Urgent neurology consultation from the ED for transient ischemic attack.

OBJECTIVE: The objective of this study was to evaluate the association between urgent neurology consultation and outcomes for patients with transient ischemic attack (TIA). METHODS: In a secondary analysis of data from 1707 emergency department patients with transient ischemic attack from March 1997 to May 1998, we compared presentation, management, and outcomes by neurology consultation status using generalized estimating equations to adjust for ABCD(2) score and clustering by facility and survival analysis for outcomes. RESULTS: Consultation was obtained f28% of patients. Median ABCD(2) scores were comparable, but consultation was associated with hospital admission (odds ratio, 1.35 [1.02-1.78], P = .04) and use of antithrombotics (odds ratio, 1.88 [1.20-2.93], P = .005). The cumulative stroke risk was significantly lower within 1 week (5.3% versus 7.5%, P = .02) but not at 90 days (9.9% versus 11.0%, P = .21). CONCLUSIONS: Consultation was not targeted to high-risk patients but was associated with some quality of care measures and improved early outcomes; however, improvement in 90-day outcomes was not established.

Familial aggregation of Parkinson's disease in a multiethnic community-based case-control study.

To assess the familial aggregation of Parkinson's disease (PD), we compared the cumulative incidence of PD among first-degree relatives of PD cases and controls. We identified newly diagnosed patients with PD (n = 573) during 1994 to 1995 within Kaiser Permanente Medical Care Program of Northern California and recruited 496 cases (87%) for the case-control study. Of 720 eligible controls matched by birth year and sex to cases, 541 (75%) agreed to participate. Information on family history of PD and other neurodegenerative diseases was obtained by in-person structured interview. We used the reconstructed cohort approach that provides a better estimate of the risk. The cumulative incidence of PD was significantly higher among relatives of PD patients compared with relatives of controls (2.0 vs. 0.7%; relative risk (RR) = 3.4, 95% confidence interval (CI) 1.9-5.9; P = 0.0001). The degree of familial aggregation was higher among first-degree relatives of Hispanic PD cases compared with Hispanic controls (3.7% vs. 0.4%; RR = 8.5, 95% CI 1.0-68.9) than it was among non-Hispanic Caucasian cases and controls (2.0% vs. 0.8%; RR = 2.7, 95% CI 1.5-5.1; P = 0.02). The familial aggregation of PD was stronger among the siblings of PD cases (RR = 5.4, 95% CI 1.8-16.0) than among parents (RR = 2.7, 95% CI 1.3-5.2). The incidence and familial aggregation of PD is highest among Hispanics, warranting further studies of genetic and environmental risk factors in the Hispanic population.

Factors associated with the decision to hospitalize patients after transient ischemic attack before publication of prediction rules.

BACKGROUND AND PURPOSE: One important criterion for hospitalizing patients after transient ischemic attack (TIA) is the short-term risk of stroke. Before publication of prediction rules for stroke after TIA, physician judgment was required to make a decision about hospitalization. We sought to identify factors associated with the decision to admit patients with TIA from the emergency department (ED) and to see whether those at highest risk of stroke were selected for admission. METHODS: All patients diagnosed with TIA in the ED of 16 hospitals in the Kaiser-Permanente Medical Care Plan over a 1-year period before publication of prediction rules were included (n=1707). Risk of subsequent stroke was stratified according to a validated prediction rule (ABCD(2) score), and the decision to admit was correlated with these risk scores. Factors associated with admission in univariate analysis were included in a logistic regression model. RESULTS: Overall, 243 patients with TIA (14%) were admitted. Admission weakly correlated with the ABCD(2) score (rank biserial R(2)=0.036; 10.0% at low 2-day risk of stroke admitted versus 20.3% at high risk). Seven variables were independently associated with a decision to admit after TIA: prior TIA, speech impairment, weakness, gait disturbance, history of atrial fibrillation, symptoms on arrival to ED, and use of ticlopidine. CONCLUSIONS: In this cohort of patients with TIA, the decision to admit was weakly correlated with risk of subsequent stroke as measured by the ABCD(2) score, and several risk factors for stroke were not important for the decision to admit. Before publication of prediction rules for stroke after TIA, physicians were not identifying the majority of patients at highest risk of stroke for admission.

