Health-Related Quality of Life in Patients with Inherited Ataxia in Ireland.

Inherited cerebellar ataxias (CA) are heterogeneous progressive neurological conditions associated with significant functional limitations. This study aimed to assess the implications of inherited CA on patients' self-reported quality of life (QoL) and impairments in work and activities. 129 individuals with ataxia responded to a survey focused on QoL. Health-related QoL was measured using the RAND 36-Item Short Form Survey. An adaptation of the validated Work Productivity and Activity Impairment questionnaire was used to assess the effect of health on work productivity and ability to perform activities over the past week. Nine percent of respondents were currently employed. Individuals with inherited ataxia experienced significant activity impairment, and 75% required professional or informal care. Health-related quality of life (HRQoL) was significantly worse in all areas for the individuals with inherited ataxia compared with Irish population normative values. Participants with Friedreich's ataxia (n = 56) demonstrated worse physical functioning then those with undetermined ataxia (n = 55). Female gender, younger age at symptom onset, current employment, retirement due to age or ataxia, and living in a long-term care facility were associated with higher sub-scores in different domains of HRQoL, while disease duration correlated with worse physical functioning sub-scores. This study is the first cross-sectional study on HRQoL in patients with inherited ataxia in Ireland. It highlights high rates of unemployment, difficulty with daily activities and physical functioning limitations, which is worse than comparative international studies. Given the limited therapeutic options currently available, optimising HRQoL is an important aspect of managing ataxia.

The Cost of Living with Inherited Ataxia in Ireland.

Inherited ataxias are a heterogenous group of neurodegenerative disorders characterised by progressive impairment of balance and coordination, typically leading to permanent and progressive disability. Diagnosis and management of these disorders incurs a range of direct and indirect financial costs. The aim of this study was to collect individual ataxia-related healthcare resources in a large cohort of individuals with different subtypes of inherited ataxia and calculate the associated cost of illness in the Republic of Ireland. One hundred twenty-nine respondents completed a cross-sectional study on healthcare resource utilisation for progressive ataxia in Ireland. Costs were calculated using a prevalence-based approach and bottom-up methodology. The COI for inherited ataxia in 2016 was €59,993 per person per year. Results were similar between participants with Friedreich's ataxia (FRDA, n = 56), non-FRDA (n = 18) and those with undetermined ataxia (n = 55). Indirect costs, based on productivity losses by participants or caregivers, accounted for 52% of the cost of illness. Inherited ataxia is associated with significant health and social care costs. Further funding for inherited ataxia to ease the financial burden on patients, caregivers and healthcare system and improve standards of care compliance is warranted.

Neurophysiological and ophthalmological findings of SPG7-related spastic ataxia: a phenotype study in an Irish cohort.

BACKGROUND: Mutations in SPG7 are increasingly identified as a common cause of spastic ataxia. We describe a cohort of Irish patients with recessive SPG7-associated phenotype. METHODS: Comprehensive phenotyping was performed with documentation of clinical, neurophysiological, optical coherence tomography (OCT) and genetic data from individuals with SPG7 attending two academic neurology units in Dublin, including the National Ataxia Clinic. RESULTS: Thirty-two symptomatic individuals from 25 families were identified. Mean age at onset was 39.1 years (range 12-61), mean disease duration 17.8 years (range 5-45), mean disease severity as quantified with the scale for the assessment and rating of ataxia 9/40 (range 3-29). All individuals displayed variable ataxia and spasticity within a spastic-ataxic phenotype, and additional ocular abnormalities. Two had spasmodic dysphonia and three had colour vision deficiency. Brain imaging consistently revealed cerebellar atrophy (n = 29); neurophysiology demonstrated a length-dependent large-fibre axonal neuropathy in 2/27 studied. The commonest variant was c.1529C > T (p.Ala510Val), present in 21 families. Five novel variants were identified. No significant thinning of average retinal nerve fibre layer (RNFL) was demonstrated on OCT (p = 0.61), but temporal quadrant reduction was evident compared to controls (p < 0.05), with significant average and temporal RNFL decline over time. Disease duration, severity and visual acuity were not correlated with RNFL thickness. CONCLUSIONS: Our results highlight that recessive SPG7 mutations may account for spastic ataxia with peripheral neuropathy in only a small proportion of patients. RNFL abnormalities with predominant temporal RNFL reduction are common and OCT should be considered part of the routine assessment in spastic ataxia.

Inherited Cerebellar Ataxias: 5-Year Experience of the Irish National Ataxia Clinic.

