Erin Saito

Epidemiologic and clinical factors associated with Chronic Kidney Disease among Asian Americans and Native Hawaiians

Objective. To examine the association between key susceptibility factors and measures of chronic kidney disease in Asian American and Native Hawaiian participants enrolled in the Hawai‘i site of the national Kidney Early Evaluation Program (KEEP-2) study community screening program. Design. In 2001–2003, 793 participants from five ethnic groups (Japanese, Native Hawaii an, Chinese, Filipino and Caucasian) were enrolled in the Hawai‘i KEEP-2 program. Odds ratios were used as the measure of association and were computed using unconditional logistic regression. Renal susceptibility factors for chronic kidney disease were included in a multivariable model if found to be statistically significant in univariate analysis. The proportion of Hawai‘i KEEP-2 study participants manifesting various clinical characteristics were compared by ethnicity with Japanese as the referent group. Results. Significant ethnic differences in the occurrence of chronic kidney disease were found, with Japanese having the lowest occurrence of chronic kidney disease (18%) and Native Hawaiians the highest (40%). Within each ethnic group, the occurrence of chronic kidney disease was associated with a different ethnic-specific clustering of susceptibility factors. Hypertension was associated with chronic kidney disease among four of the five ethnic groups: Japanese, Caucasian, Native Hawaiian and Filipino. Overweight was associated with a decreased occurrence of chronic kidney disease among Caucasians, while diabetes and lower educational attainment were associated with increased occurrence of chronic kidney disease among Native Hawaiians. For Filipinos, diabetes and age 65 years and older were both associated with an increased occurrence for chronic kidney disease while lower educational attainment was associated with a reduced occurrence of chronic kidney disease. Among Chinese, no factors were significantly associated with chronic kidney disease, although trends for all factors paralleled those of the overall study group. Conclusions. The occurrence of chronic kidney disease in the Hawai‘i KEEP-2 study was nearly fourfold greater compared with the general US population. The clustering of susceptibility factors for chronic kidney disease occurrence was found to differ for all five ethnic groups.

Acute Psychosis Associated with Subcortical Stroke: Comparison between Basal Ganglia and Mid-Brain Lesions

Acute onset of psychosis in an older or elderly individual without history of previous psychiatric disorders should prompt a thorough workup for neurologic causes of psychiatric symptoms. This report compares and contrasts clinical features of new onset of psychotic symptoms between two patients, one with an acute basal ganglia hemorrhagic stroke and another with an acute mid-brain ischemic stroke. Delusions and hallucinations due to basal ganglia lesions are theorized to develop as a result of frontal lobe dysfunction causing impairment of reality checking pathways in the brain, while visual hallucinations due to mid-brain lesions are theorized to develop due to dysregulation of inhibitory control of the ponto-geniculate-occipital system. Psychotic symptoms occurring due to stroke demonstrate varied clinical characteristics that depend on the location of the stroke within the brain. Treatment with antipsychotic medications may provide symptomatic relief.

Cost Effective Community Based Dementia Screening: A Markov Model Simulation

Background. Given the dementia epidemic and the increasing cost of healthcare, there is a need to assess the economic benefit of community based dementia screening programs. Materials and Methods. Markov model simulations were generated using data obtained from a community based dementia screening program over a one-year period. The models simulated yearly costs of caring for patients based on clinical transitions beginning in pre dementia and extending for 10 years. Results. A total of 93 individuals (74 female, 19 male) were screened for dementia and 12 meeting clinical criteria for either mild cognitive impairment (n = 7) or dementia (n = 5) were identified. Assuming early therapeutic intervention beginning during the year of dementia detection, Markov model simulations demonstrated 9.8% reduction in cost of dementia care over a ten-year simulation period, primarily through increased duration in mild stages and reduced time in more costly moderate and severe stages. Discussion. Community based dementia screening can reduce healthcare costs associated with caring for demented individuals through earlier detection and treatment, resulting in proportionately reduced time in more costly advanced stages.

Risk factors associated with methamphetamine use and heart failure among native Hawaiians and other Pacific Island peoples.

Objective: Heart failure (HF), a long term outcome of chronic methamphetamine use (MU), occurs more frequently in racial and ethnic minority populations at high risk for cardiovascular disparities. This study examined the association of socio-demographic and clinical risk factors with MU among heart failure patients who are Native Hawaiians (NH) or other Pacific Island peoples (PIP). Design/Setting/Patient population: Cross-sectional study of NHs and PIPs with advanced heart failure enrolled in the Malama Pu’uwai Study, a randomized control trial to test an educational intervention to reduce re-hospitalization and/or death. A total of 82 participants were enrolled between 6/1/06 to 12/31/07 and met the following eligibility criteria: 1) self-identified NH or PIP, 2) Left ventricular systolic ejection fraction ≤45%, 3) Age of 21 years or older. Data were analyzed by odds ratios (OR), 95% confidence intervals (CI), and multiple logistic regression analysis. Main outcome measure: Methamphetamine use. Results: Twenty-two percent of HF participants were identified as being current or prior methamphetamine users. Younger age and non-married status (combined never married or divorced/separated) were independently associated with MU after adjustment for sex, education, and other co-morbidities associated with HF (ie, age >50 years, OR = 0.16, 95% CI, 0.03–0.84; non-married status combined as never married OR = 8.5, CI, 1.5–47; divorced/separated OR = 11, CI 1.8–75). Conclusions: Risk factors associated with MU in NH and PIPs with heart failure include: younger age and being divorced/separated or never married. Health care providers should be aware of MU as a contributing factor in the approach and treatment of HF in NHs and PIPs.

