Mitochondrial One-Carbon Metabolism is Required for TGF-ß-Induced Glycine Synthesis and Collagen Protein Production.

A hallmark of Idiopathic Pulmonary Fibrosis is the TGF-ß-dependent activation of lung fibroblasts, leading to excessive deposition of collagen proteins and progressive scarring. We have previously shown that synthesis of collagen by lung fibroblasts requires de novo synthesis of glycine, the most abundant amino acid in collagen protein. TGF-ß upregulates the expression of the enzymes of the de novo serine/glycine synthesis pathway in lung fibroblasts through mTORC1 and ATF4-dependent transcriptional programs. SHMT2, the final enzyme of the de novo serine/glycine synthesis pathway, transfers a one-carbon unit from serine to tetrahydrofolate (THF), producing glycine and 5,10-methylene-THF (meTHF). meTHF is converted back to THF in the mitochondrial one-carbon (1C) pathway through the sequential actions of MTHFD2 (which converts meTHF to 10-formyl-THF), and either MTHFD1L, which produces formate, or ALDH1L2, which produces CO2. It is unknown how the mitochondrial 1C pathway contributes to glycine biosynthesis or collagen protein production in fibroblasts, or fibrosis in vivo. Here, we demonstrate that TGF-ß induces the expression of MTHFD2, MTHFD1L, and ALDH1L2 in human lung fibroblasts. MTHFD2 expression was required for TGF-ß-induced cellular glycine accumulation and collagen protein production. Combined knockdown of both MTHFD1L and ALDH1L2 also inhibited glycine accumulation and collagen protein production downstream of TGF-ß; however knockdown of either protein alone had no inhibitory effect, suggesting that lung fibroblasts can utilize either enzyme to regenerate THF. Pharmacologic inhibition of MTHFD2 recapitulated the effects of MTHFD2 knockdown in lung fibroblasts and ameliorated fibrotic responses after intratracheal bleomycin instillation in vivo. Our results provide insight into the metabolic requirements of lung fibroblasts and provide support for continued development of MTHFD2 inhibitors for the treatment of IPF and other fibrotic diseases.

Widespread 8-oxoguanine modifications of miRNA seeds differentially regulate redox-dependent cancer development.

Oxidative stress contributes to tumourigenesis by altering gene expression. One accompanying modification, 8-oxoguanine (o8G) can change RNA-RNA interactions via o8G•A base pairing, but its regulatory roles remain elusive. Here, on the basis of o8G-induced guanine-to-thymine (o8G > T) variations featured in sequencing, we discovered widespread position-specific o8Gs in tumour microRNAs, preferentially oxidized towards 5' end seed regions (positions 2-8) with clustered sequence patterns and clinically associated with patients in lower-grade gliomas and liver hepatocellular carcinoma. We validated that o8G at position 4 of miR-124 (4o8G-miR-124) and 4o8G-let-7 suppress lower-grade gliomas, whereas 3o8G-miR-122 and 4o8G-let-7 promote malignancy of liver hepatocellular carcinoma by redirecting the target transcriptome to oncogenic regulatory pathways. Stepwise oxidation from tumour-promoting 3o8G-miR-122 to tumour-suppressing 2,3o8G-miR-122 occurs and its specific modulation in mouse liver effectively attenuates diethylnitrosamine-induced hepatocarcinogenesis. These findings provide resources and insights into epitranscriptional o8G regulation of microRNA functions, reprogrammed by redox changes, implicating its control for cancer treatment.

Migraine-Associated Common Genetic Variants Confer Greater Risk of Posterior vs. Anterior Circulation Ischemic Stroke☆.