Establishing a molecular diagnosis in patients with progressive ataxia is often challenging due to significant genetic and clinical heterogeneity and requires a methodical approach with expert clinical evaluation and investigations. We describe the 5-year experience of the National Ataxia Clinic (NAC), Ireland. All adults with ataxia attending the NAC between 2014 and 2019 were evaluated. All individuals underwent detailed clinical assessment and investigations including, where appropriate, genetic testing using next-generation sequencing. For all patients, acquired causes were ruled out. A total of 254 patients from 196 families were assessed; with growth of the clinic cohort by 82% from 133 to 242 over the 5-year period. The underlying genetic cause was identified in 128/196 probands (65.3%). The detection rate for repeat expansion disorder gene testing was 47.7% (82/172) and using NGS gene panel, a genetic diagnosis was obtained in 30/84 (35.7%). Whole exome sequencing identified the molecular diagnosis in 4/20 (20%), and whole genome sequencing provided genetic diagnosis in 1/5 (20%). The commonest diagnosis was Friedreich's ataxia (68/128, 53.1%). SPG7-associated ataxia was the second most common diagnosis (21/128, 16.4%), followed by ANO10-associated spastic ataxia, ataxia telangiectasia (AT), and other rarer phenotypes. Our results highlight that careful clinical phenotyping in a dedicated ataxia clinic is crucial for appropriate genetic testing in selected patients in a timely manner. Advanced genetic testing has significantly improved the diagnostic yield in patients with suspected genetic ataxia and should be considered in all individuals with negative repeat expansion testing.

Organic Micropollutants in New York Lakes: A Statewide Citizen Science Occurrence Study.

The widespread occurrence of organic micropollutants (OMPs) is a challenge for aquatic ecosystem management, and closing the gaps in risk assessment of OMPs requires a data-driven approach. One promising tool for increasing the spatiotemporal coverage of OMP data sets is through the active involvement of citizen volunteers to expand the scale of OMP monitoring. Working collaboratively with volunteers from the Citizens Statewide Lake Assessment Program (CSLAP), we conducted the first statewide study on OMP occurrence in surface waters of New York lakes. Samples collected by CSLAP volunteers were analyzed for OMPs by a suspect screening method based on mixed-mode solid-phase extraction and liquid chromatography-high resolution mass spectrometry. Sixty-five OMPs were confirmed and quantified in samples from 111 lakes across New York. Hierarchical clustering of OMP occurrence data revealed the relevance of 11 most frequently detected OMPs for classifying the contamination status of lakes. Partial least squares regression and multiple linear regression analyses prioritized three water quality parameters linked to agricultural and developed land uses (i.e., total dissolved nitrogen, specific conductance, and a wastewater-derived fluorescent organic matter component) as the best combination of predictors that partly explained the interlake variability in OMP occurrence. Lastly, the exposure-activity ratio approach identified the potential for biological effects associated with detected OMPs that warrant further biomonitoring studies. Overall, this work demonstrated the feasibility of incorporating citizen science approaches into the regional impact assessment of OMPs.

Perioperative management in the patient with substance abuse.

Drug and alcohol use is a pervasive problem in the general population and in those requiring anesthesia for an operation. History and screening can help delineate those who may be acutely intoxicated or chronic drug and alcohol users. Both acute intoxication and chronic abuse of these substances present challenges for anesthetic management during and after an operation. The clinician should be aware of problems that may be encountered during any part of anesthesia or postoperative care.

Brain-type natriuretic peptide and right ventricular end-diastolic volume index measurements are imprecise estimates of circulating blood volume in critically ill subjects.

BACKGROUND: Surrogate indicators have often been used to estimate intravascular volume to guide fluid management. Brain-type natriuretic peptide (BNP) has been used as a noninvasive adjunct in the diagnosis of fluid overload and as a marker of response to therapy, especially in individuals with congestive heart failure. Similarly, right ventricular end-diastolic volume index (RVEDVI) measurements represent another parameter used to guide fluid resuscitation. The aim of this study was to evaluate whether BNP and RVEDVI are clinically valuable parameters that can distinguish among hypovolemia, euvolemia, and hypervolemia, as measured by blood volume (BV) analysis in critically ill surgical subjects. METHODS: This observational study was part of a prospective, randomized controlled trial. Subjects with pulmonary artery catheters for the treatment of traumatic injuries, severe sepsis/septic shock, cardiovascular collapse, adult respiratory distress syndrome, and postsurgical care were studied. Circulating BV was measured by a radioisotope dilution technique using the BVA-100 Analyzer (Daxor Corporation, New York, NY) within the first 24 hours of acute resuscitation. BV results were reported as percent deviation from the patient's ideal BV based on height and percent deviation from optimum weight. Hypovolemia was defined as less than 0%, euvolemia was defined as 0% to +16%, and hypervolemia was defined as greater than +16% deviation from ideal BV. RVEDVI was measured by continuous cardiac output pulmonary artery catheters (Edwards Lifesciences, Irvine, CA). BNP and RVEDVI measurements obtained with BV analysis were evaluated with Fisher's exact test and regression analysis. RESULTS: In 81 subjects, there was no difference in BV status between those with BNP of 500 pg/mL or greater and BNP of less than 500 pg/mL (p = 0.82) or in those with RVEDVI of 140 mL/m or greater and RVEDVI of less than 140 mL/m (p = 0.43). No linear relationship existed between BV and these parameters. CONCLUSION: In critically ill surgical patients, BNP and RVEDVI were not associated with intravascular volume status, although they may be useful as indices that reflect increased cardiac preload. LEVEL OF EVIDENCE: Diagnostic study, level III.

