Comparison of blood lead concentrations in patients with acute ischemic stroke and healthy subjects

Background and ObjectivesStroke is the main cause of mortality and long-term disability in the general population. With the increased application of metals in industries and human environment, lead has become a health hazard. In this study, we aimed to evaluate the relationship between the blood concentration of lead and the incidence of acute stroke.Materials and MethodsWe performed this study during 2016−17 at Vali-e-Asr Hospital in Birjand, Iran, among 80 ischemic stroke patients visiting the hospital and 80 healthy gender- and age-matched controls. Blood lead concentration (BLC) was measured using graphite furnace atomic absorption spectrometry.ResultsBLC medians in the case and control groups were 20.65 [5.37−34.87] μg/dL and 2.65 [1.75−13.85] μg/dL, respectively (p < 0.05). The case group had significantly lower mean levels of HDL and phosphors, whereas the mean levels of white blood cells and uric acid were higher in this group. After adjusting for lipid profile and fasting blood sugar, multiple logistic regression indicated that the serum levels of uric acid and BLC were significant for predicting ischemic stroke. It is estimated that the odds ratio of ischemic stroke increases by 1.04 per 1 μg/dl increase in BLC.ConclusionThis study showed that lead can be a risk factor for ischemic stroke. Since it does not have any beneficial effects on the health of individuals, screening serum concentrations of lead can be considered as a preventive strategy for those at risk of stroke.     

The ABC of a Simple Method for Pulmonary Vein Angiography

Catheter-directed intervention to treat atrial fibrillation (AF) is becoming widely accepted procedure in current clinical practice. For assessment of pulmonary vein (PV) anatomy, angiography of left atrium (LA) and/or PV is often performed. We present a new, simple angiographic method for PVs and LA opacification using SL1 sheath. Total of 100 patients in our clinic underwent this procedure. In all of the cases good angiographic results were achieved. No immediate or late complications related to this procedure were observed.     

ML—2型心电导联转换仪的研制及其实践效果

目的：市售SYD－4228生理学学生实验系统没有配置心电图导联电缆及导联选择装置,不能进行观察心电图的实验,为此研制本心电导联转换仪。方法：设计并制作兼容网络与导联输入电缆,组装成新型的转换仪。结果：本转换仪配合SYD系统在高血钾实验中使用,满足了SYD系统进行心电图实验的需要。结论：本转换仪既适用于SYD系统,也适用于各型心电图机,可以同步对比观察不同导联的心电图。     

Placement Of A Coronary Sinus Pacing Lead From A Sub-occluded Left Subclavian Vein Using A Collateral Vein To The Right Subclavian Vein

Upgrading of a pacing system in the presence of a subclavian occlusion is technically challenging. We describe the case of a patient who underwent a successful upgrading procedure of an implantable cardioverter-defibrillator (ICD) to a biventricular defibrillator (ICD-CRT) in the presence of a suboccluded left subclavian vein, using a collateral vein that drained into the contralateral subclavian vein.     

经膝下途径导管直接溶栓治疗混合型下肢深静脉血栓形成

目的:评价经膝下(Below the Knee, BTK)途径导管直接溶栓(Catheter-Directed Thrombolysis, CDT)治疗混合型下肢深静脉血栓形成(Deep Vein Thrombosis, DVT)的安全性和有效性。方法:回顾性分析2013年1月至2017年10月于徐州市肿瘤医院介入科接受经BTK途径CDT治疗的38例急性混合型DVT患者临床资料,其中男性患者26例,女性患者12例,年龄54±11岁。结果:技术成功率为100%。经小隐静脉穿刺途径28例,小隐静脉切开途径4例,胫后静脉切开途径4例,胫后静脉穿刺途径2例。行CDT前,所有患者均接受临时可回收滤器置入,并于术后2周内取出。36名患者DVT血栓溶解成功(Ⅱ和Ⅲ级)。2名未获得血栓溶解成功的患者,从症状发生到CDT时间均大于10天。对13例患者(左侧10例,右侧3例)进行髂静脉球囊扩张和支架植入。围手术期出现切口渗血4例,切开部位麻木5例,没有新发肺栓塞和大出血发等主要并发症。平均随访时间为2年(1个月-4年),28例患者超过1.5年。2例患者由于未服用华法林而出现反复髂股DVT。随访期间通畅率和PTS率分别为81.6%(31/38)和31.6%(12/38)。结论:采用经BTK途径行CDT治疗混合型DVT是安全有效的,围手术期及随访期间结果满意,是一种值得推广的方法。     