OBJECTIVE: To examine potential genetic relationships between migraine and the two distinct phenotypes posterior circulation ischemic stroke (PCiS) and anterior circulation ischemic stroke (ACiS), we generated migraine polygenic risk scores (PRSs) and compared these between PCiS and ACiS, and separately vs. non-stroke control subjects. METHODS: Acute ischemic stroke cases were classified as PCiS or ACiS based on lesion location on diffusion-weighted MRI. Exclusion criteria were lesions in both vascular territories or uncertain territory; supratentorial PCiS with ipsilateral fetal posterior cerebral artery; and cases with atrial fibrillation. We generated migraine PRS for three migraine phenotypes (any migraine; migraine without aura; migraine with aura) using publicly available GWAS data and compared mean PRSs separately for PCiS and ACiS vs. non-stroke control subjects, and between each stroke phenotype. RESULTS: Our primary analyses included 464 PCiS and 1079 ACiS patients with genetic European ancestry. Compared to non-stroke control subjects (n=15396), PRSs of any migraine were associated with increased risk of PCiS (p=0.01-0.03) and decreased risk of ACiS (p=0.010-0.039). Migraine without aura PRSs were significantly associated with PCiS (p=0.008-0.028), but not with ACiS. When comparing PCiS vs. ACiS directly, migraine PRSs were higher in PCiS vs. ACiS for any migraine (p=0.001-0.010) and migraine without aura (p=0.032-0.048). Migraine with aura PRS did not show a differential association in our analyses. CONCLUSIONS: Our results suggest a stronger genetic overlap between unspecified migraine and migraine without aura with PCiS compared to ACiS. Possible shared mechanisms include dysregulation of cerebral vessel endothelial function.

Brain and Lung Imaging Correlation in Patients with COVID-19: Could the Severity of Lung Disease Reflect the Prevalence of Acute Abnormalities on Neuroimaging? A Global Multicenter Observational Study.

PURPOSE: Our aim was to study the association between abnormal findings on chest and brain imaging in patients with coronavirus disease 2019 (COVID-19) and neurologic symptoms. MATERIALS AND METHODS: In this retrospective, international multicenter study, we reviewed the electronic medical records and imaging of hospitalized patients with COVID-19 from March 3, 2020, to June 25, 2020. Our inclusion criteria were patients diagnosed with Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) infection with acute neurologic manifestations and available chest CT and brain imaging. The 5 lobes of the lungs were individually scored on a scale of 0-5 (0 corresponded to no involvement and 5 corresponded to >75% involvement). A CT lung severity score was determined as the sum of lung involvement, ranging from 0 (no involvement) to 25 (maximum involvement). RESULTS: A total of 135 patients met the inclusion criteria with 132 brain CT, 36 brain MR imaging, 7 MRA of the head and neck, and 135 chest CT studies. Compared with 86 (64%) patients without acute abnormal findings on neuroimaging, 49 (36%) patients with these findings had a significantly higher mean CT lung severity score (9.9 versus 5.8, P < .001). These patients were more likely to present with ischemic stroke (40 [82%] versus 11 [13%], P < .0001) and were more likely to have either ground-glass opacities or consolidation (46 [94%] versus 73 [84%], P = .01) in the lungs. A threshold of the CT lung severity score of >8 was found to be 74% sensitive and 65% specific for acute abnormal findings on neuroimaging. The neuroimaging hallmarks of these patients were acute ischemic infarct (28%), intracranial hemorrhage (10%) including microhemorrhages (19%), and leukoencephalopathy with and/or without restricted diffusion (11%). The predominant CT chest findings were peripheral ground-glass opacities with or without consolidation. CONCLUSIONS: The CT lung disease severity score may be predictive of acute abnormalities on neuroimaging in patients with COVID-19 with neurologic manifestations. This can be used as a predictive tool in patient management to improve clinical outcome.

Position-specific oxidation of miR-1 encodes cardiac hypertrophy.

In pathophysiology, reactive oxygen species oxidize biomolecules that contribute to disease phenotypes1. One such modification, 8-oxoguanine2 (o8G), is abundant in RNA3 but its epitranscriptional role has not been investigated for microRNAs (miRNAs). Here we specifically sequence oxidized miRNAs in a rat model of the redox-associated condition cardiac hypertrophy4. We find that position-specific o8G modifications are generated in seed regions (positions 2-8) of selective miRNAs, and function to regulate other mRNAs through o8G•A base pairing. o8G is induced predominantly at position 7 of miR-1 (7o8G-miR-1) by treatment with an adrenergic agonist. Introducing 7o8G-miR-1 or 7U-miR-1 (in which G at position 7 is substituted with U) alone is sufficient to cause cardiac hypertrophy in mice, and the mRNA targets of o8G-miR-1 function in affected phenotypes; the specific inhibition of 7o8G-miR-1 in mouse cardiomyocytes was found to attenuate cardiac hypertrophy. o8G-miR-1 is also implicated in patients with cardiomyopathy. Our findings show that the position-specific oxidation of miRNAs could serve as an epitranscriptional mechanism to coordinate pathophysiological redox-mediated gene expression.

