OBJECTIVE Cerebral vasospasm and delayed cerebral ischemia (DCI) contribute to poor outcome following subarachnoid hemorrhage (SAH). With the paucity of effective treatments, the authors describe their experience with intrathecal (IT) nicardipine for this indication. METHODS Patients admitted to the Emory University Hospital neuroscience ICU between 2012 and 2017 with nontraumatic SAH, either aneurysmal or idiopathic, were included in the analysis. Using a propensity-score model, this patient cohort was compared to patients in the Subarachnoid Hemorrhage International Trialists (SAHIT) repository who did not receive IT nicardipine. The primary outcome was DCI. Secondary outcomes were long-term functional outcome and adverse events. RESULTS The analysis included 1351 patients, 422 of whom were diagnosed with cerebral vasospasm and treated with IT nicardipine. When compared with patients with no vasospasm (n = 859), the treated group was significantly younger (mean age 51.1 ± 12.4 years vs 56.7 ± 14.1 years, p < 0.001), had a higher World Federation of Neurosurgical Societies score and modified Fisher grade, and were more likely to undergo clipping of the ruptured aneurysm as compared to endovascular treatment (30.3% vs 11.3%, p < 0.001). Treatment with IT nicardipine decreased the daily mean transcranial Doppler velocities in 77.3% of the treated patients. When compared to patients not receiving IT nicardipine, treatment was not associated with an increased rate of bacterial ventriculitis (3.1% vs 2.7%, p > 0.1), yet higher rates of ventriculoperitoneal shunting were noted (19.9% vs 8.8%, p < 0.01). In a propensity score comparison to the SAHIT database, the odds ratio (OR) to develop DCI with IT nicardipine treatment was 0.61 (95% confidence interval [CI] 0.44–0.84), and the OR to have a favorable functional outcome (modified Rankin Scale score ≤ 2) was 2.17 (95% CI 1.61–2.91). CONCLUSIONS IT nicardipine was associated with improved outcome and reduced DCI compared with propensity-matched controls. There was an increased need for permanent CSF diversion but no other safety issues. These data should be considered when selecting medications and treatments to study in future randomized controlled clinical trials for SAH.

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Objectives To complete a systematic review and meta-analysis of nutrition interventions conducted with anemic, non-pregnant women of childbearing age to determine their impact on hemoglobin concentration (Hb). Methods Seventeen online databases were searched from November 14-December 14, 2020. Two reviewers independently screened documents via Covidence. Inclusion criteria were English-language studies; longitudinal intervention studies, including non-randomized controlled trials, randomized controlled trials, and intervention trials without control groups; women anemic at baseline; and micronutrients administered orally for &gt; 4 weeks. Data were extracted from 45 studies that met inclusion criteria. Bayesian arm-based meta-analyses estimated the mean change in hemoglobin (g/L) for several stratifying variables. Results For all delivery methods, there was a mean increase in Hb: 17.48 g/L (95% Credible Interval (CI): 13.72, 21.03) for oral supplements, 18.34 g/L (95% CI: 12.32, 25.49) for `other’ interventions (i.e., powdered leaf extract, papaya, dates, iron-cooking ingot), and 6.99 g/L (95% CI: 2.80, 11.48) for fortified food. Including iron in the nutrients administered to anemic women reliably increased their Hb. Iron alone (16.51 g/L, 95% CI: 12.53, 20.73), iron and folic acid (17.69 g/L, 95% CI: 13.25, 22.94), and multiple micronutrients including iron (16.57 g/L, 95% CI: 12.11, 21.54), all had a much larger effect on Hb change than vitamins alone (7.47 g/L, 95% CI: −0.73, 16.01). Intervention duration did not have a large effect on mean Hb change as a 4–16-wk duration increased Hb by 17.49 g/L (95% CI: 13.07, 21.64), a 17–28-wk duration increased Hb by 13.23 g/L (95% CI: 5.53, 20.18) and a &gt; 52-wk duration increased Hb by 17.9 g/L (95% CI: 9.78, 24.91). Conclusions The nutrient-delivery method and inclusion of iron modified the Hb changes observed in anemic women, while intervention duration did not. Specifically, supplements, 'other’ interventions, and iron-cooking ingots were more effective in raising Hb than fortified food; any intervention which included iron increased mean Hb compared to those with only vitamins; and the effect of interventions on mean Hb did not differ by study duration. Funding Sources Global Affairs Canada.

