Neuroprotective strategies following intraparenchymal hemorrhage

Intracerebral hemorrhage and, more specifically, intraparenchymal hemorrhage, are devastating disease processes with poor clinical outcomes. Primary injury to the brain results from initial hematoma expansion while secondary hemorrhagic injury occurs from blood-derived products such as hemoglobin, heme, iron, and coagulation factors that overwhelm the brains natural defenses. Novel neuroprotective treatments have emerged that target primary and secondary mechanisms of injury. Nonetheless, translational application of neuroprotectants from preclinical to clinical studies has yet to show beneficial clinical outcomes. This review summarizes therapeutic agents and neuroprotectants in ongoing clinical trials aimed at targeting primary and secondary mechanisms of injury after intraparenchymal hemorrhage.

Clinical effects of air pollution on the central nervous system; a review

The purpose of this review is to describe recent clinical and epidemiological studies examining the adverse effects of urban air pollution on the central nervous system (CNS). Air pollution and particulate matter (PM) are associated with neuroinflammation and reactive oxygen species (ROS). These processes affect multiple CNS pathways. The conceptual framework of this review focuses on adverse effects of air pollution with respect to neurocognition, white matter disease, stroke, and carotid artery disease. Both children and older individuals exposed to air pollution exhibit signs of cognitive dysfunction. However, evidence on middle-aged cohorts is lacking. White matter injury secondary to air pollution exposure is a putative mechanism for neurocognitive decline. Air pollution is associated with exacerbations of neurodegenerative conditions such as Alzheimer's and Parkinson's diseases. Increases in stroke incidences and mortalities are seen in the setting of air pollution exposure and CNS pathology is robust. Large populations living in highly polluted environments are at risk. This review aims to outline current knowledge of air pollution exposure effects on neurological health.

Abstract TP438: Nanoparticulate Matter Exposure Mediates White Matter Changes in a Murine Model

Background: Clinical and epidemiologic studies suggest a relationship between long-term nano-particulate matter (nPM) exposure and white matter injury 1 . Accumulating laboratory evidence suggests that nPM exposure causes inflammation in multiple brain regions 2 .

Objective: We sought to study the effects nano-particulate matter exposure on microglia activation and complement upregulation within the corpus callosum in a murine model.

Methods: C57 black 6J mice were randomized to re-aerosolized nPM (n=18, nPM <200 nm) or filtered air (n=18) cohorts. Exposures were conducted for a total of 150 cumulative hours. Post-exposure, brains were harvested and immunohistochemical analysis performed. Reactive microglia (IBA-1), reactive astrocytes (GFAP) and C5α deposition (C5α antibody) were quantified in the medial corpus callosum.

Results: There were significant differences in IBA-1 cell count staining between the groups (filtered air- 94.7± 18.87; nPM- 158.5 ± 41.69, p<0.05). No differences in GFAP cell count staining existed between the filtered air (677.5 ± 96.09) and nPM mice (656.6 ± 120.3, p=ns). There were significant differences in C5α density staining between filtered air (8.181 ± 3.863) and nPM mice (14.77 ± 5.989, p<0.01).

Conclusion: Chronic particulate matter exposure is associated with white matter changes in a murine model. Regional increases in microglia number and C5α deposition suggest an inflammatory mechanism.

References: 1. Calderon-Garciduenas L, Mora-Tiscareno A, Ontiveros E, Gomez-Garza G, Barragan-Mejia G, Broadway J, Chapman S, Valencia-Salazar G, Jewells V, Maronpot RR, Henriquez-Roldan C, Perez-Guille B, Torres-Jardon R, Herrit L, Brooks D, Osnaya-Brizuela N, Monroy ME, Gonzalez-Maciel A, Reynoso-Robles R, Villarreal-Calderon R, Solt AC, Engle RW. Air pollution, cognitive deficits and brain abnormalities: a pilot study with children and dogs. Brain Cogn. 2008;68(2):117-27. 2. Block, M. L., & Calderón-Garcidueñas, L. (2009). Air pollution: mechanisms of neuroinflammation and CNS disease. Trends in neurosciences , 32 (9), 506-516.

