | | - Gerhard F. Hamann
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Günzburg, Günzburg, Germany
| | - Manuel Hagen
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Sebastian S. Roeder
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Hannes Lücking
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Arnd Dörfler
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Fernando D. Testai
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago
| | - Daniel Woo
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Kevin N. Sheth
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Hagen B. Huttner
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
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13
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Sprügel MI, Sembill JA, Kuramatsu JB, Gerner ST, Hagen M, Roeder SS, Endres M, Haeusler KG, Sobesky J, Schurig J, Zweynert S, Bauer M, Vajkoczy P, Ringleb PA, Purrucker JC, Rizos T, Volkmann J, Muellges W, Kraft P, Schubert AL, Erbguth F, Nueckel M, Schellinger PD, Glahn J, Knappe UJ, Fink GR, Dohmen C, Stetefeld H, Fisse AL, Minnerup J, Hagemann G, Rakers F, Reichmann H, Schneider H, Wöpking S, Ludolph AC, Stösser S, Neugebauer H, Röther J, Michels P, Schwarz M, Reimann G, Bäzner H, Schwert H, Classen J, Michalski D, Grau A, Palm F, Urbanek C, Wöhrle JC, Alshammari F, Horn M, Bahner D, Witte OW, Guenther A, Hamann GF, Lücking H, Dörfler A, Schwab S, Huttner HB. Heparin for prophylaxis of venous thromboembolism in intracerebral haemorrhage. J Neurol Neurosurg Psychiatry 2019; 90:783-791. [PMID: 30992334 DOI: 10.1136/jnnp-2018-319786] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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: 10/08/2018] [Revised: 01/23/2019] [Accepted: 02/07/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine the occurrence of intracranial haemorrhagic complications (IHC) on heparin prophylaxis (low-dose subcutaneous heparin, LDSH) in primary spontaneous intracerebral haemorrhage (ICH) (not oral anticoagulation-associated ICH, non-OAC-ICH), vitamin K antagonist (VKA)-associated ICH and non-vitamin K antagonist oral anticoagulant (NOAC)-associated ICH. METHODS Retrospective cohort study (RETRACE) of 22 participating centres and prospective single-centre study with 1702 patients with VKA-associated or NOAC-associated ICH and 1022 patients with non-OAC-ICH with heparin prophylaxis between 2006 and 2015. Outcomes were defined as rates of IHC during hospital stay among patients with non-OAC-ICH, VKA-ICH and NOAC-ICH, mortality and functional outcome at 3 months between patients with ICH with and without IHC. RESULTS IHC occurred in 1.7% (42/2416) of patients with ICH. There were no differences in crude incidence rates among patients with VKA-ICH, NOAC-ICH and non-OAC-ICH (log-rank p=0.645; VKA-ICH: 27/1406 (1.9%), NOAC-ICH 1/130 (0.8%), non-OAC-ICH 14/880 (1.6%); p=0.577). Detailed analysis according to treatment exposure (days with and without LDSH) revealed no differences in incidence rates of IHC per 1000 patient-days (LDSH: 1.43 (1.04-1.93) vs non-LDSH: 1.32 (0.33-3.58), conditional maximum likelihood incidence rate ratio: 1.09 (0.38-4.43); p=0.953). Secondary outcomes showed differences in functional outcome (modified Rankin Scale=4-6: IHC: 29/37 (78.4%) vs non-IHC: 1213/2048 (59.2%); p=0.019) and mortality (IHC: 14/37 (37.8%) vs non-IHC: 485/2048 (23.7%); p=0.045) in disfavour of patients with IHC. Small ICH volume (OR: volume <4.4 mL: 0.18 (0.04-0.78); p=0.022) and low National Institutes of Health Stroke Scale (NIHSS) score on admission (OR: NIHSS <4: 0.29 (0.11-0.78); p=0.014) were significantly associated with fewer IHC. CONCLUSIONS Heparin administration for venous thromboembolism (VTE) prophylaxis in patients with ICH appears to be safe regarding IHC among non-OAC-ICH, VKA-ICH and NOAC-ICH in this observational cohort analysis. Randomised controlled trials are needed to verify the safety and efficacy of heparin compared with other methods for VTE prevention.
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Affiliation(s)
| | | | | | - Stefan T Gerner
- Neurology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Manuel Hagen
- Neurology, University of Erlangen-Nürnberg, Erlangen, Germany
| | | | - Matthias Endres
- Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Jan Sobesky
- Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Sarah Zweynert
- Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Miriam Bauer
- Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Neurosurgery, Charité-Universitäts medizin Berlin, Berlin, Germany
| | | | | | - Timolaos Rizos
- Neurology, University of Heidelberg, Heidelberg, Germany
| | - Jens Volkmann
- Neurology, University of Würzburg, Würzburg, Germany
| | | | - Peter Kraft
- Neurology, University of Würzburg, Würzburg, Germany
| | | | - Frank Erbguth
- Neurology, Paracelsus Medical University, Nürnberg, Germany
| | - Martin Nueckel
- Neurology, Paracelsus Medical University, Nürnberg, Germany
| | - Peter D Schellinger
- Neurology, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany
| | - Jörg Glahn
- Neurology, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany
| | - Ulrich J Knappe
- Neurosurgery, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany
| | | | | | | | | | | | - Georg Hagemann
- Neurology, Community Hospital Berlin-Buch, Berlin, Germany
| | - Florian Rakers
- Neurology, Community Hospital Berlin-Buch, Berlin, Germany
| | | | | | | | | | | | | | - Joachim Röther
- Neurology, Community Hospital Hamburg Altona, Hamburg, Germany
| | - Peter Michels
- Neurology, Community Hospital Hamburg Altona, Hamburg, Germany
| | | | - Gernot Reimann
- Neurology, Community Hospital Dortmund, Dortmund, Germany
| | | | | | | | | | - Armin Grau
- Neurology, Community Hospital Ludwigshafen, Ludwigshafen, Germany
| | - Frederick Palm
- Neurology, Community Hospital Ludwigshafen, Ludwigshafen, Germany
| | | | | | | | - Markus Horn
- Neurology, Community Hospital Bad Hersfeld, Bad Hersfeld, Germany
| | - Dirk Bahner
- Neurology, Community Hospital Bad Hersfeld, Bad Hersfeld, Germany
| | | | | | | | - Hannes Lücking