Background and Purpose: Cerebral vasospasm and delayed cerebral ischemia (DCI) contribute to poor outcome following subarachnoid hemorrhage (SAH). With the paucity of effective treatments, we describe our experience with intrathecal (IT) nicardipine for this indication. Methods: Patients admitted to Emory University Hospital Neuroscience ICU between 2012-2017 with non-traumatic SAH, either aneurysmal or idiopathic, were included in the analysis. This patient cohort was compared using a propensity-score model to patients in the SAH international trialist (SAHIT) repository who did not receive intrathecal nicardipine. The primary outcome was DCI. Secondary outcomes were long-term functional outcome and adverse events. Results: The analysis included 1,351 patients, 422 of whom were diagnosed with cerebral vasospasm and treated with IT nicardipine. When compared with patients with no vasospasm (n=859) the treated group was younger (51.1±12.4 vs. 56.7±14.1, p<0.01), had a higher World Federation of Neurological Surgeons score (WFNS), modified Fisher grade, and more likely to undergo clipping of the ruptured aneurysm as compared to endovascular treatment (30.3% vs. 11.3%, p<0.01). Treatment with IT nicardipine decreased daily mean transcranial Doppler velocities in 77.3% of the treated patients. When compared to patients not receiving IT nicardipine, treatment was not associated with an increase rate of bacterial ventriculitis (3.1% compared with 2.7%, p>0.1) yet higher rates of VP shunting were noted (19.9% vs. 8.8%, p<0.01). In a propensity score comparison to the SAHIT database, the odds ratio to develop DCI with IT nicardipine treatment was 0.61 with 95% CI[0.44-0.84], and to have a favorable functional outcome (mRS≤2) was 2.17[1.61-2.91]. Conclusions: IT nicardipine was associated with improved outcome and reduced DCI compared with propensity matched controls. There was an increased need for permanent CSF diversion but no other safety issues. This data should be considered when selecting medications and treatments to study in future randomized controlled clinical trial for SAH.

Objectives Review literature and conduct a meta-analysis to quantify changes in hemoglobin (Hb) and anemia prevalence among women of childbearing age after fortification of wheat flour, maize flour, rice and oil (singly or combined). Methods Online databases were searched for English-language documents with no restrictions on location or publication date that included longitudinal, pre-post cross-sectional, efficacy and effectiveness studies. A Bayesian arm-based meta-analysis estimated mean change and probability of Hb and anemia improvement from 17 studies. Results were stratified by fortified food and nutrients added to food. Results There was a &gt; 95% probability that fortified wheat flour improved Hb and reduced anemia; mean Hb increased by 3.39 g/L (95% Credible Interval (CI) –0.63, 7.17) and anemia decreased by 12.8 percentage points (pp) (95% CI –23, 0.9). Likewise, fortified rice had a &gt; 65% probability of improving Hb and reducing anemia; mean Hb increased by 2.71 g/L (95% CI –4.88, 10.64) and anemia decreased by 16.9 pp (95% CI –81, 37.8). Conversely, fortified maize flour had &lt; 45% probability of improving Hb and reducing anemia; mean Hb decreased by 2.88 g/L (95% CI−12.85, 7.24) and anemia increased by 13.5 pp (95% CI –133,164). There was a &gt; 90% probability that fortifying maize flour, oil, rice, and/or wheat flour with iron, folic acid or multiple micronutrients (MM) improved Hb. Mean Hb increase was highest for iron fortification (3.93 g/L, 95% CI 0.50, 7.56), followed by folic-acid fortification (3.42 g/L, 95% CI –2.08, 9.56), and lowest for MM fortification (2.11 g/L, 95% CI 0.75, 3.68). There was a &gt; 45% probability that fortifying with any nutrients reduced anemia. Mean anemia decrease was highest for iron at 17.3 pp (95% CI –78.2, 35), followed by folic acid at 7.2 pp (95% CI −32.5, 19.7); however, fortification with MM increased anemia by 1.2 pp (95% CI –9.8, 14.9). Conclusions There was a high probability of fortification increasing hemoglobin concentration if wheat flour or rice are fortified independently, and if foods are fortified with iron alone, folic acid alone, or a combination of multiple micronutrients. Anemia reductions were greatest for fortified wheat flour and rice and for foods fortified with iron and folic acid. Funding Sources Global Affairs Canada.