Management and prognostic features of intracerebral hemorrhage during anticoagulant therapy: a Swedish multicenter study.

BACKGROUND AND PURPOSE: Patients treated with oral anticoagulants (ACs) have an increased risk of intracerebral hemorrhage (ICH), which is more often fatal than spontaneous ICH. Options to reverse the AC effect include intravenous administration of vitamin K, plasma, and coagulation factor concentrate. However, the optimal management of AC-related ICH has not been determined in any randomized trial. In this study, the present management of AC-related ICH was surveyed, and determinants of survival were assessed. METHODS: We retrospectively reviewed the medical records of all AC-related ICHs at 10 Swedish hospitals during a 4-year period, 1993 to 1996. Survival status after the ICH was determined from the Swedish National population register. RESULTS: We identified 151 patients with AC-related ICH. Death rates were 53.6% at 30 days, 63.6% at 6 months, and 77.5% at follow-up (mean 3.5 years). The case fatality ratio at 30 days was 96% among patients unconscious on admission (n=27), 80% among patients who became unconscious before active treatment was started (n=15), 55% among patients in whom no special action was taken except withdrawal of AC treatment (n=42), and 28% among patients given active anti-coumarin treatment while they were still conscious (n=64). The case fatality ratio at 30 days was 11% in the group treated with plasma (n=18), 30% in the group treated with vitamin K (n=23), and 39% in the group treated with coagulation factor concentrate (n=23). Within the first 24 to 48 hours after admission, 47% of the patients deteriorated. Choice of therapy to reverse the AC effect differed substantially between the hospitals (P<0.0001), as did the time interval from symptom onset to start of treatment. Multiple logistic regression analysis showed only 2 factors (intraventricular extension of bleeding and ICH volume) that were independently related to case fatality at both 30 days and 6 months. The results were similar when the analysis was restricted to patients who were conscious on admission. CONCLUSIONS: In AC-related ICH, a progressive neurological deterioration during the first 24 to 48 hours after admission is frequent, and the mortality is high. Choice of therapy to reverse the AC effect differed considerably between the hospitals. There was no evidence that any treatment strategy was superior to the others. A randomized controlled trial is needed to determine the best choice of treatment.

Comparison of dietary casein and soybean protein effects on plasma lipid and gastrin levels, hepatic delta 6-desaturase activity and coronary arteriosclerosis in male Sprague-Dawley rats. A 9-month study.

An increased concentration of gastrin was observed in plasma of male Sprague-Dawley strain rats fed on soybean protein diet for a 9-month period, compared with rats fed on casein diet. Both diets contained 0.5% (w/w) cholesterol. Protein-dependent differences were also observed in the fatty acid pattern of hepatic phospholipids, hepatic delta 6-desaturase activity, and plasma cholesterol. No signs of arteriosclerosis were observed in the aortas. Sixty percent of the hearts showed various degrees of lipid staining in coronary arterial branches of different sizes. Despite a large difference in plasma cholesterol level, there was no quantitative or qualitative difference between groups in the occurrence of coronary lipid staining.

Plasma very low density lipoproteins from male rats fed casein or soybean protein diets: a comparison of fatty acid composition and influence on prostanoid production.

In studies with male rats fed for 4 wk semipurified diets containing olive oil and casein or soybean protein, protein-dependent effects were observed in the fatty acid composition of the VLDL lipids, especially with regard to the pattern of polyunsaturated fatty acids. Compared with VLDL from rats fed soybean protein diet (S-VLDL), VLDL from casein-fed rats (C-VLDL) contained a greater level of oleic acid, and a reduced level of linoleic acid and arachidonic acid, in the phosphatidylcholine fraction. The proportion of 5,8,11-eicosatrienoic acid, 20:3 (n-9), varied among the different lipid classes. The highest concentration of this fatty acid (13% by weight of total fatty acids) was observed in the phosphatidylinositol fraction of C-VLDL. The level of linoleic acid was approximately halved in the triacylglycerol and cholesteryl ester fractions of C-VLDL compared with S-VLDL. When mouse peritoneal macrophages were incubated with different concentrations of S-VLDL, a saturable accumulation of 6-keto-prostaglandin F1 alpha (6-keto-PGF1 alpha) and thromboxane B2 (TXB2) was observed in the cell medium. In contrast, very low levels of 6-keto-PGF1 alpha and TXB2 were observed in the cell medium of macrophages incubated with C-VLDL at different lipoprotein concentrations, suggesting that the composition of VLDL may play an important role in relation to cellular prostanoid metabolism.