- Neuroradiology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Arnd Dörfler
- Neuroradiology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Stefan Schwab
- Neurology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Hagen B Huttner
- Neurology, University of Erlangen-Nürnberg, Erlangen, Germany
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14
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Gerner ST, Kuramatsu JB, Sembill JA, Sprügel MI, Hagen M, Knappe RU, Endres M, Haeusler KG, Sobesky J, Schurig J, Zweynert S, Bauer M, Vajkoczy P, Ringleb PA, Purrucker JC, Rizos T, Volkmann J, Müllges W, Kraft P, Schubert AL, Erbguth F, Nueckel M, Schellinger PD, Glahn J, Knappe UJ, Fink GR, Dohmen C, Stetefeld H, Fisse AL, Minnerup J, Hagemann G, Rakers F, Reichmann H, Schneider H, Rahmig J, Ludolph AC, Stösser S, Neugebauer H, Röther J, Michels P, Schwarz M, Reimann G, Bäzner H, Schwert H, Claßen J, Michalski D, Grau A, Palm F, Urbanek C, Wöhrle JC, Alshammari F, Horn M, Bahner D, Witte OW, Günther A, Hamann GF, Engelhorn T, Lücking H, Dörfler A, Schwab S, Huttner HB. Characteristics in Non-Vitamin K Antagonist Oral Anticoagulant-Related Intracerebral Hemorrhage. Stroke 2019; 50:1392-1402. [PMID: 31092170 DOI: 10.1161/strokeaha.118.023492] [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] [Indexed: 01/15/2023]
Abstract
Background and Purpose- Given inconclusive studies, it is debated whether clinical and imaging characteristics, as well as functional outcome, differ among patients with intracerebral hemorrhage (ICH) related to vitamin K antagonists (VKA) versus non-vitamin K antagonist (NOAC)-related ICH. Notably, clinical characteristics according to different NOAC agents and dosages are not established. Methods- Multicenter observational cohort study integrating individual patient data of 1328 patients with oral anticoagulation-associated ICH, including 190 NOAC-related ICH patients, recruited from 2011 to 2015 at 19 tertiary centers across Germany. Imaging, clinical characteristics, and 3-months modified Rankin Scale (mRS) outcomes were compared in NOAC- versus VKA-related ICH patients. Propensity score matching was conducted to adjust for clinically relevant differences in baseline parameters. Subgroup analyses were performed regarding NOAC agent, dosing and present clinically relevant anticoagulatory activity (last intake <12h/24h or NOAC level >30 ng/mL). Results- Despite older age in NOAC patients, there were no relevant differences in clinical and hematoma characteristics between NOAC- and VKA-related ICH regarding baseline hematoma volume (median [interquartile range]: NOAC, 14.7 [5.1-42.3] mL versus VKA, 16.4 [5.8-40.6] mL; P=0.33), rate of hematoma expansion (NOAC, 49/146 [33.6%] versus VKA, 235/688 [34.2%]; P=0.89), and the proportion of patients with unfavorable outcome at 3 months (mRS, 4-6: NOAC 126/179 [70.4%] versus VKA 473/682 [69.4%]; P=0.79). Subgroup analyses revealed that NOAC patients with clinically relevant anticoagulatory effect had higher rates of intraventricular hemorrhage (n/N [%]: present 52/109 [47.7%] versus absent 9/35 [25.7%]; P=0.022) and hematoma expansion (present 35/90 [38.9%] versus absent 5/30 [16.7%]; P=0.040), whereas type of NOAC agent or different NOAC-dosing regimens did not result in relevant differences in imaging characteristics or outcome. Conclusions- If effectively anticoagulated, there are no differences in hematoma characteristics and functional outcome among patients with NOAC- or VKA-related ICH. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT03093233.
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Affiliation(s)
- Stefan T Gerner
- From the Department of Neurology (S.T.G., J.B.K., J.A.S., M.I.S., M. Hagen, R.U.K., S. Schwab, H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Joji B Kuramatsu
- From the Department of Neurology (S.T.G., J.B.K., J.A.S., M.I.S., M. Hagen, R.U.K., S. Schwab, H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Jochen A Sembill
- From the Department of Neurology (S.T.G., J.B.K., J.A.S., M.I.S., M. Hagen, R.U.K., S. Schwab, H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Maximilian I Sprügel
- From the Department of Neurology (S.T.G., J.B.K., J.A.S., M.I.S., M. Hagen, R.U.K., S. Schwab, H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Manuel Hagen
- From the Department of Neurology (S.T.G., J.B.K., J.A.S., M.I.S., M. Hagen, R.U.K., S. Schwab, H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Ruben U Knappe
- From the Department of Neurology (S.T.G., J.B.K., J.A.S., M.I.S., M. Hagen, R.U.K., S. Schwab, H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Matthias Endres
- Department of Neurology (M.E., K.G.H., J. Sobesky, S.Z.), Charité-Universitätsmedizin Berlin, Germany.,Center for Stroke Research Berlin, Berlin, Germany (M.E., K.G.H., J. Sobesky, J. Schurig, M.B.).,German Centre for Cardiovascular Research (DZHK), Oudenarder Straße, Berlin (M.E.).,German Center for Neurodegenerative Diseases (DZNE), partner site Berlin (M.E.)
| | - Karl Georg Haeusler
- Department of Neurology (M.E., K.G.H., J. Sobesky, S.Z.), Charité-Universitätsmedizin Berlin, Germany.,Center for Stroke Research Berlin, Berlin, Germany (M.E., K.G.H., J. Sobesky, J. Schurig, M.B.).,Department of Neurology, University of Würzburg, Germany (K.G.H., J.V., W.M., P.K., A.-L.S.)
| | - Jan Sobesky
- Department of Neurology (M.E., K.G.H., J. Sobesky, S.Z.), Charité-Universitätsmedizin Berlin, Germany.,Center for Stroke Research Berlin, Berlin, Germany (M.E., K.G.H., J. Sobesky, J. Schurig, M.B.)
| | - Johannes Schurig
- Center for Stroke Research Berlin, Berlin, Germany (M.E., K.G.H., J. Sobesky, J. Schurig, M.B.)
| | - Sarah Zweynert
- Department of Neurology (M.E., K.G.H., J. Sobesky, S.Z.), Charité-Universitätsmedizin Berlin, Germany
| | - Miriam Bauer
- Center for Stroke Research Berlin, Berlin, Germany (M.E., K.G.H., J. Sobesky, J. Schurig, M.B.)
| | - Peter Vajkoczy
- Department of Neurosurgery (P.V.), Charité-Universitätsmedizin Berlin, Germany
| | - Peter A Ringleb
- Department of Neurology, Heidelberg University Hospital, Germany (P.A.R., J.C.B., T.R.)
| | - Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Germany (P.A.R., J.C.B., T.R.)
