Association between essential tremor and blood lead concentration

Lead is a ubiquitous toxicant that causes tremor and cerebellar damage. Essential tremor (ET) is a highly prevalent neurologic disease associated with cerebellar involvement. Although environmental toxicants may play a role in ET etiology and their identification is a critical step in disease prevention, these toxicants have received little attention. Our objective was to test the hypothesis that ET is associated with lead exposure. Therefore, blood lead (BPb) concentrations were measured and a lifetime occupational history was assessed in ET patients and in controls. We frequency matched 100 ET patients and 143 controls on age, sex, and ethnicity. BPb concentrations were analyzed using graphite furnace atomic absorption spectrophotometry. A lifetime occupational history was reviewed by an industrial hygienist. BPb concentrations were higher in ET patients than in controls (mean ± SD, 3.3 ± 2.4 and 2.6 ± 1.6 µg/dL, respectively; median, 2.7 and 2.3 µg/dL; p = 0.038). In a logistic regression model, BPb concentration was associated with diagnosis [control vs. ET patient, odds ratio (OR) per unit increase = 1.21; 95% confidence interval (CI), 1.05-1.39; p = 0.007]. BPb concentration was associated with diagnosis (OR per unit increase = 1.19; 95% CI, 1.03-1.37; p = 0.02) after adjusting for potential confounders. Prevalence of lifetime occupational lead exposure was similar in ET patients and controls. We report an association between BPb concentration and ET. Determining whether this association is due to increased exposure to lead or a difference in lead kinetics in ET patients requires further investigation

The ARUBA trial:current status, future hopes

Background and Purpose— Report on the status of an on-going National Institutes of Neurological Disorders and Stroke (NINDS)-supported clinical trial of management of unbled brain arteriovenous malformations. Summary of Review— Begun in April 2007 with 3 centers, the trial has grown to 65 centers, and has randomized 124 patients through mid-June 2010 en route to the planned 400. The current literature continues to support the rationale for the trial. Conclusions— ARUBA is steadily approaching its monthly randomization goals and has already reached the number needed to test the maximum published interventional complication rates against the minimum hemorrhage rates for natural history. </jats:p

Admission Serum Bicarbonate Predicts Adverse Clinical Outcomes in Hospitalized Cirrhotic Patients

A low serum bicarbonate (SB) level is predictive of adverse outcomes in kidney injury, infection, and aging. Because the liver plays an important role in acid-base homeostasis and lactic acid metabolism, we speculated that such a relationship would exist for patients with cirrhosis. To assess the prognostic value of admission SB on adverse hospital outcomes, clinical characteristics were extracted and analyzed from a large electronic health record system. Patients were categorized based on admission SB (mEq/L) into 7 groups based on the reference range (22–25) into mildly (18–21), moderately (14–17), and severely (30) increased groups, and the relationship of SB category with the frequency of complications (acute kidney injury/hepatorenal syndrome, portosystemic encephalopathy, gastrointestinal bleeding, ascites, and spontaneous bacterial peritonitis) and hospital metrics (length of stay [LOS], admission to an intensive care unit [ICU], and mortality) was assessed. A total of 2,693 patients were analyzed. Mean SB was 22.9 ± 4.5 mEq/L. SB was within the normal range (22–25 mEq/L) in 1,072 (39.8%) patients, and 955 patients (36%) had a low SB. As the SB category decreased, the incidence of complications progressively increased (p<0.001). Increased MELD-Na score and low serum albumin also correlated with frequency of complications (p<0.001). As the SB category decreased, LOS, ICU admission, and mortality progressively increased (p<0.001). On multivariate analysis, the association of decreased SB with higher odds of complications, LOS, ICU admission, and mortality persisted. Conclusion. Low admission SB in patients with cirrhosis is associated with cirrhotic complications, longer LOS, increased ICU admissions, and increased hospital mortality

Admission Serum Bicarbonate Predicts Adverse Clinical Outcomes in Hospitalized Cirrhotic Patients