Exhaled Nitric Oxide Levels Among Adults With Excessive Alcohol Consumption

BACKGROUND

More than one-quarter of the US population qualify as excessive alcohol consumers. Alcohol use impacts several lung diseases, and heavy consumption has been associated with poor clinical outcomes. The fractional excretion of exhaled nitric oxide (Feno) has clinical implications in multiple airways diseases. We hypothesized that excessive alcohol intake is associated with lower Feno levels.

METHODS

To test this hypothesis, we examined a sample consisting of 12,059 participants, aged 21 to 79 years, interviewed between 2007 and 2012 from the National Health and Examination Survey. Two valid Feno measurements that were reproducible were recorded. Alcohol questionnaire data were used to define the following alcohol groups: never drinkers, nonexcessive drinkers, excessive drinkers, and former excessive drinkers. The natural logarithm of Feno values [ln(Feno)] as well as blood eosinophil count and C-reactive protein were used as dependent variables to test the association with alcohol groups including multivariable linear regression models with adjustment for predictors of Feno.

RESULTS

Excessive alcohol consumption comprised 3,693 (26.9%) of the US sample population. Controlling for all other factors, excessive alcohol consumption had a negative association and was an independent predictor for ln(Feno) levels in comparison with the never-drinker group (-0.11; 95% CI, -0.17 to -0.06; P < .001). ln(Feno) levels decreased across categories of increasing alcohol use (P < .001).

CONCLUSIONS

Accounting for alcohol use in the interpretation of Feno levels should be an additional consideration, and further investigations are warranted to explore the complex interaction between alcohol and nitric oxide in the airways.

Abstract TP295: Predictability of Stroke Symptoms in Acute Stroke

Background: Prompt signs and symptoms recognition and intervention are essential to achieve the best outcome after stroke. Stroke codes were developed to expedite assessment and treatment. Their optimal use requires accurate identification of stroke patients. In order to improve diagnostic accuracy in our institution, we analyzed the predictive value of individual stroke signs and symptoms in patients in whom stroke codes were activated from the emergency department (ED) by physicians and nurses and from inpatient wards by nurses, residents and hospitalists.

Methods: We retrospectively analyzed 501 consecutive stroke codes in our stroke log from May 2013 to May 2015. Age, gender, presenting signs and symptoms, medical history and final diagnosis were assessed. Patients were classified as stroke (ischemic and hemorrhagic) or non-stroke based on the final impression after the completed work-up. X2 statistic was utilized to assess associations.

Results: Overall, 202 (40.3%) patients were classified as stroke and 299 (59.7%) non-stroke. 78% of stroke codes were activated from ED and 22% from the inpatient wards. Unilateral limb weakness, aphasia and facial weakness were associated with stroke (p<0.05) with PPVs of 0.57 (95%CI 50-64%), 0.56 (43-68%), 0.51 (43-60%), respectively. Altered mental status (AMS) and sensory symptoms were associated with non-stroke (p<0.05). The PPV and NPV for stroke were 0.21 (95%CI 13-31%) and 0.55 (50-60%) for AMS respectively and 0.25 (14-39%) and 0.58 (43-63%) for sensory symptoms. Location of the stroke code (ED or inpatient ward) did not impact the results.

Conclusion: Previous studies, based on evaluation of acute stroke by paramedics and ED physicians, demonstrated that some signs or symptoms are more likely to be present in patients experiencing acute stroke. In our experience, unilateral limb weakness, aphasia, and facial weakness as identified by diverse provider disciplines and experience levels are associated with a final diagnosis of acute stroke. However, isolated altered mental status or sensory symptoms seldom result in a final diagnosis of stroke. These data can assist healthcare providers, to more accurately identify stroke patients, thus improving outcomes as well as resources utilization.

Association of carotid intima-media thickness with progression of urine albumin-creatinine ratios in The Multi-Ethnic Study of Atherosclerosis (MESA)

BACKGROUND

The association between measures of subclinical cardiovascular disease and progression of urine albumin-creatinine ratios (UACRs) over time is uncertain.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

The Multi-Ethnic Study of Atherosclerosis (MESA), a cohort of adults aged 45-84 years without baseline clinical cardiovascular disease. Examinations were completed approximately every 1.5 years, and UACR was measured during the first 3 examinations. Analysis was limited to 4,878 participants without baseline micro- or macroalbuminuria.