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University Hospital, Germany (P.A.R., J.C.B., T.R.)
| | - Jens Volkmann
- Department of Neurology, University of Würzburg, Germany (K.G.H., J.V., W.M., P.K., A.-L.S.)
| | - Wolfgang Müllges
- Department of Neurology, University of Würzburg, Germany (K.G.H., J.V., W.M., P.K., A.-L.S.)
| | - Peter Kraft
- Department of Neurology, University of Würzburg, Germany (K.G.H., J.V., W.M., P.K., A.-L.S.)
| | - Anna-Lena Schubert
- Department of Neurology, University of Würzburg, Germany (K.G.H., J.V., W.M., P.K., A.-L.S.)
| | - Frank Erbguth
- Department of Neurology, Community Hospital Nuremberg, Germany (F.E., M.N.)
| | - Martin Nueckel
- Department of Neurology, Community Hospital Nuremberg, Germany (F.E., M.N.)
| | | | - Jörg Glahn
- Department of Neurology and Neurogeriatry (P.D.S., J.G.)
| | - Ulrich J Knappe
- Department of Neurosurgery, Johannes Wesling Medical Center Minden, University Clinic Ruhr University Bochum, Germany (U.J.K.)
| | - Gereon R Fink
- Department of Neurology, University of Cologne, Germany (G.R.F. C.D., H. Stetefeld)
| | - Christian Dohmen
- Department of Neurology, University of Cologne, Germany (G.R.F. C.D., H. Stetefeld).,Department of Neurology, LVR Klinik Bonn, Germany (C.D.)
| | - Henning Stetefeld
- Department of Neurology, University of Cologne, Germany (G.R.F. C.D., H. Stetefeld)
| | - Anna Lena Fisse
- Department of Neurology, University of Münster, Germany (A.L.F., J.M.)
| | - Jens Minnerup
- Department of Neurology, University of Münster, Germany (A.L.F., J.M.)
| | - Georg Hagemann
- Department of Neurology, Community Hospital Helios Klinikum Berlin-Buch, Germany (G.H., F.R.)
| | - Florian Rakers
- Department of Neurology, Community Hospital Helios Klinikum Berlin-Buch, Germany (G.H., F.R.)
| | - Heinz Reichmann
- Department of Neurology, University of Dresden, Germany (H.R., H. Schneider, J. Rahmig).,Department of Neurology, Klinikum Augsburg, Germany (H. Schneider)
| | - Hauke Schneider
- Department of Neurology, University of Dresden, Germany (H.R., H. Schneider, J. Rahmig)
| | - Jan Rahmig
- Department of Neurology, University of Dresden, Germany (H.R., H. Schneider, J. Rahmig)
| | | | - Sebastian Stösser
- Department of Neurology, University of Ulm, Germany (A.C.L., S. Stösser, H.N.)
| | - Hermann Neugebauer
- Department of Neurology, University of Ulm, Germany (A.C.L., S. Stösser, H.N.)
| | - Joachim Röther
- Department of Neurology, Community Hospital Asklepios Klinik Hamburg Altona, Germany (J. Röther, P.M.)
| | - Peter Michels
- Department of Neurology, Community Hospital Asklepios Klinik Hamburg Altona, Germany (J. Röther, P.M.)
| | - Michael Schwarz
- Department of Neurology, Community Hospital Klinikum Dortmund, Germany (M.S., G.R.)
| | - Gernot Reimann
- Department of Neurology, Community Hospital Klinikum Dortmund, Germany (M.S., G.R.)
| | - Hansjörg Bäzner
- Department of Neurology, Community Hospital Klinikum Stuttgart, Germany (H.B., H. Schwert)
| | - Henning Schwert
- Department of Neurology, Community Hospital Klinikum Stuttgart, Germany (H.B., H. Schwert)
| | - Joseph Claßen
- Department of Neurology, University of Leipzig, Germany (J.C., D.M.)
| | - Dominik Michalski
- Department of Neurology, University of Leipzig, Germany (J.C., D.M.)
| | - Armin Grau
- Department of Neurology, Community Hospital Klinikum der Stadt Ludwigshafen am Rhein, Germany (A. Grau, F.P., C.U.)
| | - Frederick Palm
- Department of Neurology, Community Hospital Klinikum der Stadt Ludwigshafen am Rhein, Germany (A. Grau, F.P., C.U.)
| | - Christian Urbanek
- Department of Neurology, Community Hospital Klinikum der Stadt Ludwigshafen am Rhein, Germany (A. Grau, F.P., C.U.)
| | - Johannes C Wöhrle
- Department of Neurology, Community Hospital Klinikum Koblenz, Germany (J.C.W., F.A.)
| | - Fahid Alshammari
- Department of Neurology, Community Hospital Klinikum Koblenz, Germany (J.C.W., F.A.)
| | - Markus Horn
- Department of Neurology, Community Hospital Bad Hersfeld, Germany (M. Horn, D.B.)
| | - Dirk Bahner
- Department of Neurology, Community Hospital Bad Hersfeld, Germany (M. Horn, D.B.)
| | - Otto W Witte
- Department of Neurology, University of Jena, Germany (O.W.W., A. Günther)
| | - Albrecht Günther
- Department of Neurology, University of Jena, Germany (O.W.W., A. Günther)
| | - Gerhard F Hamann
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Günzburg, Germany (J.F.H.)