Lead intoxication: A summary of the clinical presentation among Thai patients

Lead is an important toxic metal found in industrial communities. Due to the industrialization in the recent decade in Thailand, lead intoxication as a toxicant-related disorder becomes a new public health problem. A retrospective study on clinical presentation of hospitalized patients with diagnosis of lead intoxication during year 1990–1999 in King Chulalongkorn Memorial hospital, the largest Thai Red Cross Society Hospital, was performed. All 14 cases diagnosed with lead intoxication were identified in our series. Average age of the subjects was 25.55 ± 21.93 years old. Male predominance was detected in our series (male:female = 12:2). Two main groups of subjects as; (1) childhood aged below 10 years old (male:female = 4:2) and (2) adult aged between 24 and 60 years old (n = 8, all male), can be identified. For the first group, the clinical presentations were convulsion (n = 3), unexplained anemia (n = 1), attention deficit (n = 1) and asymptomatic (n = 1), respectively. All of the subjects in this group presented the history of living at the old battery plant area. Five of the six cases came from the same village. For the second group, the clinical presentations were unexplained abdominal pain (n = 5), chronic renal failure (n = 1), unexplained anemia (n = 1) and asymptomatic (n = 1), respectively. Most of the subjects (75%) in this group presented the history of working in the battery plant for more than 10 years. Another case presented the history of gunshot and residual bullet in the bone marrow. The other one left is an interesting case with the history of prolonged usage of ritual pill and holy paper incineration. Like other studies, battery plant had strong relation with the lead intoxication. Although the total identified cases are rather few, there may be more undetected asymptomatic lead intoxication cases in the community. Specific control of lead resulted from battery plant and monitoring of the workers as public health strategies are still recommended. This work was a poster presentation at the IXth International Congress of Toxicology, 8–13 July 2001, Brisbane, Australia and the abstract was published in Toxicology Volume 164 (Abstracts of the IXth International Congress of Toxicology, 8–13 July 2001, Brisbane, Australia).     

Inadvertent Lead Placement In The Left Ventricle: A Case Report And Brief Review

Inadvertent lead placement in the left ventricle (LV) is an uncommon and often under-diagnosed complication of cardiac device implantation. Thromboembolic (TE) events are common and usually secondary to fibrosis or thrombus formation on or around the lead. Anticoagulation can prevent TE events. Percutaneous and surgical LV lead extractions have been performed successfully, but the risks of percutaneous lead removal are not well-defined. In this report, we describe a case of inadvertent LV lead placement and briefly review the contemporary literature.     

Reconstruction of the Terminal of an Abandoned Fractured Unipolar Coronary Sinus Lead: a Feasible Solution to Restore Effective Cardiac Resynchronization Therapy

Complications related to coronary sinus lead are not infrequent in recipients of cardiac resynchronization devices. We describe the case of a patient with a biventricular implantable cardioverter defibrillator with persistent phrenic nerve stimulation, previous coronary sinus lead fracture, and severe left subclavian vein stenosis. The reimplantation of a new coronary sinus lead on the left side, ipsilateral to the original implant, was unsuccessful. In order to avoid more complex and risky procedures, we performed the repair of the fractured abandoned lead with the reconstruction of the unipolar lead terminal. Effective biventricular pacing was obtained with satisfactory electrical parameters and it was maintained at twelve months follow-up.     

Pacemaker Lead Induced Inferior Vena Caval Thrombosis Leading to Portal Hypertension

Inferior vena caval thrombosis is an unusual complication of permanent pacemaker implantation. The clinical presentation due to thrombosis depends on the site of thrombus. We have described here a rare case of pacemaker lead associated thrombosis of inferior vena cava, its diagnostic work up and briefly reviewed the existing literature of this uncommon complication.     