Detailed phenotyping of posterior vs. anterior circulation ischemic stroke: a multi-center MRI study.

OBJECTIVE: Posterior circulation ischemic stroke (PCiS) constitutes 20-30% of ischemic stroke cases. Detailed information about differences between PCiS and anterior circulation ischemic stroke (ACiS) remains scarce. Such information might guide clinical decision making and prevention strategies. We studied risk factors and ischemic stroke subtypes in PCiS vs. ACiS and lesion location on magnetic resonance imaging (MRI) in PCiS. METHODS: Out of 3,301 MRIs from 12 sites in the National Institute of Neurological Disorders and Stroke (NINDS) Stroke Genetics Network (SiGN), we included 2,381 cases with acute DWI lesions. The definition of ACiS or PCiS was based on lesion location. We compared the groups using Chi-squared and logistic regression. RESULTS: PCiS occurred in 718 (30%) patients and ACiS in 1663 (70%). Diabetes and male sex were more common in PCiS vs. ACiS (diabetes 27% vs. 23%, p < 0.05; male sex 68% vs. 58%, p < 0.001). Both were independently associated with PCiS (diabetes, OR = 1.29; 95% CI 1.04-1.61; male sex, OR = 1.46; 95% CI 1.21-1.78). ACiS more commonly had large artery atherosclerosis (25% vs. 20%, p < 0.01) and cardioembolic mechanisms (17% vs. 11%, p < 0.001) compared to PCiS. Small artery occlusion was more common in PCiS vs. ACiS (20% vs. 14%, p < 0.001). Small artery occlusion accounted for 47% of solitary brainstem infarctions. CONCLUSION: Ischemic stroke subtypes differ between the two phenotypes. Diabetes and male sex have a stronger association with PCiS than ACiS. Definitive MRI-based PCiS diagnosis aids etiological investigation and contributes additional insights into specific risk factors and mechanisms of injury in PCiS.

Age, Sex, and Racial Differences in Neuroimaging Use in Acute Stroke: A Population-Based Study.

BACKGROUND AND PURPOSE: Limited information is available regarding differences in neuroimaging use for acute stroke work-up. Our objective was to assess whether race, sex, or age differences exist in neuroimaging use and whether these differences depend on the care center type in a population-based study. MATERIALS AND METHODS: Patients with stroke (ischemic and hemorrhagic) and transient ischemic attack were identified in a metropolitan, biracial population using the Greater Cincinnati/Northern Kentucky Stroke Study in 2005 and 2010. Multivariable regression was used to determine the odds of advanced imaging use (CT angiography/MR imaging/MR angiography) for race, sex, and age. RESULTS: In 2005 and 2010, there were 3471 and 3431 stroke/TIA events, respectively. If one adjusted for covariates, the odds of advanced imaging were higher for younger (55 years or younger) compared with older patients, blacks compared with whites, and patients presenting to an academic center and those seen by a stroke team or neurologist. The observed association between race and advanced imaging depended on age; in the older age group, blacks had higher odds of advanced imaging compared with whites (odds ratio, 1.34; 95% CI, 1.12-1.61; P < .01), and in the younger group, the association between race and advanced imaging was not statistically significant. Age by race interaction persisted in the academic center subgroup (P < .01), but not in the nonacademic center subgroup (P = .58). No significant association was found between sex and advanced imaging. CONCLUSIONS: Within a large, biracial stroke/TIA population, there is variation in the use of advanced neuroimaging by age and race, depending on the care center type.