Dietary protein and fatty acid composition of liver lipids in the rat.

In order to compare the effects of different sources of dietary protein on the fatty acid composition of phosphatidylcholines (PC), phosphatidylethanolamines (PE), phosphatidylinositols (PI), cholesteryl esters and triacylglycerols, male rats were fed for a 4-week period on cholesterol-free, or cholesterol-containing, diets based on casein, or soybean protein and olive oil. The most conspicuous difference observed was the occurrence of significantly higher levels of 5,8,11-eicosatrienoic acid, 20:3 (n - 9), in the different lipid classes of casein-fed, compared with soybean protein-fed, animals. In the PI fraction of livers from the groups of rats fed casein diet, this fatty acid amounted to between 9.9 and 13.3% by weight of the total fatty acids. Phospholipids from livers of casein-fed rats contained increased levels of oleic acid, 18:1 (n - 9) (in PC and PE) and reduced levels of stearic acid (18:0). Moreover, in this group of rats PI contained a reduced level of arachidonic acid, 20:4 (n - 6). A casein-related decrease in the linoleic acid, 18:2 (n - 6), content of PC and PE was observed only in the rats fed on cholesterol-free diet. Effects on the fatty acid composition were also observed in the triacyglycerol and cholesteryl ester fractions, in which the rats fed casein diet showed higher levels of palmitoleic acid, 16:1 (n - 7) (cholesterol-supplemented diet) and lower values for linoleic acid, than the soybean protein-fed rats.

Metabolism of very low density lipoproteins in rats with isotretinoin (13-cis retinoic acid)-induced hyperlipidemia.

A significant rise in plasma triacylglycerols from the control level of 0.89 mmol/l to 1.88 mmol/l (P less than 0.001) was observed in male Sprague-Dawley rats treated for 11 days with isotretinoin (oral dosing; 10 mg/day). This rise was due to an increased level of plasma very low density lipoproteins (VLDL). When VLDL from untreated rats were labeled with 125I-labeled tyramine-cellobiose and injected intravenously into rats treated for 10 days with isotretinoin (n = 6) and in control rats (n = 6), it was found that the disappearance of radioactivity from the blood was dramatically retarded in the treated animals. The disappearance could be divided into two phases, a rapid (alpha) phase dominated the first 5 min and was followed by a slower (beta) phase. The half-life of the beta-phase increased significantly from 53 +/- 7 min in the controls, to 120 +/- 62 min after isotretinoin. VLDL prepared from isotretinoin-treated animals (n = 6) had about the same half-life in control animals (62 +/- 8 min) as had ordinary VLDL. The elimination of tracer from the blood was mainly due to uptake by the liver. The amount of radioactivity in the liver after 30 min of circulation was significantly reduced from 34 +/- 7% of injected dose in controls to 24 +/- 5% in the isotretinoin group (P = 0.013). The uptake in other organs was less than 3% per organ and was essentially unaffected by the treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of metoprolol on plasma lipids and arterial intimal lipid deposition in spontaneously hypertensive rats.

The purpose of the present study was to characterize possible effects of dietary-induced plasma lipid elevations on the development of arterial lesions in spontaneously hypertensive rats (SHR) and to reveal any influence of treatment with metoprolol on these parameters. Metoprolol treatment caused an 8% decrease in heart rate and a 13% decrease in blood pressure and led to a rise in plasma triglycerides, 24%, 17% and 34% after 1, 3 and 6 months of metoprolol treatment, respectively. However, no effect on plasma triglycerides was observed after 9 months of metoprolol treatment while a reduced cholesterolemic response was observed. Intimal proliferations containing accumulations of lipids were observed in small intramural branches of coronary arteries (greater than 100 microns) in 11 of 31 control rats fed the atherogenic diet for 9 months. In contrast, similar changes were observed in only 1 of 34 metoprolol-treated rats fed an otherwise identical diet. The corresponding figures for the frequency of lipid containing intimal plaques in aorta were 6/19 in controls and 2/24 in the metoprolol-treated group.