| | - Tobias Engelhorn
- Department of Neuroradiology (T.E., H.L., A.D.), University of Erlangen-Nuremberg, Germany
| | - Hannes Lücking
- Department of Neuroradiology (T.E., H.L., A.D.), University of Erlangen-Nuremberg, Germany
| | - Arnd Dörfler
- Department of Neuroradiology (T.E., H.L., A.D.), University of Erlangen-Nuremberg, Germany
| | - Stefan Schwab
- From the Department of Neurology (S.T.G., J.B.K., J.A.S., M.I.S., M. Hagen, R.U.K., S. Schwab, H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Hagen B Huttner
- From the Department of Neurology (S.T.G., J.B.K., J.A.S., M.I.S., M. Hagen, R.U.K., S. Schwab, H.B.H.), University of Erlangen-Nuremberg, Germany
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15
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Nistor M, Schmidt M, Graul I, Rakers F, Schiffner R. A Systematic Review of Neuroprotective Strategies in the Management of Hypoglycemia. Int J Mol Sci 2019; 20:ijms20030550. [PMID: 30696060 PMCID: PMC6386855 DOI: 10.3390/ijms20030550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 01/18/2019] [Accepted: 01/24/2019] [Indexed: 02/07/2023] Open
Abstract
Severe hypogylcemia has been found to induce cerebral damage. While a number of illnesses can lead to hypoglycemic episodes, antidiabetic medications prescribed for glycemic control are a common cause. Considering the rising prevalence of diabetes mellitus in the population, we investigated neuroprotective strategies during hypoglycemia in the form of a systematic review in adherence to the PRISMA statement. A review protocol was registered in the PROSPERO database. A systematic literature search of PubMed, Web of Science, and CENTRAL was performed in September 2018. Based on a predefined inclusion protocol, results were screened and evaluated by two researchers. Both animal experiments and human studies were included, and their risk of bias was assessed with SYRCLE’s and the Cochrane risk of bias tools, respectively. Of a total of 16,230 results, 145 were assessed in full-text form: 27 articles adhered to the inclusion criteria and were qualitatively analyzed. The retrieved neuroprotective strategies could be categorized into three subsets: (1) Energy substitution, (2) hypoglycemia unawareness, and (3) other neuroprotective strategies. While on a study level, the individual results appeared promising, more research is required to investigate not only specific neuroprotective strategies against hypoglycemic cerebral damage, but also its underlying pathophysiological mechanisms.
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Affiliation(s)
- Marius Nistor
- Department of Neurology, Jena University Hospital - Friedrich Schiller University, Jena 07747, Germany.
| | - Martin Schmidt
- Institute for Biochemistry II, Jena University Hospital - Friedrich Schiller University, Jena 07743, Germany.
| | - Isabel Graul
- Orthopedic Department, Jena University Hospital - Friedrich Schiller University, Campus Eisenberg, Klosterlausnitzer Straße 81, Eisenberg 07607, Germany.
| | - Florian Rakers
- Department of Neurology, Jena University Hospital - Friedrich Schiller University, Jena 07747, Germany.
| | - René Schiffner
- Department of Neurology, Jena University Hospital - Friedrich Schiller University, Jena 07747, Germany.
- Orthopedic Department, Jena University Hospital - Friedrich Schiller University, Campus Eisenberg, Klosterlausnitzer Straße 81, Eisenberg 07607, Germany.
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16
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Franzke P, Bitsch A, Walther M, Schiffner R, Rupprecht S, Rasche M, Volk GF, Witte OW, Schlattmann P, Guntinas-Lichius O, Hagemann G, Schwab M, Rakers F. Weather, Weather Changes and the Risk of Bell's Palsy: A Multicenter Case-Crossover Study. Neuroepidemiology 2018; 51:207-215. [PMID: 30205396 DOI: 10.1159/000492671] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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: 04/30/2018] [Accepted: 08/04/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND To evaluate if weather or changes in weather are risk factors for Bell's palsy (BP) as exposure to draught of cold air has been popularly associated with the occurrence of BP. METHODS Using a multicenter hospital-based case-crossover study, we analyzed the association between ambient temperature, atmospheric pressure, relative air humidity or their 24 h changes and the risk for BP in 825 patients or subgroups. RESULTS One day following a 24 h increase in atmospheric pressure of more than 6 hPa, the risk for BP increased by 35% (OR 1.35; 95% CI 1.03-1.78) in the overall population. The risk for BP more than doubled in patients with diabetes mellitus after rapid variations in ambient temperature, independent of the direction (temperature decrease > 2.25°C; OR 2.15; 95% CI 1.08-4.25; temperature increase between 0.75 and 2.25°C; OR 2.88; 95% CI 1.63-5.10). CONCLUSIONS Our findings support the hypothesis of an association between certain weather conditions and the risk for BP with acute changes in atmospheric pressure and ambient temperature as the main risk factors. Additionally, contrasting results for risk of BP after temperature changes in the diabetic and non-diabetic subgroups support the paradigm of a diabetic facial palsy as a distinct disease entity.
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Affiliation(s)
- Peter Franzke
- Hans Berger Department of Neurology, Jena, .,Department of Neurology, Neuruppin,
| | | | - Mario Walther
- Institute of Medical Statistics, Computer Sciences and Documentation, Jena, Germany.,Department of Fundamental Sciences, Ernst-Abbe-University of Applied Sciences, Jena, Germany
| | | | | | | | - Gerd Fabian Volk
- Department of Otorhinolaryngology, Jena University Hospital, Jena, Germany
| | - Otto W Witte
- Hans Berger Department of Neurology, Jena, Germany
| | - Peter Schlattmann
- Institute of Medical Statistics, Computer Sciences and Documentation, Jena, Germany
| | | | - Georg Hagemann
- HELIOS Hospital Berlin-Buch, Department of Neurology, Berlin, Germany
| | | | - Florian Rakers
- Hans Berger Department of Neurology, Jena, Germany.,Department of Psychiatry, Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
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17
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Rakers F, Rasche M, Schwab M. Reply to the letter ‘Is a rapid increase in nitrogen oxides really associated with an acute myocardial infarction?’. Eur J Prev Cardiol 2018; 25:997-998. [DOI: 10.1177/2047487318768324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Florian Rakers
- Hans Berger Department of Neurology, University Hospital Jena, Germany
| | - Marius Rasche
- Hans Berger Department of Neurology, University Hospital Jena, Germany
| | - Matthias Schwab
- Hans Berger Department of Neurology, University Hospital Jena, Germany
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18
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Rasche M, Walther M, Schiffner R, Kroegel N, Rupprecht S, Schlattmann P, Schulze PC, Franzke P, Witte OW, Schwab M, Rakers F. Rapid increases in nitrogen oxides are associated with acute myocardial infarction: A case-crossover study. Eur J Prev Cardiol 2018; 25:1707-1716. [PMID: 29446990 DOI: 10.1177/2047487318755804] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [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] [Indexed: 11/17/2022]
Abstract
Aims High concentrations of air pollutants are associated with increased risk for myocardial infarction. The European Union has defined statutory limits for air pollutants based on upper absolute concentrations. We evaluated the association between rapid changes in air pollutants and the risk of myocardial infarction independently of absolute concentrations. Methods and results Using a hospital-based case-crossover study, effects of 24h changes of nitrogen oxides (NOX/2), particulate matter (PM10), and ozone on the risk of myocardial infarction was assessed in 693 patients. In the overall population, increases of NOX of more than 20 µg/m3 within 24 h were associated with an increase in the risk of myocardial infarction by up to 121% (odds ratio (OR) 2.21, 95% confidence interval (CI) 1.19-4.08). Comparably, rapid increases of NO2 of more than 8 µg/m3 tended to increase myocardial infarction risk by 73% (OR 1.73, 95% CI 0.91-3.28) while myocardial infarction risk decreased by 60% after a decrease of NO2 concentration of more than 8 µg/m3 (OR 0.4, 95% CI 0.21-0.77), suggesting a close-to-linear association. While results for ozone concentrations were ambiguous, rapid change in PM10 was not associated with myocardial infarction risk. Conclusion Dynamics and extent of increase in nitrogen oxide concentrations may be an independent risk factor for myocardial infarction. As there are currently no European Union statutory limits reflecting this dynamic variation of air pollutants on a daily basis, the results urgently call for confirming studies in different geographical regions to verify the observations.