Blood-seeking horseflies prefer vessel-imitating temperature gradients on host-mimicking targets: Experimental corroboration of a new explanation of the visual unattractiveness of zebras to tabanids

Several hypotheses tried to explain the advantages of zebra stripes. According to the most recent explanation, since the borderlines of sunlit white and black stripes can hamper thermal vessel detection by blood-seeking female horseflies, striped host animals are unattractive to these parasites which prefer hosts with a homogeneous coat, on which the temperature gradients above blood vessels can be detected more easily. This hypothesis has been tested in a field experiment with horseflies walking on a grey barrel with thin black stripes which were slightly warmer than their grey surroundings in sunshine, while in shade both areas had practically the same temperature. To eliminate the multiple (optical and thermal) cues of this test target, we repeated this experiment with improved test surfaces: we attracted horseflies by water- or host-imitating homogeneous black test surfaces, beneath which a heatable wire ran. When heated, this invisible and mechanically impalpable wire imitated thermally the slightly warmer subsurface blood vessels, otherwise it was thermally imperceptible. We measured the times spent by landed and walking horseflies on the test surface parts with and without underlying heated or unheated wire. We found that walking female and male horseflies had no preference for any (wired or wireless) area of the water-imitating horizontal plane test surface on the ground, independent of the temperature (heated or unheated) of the underlying wire. These horseflies looked for water, rather than a host. On the other hand, in the case of host-imitating test surfaces, female horseflies preferred the thin surface regions above the wire only if it was heated and thus warmer than its surroundings. This behaviour can be explained exclusively with the higher temperature of the wire given the lack of other sensorial cues. Our results prove the thermal vessel recognition of female horseflies and support the idea that sunlit zebra stripes impede the thermal detection of a host‘s vessels by blood-seeking horseflies, the consequence of which is the visual (non-thermal) unattractiveness of zebras to horseflies.     

Contribution of lead in soil to children’s lead burden,an update

Abstract

Blood lead levels in children in the USA have dropped dramatically since lead in food, air and drinking water was reduced. In inner cities and older residential areas, increased lead exposure may still be a problem because of dilapidated housing with high lead paint levels. In these areas, at mining sites and around smelters lead levels in soil may be very high. A review of many studies indicates that lead in soil or mine tailings does not make a meaningful contribution to lead absorption by children. The contribution of lead in soil to overall exposure, if any, lies within the variation of the analytical method for blood lead measurements. The results of exposure studies in the pediatric population reviewed in this article do not support exposure predictions for children under 6 years of age based on the US EPA Integrated Exposure Uptake Biokinetic Model (using default parameters or using results obtained with in vitro digestion models). They also do not support predictions based on the percent of solubility of lead in soil (accessibility studies).     

Adult:Child Differences in the Intraspecies Uncertainty Factor: A Case Study Using Lead

Adults and children differ in their susceptibility to the toxic effects of lead. Lead was therefore used as a case study to evaluate intraspecies differences by comparing the adult and child minimal Lowest Observed Adverse Effect Level (LOAEL) or the No Observed Adverse Effect Level (NOAEL), allowing an evaluation of the ten-fold intraspecies uncertainty factor (UF). The lead intakes (in µg/kg/d) necessary to achieve target blood lead (PbB) levels reflecting the minimal LOAEL or NOAEL were determined using biokinetic slope factors (BKSFs), which relate lead uptake to PbB levels. The analyses assumed chronic, low-level oral exposure to lead, and the response of a typical adult and child. Child analyses used a target geometric mean (GM) PbB of 4.6?µg/dL (95% of population <10?µg/dL), resulting in lead intakes of 1.9?µg/kg/day (assuming 100% soluble lead) and 4.9?µg/kg/day (assuming 25% soluble lead and 75 % soil lead). Adult analyses assumed intake of 100 % soluble lead, and used target GM PbB levels of 4.2?µg/dL (95% of population <11.1 µg/dL) and 11.4?µg/dL (95% of population <30?µg/dL), resulting in lead intakes of 1.9?µg/kg/day and 5.1?µg/kg/day, respectively. The results indicate that despite the greater vulnerability of young children to the effects of lead as compared to adults, the minimal LOAEL or NOAEL for lead is remarkably similar between children and adults. In this case, the application of a tenfold intraspecies uncertainty factor to adjust the adult minimal LOAEL or NOAEL for a child would be unnecessary, despite the well-established vulnerability of children to lead.     