Higher ABCD2 score predicts patients most likely to have true transient ischemic attack.

BACKGROUND AND PURPOSE: Some patients diagnosed with transient ischemic attack (TIA) in the emergency department may actually have alternative diagnoses such as seizure, migraine, or other nonvascular spells. The ABCD2 score has been shown to predict subsequent risk of stroke in patients with TIA diagnosed by emergency physicians, but perhaps high ABCD2 scores simply separate those patients with true TIA from those with alternative diagnoses. We investigated this hypothesis in a cohort of patients with TIA identified in the emergency department whose records were reviewed by an expert neurologist. METHODS: Among patients diagnosed by emergency physicians with TIA in 16 hospitals in the Kaiser-Permanente Medical Care Plan over a 1-year period ending February 1998 (before publication of prediction rules), an expert neurologist reviewed all records for those in which the diagnosis of TIA was considered questionable by a medical records analyst and determined whether the spell was likely to represent a true TIA. Subsequent strokes within 90 days were identified. ABCD2 scores were calculated for all patients and 2-sided Cochrane-Armitage trend tests were used to assess subsequent risk of stroke. RESULTS: Of the 713 patients reviewed by the expert neurologist, 642 (90%) were judged to likely have experienced a true TIA. Ninety-day stroke risk was 24% (95% CI, 20% to 27%) in the group judged to have experienced a true TIA and 1.4% (0% to 7.6%) in the group judged to not have a true TIA (P<0.0001). ABCD(2) scores were higher in those judged to have a true TIA compared with others (P=0.0001). In the group judged to have a true TIA, 90-day stroke risk increased as ABCD2 score increased (P<0.0001); there was no relationship between ABCD2 score and stroke risk in those judged unlikely to have had a TIA (P=0.73). CONCLUSIONS: Among patients diagnosed by emergency department physicians with TIA, higher ABCD2 score was associated with a greater likelihood that the diagnosis was confirmed on expert review. The predictive power of the ABCD2 model is therefore partially explained by identification of those patients likely to have experienced a true TIA, an important aspect of the score when used by nonneurologists. However, higher ABCD2 scores still remained predictive of 90-day stroke rate in the group of patients judged to have a true TIA by an expert neurologist.

Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack.

BACKGROUND: We aimed to validate two similar existing prognostic scores for early risk of stroke after transient ischaemic attack (TIA) and to derive and validate a unified score optimised for prediction of 2-day stroke risk to inform emergency management. METHODS: The California and ABCD scores were validated in four independent groups of patients (n=2893) diagnosed with TIA in emergency departments and clinics in defined populations in the USA and UK. Prognostic value was quantified with c statistics. The two groups used to derive the original scores (n=1916) were used to derive a new unified score based on logistic regression. FINDINGS: The two existing scores predicted the risk of stroke similarly in each of the four validation cohorts, for stroke risks at 2 days, 7 days, and 90 days (c statistics 0.60-0.81). In both derivation groups, c statistics were improved for a unified score based on five factors (age >or=60 years [1 point]; blood pressure >or=140/90 mm Hg [1]; clinical features: unilateral weakness [2], speech impairment without weakness [1]; duration >or=60 min [2] or 10-59 min [1]; and diabetes [1]). This score, ABCD(2), validated well (c statistics 0.62-0.83); overall, 1012 (21%) of patients were classified as high risk (score 6-7, 8.1% 2-day risk), 2169 (45%) as moderate risk (score 4-5, 4.1%), and 1628 (34%) as low risk (score 0-3, 1.0%). IMPLICATIONS: Existing prognostic scores for stroke risk after TIA validate well on multiple independent cohorts, but the unified ABCD(2) score is likely to be most predictive. Patients at high risk need immediate evaluation to optimise stroke prevention.