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Affiliation(s)
- Marius Rasche
- 1 Hans Berger Department of Neurology, University Hospital Jena, Germany
| | - Mario Walther
- 2 Institute of Medical Statistics, Computer Sciences and Documentation, University Hospital Jena, Germany.,3 Department of Fundamental Sciences, Ernst-Abbe-University of Applied Sciences, Jena, Germany
| | - Rene Schiffner
- 1 Hans Berger Department of Neurology, University Hospital Jena, Germany
| | - Nasim Kroegel
- 1 Hans Berger Department of Neurology, University Hospital Jena, Germany
| | - Sven Rupprecht
- 1 Hans Berger Department of Neurology, University Hospital Jena, Germany
| | - Peter Schlattmann
- 2 Institute of Medical Statistics, Computer Sciences and Documentation, University Hospital Jena, Germany
| | | | - Peter Franzke
- 5 Department of Neurology, Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
| | - Otto W Witte
- 1 Hans Berger Department of Neurology, University Hospital Jena, Germany
| | - Matthias Schwab
- 1 Hans Berger Department of Neurology, University Hospital Jena, Germany
| | - Florian Rakers
- 1 Hans Berger Department of Neurology, University Hospital Jena, Germany.,6 Department of Psychiatry, Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
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Dreiling M, Schiffner R, Bischoff S, Rupprecht S, Kroegel N, Schubert H, Witte OW, Schwab M, Rakers F. Impact of chronic maternal stress during early gestation on maternal-fetal stress transfer and fetal stress sensitivity in sheep. Stress 2018; 21:1-10. [PMID: 29041862 DOI: 10.1080/10253890.2017.1387534] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Acute stress-induced reduction of uterine blood flow (UBF) is an indirect mechanism of maternal-fetal stress transfer during late gestation. Effects of chronic psychosocial maternal stress (CMS) during early gestation, as may be experienced by many working women, on this stress signaling mechanism are unclear. We hypothesized that CMS in sheep during early gestation augments later acute stress-induced decreases of UBF, and aggravates the fetal hormonal, cardiovascular, and metabolic stress responses during later development. Six pregnant ewes underwent repeated isolation stress (CMS) between 30 and 100 days of gestation (dGA, term: 150 dGA) and seven pregnant ewes served as controls. At 110 dGA, ewes were chronically instrumented and underwent acute isolation stress. The acute stress decreased UBF by 19% in both the CMS and control groups (p < .05), but this was prolonged in CMS versus control ewes (74 vs. 30 min, p < .05). CMS increased fetal circulating baseline and stress-induced cortisol and norepinephrine concentrations indicating a hyperactive hypothalamus-pituitary-adrenal (HPA)-axis and sympathetic-adrenal-medullary system. Increased fetal norepinephrine is endogenous as maternal catecholamines do not cross the placenta. Cortisol in the control but not in the CMS fetuses was correlated with maternal cortisol blood concentrations; these findings indicate: (1) no increased maternal-fetal cortisol transfer with CMS, (2) cortisol production in CMS fetuses when the HPA-axis is normally inactive, due to early maturation of the fetal HPA-axis. CMS fetuses were better oxygenated, without shift towards acidosis compared to the controls, potentially reflecting adaptation to repeated stress. Hence, CMS enhances maternal-fetal stress transfer by prolonged reduction in UBF and increased fetal HPA responsiveness.
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Affiliation(s)
- Michelle Dreiling
- a Hans Berger Department of Neurology , Jena University Hospital , Jena , Germany
| | - Rene Schiffner
- a Hans Berger Department of Neurology , Jena University Hospital , Jena , Germany
| | - Sabine Bischoff
- b Institute of Lab Animal Sciences and Welfare , Jena University Hospital , Jena , Germany
| | - Sven Rupprecht
- a Hans Berger Department of Neurology , Jena University Hospital , Jena , Germany
| | - Nasim Kroegel
- a Hans Berger Department of Neurology , Jena University Hospital , Jena , Germany
| | - Harald Schubert
- b Institute of Lab Animal Sciences and Welfare , Jena University Hospital , Jena , Germany
| | - Otto W Witte
- a Hans Berger Department of Neurology , Jena University Hospital , Jena , Germany
| | - Matthias Schwab
- a Hans Berger Department of Neurology , Jena University Hospital , Jena , Germany
| | - Florian Rakers
- a Hans Berger Department of Neurology , Jena University Hospital , Jena , Germany
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20
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Schiffner R, Rodríguez-González GL, Rakers F, Nistor M, Nathanielsz PW, Daneva T, Schwab M, Lehmann T, Schmidt M. Effects of Late Gestational Fetal Exposure to Dexamethasone Administration on the Postnatal Hypothalamus-Pituitary-Adrenal Axis Response to Hypoglycemia in Pigs. Int J Mol Sci 2017; 18:ijms18112241. [PMID: 29077038 PMCID: PMC5713211 DOI: 10.3390/ijms18112241] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Revised: 10/19/2017] [Accepted: 10/21/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Prenatal glucocorticoid administration alters the activity of the fetal hypothalamic-pituitary-adrenocortical axis (HPAA), and correspondingly the adenocorticotropic hormone (ACTH) and cortisol levels after birth. The dosages required for these effects are critically discussed. Activation of the HPAA is related to metabolic syndrome and diabetes mellitus. Hypoglycemia is the classic side effect of antidiabetic treatment. We hypothesized that a low dosage of dexamethasone in late pregnancy alters the HPAA response to hypoglycemia in pigs. METHODS 12 pregnant sows were randomly assigned to two groups which received either a low-dose intramuscular injection (99th and 100th day of gestation) of dexamethasone (0.06 μg/kg body weight) or vehicle. Three months after birth, 18 dexamethasone-treated anaesthetized offspring and 12 control offspring underwent a 75 min hypoglycemic clamp (blood glucose below 4 mmol/L) procedure. Heart rate (HR), blood pressure, ACTH and cortisol levels and body weight (at birth and after three months) were recorded. RESULTS Dexamethasone-treated animals exhibited significantly elevated ACTH (139.9 ± 12.7 pg/mL) and cortisol (483.1 ± 30.3 nmol/L) levels during hypoglycemia as compared to the control group (41.7 ± 6.5 pg/mL and 257.9 ± 26.7 nmol/L, respectively), as well as an elevated HR (205.5 ± 5.7 bpm) and blood pressure (systolic: 128.6 ± 1.5, diastolic: 85.7 ± 0.7 mmHg) response as compared to the control group (153.2 ± 4.5 bpm; systolic: 118.6 ± 1.6, diastolic: 79.5 ± 1.4 mmHg, respectively; p < 0.001). CONCLUSIONS Low-dose prenatal administration of dexamethasone not only exerts effects on the HPAA (ACTH and cortisol concentration) and vital parameters (HR and diastolic blood pressure) under baseline conditions, but also on ACTH, HR and systolic blood pressure during hypoglycemia.