A low serum bicarbonate (SB) level is predictive of adverse outcomes in kidney injury, infection, and aging. Because the liver plays an important role in acid-base homeostasis and lactic acid metabolism, we speculated that such a relationship would exist for patients with cirrhosis. To assess the prognostic value of admission SB on adverse hospital outcomes, clinical characteristics were extracted and analyzed from a large electronic health record system. Patients were categorized based on admission SB (mEq/L) into 7 groups based on the reference range (22–25) into mildly (18–21), moderately (14–17), and severely (&lt;14) decreased groups and mildly (26–29), moderately (30–33), and severely (&gt;30) increased groups, and the relationship of SB category with the frequency of complications (acute kidney injury/hepatorenal syndrome, portosystemic encephalopathy, gastrointestinal bleeding, ascites, and spontaneous bacterial peritonitis) and hospital metrics (length of stay [LOS], admission to an intensive care unit [ICU], and mortality) was assessed. A total of 2,693 patients were analyzed. Mean SB was 22.9 ± 4.5 mEq/L. SB was within the normal range (22–25 mEq/L) in 1,072 (39.8%) patients, and 955 patients (36%) had a low SB. As the SB category decreased, the incidence of complications progressively increased ( p &lt; 0.001 ). Increased MELD-Na score and low serum albumin also correlated with frequency of complications ( p &lt; 0.001 ). As the SB category decreased, LOS, ICU admission, and mortality progressively increased ( p &lt; 0.001 ). On multivariate analysis, the association of decreased SB with higher odds of complications, LOS, ICU admission, and mortality persisted. Conclusion. Low admission SB in patients with cirrhosis is associated with cirrhotic complications, longer LOS, increased ICU admissions, and increased hospital mortality.</jats:p

Abstract TP430: A Family/Friend Network Approach to Secondary Stroke Prevention: Findings From the FURRThER Pilot

Importance: Despite prevention strategies with proven efficacy, recurrent stroke rates, especially in minority populations, remain high. Mobilizing stroke patients’ social networks on risk reduction goals may optimize secondary prevention efforts. Families/Friends Understanding Risk Reduction Through Educational Reinforcement (FURRThER) is a culturally-tailored, social network-based intervention facilitated by an interactive web portal and targeted at management of vascular risk factors. Objective/ outcome: To identify a signal of efficacy for the FURRThER intervention by evaluating changes in participants’ mean systolic blood pressure. Methods: Pilot study with pre-post design and 3 month follow-up. Participants are multi-ethnic patients with mild/moderate stroke prospectively enrolled in hospital. Participants (patients and family/friends) were CVD risk assessed (AHA Life’s Simple 7 survey). Family/friends networks’ identified risk reduction goals and worked together to reinforce positive behavior. Participants received follow-up call at 72 hours and via FURRThER web portal/phone weekly for 3 months. Portal communication included messages of encouragement, resources, reminders about selected goals and medical appointments. Results: The pilot recruited 13 family/friend networks in hospital (13 patients, 17 family/friends). Patients were 70% male; 61 + 8 yrs; 8% Hispanic, 15% black and 8% Asian. Average BP at baseline was 131/76 mmHg; at follow-up 123/72(p=0.04). Family/friend networks mostly choose to work together on diet and physical activity.. Some goals were network based (e.g., grocery shopping together). Medication adherence was reinforced with all groups. The pilot also identified significantly high unrecognized HTN in 30% of family/friends. Summary: FURRThER pilot demonstrated an 8mmHg decrease in SBP in patients. Involving family/friends allowed for the identification of risk factors within networks and for discussion of support/lifestyle modification towards risk reduction. Family/friend groups reported they continued to engage in lifestyle changes agreed upon in the goal setting session. A multisite, phase 2b/3A trial is needed to demonstrate efficacy. </jats:p

Endoscopic Evaluation of Swallowing as an Alternative to 24-Hour pH Monitoring for Diagnosis of Extraesophageal Reflux

Patients with symptoms of extraesophageal reflux may not be eager to undergo 24-hour pH probe monitoring for the sake of a definitive diagnosis. It has been anecdotally noted that extraesophageal reflux can be detected during an endoscopic swallowing evaluation. The purpose of this pilot study was to demonstrate that flexible endoscopic evaluation of swallowing with sensory testing (FEESST) can be implemented to identify and subsequently treat patients with extraesophageal reflux. Over a 6-month period, FEESST was prospectively performed in 20 healthy control subjects and in 20 patients with dysphagia. The dysphagic patients did not have a history of stroke or chronic neurologic disease. Attention was specifically directed toward noting the presence or absence of reflux into the laryngopharynx during the endoscopic swallowing evaluation. None of the control subjects were noted to have reflux during FEESST, but 18 of the 20 patients with dysphagia were found to have reflux during the evaluation; this difference was statistically significant (p &lt; .001, Fisher's exact test). We conclude that FEESST is useful as a means of diagnosing extraesophageal reflux in patients with dysphagia. </jats:p