Quasi 3D ECE imaging system for study of MHD instabilities in KSTAR.

A second electron cyclotron emission imaging (ECEI) system has been installed on the KSTAR tokamak, toroidally separated by 1/16th of the torus from the first ECEI system. For the first time, the dynamical evolutions of MHD instabilities from the plasma core to the edge have been visualized in quasi-3D for a wide range of the KSTAR operation (B0 = 1.7∼3.5 T). This flexible diagnostic capability has been realized by substantial improvements in large-aperture quasi-optical microwave components including the development of broad-band polarization rotators for imaging of the fundamental ordinary ECE as well as the usual 2nd harmonic extraordinary ECE.

The adverse effect of spasticity on 3-month poststroke outcome using a population-based model.

Several devices and medications have been used to address poststroke spasticity. Yet, spasticity's impact on outcomes remains controversial. Using data from a cohort of 460 ischemic stroke patients, we previously published a validated multivariable regression model for predicting 3-month modified Rankin Score (mRS) as an indicator of functional outcome. Here, we tested whether including spasticity improved model fit and estimated the effect spasticity had on the outcome. Spasticity was defined by a positive response to the question "Did you have spasticity following your stroke?" on direct interview at 3 months from stroke onset. Patients who had expired by 90 days (n = 30) or did not have spasticity data available (n = 102) were excluded. Spasticity affected the 3-month functional status (ß = 0.420, 95 CI = 0.194 to 0.645) after accounting for age, diabetes, leukoaraiosis, and retrospective NIHSS. Using spasticity as a covariable, the model's R (2) changed from 0.599 to 0.622. In our model, the presence of spasticity in the cohort was associated with a worsened 3-month mRS by an average of 0.4 after adjusting for known covariables. This significant adverse effect on functional outcomes adds predictive value beyond previously established factors.

Asynchronous arterial systolic expansion as a marker of vascular aging: assessment of the carotid artery with velocity vector imaging.

OBJECTIVE: Arterial elastic properties change with aging. Measurements of pulse wave velocity and augmentation index are useful for the evaluation of arterial stiffness. However, they likely represent only global characteristics of the arterial tree rather than local vascular alterations. The aim of this study was to evaluate whether local vascular properties assessed by velocity vector imaging differed with aging. METHODS: Vascular properties of carotid arteries with ages were assessed in 100 healthy volunteers (52 men) ranging from 20 to 68 years using velocity vector imaging. The peak circumferential strain and strain rate of the six segments in left common carotid arteries were analyzed and the standard deviation of the time to peak circumferential strain and strain rate of the six segments, representing the synchronicity of the arterial expansion, were calculated. Central blood pressure, augmentation index and pulse wave velocity were assessed by commercially available radial artery tonometry, the SphygmoCor system (AtCor Medical, West Ryde, Australia). A validated generalized transfer function was used to acquire the central aortic pressures and pressure waveforms. RESULTS: Pulse wave velocity, augmentation index and velocity vector imaging parameters showed significant changes with age. However, the age-related changes in pulse wave velocity, augmentation index and velocity vector imaging parameters were different. The increase in pulse wave velocity was more prominent in older individuals, whereas the changes in augmentation index and carotid strain and strain rate were evident earlier, at the age of 30 years. Unlike augmentation index, which showed little change in older individuals, the standard deviation of time to peak strain and strain rate showed a steady increase from younger to older individuals. CONCLUSION: Asynchronous arterial expansion could be a useful discriminative marker of vascular aging independent of individual's age.

Population-based study of wake-up strokes.

