Individual Patient Data Subgroup Meta-Analysis of Surgery for Spontaneous Supratentorial Intracerebral Hemorrhage

Peer reviewe

Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II):a randomised trial

SummaryBackgroundThe balance of risk and benefit from early neurosurgical intervention for conscious patients with superficial lobar intracerebral haemorrhage of 10–100 mL and no intraventricular haemorrhage admitted within 48 h of ictus is unclear. We therefore tested the hypothesis that early surgery compared with initial conservative treatment could improve outcome in these patients.MethodsIn this international, parallel-group trial undertaken in 78 centres in 27 countries, we compared early surgical haematoma evacuation within 12 h of randomisation plus medical treatment with initial medical treatment alone (later evacuation was allowed if judged necessary). An automatic telephone and internet-based randomisation service was used to assign patients to surgery and initial conservative treatment in a 1:1 ratio. The trial was not masked. The primary outcome was a prognosis-based dichotomised (favourable or unfavourable) outcome of the 8 point Extended Glasgow Outcome Scale (GOSE) obtained by questionnaires posted to patients at 6 months. Analysis was by intention to treat. This trial is registered, number ISRCTN22153967.Findings307 of 601 patients were randomly assigned to early surgery and 294 to initial conservative treatment; 298 and 291 were followed up at 6 months, respectively; and 297 and 286 were included in the analysis, respectively. 174 (59%) of 297 patients in the early surgery group had an unfavourable outcome versus 178 (62%) of 286 patients in the initial conservative treatment group (absolute difference 3·7% [95% CI −4·3 to 11·6], odds ratio 0·86 [0·62 to 1·20]; p=0·367).InterpretationThe STICH II results confirm that early surgery does not increase the rate of death or disability at 6 months and might have a small but clinically relevant survival advantage for patients with spontaneous superficial intracerebral haemorrhage without intraventricular haemorrhage.FundingUK Medical Research Council

Surgical Trial in Lobar Intracerebral Haemorrhage (STICH II) Protocol

<p>Abstract</p> <p>Background</p> <p>Within the spectrum of spontaneous intracerebral haemorrhage there are some patients with large or space occupying haemorrhage who require surgery for neurological deterioration and others with small haematomas who should be managed conservatively. There is equipoise about the management of patients between these two extremes. In particular there is some evidence that patients with lobar haematomas and no intraventricular haemorrhage might benefit from haematoma evacuation. The STICH II study will establish whether a policy of earlier surgical evacuation of the haematoma in selected patients will improve outcome compared to a policy of initial conservative treatment.</p> <p>Methods/Design</p> <p>an international multicentre randomised parallel group trial. Only patients for whom the treating neurosurgeon is in equipoise about the benefits of early craniotomy compared to initial conservative treatment are eligible. All patients must have a CT scan confirming spontaneous lobar intracerebral haemorrhage (≤1 cm from the cortex surface of the brain and 10-100 ml in volume). Any clotting or coagulation problems must be corrected and randomisation must take place within 48 hours of ictus. With 600 patients, the study will be able to demonstrate a 12% benefit from surgery (2p < 0.05) with 80% power.</p> <p>Stratified randomisation is undertaken using a central 24 hour randomisation service accessed by telephone or web. Patients randomised to early surgery should have the operation within 12 hours. Information about the status (Glasgow Coma Score and focal signs) of all patients through the first five days of their trial progress is also collected in addition to another CT scan at about five days (+/- 2 days). Outcome is measured at six months via a postal questionnaire to the patient. Primary outcome is death or severe disability defined using a prognosis based 8 point Glasgow Outcome Scale. Secondary outcomes include: Mortality, Rankin, Barthel, EuroQol, and Survival.</p> <p>Trial Registration</p> <p>ISRCTN: <a href="http://www.controlled-trials.com/ISRCTN22153967">ISRCTN22153967</a></p

Gemeente en corporatie hebben verschillend doel bij buurtinterventies

In veel buurten met een neergaande ontwikkeling proberen gemeenten en corporaties opwaardering te genereren. Vaak wordt verondersteld dat zij hierbij dezelfde doelen nastreven. Er zijn echter wel degelijk verschillen in doelstellingen en motieven van gemeenten en corporaties bij buurtinterventies. Dit heeft zijn weerslag op de ontwikkeling van de buurt en de mate waarin doelstellingen kunnen worden bereikt

De buurt als roltrap

De instroom van lage inkomensgroepen wordt vaak als zorgwekkend beschouwd, evenals de uitstroom van hogere inkomensgroepen. De buurt zou hierdoor in een neerwaartse spiraal terechtkomen. Uit onderzoek blijkt echter dat zowel upgrading- als downgradingbuurten als roltrap functioneren: huishoudens stromen in met een laag inkomen, maken sociale stijging door en verlaten de buurt met een hoger inkomen. Zij worden opgevolgd door huishoudens die hetzelfde proces doormaken

Gentrification in Amsterdam: assessing the importance of context

This paper investigates the income levels and income developments of in-migrating, out-migrating, and sitting households in gentrifying neighbourhoods in Amsterdam over a 10-year period (1999-2008). First, to analyse these data, this paper discusses the impact of institutional and housing market contexts on the residential-mobility patterns of households and subsequently discusses the outcomes of gentrification processes. The general Continental-European context and the specific context of Amsterdam are highlighted in particular. We argue that in highly regulated markets, marginal gentrification can form an important process of neighbourhood upgrading. This contrasts the gentrification stage model. Second, using a unique, individual-level longitudinal dataset, we show that gentrifying neighbourhoods in Amsterdam arguably form cases of marginal gentrification. Recent in-migrants possess incomes that are structurally lower than the incomes of sitting residents. However, in-migrants experience significant incumbent upgrading after moving in, more so than the sitting population. The Amsterdam housing market, dominated by social-rental housing, is key to explaining these mobility patterns. Yet, a gradual liberalisation of the social-rental stock could arguably contribute to more mature forms of gentrification