PREDICTOR

1-standard deviation (SD) unit difference in baseline maximum common and internal carotid intima-media thickness (CIMT) measured using ultrasonography.

OUTCOMES & MEASUREMENTS

Baseline UACR was categorized as normal or high-normal. UACR progression was categorized as no progression (consistent UACR category across all 3 examinations or regression to a lower category) and definite progression (higher UACR category at examination 2 compared with baseline, then stabilizing or progressing at examination 3). UACR changes not consistent with definite or no UACR progression were classified as intermediate UACR progression. Change in log UACR also was examined.

RESULTS

In the 4,878 participants, median baseline UACR was 4.6 mg/g (range, 0.4-24.6 mg/g). Definite and intermediate UACR progression was noted in 279 and 807, respectively. Every 1-SD unit difference in common CIMT was associated with a 22% increased adjusted odds of definite compared with no UACR progression (95% CI, 1.07-1.41). No significant association was noted between 1-SD unit difference in maximum internal CIMT and definite UACR progression after adjusting for covariates (OR, 1.08; 95% CI, 0.96-1.21). In the mixed-effects model, changes in log UACR were 0.029 (95% CI, 0.012-0.046) and 0.019 mg/g (95% CI, 0.001-0.037) per 1-SD difference in maximum common and internal CIMT after adjustment for covariates, respectively.

LIMITATIONS

UACR was measured in a single spot urine specimen at each exam.

CONCLUSION

Higher common CIMT is associated with UACR progression.

Effect of mindfulness based stress reduction on immune function, quality of life and coping in women newly diagnosed with early stage breast cancer

This investigation used a non-randomized controlled design to evaluate the effect and feasibility of a mindfulness based stress reduction (MBSR) program on immune function, quality of life (QOL), and coping in women recently diagnosed with breast cancer. Early stage breast cancer patients, who did not receive chemotherapy, self-selected into an 8-week MBSR program or into an assessment only, control group. Outcomes were evaluated over time. The first assessment was at least 10 days after surgery and prior to adjuvant therapy, as well as before the MBSR start-up. Further assessments were mid-MBSR, at completion of MBSR, and at 4-week post-MBSR completion. Women with breast cancer enrolled in the control group (Non-MBSR) were assessed at similar times. At the first assessment (i.e., before MBSR start), reductions in peripheral blood mononuclear cell NK cell activity (NKCA) and IFN-gamma production with increases in IL-4, IL-6, and IL-10 production and plasma cortisol levels were observed for both the MBSR and Non-MBSR groups of breast cancer patients. Over time women in the MBSR group re-established their NKCA and cytokine production levels. In contrast, breast cancer patients in the Non-MBSR group exhibited continued reductions in NKCA and IFN-gamma production with increased IL-4, IL-6, and IL-10 production. Moreover, women enrolled in the MBSR program had reduced cortisol levels, improved QOL, and increased coping effectiveness compared to the Non-MBSR group. In summary, MBSR is a program that is feasible for women recently diagnosed with early stage breast cancer and the results provide preliminary evidence for beneficial effects of MBSR; on immune function, QOL, and coping.

Emergence of ganciclovir-resistant cytomegalovirus in lung transplant recipients

BACKGROUND

Since ganciclovir-resistant cytomegalovirus (CMV) disease was initially described in a patient with acquired immunodeficiency syndrome (AIDS) in 1986, the incidence of ganciclovir-resistant CMV disease appears to be increasing in immunocompromised patients. More recently, there have been sporadic reports of ganciclovir-resistant CMV disease in solid organ transplantation.

METHODS

We retrospectively assessed the incidence of ganciclovir-resistant CMV disease in all lung transplant recipients transplanted between 6/93 and 6/01 at Loyola University Medical Center. All patients underwent routine CMV blood culture, shell vial assay as well as phenotypic and genotypic anti-viral susceptibility testing according to a pre-determined schedule. The number of CMV episodes, intravenous ganciclovir use, acute and chronic rejection and survival data were documented for all patients.