OBJECTIVE: Previous studies have estimated that wake-up strokes comprise 8%to 28% of all ischemic strokes, but these studies were either small or not population-based. We sought to establish the proportion and event rate of wake-up strokes in a large population-based study and to compare patients who awoke with stroke symptoms with those who were awake at time of onset. METHODS: First-time and recurrent ischemic strokes among residents of the Greater Cincinnati/Northern Kentucky region (population 1.3 million) in 2005 were identified using International Classification of Diseases-9 codes 430-436 and verified via study physician review. Ischemic strokes in patients aged 18 years and older presenting to an emergency department were included. Baseline characteristics were ascertained, along with discharge modified Rankin Scale scores and 90-day mortality. RESULTS: We identified 1,854 ischemic strokes presenting to an emergency department, of which 273 (14.3%) were wake-up strokes. There were no differences between wake-up strokes and all other strokes with regard to clinical features or outcomes except for minor differences in age and baseline retrospective NIH Stroke Scale score. The adjusted wake-up stroke event rate was 26.0/100,000. Of the wake-up strokes, at least 98 (35.9%) would have been eligible for thrombolysis if arrival time were not a factor. CONCLUSIONS: Within our population, approximately 14% of ischemic strokes presenting to an emergency department were wake-up strokes. Wake-up strokes cannot be distinguished from other strokes by clinical features or outcome. We estimate that approximately 58,000 patients with wake-up strokes presented to an emergency department in the United States in 2005.

Prior antiplatelet therapy and outcome following intracerebral hemorrhage: a systematic review.

OBJECTIVES: Antiplatelet therapy (APT) promotes bleeding; therefore, APT might worsen outcome in patients with intracerebral hemorrhage (ICH). We performed a systematic review and meta-analysis to address the hypothesis that pre-ICH APT use is associated with mortality and poor functional outcome following ICH. METHODS: The Medline and Embase databases were searched in February 2008 using relevant key words, limited to human studies in the English language. Cohort studies of consecutive patients with ICH reporting mortality or functional outcome according to pre-ICH APT use were identified. Of 2,873 studies screened, 10 were judged to meet inclusion criteria by consensus of 2 authors. Additionally, we solicited unpublished data from all authors of cohort studies with >100 patients published within the last 10 years, and received data from 15 more studies. Univariate and multivariable-adjusted odds ratios (ORs) for mortality and poor functional outcome were abstracted as available and pooled using a random effects model. RESULTS: We obtained mortality data from 25 cohorts (15 unpublished) and functional outcome data from 21 cohorts (14 unpublished). Pre-ICH APT users had increased mortality in both univariate (OR 1.41, 95% confidence interval [CI] 1.21 to 1.64) and multivariable-adjusted (OR 1.27, 95% CI 1.10 to 1.47) pooled analyses. By contrast, the pooled OR for poor functional outcome was no longer significant when using multivariable-adjusted estimates (univariate OR 1.29, 95% CI 1.09 to 1.53; multivariable-adjusted OR 1.10, 95% CI 0.93 to 1.29). CONCLUSIONS: In cohort studies, APT use at the time of ICH compared to no APT use was independently associated with increased mortality but not with poor functional outcome.

Incidence and risk factors for chronic pain after caesarean section under spinal anaesthesia.

This study investigated the incidence and risk factors associated with chronic pain after elective caesarean section under spinal anaesthesia in an Asian population. A prospective cohort study was conducted among subjects who underwent elective caesarean section under spinal anaesthesia, with morphine patient-controlled analgesia administered for 24 hours postoperatively. Perioperative, surgical and obstetric factors were investigated prospectively. Phone surveys were conducted to identify risk factors associated with chronic pain. A total of 857 subjects completed both the perioperative study and phone survey. The incidence of wound scar pain for three months after surgery was 9.2% (79). Of the 51 subjects with persistent pain at the time of subsequent survey, 9.8% (n = 5) had constant pain, 9.8% (n = 5) had daily pain and 23.5% (n = 12) had pain intermittently, at an interval of days. The independent risk factors for development of chronic pain were higher pain scores recalled in the immediate postoperative period (odds ratio [OR, 95% confidence interval] 1.348 [1.219 to 1.490], P = 0.0001), pain present elsewhere (OR 2.471 [1.485 to 4.112], P = 0.001) and non-private insurance status (OR 1.679 [1.034 to 2.727], P = 0.036). The two most common sites of pain other than wound pain were back pain (n = 316) and migraine (n = 87).

Unilateral ovarian metastasis in a case of squamous cervical carcinoma IA1.