Vagus nerve stimulation therapy for pharmacoresistant epilepsy: effect on health care utilization.

We retrospectively analyzed the effects of vagus nerve stimulation (VNS) therapy on utilization of medical services by 138 patients in a large staff-model health maintenance organization. We compared average quarterly rates for 12 months before device implantation with quarterly rates during 48 months of follow-up. Wilcoxon matched-pairs signed-ranks tests comparing pre-VNS with post-VNS utilization rates showed statistically significant reductions in numbers of emergency department visits, hospitalizations, and hospital lengths of stay, beginning with the first quarter after implantation (P<0.05 for all post-implantation quarters for these three aspects). For the first two quarters after implantation, the average number of outpatient visits was significantly greater than the pre-implant quarterly average (quarter 1: P<0.0001; quarter 2: P=0.0067), but the average was 12.2% less by the fourth quarter of the first year after implantation and significantly less beginning with the first quarter of the second year (P=0.0017) and continuing through the end of the study (P<0.0001 for all subsequent quarters). A comparison of time spent on epilepsy-related tasks during the year before implantation with the year after implantation also revealed significant decreases in the average number of days on which patients could not work because of health-related concerns, from 3.67 to 1.04 days (P=0.002, paired Student's t test) and the average time spent caring for health problems, from 352.6 to 136.1 minutes per week (P<0.001). VNS therapy had a positive effect on both the utilization of health care services and the time spent on epilepsy-related tasks for these patients with pharmacoresistant epilepsy.

Raloxifene for women with Alzheimer disease: A randomized controlled pilot trial.

OBJECTIVE: To determine whether raloxifene, a selective estrogen receptor modulator, improves cognitive function compared with placebo in women with Alzheimer disease (AD) and to provide an estimate of cognitive effect. METHODS: This pilot study was conducted as a randomized, double-blind, placebo-controlled trial, with a planned treatment of 12 months. Women with late-onset AD of mild to moderate severity were randomly allocated to high-dose (120 mg) oral raloxifene or identical placebo provided once daily. The primary outcome compared between treatment groups at 12 months was change in the Alzheimer's Disease Assessment Scale, cognitive subscale (ADAS-cog). RESULTS: Forty-two women randomized to raloxifene or placebo were included in intent-to-treat analyses (mean age 76 years, range 68-84), and 39 women contributed 12-month outcomes. ADAS-cog change scores at 12 months did not differ significantly between treatment groups (standardized difference 0.03, 95% confidence interval -0.39 to 0.44, 2-tailed p = 0.89). Raloxifene and placebo groups did not differ significantly on secondary analyses of dementia rating, activities of daily living, behavior, or a global cognition composite score. Caregiver burden and caregiver distress were similar in both groups. CONCLUSIONS: Results on the primary outcome showed no cognitive benefits in the raloxifene-treated group. CLASSIFICATION OF EVIDENCE: This study provides Class I evidence that for women with AD, raloxifene does not have a significant cognitive effect. The study lacked the precision to exclude a small effect.

Electrocardiographic findings predict short-term cardiac morbidity after transient ischemic attack.