RESULTS

Twelve of 212 (6%) transplant recipients developed ganciclovir-resistant CMV disease. Ganciclovir resistance was associated with a higher number of CMV episodes (3.4 +/- 2.3 episodes/patient vs 1.7 +/- 0.7 episodes/patient [p < 0.05]) and an increased exposure to cumulative intravenous ganciclovir in the primary CMV-mismatched (D(+)R(-)) population (22 +/- 10 vs 13 +/- 7 days [p < 0.05]) compared with patients who did not develop ganciclovir resistance. In addition, the use of daclizumab therapy was associated with a 7-fold greater likelihood of developing ganciclovir resistance (p < 0.0001). The presence of ganciclovir-resistant CMV disease in our population was associated with a decreased survival that could be attributed to CMV disease itself (p < 0.05).

CONCLUSIONS

By screening all lung transplant recipients with CMV disease for ganciclovir resistance, we were able to detect a higher incidence of ganciclovir-resistant CMV disease (6%) than previously seen in solid organ transplantation. High-risk patients (D(+)R(-) CMV serostatus) who receive anti-lymphocytic therapy should be monitored aggressively and treated to prevent the development of ganciclovir resistance and avert a negative outcome.

Relationship between birth weight and awake blood pressure in children and adolescents in absence of intrauterine growth retardation

This study was designed to examine the relationship between birth weight (BW) and ambulatory blood pressure in children and adolescents, born at term in absence of intrauterine growth retardation. Twenty-four hour ambulatory blood pressure monitoring (ABPM) was performed on 332 children (150 boys), aged from 6 to 16 years. Subjects were stratified by BW tertiles and age. ABPM was performed using SpaceLabs 90207 monitor during a regular school day. Blood pressure (BP) was measured every 20 min from 06:00 to 24:00, and thereafter every 30 min. Means of systolic BP (SBP) and diastolic BP (DBP) during 24 h, daytime (08:00 to 22:00), and nighttime (24:00 to 06:00) were calculated. Systolic and diastolic load was estimated as the percentage of measurements above the age- and sex-specific 95th percentile during the 24 h. BW was inversely related to daytime (SBP (P = .04) and SBP load (P = .04) when controlled for sex, current height, ponderal index (weight/height3), and age. The predictive values of daytime SBP throughout the pediatric age group in the two extreme tertiles of BW (lowest, 2.500 to 3.200 kg; and highest, 3.501 to 4.820 kg) were obtained from regression equations including SBP during activity period or SBP load and age. Children who had lower BW tended to have higher daytime SBP or SBP load at any age although this difference was not statistically significant. These differences became more evident as the subjects got older. BW is a determinant of daytime SBP even in the absence of intrauterine growth retardation. The influence of BW seems to increase with age.

Angiotensinogen and blood pressure among blacks: findings from a community survey in Jamaica

OBJECTIVE

To examine the association between blood pressure, angiotensinogen levels, angiotensin converting enzyme activity and polymorphisms of the angiotensinogen and angiotensin converting enzyme genes in a population-based sample.

METHOD

Five hundred participants were recruited in a house-to-house survey of three communities in metropolitan areas of Kingston and St Andrew, in Jamaica. Demographic data, anthropometric and blood pressure measurements were obtained for each participant during a brief clinic visit. Circulating levels of angiotensinogen and angiotensin converting enzyme activity were measured in venous blood samples. Polymorphisms of the angiotensinogen and angiotensin converting enzyme genes were determined.

RESULTS

A weak association between angiotensinogen level, angiotensin converting enzyme activity and blood pressure was identified in this population, but substantial joint effect of angiotensin converting enzyme activity and angiotensinogen level on blood pressure was apparent. Variants of the angiotensinogen gene had inconsistent effects on blood pressure and on the risk of hypertension. Angiotensinogen level and angiotensin converting enzyme activity were significantly related to several measures of obesity, including body mass index, waist circumference and skin fold thickness.

CONCLUSION

The angiotensinogen and angiotensin converting enzyme genetic variants which were studied appear to have only a modest relationship with blood pressure and associated anthropometric risk factors among blacks.