Ovarian metastasis from early-stage squamous cervical cancer is rare. We report a case of unilateral ovarian metastasis from squamous cervical cancer IA1. Although ovarian metastasis from early-stage squamous cervical cancer is rare, gynecological oncologists should not overlook its possibility.

Relationship between nutrition factors and osteopenia: Effects of experimental diets on immature bone quality.

To investigate the influence of experimental diets on morphological and mechanical characteristics of immature bone, this study thoroughly examined the nutrition-bone connection. A non-destructive evaluation method involving high-resolution in-vivo micro-computed tomography and finite element (FE) analysis was used to investigate the relationship between obesity and osteopenia-two disorders of body composition. Correlation of nutritional deficiency with bone characteristics was also investigated. Some recent studies have shown that both obesity and osteopenia share several common genetic and environmental factors. However, there have been few studies correlating these pathologies in-vivo from a structural and biomechanical point of view. In the present study, detailed changes in morphological and mechanical characteristics of trabecular bone architecture were detected and tracked by longitudinal studies of morphometric parameters and simulated compression testing. Rats were randomized into three groups: overeaten diet (OD) for formation of obesity, normal diet (ND), and restricted diet (RD) in which rats received 65% of the normal diet. In the OD and ND groups, all structural parameters changed significantly (p<0.05). The degree of alteration in the structural parameters of the ND group was similar to that of the RD group (p<0.05). In simulated compression tests using FE models, the effective modulus of the OD group significantly decreased, depending on measuring time (p<0.05), whereas that of the ND and RD groups significantly increased (p>0.05). The key finding of the present study is that fat mass is morphologically and mechanically inversely correlated with bone mass when the mechanical loading effects of greater body weight on bone mass are applied.

Age at intracranial aneurysm rupture among generations: Familial Intracranial Aneurysm Study.

BACKGROUND: Previous studies have reported intracranial aneurysm (IA) occurring at young ages in subsequent generations. These studies did not correct for duration of follow-up. Second-generation members who would have their ruptured IA late in life may not be detected due to shorter follow-up time than the first generation. We examined families in which ruptured IA occurred in two consecutive generations for the hypothesis that the second generation (F1) was more likely to have a rupture at a younger age than the older generation (F0). METHODS: The Familial Intracranial Aneurysm (FIA) Study is a multicenter, international study recruiting families of ruptured and unruptured IA. All available family members are interviewed. Cox proportional hazards regression models and Kaplan-Meier curves were used to examine differences by generation. RESULTS: Although we found that the F1 generation was more likely to have an aneurysm rupture at a younger age than the F0 generation, we found that this was largely because of a lack of follow-up time in the F1 generation. The F1 generation had 50% the rupture rate of the prior generation. When analyzed by Kaplan-Meier curves, we found a tendency to have a slightly later rupture rate in the F1 generation once time to follow-up was included in the analysis model. CONCLUSIONS: Families of ruptured intracranial aneurysm (IA) do not appear to demonstrate "anticipation." Our finding suggests that genetic epidemiology of ruptured IA should examine all types of variations such as single base-pair changes, deletions, insertions, and other variations that do not demonstrate anticipation.

Smoking and family history and risk of aneurysmal subarachnoid hemorrhage.

OBJECTIVE: Smoking and family history of aneurysmal subarachnoid hemorrhage (aSAH) are independent risk factors for aSAH. Using a population-based case-control study of hemorrhagic stroke, we hypothesized that having both a first-degree relative with a brain aneurysm or SAH (+FH) and current smoking interact to increase the risk of aSAH. METHODS: Cases of aneurysmal SAH were prospectively recruited from all 17 hospitals in the five-county region around the University of Cincinnati. Controls were identified by random digit dialing. Controls were matched to cases of aSAH by age (+/-5 years), race, and sex. Conditional multiple logistic regression was used to identify independent risk factors. For deviation from the additive model, the interaction constant ratio test was used. RESULTS: A total of 339 cases of aSAH were matched to 1,016 controls. Compared to current nonsmokers with no first-degree relatives with aSAH (-FH), the odds ratio (OR) for aSAH for current nonsmokers with +FH was 2.5 (95% confidence interval [CI] 0.9-6.9); for current smokers with -FH, OR = 3.1 (95% CI 2.2-4.4); and for current smokers with +FH, OR = 6.4 (95% CI 3.1-13. 2). The interaction constant ratio, which measured the deviation from the additive model, was significant: 2.19 (95% CI 0.80-5.99). The lower bound of the 95% CI >0.5 signifies a departure from the additive model. CONCLUSION: Evidence of a gene-environment interaction with smoking exists for aneurysmal subarachnoid hemorrhage. This finding is important to counseling family members and for screening of intracranial aneurysm (IA) as well as the design and interpretation of genetic epidemiology of IA studies.

