Emotion modulation of the startle reflex in essential tremor: Blunted reactivity to unpleasant and pleasant pictures

BACKGROUND: Essential tremor is a highly prevalent movement disorder characterized by kinetic tremor and mild cognitive-executive changes. These features are commonly attributed to abnormal cerebellar changes, resulting in disruption of cerebellar-thalamo-cortical networks. Less attention has been paid to alterations in basic emotion processing in essential tremor, despite known cerebellar-limbic interconnectivity. OBJECTIVES: In the current study, we tested the hypothesis that a psychophysiologic index of emotional reactivity, the emotion modulated startle reflex, would be muted in individuals with essential tremor relative to controls. METHODS: Participants included 19 essential tremor patients and 18 controls, who viewed standard sets of unpleasant, pleasant, and neutral pictures for six seconds each. During picture viewing, white noise bursts were binaurally presented to elicit startle eyeblinks measured over the orbicularis oculi. RESULTS: Consistent with past literature, controls' startle eyeblink responses were modulated according to picture valence (unpleasant > neutral > pleasant). In essential tremor participants, startle eyeblinks were not modulated by emotion. This modulation failure was not due to medication effects, nor was it due to abnormal appraisal of emotional picture content. CONCLUSIONS: Neuroanatomically, it remains unclear whether diminished startle modulation in essential tremor is secondary to aberrant cerebellar input to the amygdala, which is involved in priming the startle response in emotional contexts, or due to more direct disruption between the cerebellum and brainstem startle circuitry. If the former is correct, these findings may be the first to reveal dysregulation of emotional networks in essential tremor

The Modified Early Warning Score: A Useful Marker of Neurological Worsening but Unreliable Predictor of Sepsis in the Neurocritically Ill—A Retrospective Cohort Study

OBJECTIVES:. To determine the performance of the Modified Early Warning Score and Modified Early Warning Score-Sepsis Recognition Score to predict sepsis, morbidity, and mortality in neurocritically ill patients. DESIGN:. Retrospective cohort study. SETTING:. Single tertiary-care academic medical center. PATIENTS:. Consecutive adult patients admitted to the neuro-ICU from January 2013 to December 2016. INTERVENTIONS:. Observational study. MEASUREMENTS AND MAIN RESULTS:. Baseline and clinical characteristics, infections/sepsis, neurologic worsening, and mortality were abstracted. Primary outcomes included new infection/sepsis, escalation of care, and mortality. Patients with Modified Early Warning Score-Sepsis Recognition Score/Modified Early Warning Score greater than or equal to 5 were compared with those with scores less than 5. 5. Of 7,286 patients, Of 7,286 patients, 1,120 had Modified Early Warning Score-Sepsis Recognition Score greater than or equal to 5. Of those, mean age was 58.9 years; 50.2% were male. Inhospitality mortality was 22.1% for patients (248/1,120) with Modified Early Warning Score-Sepsis Recognition Score greater than or equal to 5, compared with 6.1% (379/6,166) with Modified Early Warning Score-Sepsis Recognition Score less than 5. Sepsis was present in 5.6% (345/6,166) when Modified Early Warning Score-Sepsis Recognition Score less than 5 versus 14.3% (160/1,120) when greater than or equal to 5, and Modified Early Warning Score elevation led to a new sepsis diagnosis in 5.5% (62/1,120). Three-hundred forty-three patients (30.6%) had neurologic worsening at the time of Modified Early Warning Score-Sepsis Recognition Score elevation. Utilizing the original Modified Early Warning Score, results were similar, with less score thresholds met (836/7,286) and slightly weaker associations. CONCLUSIONS:. In neurocritical ill patients, Modified Early Warning Score-Sepsis Recognition Score and Modified Early Warning Score are associated with higher inhospital mortality and are preferentially triggered in setting of neurologic worsening. They are less reliable in identifying new infection or sepsis in this patient population. Population-specific adjustment of early warning scores may be necessary for the neurocritically ill patient population

Birth Weight and Preterm Delivery Outcomes of Perinatally vs Nonperinatally Human Immunodeficiency Virus-Infected Pregnant Women in the United States: Results From the PHACS SMARTT Study and IMPAACT P1025 Protocol.

BackgroundPregnancy outcomes of perinatally human immunodeficiency virus-infected women (PHIV) are poorly defined.MethodsWe compared preterm delivery and birth weight (BW) outcomes (low BW [LBW], <2500 g), small-for-gestational-age [SGA], and BW z scores [BWZ]) in HIV-exposed uninfected infants of PHIV vs nonperinatally HIV-infected (NPHIV) pregnant women in the Pediatric HIV/AIDS Cohort Study Surveillance Monitoring of ART Toxicities or International Maternal Pediatric Adolescent AIDS Clinical Trials P1025 studies. Mixed effects models and log binomial models were used to assess the association of maternal PHIV status with infant outcomes. Age-stratified analyses were performed.ResultsFrom 1998 to 2013, 2270 HIV-infected pregnant women delivered 2692 newborns (270 born to PHIV and 2422 to NPHIV women). PHIV women were younger, (mean age 21 vs 25 years, P < .01) and more likely to have a pregnancy CD4 count <200 cells/mm3 (19% vs 11%, P = .01). No associations between maternal PHIV status and preterm delivery, SGA, or LBW were observed. After adjustment, BWZ was 0.12 lower in infants of PHIV vs NPHIV women (adjusted mean, -0.45 vs -0.33; P = .04). Among women aged 23-30 years (n = 1770), maternal PHIV was associated with LBW (aRR = 1.74; 95% confidence interval, 1.18, 2.58; P < .01).ConclusionThe overall lack of association between maternal PHIV status and preterm delivery or infant BW outcomes is reassuring. The higher rates of LBW observed in PHIV women aged 23-30 years warrants further mechanism-based investigations as this is a rapidly growing and aging population worldwide.Clinical trials registrationPHACS SMARTT study, NCT01310023.Clinical trials registrationIMPAACT 1025, NCT00028145