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Affiliation(s)
- René Schiffner
- Department of Neurology, Jena University Hospital-Friedrich Schiller University, 07747 Jena, Germany.
- Orthopaedic Department, Jena University Hospital-Friedrich Schiller University, 07747 Jena, Germany.
| | | | - Florian Rakers
- Department of Neurology, Jena University Hospital-Friedrich Schiller University, 07747 Jena, Germany.
| | - Marius Nistor
- Department of Neurology, Jena University Hospital-Friedrich Schiller University, 07747 Jena, Germany.
| | - Peter W Nathanielsz
- Department of Animal Science, University of Wyoming, Laramie, 82071 WY, USA.
| | - Teodora Daneva
- Institute of Biology and Immunology of Reproduction, Bulgarian Academy of Sciences, 1113 Sofia, Bulgaria.
| | - Matthias Schwab
- Department of Neurology, Jena University Hospital-Friedrich Schiller University, 07747 Jena, Germany.
| | - Thomas Lehmann
- Institute of Medical Statistics, Computer Sciences and Documentation Science, Jena University Hospital-Friedrich Schiller University, 07743 Jena, Germany.
| | - Martin Schmidt
- Institute for Biochemistry II, Jena University Hospital-Friedrich Schiller University, 07743 Jena, Germany.
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21
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Müller JJ, Schwab M, Rosenfeld CR, Antonow-Schlorke I, Nathanielsz PW, Rakers F, Schubert H, Witte OW, Rupprecht S. Fetal Sheep Mesenteric Resistance Arteries: Functional and Structural Maturation. J Vasc Res 2017; 54:259-271. [PMID: 28810262 DOI: 10.1159/000477629] [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: 06/08/2016] [Accepted: 05/14/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Fetal blood pressure increases during late gestation; however, the underlying vascular mechanisms are unclear. Knowledge of the maturation of resistance arteries is important to identify the mechanisms and vulnerable periods for the development of vascular dysfunction in adulthood. METHODS We determined the functional and structural development of fetal sheep mesenteric resistance arteries using wire myography and immunohistochemistry. RESULTS Media mass and distribution of myosin heavy-chain isoforms showed no changes between 0.7 (100 ± 3 days) and 0.9 (130 ± 3 days) gestation. However, from 0.7 to 0.9 gestation, the resting wall tension increased accompanied by non-receptor-dependent (potassium) and receptor-dependent (noradrenaline; endothelin-1) increases in vasocontraction. Angiotensin II had no contractile effect at both ages. Endothelium-dependent relaxation to acetylcholine and prostaglandin E2 was absent at 0.7 but present at 0.9 gestation. Augmented vascular responsiveness was paralleled by the maturation of sympathetic and sensory vascular innervation. Non-endothelium-dependent relaxation to nitric oxide showed no maturational changes. The expression of vasoregulator receptors/enzymes did not increase between 0.7 and 0.9 gestation. CONCLUSION Vascular maturation during late ovine gestation involves an increase in resting wall tension and the vasoconstrictor and vasodilator capacity of the mesenteric resistance arteries. Absence of structural changes in the tunica media and the lack of an increase in vasoregulator receptor/enzyme expression suggest that vasoactive responses are due to the maturation of intracellular pathways at this gestational age.
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Affiliation(s)
- Julia J Müller
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
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22
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Rakers F, Walther M, Schiffner R, Rupprecht S, Rasche M, Kockler M, Witte OW, Schlattmann P, Schwab M. Weather as a risk factor for epileptic seizures: A case-crossover study. Epilepsia 2017; 58:1287-1295. [PMID: 28480567 DOI: 10.1111/epi.13776] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2017] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Most epileptic seizures occur unexpectedly and independently of known risk factors. We aimed to evaluate the clinical significance of patients' perception that weather is a risk factor for epileptic seizures. METHODS Using a hospital-based, bidirectional case-crossover study, 604 adult patients admitted to a large university hospital in Central Germany for an unprovoked epileptic seizure between 2003 and 2010 were recruited. The effect of atmospheric pressure, relative air humidity, and ambient temperature on the onset of epileptic seizures under temperate climate conditions was estimated. RESULTS We found a close-to-linear negative correlation between atmospheric pressure and seizure risk. For every 10.7 hPa lower atmospheric pressure, seizure risk increased in the entire study population by 14% (odds ratio [OR] 1.14, 95% confidence interval [CI] 1.01-1.28). In patients with less severe epilepsy treated with one antiepileptic medication, seizure risk increased by 36% (1.36, 1.09-1.67). A high relative air humidity of >80% increased seizure risk in the entire study population by up to 48% (OR 1.48, 95% CI 1.11-1.96) 3 days after exposure in a J-shaped association. High ambient temperatures of >20°C decreased seizure risk by 46% in the overall study population (OR 0.54, 95% CI 0.32-0.90) and in subgroups, with the greatest effects observed in male patients (OR 0.33, 95% CI 0.14-0.74). SIGNIFICANCE Low atmospheric pressure and high relative air humidity are associated with an increased risk for epileptic seizures, whereas high ambient temperatures seem to decrease seizure risk. Weather-dependent seizure risk may be accentuated in patients with less severe epilepsy. Our results require further replication across different climate regions and cohorts before reliable clinical recommendations can be made.