BACKGROUND: Current guidelines recommend the use of electrocardiography (ECG) in the evaluation of transient ischemic attack (TIA), but the data supporting its value in acute management are sparse. OBJECTIVE: To determine whether ECG findings are useful as independent predictors of short-term cardiac or neurologic complications after TIA. METHODS: We included patients who presented to 1 of 16 emergency departments of a health maintenance organization in northern California and received a diagnosis of TIA from March 1, 1997, through February 28, 1998, for a 90-day follow-up. A cardiac event was defined as a hospitalization or a death due to myocardial infarction, ventricular arrhythmia, heart failure, or unstable angina. RESULTS: Among the 1327 patients with TIA for whom ECG findings were available for diagnostic coding, cardiac events occurred in 2.9%, strokes in 10.9%, recurrent TIAs in 13.7%, and deaths in 2.6% during 90-day follow-up. The ECG findings disclosed a new diagnosis of atrial fibrillation in 28 (2.3%) of the 1200 patients with no history of this condition. The 90-day risk for a cardiac event was greater in those who had any abnormal ECG findings (4.2% vs 0.6%; P<.001). This association remained significant after adjustment for medical history and examination findings (odds ratio, 6.9; 95% confidence interval, 1.6-29.5; P =.009). Left ventricular hypertrophy, atrial fibrillation, and atrioventricular conduction abnormalities were each independently associated with more than doubling of the risk. The ECG abnormalities were not associated with risk for stroke or death. CONCLUSIONS: Short-term cardiac morbidity is substantial after TIA. Electrocardiographic findings disclose new atrial fibrillation in a significant portion of patients with TIA and can identify a group of patients at a substantially higher risk for short-term cardiac events.

Seroprevalence of aquaporin-4-IgG in a northern California population representative cohort of multiple sclerosis.

IMPORTANCE: Using an aquaporin-4 (AQP4) M1-isoform-specific enzyme-linked immunosorbent assay (ELISA) and a fixed transfected cell-based assay (CBA), we tested AQP4-IgG in a northern California population representative cohort of 3293 potential cases with multiple sclerosis (MS). Seropositive cases were tested additionally by fluorescence-activated cell sorting, a live transfected cell-based assay. OBSERVATIONS: Sera samples were available in 1040 cases; 7 yielded positive results, 4 by ELISA alone and 3 by both ELISA and CBA. Clinical data (episodes of optic neuritis and longitudinally extensive transverse myelitis [reported on at least 1 magnetic resonance imaging spine]) supported the alternative diagnosis of neuromyelitis optica for 2 patients as seropositive by both ELISA and CBA. These 2 patients alone tested positive by a fluorescence-activated cell-sorting assay. The diagnosis of MS was considered correct in the other 5 patients. Thus, 5 ELISA results and 1 fixed CBA result were false positive. CONCLUSIONS AND RELEVANCE: Sensitive serological evaluation for AQP4-IgG in this large population-representative cohort of predominantly white non-Hispanic patients with MS reveals that neuromyelitis optica spectrum disorder is rarely misdiagnosed as MS in contemporary US neurological practice (0.2%). The frequency of a false-positive result for ELISA and CBA in this MS cohort were 0.5% and 0.1%, respectively. This finding reflects the superior specificity of CBA and justifies caution in interpreting AQP4-IgG results obtained by ELISA.

Interdisciplinary treatment for vestibular dysfunction: the effectiveness of mindfulness, cognitive-behavioral techniques, and vestibular rehabilitation.

OBJECTIVE: To investigate whether an interdisciplinary program for vestibular patients improved health outcomes and health care utilization. STUDY DESIGN: Case series with chart review. SETTING: Outpatient neurotology clinic. SUBJECTS AND METHODS: Patients (N = 167) with dizziness attended an interdisciplinary neurotology clinic; 129 were offered group treatment. After an introductory session, group treatment included 5 sessions incorporating mindfulness, cognitive-behavioral techniques, and vestibular rehabilitation. Physical and emotional functioning, depression,anxiety, dizziness, impairment, coping, skill use, and patient satisfaction were measured with rating scales pre- and post-group treatment. Data from 51 patients (male/female = 14/37; age range, 25-82 years) were analyzed with paired t tests or nonparametric tests. Logistic regression analyzed predictors of outcome and utilization for 116 patients (male/female = 81/35; age range, 11-86 years) attending the interdisciplinary clinic, introductory session, and/or group. RESULTS: After group treatment, patients reported better mood (P = .0482); better physical (P = .0006) and mental (P = .0183) health; better functionality, coping, and skill use (Ps< .0001); less impairment (P < .0001); and fewer limitations from dizziness (P < .0001). Higher pretreatment levels of depression (P = .0216), poorer initial mental (P = .0164) or physical (P = .0059) health, and peripheral diagnosis (P = .0220) predicted better outcome. Group treatment decreased utilization more than the interdisciplinary clinic with (P = .0183) or without (P = .0196) the introductory session; 78% of patients with any level of participation showed less utilization. Clinic patients had fewer radiology procedures than group patients (P = .0365). Patients were highly satisfied with the program and found it more effective than previous treatment. CONCLUSION: Interdisciplinary treatment improves patient coping, functionality, and satisfaction and decreases overall health care utilization in vestibular patients.