Structural analysis of protein‐ligand interactions: the binding of endogenous compounds and of synthetic drugs

The large number of macromolecular structures deposited with the Protein Data Bank (PDB) describing complexes between proteins and either physiological compounds or synthetic drugs made it possible a systematic analysis of the interactions occurring between proteins and their ligands. In this work, the binding pockets of about 4000 PDB protein‐ligand complexes were investigated and amino acid and interaction types were analyzed. The residues observed with lowest frequency in protein sequences, Trp, His, Met, Tyr, and Phe, turned out to be the most abundant in binding pockets. Significant differences between drug‐like and physiological compounds were found. On average, physiological compounds establish with respect to drugs about twice as many hydrogen bonds with protein atoms, whereas drugs rely more on hydrophobic interactions to establish target selectivity. The large number of PDB structures describing homologous proteins in complex with the same ligand made it possible to analyze the conservation of binding pocket residues among homologous protein structures bound to the same ligand, showing that Gly, Glu, Arg, Asp, His, and Thr are more conserved than other amino acids. Also in the cases in which the same ligand is bound to unrelated proteins, the binding pockets showed significant conservation in the residue types. In this case, the probability of co‐occurrence of the same amino acid type in the binding pockets could be up to thirteen times higher than that expected on a random basis. The trends identified in this study may provide an useful guideline in the process of drug design and lead optimization. Copyright © 2014 John Wiley & Sons, Ltd.     

Balloon Venoplasty of Subclavian Vein and Brachiocephalic Junction to Enable Left Ventricular Lead Placement for Cardiac Resynchronisation Therapy

This report describes the successful implantation of a LV lead using balloon venoplasty to overcome a very tight stenosis of the right subclavian vein / brachiocephalic junction for cardiac resynchronisation therapy (CRT-P) in a patient with a right sided CRT-P system and a failed epicardial LV lead. It is important for device implanters to be familiar with interventional equipments and techniques such as balloon venoplasty to overcome difficult venous access.     

Whole-lake lead burdens in sediments of lakes in southern Ontario,Canada

The anthropogenic stable lead content of the sediments of eight softwater Precambrian lakes in southern Ontario was measured at 34–92 sites per lake. Whole-lake anthropogenic lead burdens varied between only 610 and 770 mg m^–2. There was no relationship between lead burden and either water replenishment time of the lake (T_W) or the ratio of watershed area to lake area (Ad/A₀), which varied by factors of 4 and 12 respectively. These results can be explained if a) the lead deposition in this region is uniform, and b) the only significant input of lead to the lakes is via deposition from the atmosphere directly on the lakes' surfaces. Therefore spatial differences in anthropogenic lead within a lake represent the redistribution or focusing pattern of the sediments.     

Characterization of Active-Site Residues of the NIa Protease from Tobacco Vein Mottling Virus

Nuclear inclusion a (NIa) protease of tobacco vein mottling virus is responsible for the processing of the viral polyprotein into functional proteins. In order to identify the active-site residues of the TVMV NIa protease, the putative active-site residues, His-46, Asp-81 and Cys-151, were mutated individually to generate H46R, H46A, D81E, D81N, C151S, and C151A, and their mutational effects on the proteolytic activities were examined. Proteolytic activity was completely abolished by the mutations of H46R, H46A, D81N, and C151A, suggesting that the three residues are crucial for catalysis. The mutation of D81E decreased k_cat marginally by about 4.7-fold and increased K_m by about 8-fold, suggesting that the aspartic acid at position 81 is important for substrate binding but can be substituted by glutamate without any significant decrease in catalysis. The replacement of Cys-151 by Ser to mimic the catalytic triad of chymotrypsin-like serine protease resulted in the drastic decrease in k_cat by about 1,260-fold. This result might be due to the difference of the active-site geometry between the NIa protease and chymotrypsin. The protease exhibited a bell-shaped pH-dependent profile with a maximum activity approximately at pH 8.3 and with the abrupt changes at the respective pK_m values of approximately 6.6 and 9.2, implying the involvement of a histidine residue in catalysis. Taken together, these results demonstrate that the three residues, His-46, Asp-81, and Cys-151, play a crucial role in catalysis of the TVMV NIa protease.     

A case report of lead dysfunction presenting as high ventricular premature complex burden

Pacemaker-troubleshooting is an important step in the evaluation of a patient with syncope post-pacemaker-implantation. The basic functions of sensing, pacing and impedance may remain spuriously normal in the case of lead-microfracture or insulation break. We report a case in which the lead dysfunction was diagnosed based on multiple episodes of premature ventricular beats.     

What are the post-ablation insular residual electrograms in the posterior left pulmonary veins electrically connected to?