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Affiliation(s)
- Florian Rakers
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany.,Department of Neurology, HELIOS Hospital Berlin-Buch, Berlin, Germany
| | - Mario Walther
- Institute of Medical Statistics, Computer Sciences and Documentation, Jena University Hospital, Jena, Germany.,Department of Fundamental Sciences, Ernst-Abbe-University of Applied Sciences, Jena, Germany
| | - Rene Schiffner
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Sven Rupprecht
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Marius Rasche
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Michael Kockler
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Otto W Witte
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Peter Schlattmann
- Institute of Medical Statistics, Computer Sciences and Documentation, Jena University Hospital, Jena, Germany
| | - Matthias Schwab
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
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23
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Rakers F, Rupprecht S, Dreiling M, Bergmeier C, Witte OW, Schwab M. Transfer of maternal psychosocial stress to the fetus. Neurosci Biobehav Rev 2017; 117:S0149-7634(16)30719-9. [PMID: 28237726 DOI: 10.1016/j.neubiorev.2017.02.019] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [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: 11/18/2016] [Revised: 02/14/2017] [Accepted: 02/20/2017] [Indexed: 12/18/2022]
Abstract
Psychosocial maternal stress experienced during different vulnerable periods throughout gestation is thought to increase the individual's risk to develop neuropsychiatric, cardiovascular and metabolic disease in later life. Cortisol has generally been identified as the major mediator of maternal stress transfer to the fetus. Its lipophilic nature allows a trans-placental passage and thus excessive maternal cortisol could persistently impair the development of the fetal hypothalamic-pituitary-adrenal axis (HPAA). However, cortisol alone cannot fully explain all effects of maternal stress especially during early to mid pregnancy before maturation of the fetal HPAA has even begun and expression of fetal glucocorticoid receptors is limited. This review focuses on mediators of maternal fetal stress transfer that in addition to cortisol have been proposed as transmitters of maternal stress: catecholamines, cytokines, serotonin/tryptophan, reactive-oxygen-species and the maternal microbiota. We propose that the effects of psychosocial maternal stress on fetal development and health and disease in later life are not a consequence of a single pathway but are mediated by multiple stress-transfer mechanisms acting together in a synergistic manner.
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Affiliation(s)
- Florian Rakers
- Hans Berger Department of Neurology, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany.
| | - Sven Rupprecht
- Hans Berger Department of Neurology, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany.
| | - Michelle Dreiling
- Hans Berger Department of Neurology, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany.
| | - Christoph Bergmeier
- Hans Berger Department of Neurology, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany.
| | - Otto W Witte
- Hans Berger Department of Neurology, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany.
| | - Matthias Schwab
- Hans Berger Department of Neurology, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany.
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Dreiling M, Bischoff S, Schiffner R, Rupprecht S, Kiehntopf M, Schubert H, Witte OW, Nathanielsz PW, Schwab M, Rakers F. Stress-induced decrease of uterine blood flow in sheep is mediated by alpha 1-adrenergic receptors. Stress 2016; 19:547-51. [PMID: 27352901 DOI: 10.1080/10253890.2016.1203417] [Citation(s) in RCA: 8] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Prenatal maternal stress can be transferred to the fetus via a catecholamine-dependent decrease of uterine blood flow (UBF). However, it is unclear which group of adrenergic receptors mediates this mechanism of maternal-fetal stress transfer. We hypothesized that in sheep, alpha 1-adrenergic receptors may play a key role in catecholamine mediated UBF decrease, as these receptors are mainly involved in peripheral vasoconstriction and are present in significant number in the uterine vasculature. After chronic instrumentation at 125 ± 1 days of gestation (dGA; term 150 dGA), nine pregnant sheep were exposed at 130 ± 1 dGA to acute isolation stress for one hour without visual, tactile, or auditory contact with their flockmates. UBF, blood pressure (BP), heart rate (HR), stress hormones, and blood gases were determined before and during this isolation challenge. Twenty-four hours later, experiments were repeated during alpha 1-adrenergic receptor blockage induced by a continuous intravenous infusion of urapidil. In both experiments, ewes reacted to isolation with an increase in serum norepinephrine, cortisol, BP, and HR as typical signs of activation of sympatho-adrenal and the hypothalamic-pituitary-adrenal axis. Stress-induced UBF decrease was prevented by alpha 1-adrenergic receptor blockage. We conclude that UBF decrease induced by maternal stress in sheep is mediated by alpha 1-adrenergic receptors. Future studies investigating prevention strategies of impact of prenatal maternal stress on fetal health should consider selective blockage of alpha 1-receptors to interrupt maternal-fetal stress transfer mediated by utero-placental malperfusion.