Determination of HDL2 cholesterol by precipitation with dextran sulfate and magnesium chloride: establishing optimal conditions for rat plasma.

Optimal conditions for analyzing HDL2 cholesterol in small amounts of rat plasma have been studied using different concentrations of dextran sulfate and MgCl2 to precipitate lipoproteins containing apolipoprotein B and/or apo E. When the MgCl2 level was 91 mM, the supernate cholesterol was rather constant at a level of about 50-60% of the total plasma cholesterol concentration. Immunochemical determination of the apo A-I content indicated that no major losses of the HDL2 fraction took place under these conditions. The recovery of about 96% of HDL2 lipoproteins after the precipitation of rat plasma and the almost complete absence of lipoproteins belonging to the VLDL, LDL and HDL1 fractions was demonstrated by agarose gel electrophoresis. Thus, the method should be suitable for screening the HDL2 cholesterol content in small volumes of rat plasma.

Effects of diet and metoprolol on lipid levels in the blood plasma and morphology of the heart and intramural branches of coronary arteries of spontaneously hypertensive male rats. A 9-month study.

Semipurified diets containing 0.5% cholesterol were used in a 9-month study with spontaneously hypertensive male rats to characterize the effects of the protein source (casein vs. soybean protein), and the selective beta 1-adrenoceptor antagonist metoprolol on both lipid levels in blood plasma and the aorta, and on the morphology of intramural branches of coronary arteries. Raised blood lipid levels were observed in these rats. A significant decline in HDL2 cholesterol took place, while plasma cholesterol belonging to lipoprotein fractions of lower density increased. Metoprolol treatment led to a substantial elevation of the plasma triacylglycerol level and, with time, a reduced cholesterolemic response. The use of soybean protein instead of casein had a persistent plasma lipid-lowering effect. Arteriosclerotic changes in the form of musculo-elastic thickenings, intimal cushions and homogeneous hyalin deposits appeared in the intramural coronary arteries of rats in all groups after 9 months on the diet. However, intimal deposition of lipid was only present in rats belonging to the casein group not treated with metoprolol. Rats of this group also showed more severe myocardial lesions in the form of scar tissue with or without inflammatory cell reaction.

Accumulation of cholesteryl esters and triglycerides in cultured macrophages incubated with plasma very low density lipoproteins from rats fed on casein or soybean protein diets containing moderate levels of cholesterol.

Even when administered at a comparatively low level, dietary cholesterol produces significant changes in the properties of plasma lipoproteins in rats, particularly the d less than or equal to 1.006 g/ml fraction (VLDL). The occurrence of these changes is promoted by dietary casein. To test the hypothesis that these dietary-induced perturbations might include properties influencing lipoprotein-cell interactions of relevance to atherogenesis, cultured mouse peritoneal macrophages were incubated with VLDL isolated from male rats fed on diets containing either 0, 0.25 or 0.5% cholesterol with casein or soybean protein, respectively, as the sole source of protein. No increase in cholesteryl ester content, and a comparatively small rise in triglyceride content, was observed in macrophages incubated with VLDL from rats fed on cholesterol-free diets. In contrast, a significant and apparently saturable cellular accumulation of cholesteryl esters as well as triglycerides was produced by VLDL from cholesterol-fed rats. The curves showing cellular lipid accumulation versus VLDL-protein (or VLDL-cholesterol) content in the cell medium indicated different cellular affinity for VLDL from casein-fed rats in comparison with VLDL from soybean protein-fed rats. The apoprotein composition of VLDL differed between groups of rats fed on different types of dietary protein with higher proportions of apo C's in the casein-fed rats. In addition, cholesterol feeding resulted in increased proportions of apo A-I and apo A-IV in the plasma VLDL fraction.

Effect of dietary proteins on hepatic and plasma lipids, and some properties of major plasma lipoprotein fractions during dietary-induced hypercholesterolemia in male rats.