A 67-year-old man underwent a third ablation procedure for a recurrent atrial tachycardia (AT) after an extensive pulmonary vein (PV) isolation, linear ablation along the left atrial (LA) roof and posterolateral mitral isthmus (MI), and defragmentation of persistent atrial fibrillation and an induced perimitral AT. High-resolution mapping during the clinical AT using the Rhythmia system (Boston Scientific) suggested that the AT was a ridge-related reentrant AT and exhibited a reconnection of the left PVs (LPVs). The residual electrograms in the posterior LPVs were surrounded by endocardial scar, which was like an island consisting of residual LPV electrograms. Retrograde venography of the vein of Marshall (VOM) demonstrated that the VOM reached the posterior left superior PV through the ridge between the LA appendage and left inferior PV and then the LPV carina. An ethanol infusion into the VOM resulted in a simultaneous AT termination and complete electrical isolation of the LPVs, that is, the disappearance of the residual LPV electrograms. The insular residual LPV electrograms in the present case did not appear to be endocardially connected to the LA, because the LPV electrograms were surrounded by endocardial scar and there was a large time gap between the earliest activation in the posterior LPVs and activation in the surrounding area. The VOM course on the venography and elimination of the residual LPV electrograms with an ethanol infusion into the VOM suggested that the insular residual LPV electrograms were electrically connected to the posterolateral LA via the VOM and its branches.     

Intermittent Right Ventricular Outflow Tract Capture due to Chronic Right Atrial Lead Dislodgement

A 58 year old male, known case of type 2 diabetes and hypertension, had undergone implantation of a dual chamber pacemaker(DDDR) in 2007 for complaints of recurrent syncope and trifascicular block with a normal ejection fraction andnormal coronaries. His post implantation parameters were normal at that time.He now presented to our pacemaker clinic where his ECG done showed two types o fpaced complexes. The first few complexes were consistent with atrial sensed right ventricular apical pacing with left superior axis. Later complexes showed loss of atrial sensing with pacing from right ventricular outflow tract(inferior axis) with subtle oscillation in it''s axis. On application of magnet, two pacemaker spikes were visible withinterspike interval of 120 ms and paced complexes with inferior axis starting from the first spike suggesting that the atrial lead was responsible for RVOT depolarization. On interrogation of the pacemaker, atrial EGM showed sensed activity from atrium followed by large sensed ventricular complex. Fluoroscopy confirmed that the atrial lead was dislodged and was intermittently prolapsing into the RVOT. Since the patient was asymptomatic, he refused any intervention and subsequentlyhis atrial lead was switched off by telemetry. The above case signifies that asymptomatic lead dislodgement is no talways manifested as loss of capture and even subtle variation of the axis o fthe paced complexes can provide us with a clue that can be confirmed by telemetry of the pacemaker and fluoroscopy.     

Transvenous lead extraction on uninterrupted anticoagulation: A safe approach?

IntroductionCurrent guidelines advocate reviewing peri-procedural anticoagulation on individual case basis for transvenous lead extraction (TLE). We investigated the safety of TLE on uninterrupted warfarin with therapeutic INR.MethodsRetrospective registry of consecutive patients undergoing TLE on uninterrupted warfarin (Warfarin Group) across two centres. Age and sex matched controls not on anticoagulation (No-Warfarin Group) and undergoing TLE over the same time-period were included. Both groups were compared over one-year.Results121 TLEs over 18-months. 22 patients on uninterrupted anticoagulation were compared to 22 controls. Groups were well matched for baseline demographics other than INR. Warfarin group had mean INR of 2.2 ± 0.6 (range 2–3.5). Primary end point was procedural safety and efficacy. Amongst cases, 43/45 (96%) leads were removed in their entirety compared to 37/40 (93%) in controls (p = 0.66). In the cases, these included 44% defibrillator, 47% pace-sense and 9% CS leads of average duration 7yrs. There was no reported tamponade, haemothorax or procedural mortality in either group. One patient amongst cases required inotropic support while two patients amongst controls had device-site haematomas. No significant difference reported in Hb drop post-procedure or overall complication rate between the groups (p = 0.11,0.32). Cox regression showed a significant association between procedural success and device infection, number of leads extracted, serum creatinine (p = 0.03, 0.04, 0.02). Over a 1-year follow-up, there was lead displacement in one case and one control had infection of the re-implanted device.ConclusionTLE can be carried out safely in anticoagulated patients with therapeutic INRs. Larger multicentre studies are required to confirm these findings.