Comparison of computer-integrated patient-controlled epidural analgesia and patient-controlled epidural analgesia with a basal infusion for labour and delivery.

Computer-integrated patient-controlled epidural analgesia (CIPCEA) is a novel epidural drug delivery system. It automatically adjusts the background infusion based on the individual parturient's need for analgesia as labour progresses. In this randomised controlled trial, we compared the local anaesthetic consumption by parturients using either CIPCEA or patient-controlled epidural analgesia with a moderate basal infusion (PCEABI) of 5 ml/hour. We recruited 60 parturients after receiving ethics committee approval. Group CIPCEA (n = 30) received a similar patient-controlled epidural analgesia regimen but the computer integration titrated the background infusion to 5, 10 or 15 ml/hour if the patient required respectively one, two or three demand boluses in the previous hour. The background infusion was decreased by 5 ml/hour if there was no demand in the previous hour. Group PCEABI received patient-controlled epidural analgesia with a basal infusion of 5 ml/hour. The sample size was calculated to show equivalence in local anaesthetic use. The time-weighted consumption of local anaesthetic was similar in both groups (mean difference 0.3 mg/hour 95% confidence interval: -1.8, 1.3, P = 0.755). The CIPCEA group had higher maternal satisfaction scores: mean (SD) 94.8 (6.32) vs. 85.5 (9.41), P = 0.0001. The CIPCEA group had a higher infusion rate during the second stage of labour (mean (SD) 7.0 (4.1) ml/hour vs. 4.5 (1.5) ml/hour P = 0.008), but did not have a longer duration of this stage. There were no differences between the groups in obstetric or foetal outcomes or side-effect profiles. The CIPCEA system has similar time-weighted, hourly consumption of local anaesthetic to PCEABI and may increase patient satisfaction.

Warfarin use leads to larger intracerebral hematomas.

BACKGROUND: Among patients with intracerebral hemorrhage (ICH), warfarin use before onset leads to greater mortality. In a retrospective study, we sought to determine whether warfarin use is associated with larger initial hematoma volume, one determinant of mortality after ICH. METHODS: We identified all patients hospitalized with ICH in the Greater Cincinnati region from January through December 2005. ICH volumes were measured on the first available brain scan by using the abc/2 method. Univariable analyses and a multivariable generalized linear model were used to determine whether international normalized ratio (INR) influenced initial ICH volume after adjusting for other factors, including age, race, sex, antiplatelet use, hemorrhage location, and time from stroke onset to scan. RESULTS: There were 258 patients with ICH, including 51 patients taking warfarin. In univariable comparison, when INR was stratified, there was a trend toward a difference in hematoma volume by INR category (INR <1.2, 13.4 mL; INR 1.2-2.0, 9.3 mL; INR 2.1-3.0, 14.0 mL; INR >3.0, 33.2 mL; p = 0.10). In the model, compared with patients with INR <1.2, there was no difference in hematoma size for patients with INR 1.2-2.0 (p = 0.25) or INR 2.1-3.0 (p = 0.36), but patients with INR >3.0 had greater hematoma volume (p = 0.02). Other predictors of larger hematoma size were ICH location (lobar compared with deep cerebral, p = 0.02) and shorter time from stroke onset to scan (p < 0.001). CONCLUSION: Warfarin use was associated with larger initial intracerebral hemorrhage (ICH) volume, but this effect was only observed for INR values >3.0. Larger ICH volume among warfarin users likely accounts for part of the excess mortality in this group.