Gender and Ethnicity Based Differences in Clinical and Laboratory Features of Myasthenia Gravis

Background. Previous reports describe ethnicity based differences in clinical and laboratory features between Caucasians and African Americans with myasthenia gravis. However, it is not known whether these findings apply to other ethnicities. Methods. Retrospective analysis of all patients treated for myasthenia gravis during a three-year period at a community based medical center. Results. A total of 44 patients were included, including 19 of Hispanic, 16 of African American, 6 of Caucasian, and 3 of Asian ethnicities. Female gender was more common among those with Hispanic, Asian, and African American ethnicities compared to Caucasian ethnicity (p = 0.029). Anti-acetylcholine receptor antibody subtypes demonstrated no significant ethnicity based differences in either generalized or ocular myasthenia gravis. A trend was noted towards greater frequency of blocking antibodies among Hispanics (52.6%) compared to African American (37.5%) and Caucasian (33.3%) patients (p = 0.059). Generalized but not ocular myasthenia patients showed greater frequency of anti-muscle specific kinase antibodies in Asians and Hispanics compared to African Americans and Caucasians (p = 0.041). Conclusions. The results of this study support the existence of ethnicity based differences in clinical and laboratory features of myasthenia gravis. Further study of genetic factors influencing clinical features of myasthenia gravis is indicated.

Effects of Obesity and Gender on Chronic Pain Severity in a Community Based Cohort

Introduction: Obesity and chronic pain are common problems affecting quality of life for many men and women, however, little is known about gender specific effects of obesity on chronic pain severity. This study examines the relationship between chronic pain severity and Body Mass Index (BMI) in male and female patients from a community neurology clinic. Methods and materials: Cross-sectional analysis of 232 men and 224 women presenting sequentially to a community based general neurology clinic for evaluation of chronic pain. Results: In the combined group of men and women, BMI correlated with pain severity score for neck (R-square = 0.08, SE = 2.9, p = 0.01), back (R-square = 0.07, SE = 2.9, p < 0.01), and joint pain (R-square = 0.08, SE = 3.1, p < 0.01), but not for headache or whole body pain. In men, BMI correlated with pain severity score for neck (R-square = 0.18, SE = 3, p = 0.03), back (R-square = 0.16, SE = 2.9, p < 0.01), and joint pain (R-square = 0.12, SE = 2.5, p < 0.01), but not headache pain. In women BMI correlated with pain severity score for back (R-square = 0.07, SE = 2.9, p < 0.01), and joint pain (R-square = 0.05, SE = 3.5, p = 0.02), but not for headache or neck pain. Conclusions: Obesity affects severity of chronic pain in a variety of pain locations. Reduction in body mass index may be one method for reducing chronic pain severity in men and women.

The burden of diagnosed and undiagnosed diabetes in Native Hawaiian and Asian American hospitalized patients

Highlights • 38% of Native Hawaiian, 34% of Japanese, 33% of Filipino, 23% of Chinese and 19% of White inpatients had diagnosed diabetes.• 3% Native Hawaiian, 3% Japanese, 4% Filipino, 4% Chinese and 4% White inpatients had potentially undiagnosed diabetes.• Few potentially undiagnosed diabetes cases were found. Prospective methods are recommended.• Potentially undiagnosed diabetes was associated with a longer hospital stay and higher mortality.• Inpatient diabetes screening with HbA1c is suggested, which should be evaluated prospectively for improved outcomes.

Neuropsychiatric and Cognitive Symptoms in Spinocerebellar Ataxia: Relationship to Neuropathological Differences

The autosomal dominant spinocerebellar ataxias (SCA) are a heterogeneous group of disorders associated with progressive degeneration of the cerebellum and other brain regions to varying degrees. Neuropsychiatric and cognitive symptoms are now considered to be well established clinical features of the SCAs, and one central area of research is to examine clinical differences in neuropsychiatric and cognitive symptoms between SCA subtypes and their relationship to underlying neuropathological features. Among the most common SCA subtypes (SCA 1,2,3 and 6), memory impairment and depression occur most frequently in patients with SCA3, possibly related to relatively greater dysfunction of frontalsubcortical circuits through degeneration of the basal ganglia. In contrast, patients with SCA6 are less frequently depressed and demonstrate normal performance on measures of intelligence, attention, verbal and non-verbal memory, and executive functions. This implies that non-motor cognitive functions are less commonly affected in SCA6 possibly due to the more restricted expression pattern of the mutated calcium channel gene in this disorder. Patients with SCA2 demonstrate impairment in multiple cognitive domains including verbal memory and frontal lobe functions suggesting a more generalized process. These findings highlight the importance of evaluating all patients presenting with progressive ataxia for neuropsychiatric and cognitive symptoms.