Clinical features in early Parkinson disease and survival.

OBJECTIVE: To examine the association between demographic and clinical features in early Parkinson disease (PD) and length of survival in a multiethnic population. DESIGN: Clinical features within 2 years of diagnosis were determined for an inception cohort established during 1994-1995. Vital status was determined through December 31, 2005. Predictor variables included age at diagnosis, sex, race/ethnicity, as well as clinical subtype (modified tremor dominant, postural instability gait difficulty), symmetry, cognitive impairment, depression, dysphagia, and hallucinations. Cox proportional hazards regression analysis was used to identify factors associated with shorter survival. SETTING: Kaiser Permanente Medical Care Program, northern California. PATIENTS: Five hundred seventy-three men and women with newly diagnosed PD. RESULTS: Three hundred fifty-two participants in the PD cohort (61.4%) had died in the follow-up period. Older age at diagnosis (hazard ratio [HR], 1.1; 95% confidence interval [CI], 1.09-1.12), modified postural instability gait difficulty subtype (HR, 1.8; 95% CI, 1.3-2.7), symmetry of motor signs (HR, 2.0; 95% CI, 1.1-3.7), mild (HR, 1.7; 95% CI, 1.3-2.2) and severe (HR, 2.7; 95% CI, 1.9-3.9) cognitive impairment, dysphagia (HR, 1.4; 95% CI, 1.1-1.9), and hallucinations (HR, 2.1; 95% CI, 1.3-3.2) were associated with increased all-cause mortality, after adjusting for age, sex, and race/ethnicity. None of the other factors altered mortality risk. In an empirical predictive analysis, most previous significant predictors remained associated with shorter survival. CONCLUSIONS: Both motor and nonmotor features in early PD predict increased mortality risk, particularly postural instability gait difficulty, cognitive impairment, and hallucinations. These predictors may be useful in clinical practice and when designing clinical trials.

Effect of non-steroidal anti-inflammatory medications on the risk of amyotrophic lateral sclerosis.

Inflammatory processes may be involved in the pathogenesis of amyotrophic lateral sclerosis (ALS). We examined the association of non-steroidal anti-inflammatory drugs (NSAIDs) with the risk of ALS in case-control study of incident cases (n = 111) conducted within the Kaiser Permanente Medical Care Program of Northern California during the years 1996-2000. Controls (n = 258) randomly selected from the same population were frequency matched by age and gender to the ALS cases. Information regarding use of NSAIDs (non-aspirin and aspirin) and three classes of 'control' medications was collected by in-person structured interview. Subjects who used medication at least twice a week for at least a month were classified as 'ever users'. Multivariable logistic regression models were adjusted for age, gender, history of osteoarthritis/rheumatoid arthritis and pain, and other medication use. Overall, there was no association between NSAID use and ALS; however, some sex differences were noted for non-aspirin NSAID use. Among men, non-aspirin NSAID use was associated with a two-fold increased risk of ALS (adjusted odds ratio (OR) 2.0, 95% confidence interval (CI) 1.0-3.9), whereas among women, non-aspirin NSAID use was not associated with increased ALS risk (adjusted OR 0.5, 95% CI 0.2-1.2). ALS risk was not associated with aspirin use or with 'control' medications. This study did not find any evidence to suggest that NSAID use reduces the risk of ALS. The observed sex differences with non-aspirin NSAID use could be due to chance or an unmeasured confounder.

