Emergency department control of blood pressure in intracerebral hemorrhage.

BACKGROUND: Early treatment of elevated blood pressure (BP) in patients presenting with spontaneous intracerebral hemorrhage (ICH) may decrease hematoma enlargement and lead to better neurologic outcome. STUDY OBJECTIVE: To determine whether early BP control in patients with spontaneous ICH is both feasible and tolerated when initiated in the Emergency Department (ED). METHODS: A single-center, prospective observational study in patients with spontaneous ICH was performed to evaluate a protocol to lower, and maintain for 24 h, the mean arterial pressure (MAP) to a range of 100-110 mm Hg within 120 min of arrival to the ED. An additional goal of placing a functional arterial line within 90 min was specified in our protocol. Hematoma volume, neurologic disability, adverse events, and in-hospital mortality were recorded. RESULTS: A total of 22 patients were enrolled over a 1-year study period. The average time to achieve our target MAP after implementation of our protocol was 123 min (range 19-297 min). The average time to arterial line placement was 84 min (range 36-160 min). Overall, 77% of the patients tolerated the 24-h protocol. The in-hospital mortality rate in this group of patients was 41%. CONCLUSIONS: Adopting a protocol to reduce and maintain the MAP to a target of 100-110 mm Hg within 120 min of ED arrival was safe and well tolerated in patients presenting with spontaneous ICH. If future trials demonstrate a clinical benefit of early BP control in spontaneous ICH, EDs should implement similar protocols.

Prevalence of dementia in older latinos: the influence of type 2 diabetes mellitus, stroke and genetic factors.

OBJECTIVES: To estimate dementia prevalence in older Mexican Americans, determine the distribution of dementia by etiology, and evaluate the contribution of type 2 diabetes mellitus, stroke, and apolipoprotein E (ApoE) genotype to dementia. DESIGN: Analysis of baseline data from an epidemiological cohort study. SETTING: Sacramento Valley, California. PARTICIPANTS: One thousand seven hundred eighty-nine Latinos aged 60 and older residing in targeted census tracts during 1998-99. MEASUREMENTS: Each subject was interviewed and screened for dementia and cardiovascular risk factors and diseases. Fasting blood samples were drawn for glucose, insulin, and lipids. Buccal cells were obtained for genetic analysis of ApoE. A three-stage process of screening was used to diagnose dementia, including cognitive testing, a clinical examination, and imaging to determine etiology. Presence of dementia was established according to National Institute of Neurological Disorders and Stroke/Alzheimers and Related Disorders Association criteria and California Alzheimer's Disease Diagnostic and Treatment Criteria. RESULTS: Overall dementia prevalence was 4.8%. Prevalence in those aged 85 and older was 31%. Education and Anglo cultural orientation was negatively associated with dementia risk. Risk of dementia was nearly eight times higher in those with both type 2 diabetes mellitus and stroke. Forty-three percent of dementia was attributable to type 2 diabetes mellitus, stroke, or a combination of the two. ApoE allele frequency was E2 5.9%, E3 90.1%, and E4 4%. Those with any E4 and 4-4 combinations had a higher risk for dementia than those with the E3-3 combination. CONCLUSIONS: Dementia prevalence in this ethnic group is similar to that reported in Canadian and European studies but lower than in Caribbean-Hispanics residing in the United States. The etiological fraction of dementia attributable to type 2 diabetes mellitus and stroke is substantial and points toward the need for intervention research and treatment with the goal of reducing neurological sequelae in groups with high prevalence of type 2 diabetes mellitus. The allele frequency of ApoE was similar to that in other published studies on Mexican Americans. The low frequency of the E4 allele may contribute to the difference in etiology of dementia in older Mexican Americans and older people of European background. Dementia in this ethnic group may be related to preventable causes, with a smaller genetic component than in Europeans.