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Affiliation(s)
- Michelle Dreiling
- a Hans Berger Department of Neurology , Jena University Hospital , Jena , Germany
| | - Sabine Bischoff
- b Institute of Lab Animal Sciences and Welfare, Jena University Hospital , Jena , Germany
| | - Rene Schiffner
- a Hans Berger Department of Neurology , Jena University Hospital , Jena , Germany
| | - Sven Rupprecht
- a Hans Berger Department of Neurology , Jena University Hospital , Jena , Germany
| | - Michael Kiehntopf
- c Institute of Clinical Chemistry and Laboratory Medicine, Jena University Hospital , Jena , Germany
| | - Harald Schubert
- b Institute of Lab Animal Sciences and Welfare, Jena University Hospital , Jena , Germany
| | - Otto W Witte
- a Hans Berger Department of Neurology , Jena University Hospital , Jena , Germany
- d Center for Sepsis Control and Care, Jena University Hospital , Jena , Germany
| | | | - Matthias Schwab
- a Hans Berger Department of Neurology , Jena University Hospital , Jena , Germany
| | - Florian Rakers
- a Hans Berger Department of Neurology , Jena University Hospital , Jena , Germany
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25
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Rakers F, Bischoff S, Schiffner R, Haase M, Rupprecht S, Kiehntopf M, Kühn-Velten WN, Schubert H, Witte OW, Nijland MJ, Nathanielsz PW, Schwab M. Role of catecholamines in maternal-fetal stress transfer in sheep. Am J Obstet Gynecol 2015. [PMID: 26212181 DOI: 10.1016/j.ajog.2015.07.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [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] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We sought to evaluate whether in addition to cortisol, catecholamines also transfer psychosocial stress indirectly to the fetus by decreasing uterine blood flow (UBF) and increasing fetal anaerobic metabolism and stress hormones. STUDY DESIGN Seven pregnant sheep chronically instrumented with uterine ultrasound flow probes and catheters at 0.77 gestation underwent 2 hours of psychosocial stress by isolation. We used adrenergic blockade with labetalol to examine whether decreased UBF is catecholamine mediated and to determine to what extent stress transfer from mother to fetus is catecholamine dependent. RESULTS Stress induced transient increases in maternal cortisol and norepinephrine (NE). Maximum fetal plasma cortisol concentrations were 8.1 ± 2.1% of those in the mother suggesting its maternal origin. In parallel to the maternal NE increase, UBF decreased by maximum 22% for 30 minutes (P < .05). Fetal NE remained elevated for >2 hours accompanied by a prolonged blood pressure increase (P < .05). Fetuses developed a delayed and prolonged shift toward anaerobic metabolism in the presence of an unaltered oxygen supply. Adrenergic blockade prevented the stress-induced UBF decrease and, consequently, the fetal NE and blood pressure increase and the shift toward anaerobic metabolism. CONCLUSION We conclude that catecholamine-induced decrease of UBF is a mechanism of maternal-fetal stress transfer. It may explain the influence of maternal stress on fetal development and on programming of adverse health outcomes in later life especially during early pregnancy when fetal glucocorticoid receptor expression is limited.
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Affiliation(s)
- Florian Rakers
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany.
| | - Sabine Bischoff
- Institute of Laboratory Animal Sciences and Welfare, Jena University Hospital, Jena, Germany
| | - Rene Schiffner
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Michelle Haase
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Sven Rupprecht
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Michael Kiehntopf
- Institute of Clinical Chemistry and Laboratory Medicine, Jena University Hospital, Jena, Germany
| | | | - Harald Schubert
- Institute of Laboratory Animal Sciences and Welfare, Jena University Hospital, Jena, Germany
| | - Otto W Witte
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany; Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
| | - Mark J Nijland
- Center for Pregnancy and Newborn Research, Department of Obstetrics and Gynecology, University of Texas, San Antonio, School of Medicine, San Antonio, TX
| | - Peter W Nathanielsz
- Center for Pregnancy and Newborn Research, Department of Obstetrics and Gynecology, University of Texas, San Antonio, School of Medicine, San Antonio, TX
| | - Matthias Schwab
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
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Rakers F, Frauendorf V, Rupprecht S, Schiffner R, Bischoff SJ, Kiehntopf M, Reinhold P, Witte OW, Schubert H, Schwab M. Effects of early- and late-gestational maternal stress and synthetic glucocorticoid on development of the fetal hypothalamus-pituitary-adrenal axis in sheep. Stress 2013; 16:122-9. [PMID: 22512268 DOI: 10.3109/10253890.2012.686541] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Prenatal maternal stress (PMS) programs dysregulation of the hypothalamus-pituitary-adrenal axis (HPAA) in postnatal life, though time periods vulnerable to PMS, are still unclear. We evaluated in pregnant sheep the effect of PMS during early gestation [30-100 days of gestation (dGA); term is 150 dGA] or late gestation (100-120 dGA) on development of fetal HPAA function. We compared the effects of endogenous cortisol with synthetic glucocorticoid (GC) exposure, as used clinically to enhance fetal lung maturation. Pregnant sheep were exposed to repeated isolation stress twice per week for 3 h in a separate box with no visual, tactile, or auditory contact with their flock-mates either during early (n = 7) or late (n = 7) gestation. Additional groups received two courses of betamethasone (BM; n = 7; 2 × 110 μg kg(- 1) body weight, 24 h apart) during late gestation (106/107 and 112/113 dGA, n = 7) or acted as controls (n = 7). Fetal cortisol responses to hypotensive challenge, a physiological fetal stressor, were measured at 112 and 129 dGA, i.e. before and during maturation of the HPAA. Hypotension was induced by fetal infusion of sodium nitroprusside, a potent vasodilator. At 112 dGA, neither PMS nor BM altered fetal cortisol responses. PMS, during early or late gestation, and BM treatment increased fetal cortisol responses at 129 dGA with the greatest increase achieved in stressed early pregnant sheep. Thus, development of the HPAA is vulnerable to inappropriate levels of GCs during long periods of fetal life, whereas early gestation is most vulnerable to PMS.
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Affiliation(s)
- Florian Rakers
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany.
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27
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Döhnert N, Rakers F, Liebers U, Köhler F, Endlicher W, Witt C. Früherkennungs-System bei COPD – telemedizinische Intervention bei Exazerbation als Adaptationsstrategie an den Klimawandel in Berlin? Pneumologie 2012. [DOI: 10.1055/s-0032-1302714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Schwab M, Coksaygan T, Rakers F, Nathanielsz PW. Glucocorticoid exposure of sheep at 0.7 to 0.75 gestation augments late-gestation fetal stress responses. Am J Obstet Gynecol 2012; 206:253.e16-22. [PMID: 22192534 DOI: 10.1016/j.ajog.2011.11.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Revised: 10/24/2011] [Accepted: 11/11/2011] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Exposure to glucocorticoid levels inappropriately high for current maturation alters fetal hypothalamo-pituitary-adrenal axis (HPAA) development. In an established fetal sheep model, we determined whether clinical betamethasone doses used to accelerate fetal lung maturation have persistent effects on fetal HPAA hypotensive-stress responses. STUDY DESIGN Pregnant ewes received saline (n = 6) or betamethasone (n = 6); 2 × 110 μg/kg body weight doses injected 24 hours apart (106/107 and 112/113 days' gestational age, term 150 days). Basal adrenocorticotropin (ACTH) and cortisol and responses to fetal hypotension were measured before and 5 days after the first course and 14 days after the second course. RESULTS Basal ACTH and cortisol were similar with treatment. HPAA responses to hypotension increased after the second but not first course and ACTH/cortisol ratio increased indicating central HPAA effects. CONCLUSIONS Results demonstrate latency in the emergence of fetal HPAA hyperresponsiveness following betamethasone exposure that may explain hyperresponsiveness in full-term but not preterm neonates.
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Affiliation(s)
- Matthias Schwab
- Department of Neurology, Friedrich Schiller University, Jena, Germany.
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