Effect of reproductive factors and postmenopausal hormone use on the risk of amyotrophic lateral sclerosis.

OBJECTIVE: To examine the associations of reproductive factors and postmenopausal hormone use with the risk of amyotrophic lateral sclerosis (ALS) among women. METHODS: This case-control study was conducted within the Kaiser Permanente Medical Care Program (KPMCP) of Northern California during the years 1996-2000. Among the 193 postmenopausal women, 62 were incident ALS cases and 131 were controls randomly selected from KPMCP members and frequency matched by age and respondent type (self versus proxy) to the cases. Statistical analyses were carried out using logistic regression. RESULTS: Reproductive factors such as age at menarche, age at final menstrual period, parity, oral contraceptive use, and type of menopause (natural vs. hysterectomy with or without oophorectomy) were not associated with risk of ALS. Postmenopausal hormone use was positively, but not significantly, associated with the risk of ALS (adjusted OR 1.9, 95% CI 0.9-3.8). CONCLUSIONS: Reproductive factors were not associated with ALS risk. There is no evidence that suggests a protective effect of postmenopausal hormone use against the development of ALS. However, due to insufficient power, we cannot rule out a possible increase in ALS risk associated with postmenopausal hormone use.

Atypical headache after prolonged treatment with nasal continuous positive airway pressure.

We report a case of atraumatic pneumocephalus associated with prolonged use of nasal continuous positive airway pressure. Initial symptoms included headache, ataxia, vertigo, and a "gurgling" sensation in the head; and a CT image showed small air bubbles along the falx of cerebrum and adjacent to the temporal epidural spaces bilaterally. Although no evidence of cerebrospinal fluid (CSF) leak was either reported by the patient or found at initial clinical examination, subsequent nasal discharge tested positive for beta2-transferrin, a finding consistent with CSF leak in the paranasal sinus region or through the cribriform plate. To try to prevent infection from an open communication between the paranasal sinuses and intracranial structures, an attempt should be made to localize the anatomic defect.

Reducing the risk for distal forearm fracture: preserve bone mass, slow down, and don't fall!

A case-control study of 1,150 female and male distal forearm cases and 2,331 controls of age 45 years and older was undertaken from 1996-2001 in five Northern California Kaiser Permanente Medical Centers. Most information on possible risk factors was obtained by an interviewer-administered questionnaire, supplemented by a few tests of lower extremity neurological function. Previous fractures since 45 years of age, a rough marker of osteoporosis, were associated with an increased risk (adjusted odds ratio [OR] [95% confidence interval] = 1.48 [1.20-1.84 ] per previous fracture). Several factors thought to protect against low bone mass were associated with a reduced risk, including current use of menopausal hormone therapy (adjusted OR = 0.60 [0.49-0.74]), ever used thiazide diuretics or water pills for at least 1 year (adjusted OR = 0.79 [0.64-0.97]), high body mass index (weight in kg/height in m2) (adjusted OR = 0.96 [0.89-1.04] per 5 unit increase), and high dietary calcium intake (adjusted OR = 0.88 [0.75-1.03] per 500 mg/day). Falls in the past year and conditions associated with falling, such as epilepsy and/or use of seizure medication (adjusted OR = 2.07 [1.35-3.17]) and a history of practitioner-diagnosed depression (adjusted OR = 1.40 [1.13-1.73]), were associated with increased risks. Having difficulty performing physical functions and all lower-extremity problems measured in this study were associated with reduced risks. The results from this and other studies indicate that distal forearm fractures tend to occur in people with low bone mass who are otherwise in relatively good health and are physically active, but who are somewhat prone to falling (particularly on an outstretched hand), and whose movements are not slowed by lower extremity problems and other debilities. Thus, measures to decrease fall frequency and to slow down the pace of relatively healthy people with low bone mass should lead to a lower frequency of distal forearm fracture.