In order to characterize further the cholesterolemic effect of casein compared with soybean protein isolate, each of these proteins were fed to male rats at different levels of dietary cholesterol administration. An increase in the dietary cholesterol level from zero to 0.25% led to a several-fold increase in plasma triacylglycerols with a comparatively small rise in plasma cholesterol. Further increase in the cholesterol content of diet to 0.5, 1 and 2% resulted in a return of plasma triacylglycerols to normal or even subnormal values, whereas the plasma cholesterol values rose progressively. The triacylglycerolemic and cholesterolemic effects were 2-3-fold higher with casein diet than with soybean protein diet, respectively. A major part of the increased plasma cholesterol value was accounted for by cholesterol in the very-low-density lipoprotein (VLDL) fraction. Even at moderate levels (0.05-0.5%), the dietary cholesterol administration produced a series of changes in the electrophoretic pattern of plasma lipoproteins. These changes were more prominent in the rats fed casein diet, which often showed an enhanced VLDL band even on a cholesterol-free diet. An additional lipoprotein band, localized between VLDL and the LDL/HDL1 band, was observed in several rats fed casein diet with 0.05 or 0.1% cholesterol, and in rats fed soybean protein diet containing 0.25 or 0.5% cholesterol. In contrast, at the 0.25 and 0.5% levels of dietary cholesterol, plasma of casein-fed rats contained only one broad band within the VLDL-LDL/HDL1 region. All these findings indicate that casein diet promotes the appearance of one or more specific type(s) of cholesterol-induced plasma lipoprotein particles even at a comparatively low level of dietary cholesterol.

Improved banding pattern of rat plasma lipoproteins developed by agarose gel electrophoresis at pH 7.0.

The use of a conventional agarose gel electrophoretic method to separate rat plasma lipoproteins resulted in a rather poor resolution of lipoproteins of lower density. Therefore, attempts were made to improve the resolution by running the electrophoresis under different conditions. It was shown that rat plasma lipoproteins could be separated into at least three fractions by agarose gel electrophoresis in phosphate buffer at pH 7.0. Using rat plasma lipoproteins isolated by sequential flotation as standards, these fractions were shown to correspond to high-density lipoprotein (HDL2), very-low-density lipoprotein (VLDL) and a mixed low-density lipoprotein (LDL)/high-density lipoprotein (HDL1) fraction. Since VLDL is completely separated from the other lipoprotein classes the method could be used to monitor changes in plasma VLDL.

Effects of the source of dietary protein on serum lower density lipoprotein (VLDL + LDL) and tocopherol levels in female rats.

The effect of dietary protein on lipid levels of serum and liver and mineral contents of bone tissue was studied in female rats by using 13 semi-purified diets differing with respect to protein source. The diets were characterized with regard to contents of protein, amino acids, fat, crude fiber, phytate, zinc, copper, iron, magnesium, calcium, sodium, potassium, tocopherol and metabolizable energy. Six of the proteins tested were of animal origin and six proteins used were plant proteins. Each diet was fed at a 20% protein, 10% fat level. There was a large variation between groups in the serum content of lower density lipoproteins (VLDL + LDL). Rats fed plant protein diets showed values in a lower range than rats consuming animal protein diets. Triglyceride values showed a similar tendency. A comparison of dietary amino acid composition and blood lipid parameters revealed a significant negative correlation between dietary arginine content and serum VLDL + LDL levels (r = 0.863; P < 0.01). Group differences in total serum cholesterol were also observed. However, this variation was within the same range in animal as well as plant protein diets. Serum tocopherol levels were correlated to the total dietary intakes of tocopherol. No significant trend was observed for the mineral content of bone tissue or for the total lipid content of liver with regard to class of dietary protein. However, all rats fed a blood protein diet developed fatty livers.

Simultaneous solubilization of steroid hormones I: estrogens and C21 steroids.

The simultaneous solubilization of some estrogens and C21 steroids in aqueous polysorbate 40, tetradecyltrimethylammonium bromide, and sodium lauryl sulfate was studied. The less soluble estrogen estradiol was solubilized independently of the C21 steroids. The micellar solubilities of ethinyl estradiol and both corticosterone and hydrocortisone were independnet of the presence of each other while the solubility of 11alpha-hydroxyprogesterone was enhanced by ethinyl estradiol. The solubilizations of ethinyl estradiol and the two C21 steroids, progesterone and 21-hydroxyprogesterone, were dependent on each other so that a varying amount of the steroid solubilized first was precipitated by an excess of the second steroid. If saturated solutions of the two steroids were mixed, no precipitation occurred. A possible mechanism for the simultaneous solubilization of steroids and its relation to structure are discussed.