A prospective randomized trial using blood volume analysis in addition to pulmonary artery catheter, compared with pulmonary artery catheter alone, to guide shock resuscitation in critically ill surgical patients.

Measurement of blood volume (BV) may guide fluid and red blood cell management in critically ill patients when capillary leak from shock and fluid resuscitation makes assessment of intravascular volume difficult. This is a prospective randomized trial of critically ill surgical patients with septic shock, severe sepsis, severe respiratory failure, and/or cardiovascular collapse. The control group received fluid management based on pulmonary artery catheter parameters and red blood cell transfusions based on hematocrit values. The BV group received fluid and red blood cell transfusions based on BV analyses in addition to pulmonary artery catheter parameters. Blood volume was measured using the radioisotope tracer technique with iodine 131-labeled albumin. This allowed direct measurement of plasma volume and calculation of the red blood cell volume. The control group was blinded to the BV results. There were statistically significantly more times when the control group (compared with the BV group) demonstrated hypervolemia (48% vs. 37%) and red blood cell deficiency (33% vs. 16%). There was a delay in red blood cell transfusions administered to the control group by 1.5 +/- 2 days at which time the abnormality became clinically evident. Blood volume analyses provided additional information to the clinicians resulting in a change in treatment in 44% of the time to patients randomized to the BV group. The mortality rates were significantly different between the two groups (8% for the BV group and 24% in the control group; P = 0.03). Blood volume measurements allowed the physicians to promptly treat physiologic disturbances in both red blood cell volume and plasma volume, resulting in improved survival.

Applicator exposure to acetochlor based on biomonitoring.

Biomonitoring was used to assess the combined dermal, oral, and inhalation exposure associated with the agricultural use of Harness Plus, an emulsifiable concentrate formulation of the herbicide acetochlor. Twenty Spanish farmers handled and applied acetochlor to maize in the spring of 2003, following the product label recommendations. Open- and closed-cabin applications were equally represented. Urine was collected during six consecutive days, starting the day prior to application. Daily composites were analyzed for 2-ethyl-6-methyl-aniline, a common chemophore representing the major urinary acetochlor metabolites. All applicators showed detectable concentrations in urine after application. Although, the open-cabin applicators treated fewer hectares, they showed significantly higher exposure compared to the closed-cabin applicators (average exposure: 0.004 and 0.002 mg/kg bw/day, respectively). Linear regression analysis suggested that untracked incidents had a significant impact on the total exposure. Other events that may have contributed to the observed exposure are repair of faulty equipment, accidental spillages, splashes, and inadequate use of protective gloves. The average margins of exposure (MOE) for farmers ranged from 23,000 (open cabin) to about 44,000 (closed cabin). For professional applicators the MOEs were 10-fold lower. These MOEs clearly indicate that no adverse health effects should be expected from agricultural acetochlor applications.

The acetochlor registration partnership surface water monitoring program for four corn herbicides.

A surface drinking water monitoring program for four corn (Zea mays L.) herbicides was conducted during 1995-2001. Stratified random sampling was used to select 175 community water systems (CWSs) within a 12-state area, with an emphasis on the most vulnerable sites, based on corn intensity and watershed size. Finished drinking water was monitored at all sites, and raw water was monitored at many sites using activated carbon, which was shown capable of removing herbicides and their degradates from drinking water. Samples were collected biweekly from mid-March through the end of August, and twice during the off-season. The analytical method had a detection limit of 0.05 microg L(-1) for alachlor [2-chloro-N-(2,6-diethylphenyl)-N-(methoxymethyl)-acetamide] and 0.03 microg L(-1) for acetochlor [2-chloro-N-(ethoxymethyl)-N-(2-ethyl-6-methylphenyl)-acetamide], atrazine [6-chloro-N-ethyl-N'-(1-methylethyl)-1,3,5-triazine-2,4-diamine], and metolachlor [2-chloro-N-(2-ethyl-6-methylphenyl)-N-(2-methoxy-1-methylethyl)-acetamide]. Of the 16528 drinking water samples analyzed, acetochlor, alachlor, atrazine, and metolachlor were detected in 19, 7, 87, and 53% of the samples, respectively. During 1999-2001, samples were also analyzed for the presence of six major degradates of the chloroacetanilide herbicides, which were detected more frequently than their parent compounds, despite having higher detection limits of 0.1 to 0.2 microg L(-1). Overall detection frequencies were correlated with product use and environmental fate characteristics. Reservoirs were particularly vulnerable to atrazine, which exceeded its 3 microg L(-1) maximum contaminant level at 25 such sites during 1995-1999. Acetochlor annualized mean concentrations (AMCs) did not exceed its mitigation trigger (2 microg L(-1)) at any site, and comparisons of observed levels with standard measures of human and ecological hazards indicate that it poses no significant risk to human health or the environment.