Pseudodementia associated with use of ibuprofen.

OBJECTIVE: To report a case of dementing syndrome resulting from ibuprofen use. CASE SUMMARY: A 76-year-old white man with normal mental status became confused, was lost in familiar places, and showed short-term memory loss after beginning a therapeutic regimen of ibuprofen 600 mg 3 times daily for osteoarthritis in anticipation of embarking on a foreign trip. Symptoms of dementia began within 1 week after taking ibuprofen and resolved completely within 1 week after the ibuprofen regimen was stopped. This pattern was repeated 6 months later, when the patient again traveled abroad. Consistently before, during, and after these events, the patient took atenolol, clonidine, lisinopril, aspirin, vitamin C, lecithin, vitamin E, and multivitamins. DISCUSSION: Using the Naranjo probability scale, we reasoned that the patient's dementia-like syndrome could be attributed to the use of ibuprofen because pseudodementia appeared after the suspected drug was administered, improved when the drug was discontinued, reappeared when the drug was readministered, had no apparent alternative cause, manifested similarly after each exposure to ibuprofen, and was confirmed by the family's observation after both episodes. Objective causality assessment revealed that the adverse drug reaction was probable. CONCLUSIONS: Use of ibuprofen must be considered during clinical evaluation of any patient with new onset of dementing illness. The Naranjo probability scale may be clinically useful for evaluating other pharmaceutical agents that may be contributing to development of dementia-like conditions.

A comparison of risk factors for recurrent TIA and stroke in patients diagnosed with TIA.

BACKGROUND: Some spells consistent with TIA may be benign, such as those produced by migraine or migraine accompaniments in the elderly. Distinguishing these from embolic or thrombotic events may be difficult. METHODS: Emergency department physicians identified patients who presented with a presumed TIA at one of 16 hospitals in Northern California from March 1997 through February 1998. Recurrent TIAs and strokes were recorded for 90 days afterwards. RESULTS: Of 1,707 patients in whom TIA had been diagnosed in the emergency department, 191 (11.2%) had a recurrent TIA and 180 (10.5%) had a stroke during 90-day followup. Independent risk factors for recurrent TIA were age >60 years (odds ratio 1.9; 95% CI 1.2 to 2.9; p = 0.003), history of multiple TIAs (odds ratio 2.9; 2.1 to 4.0; p < 0.001), duration of spell 10 minutes, diabetes, weakness, and speech impairment. Among the 30 patients with isolated sensory symptoms lasting

Incidence of Parkinson's disease: variation by age, gender, and race/ethnicity.

The goal of this study was to estimate the incidence of Parkinson's disease by age, gender, and ethnicity. Newly diagnosed Parkinson's disease cases in 1994-1995 were identified among members of the Kaiser Permanente Medical Care Program of Northern California, a large health maintenance organization. Each case met modified standardized criteria/Hughes diagnostic criteria as applied by a movement disorder specialist. Incidence rates per 100,000 person-years were calculated using the Kaiser Permanente membership information as the denominator and adjusted for age and/or gender using the direct method of standardization. A total of 588 newly diagnosed (incident) cases of Parkinson's disease were identified, which gave an overall annualized age- and gender-adjusted incidence rate of 13.4 per 100,000 (95% confidence interval (CI): 11.4, 15.5). The incidence rapidly increased over the age of 60 years, with only 4% of the cases being under the age of 50 years. The rate for men (19.0 per 100,000, 95% CI: 16.1, 21.8) was 91% higher than that for women (9.9 per 100,000, 95% CI: 7.6, 12.2). The age- and gender-adjusted rate per 100,000 was highest among Hispanics (16.6, 95% CI: 12.0, 21.3), followed by non-Hispanic Whites (13.6, 95% CI: 11.5, 15.7), Asians (11.3, 95% CI: 7.2, 15.3), and Blacks (10.2, 95% CI: 6.4, 14.0). These data suggest that the incidence of Parkinson's disease varies by race/ethnicity.