Exposure-response associations between chronic exposure to fine particulate matter and risks of hospital admission for major cardiovascular diseases: population based cohort study.

OBJECTIVE: To estimate exposure-response associations between chronic exposure to fine particulate matter (PM2.5) and risks of the first hospital admission for major cardiovascular disease (CVD) subtypes. DESIGN: Population based cohort study. SETTING: Contiguous US. PARTICIPANTS: 59 761 494 Medicare fee-for-service beneficiaries aged ≥65 years during 2000-16. Calibrated PM2.5 predictions were linked to each participant's residential zip code as proxy exposure measurements. MAIN OUTCOME MEASURES: Risk of the first hospital admission during follow-up for ischemic heart disease, cerebrovascular disease, heart failure, cardiomyopathy, arrhythmia, valvular heart disease, thoracic and abdominal aortic aneurysms, or a composite of these CVD subtypes. A causal framework robust against confounding bias and bias arising from errors in exposure measurements was developed for exposure-response estimations. RESULTS: Three year average PM2.5 exposure was associated with increased relative risks of first hospital admissions for ischemic heart disease, cerebrovascular disease, heart failure, cardiomyopathy, arrhythmia, and thoracic and abdominal aortic aneurysms. For composite CVD, the exposure-response curve showed monotonically increased risk associated with PM2.5: compared with exposures ≤5 µg/m3 (the World Health Organization air quality guideline), the relative risk at exposures between 9 and 10 µg/m3, which encompassed the US national average of 9.7 µg/m3 during the study period, was 1.29 (95% confidence interval 1.28 to 1.30). On an absolute scale, the risk of hospital admission for composite CVD increased from 2.59% with exposures ≤5 µg/m3 to 3.35% at exposures between 9 and 10 µg/m3. The effects persisted for at least three years after exposure to PM2.5. Age, education, accessibility to healthcare, and neighborhood deprivation level appeared to modify susceptibility to PM2.5. CONCLUSIONS: The findings of this study suggest that no safe threshold exists for the chronic effect of PM2.5 on overall cardiovascular health. Substantial benefits could be attained through adherence to the WHO air quality guideline.

Associations Between Age-Related Hearing Loss, Cognitive Impairment, and Multiple Chronic Conditions in a Group Care Setting.

PURPOSE: The purpose of this study was to explore the relationships between hearing loss, cognitive status, and a range of health outcomes over a period of 2 years in a sample of older adults who are enrolled in Program of All-Inclusive Care for the Elderly, which is a Medicare/Medicaid beneficiary program for individuals who are nursing home eligible but living in the community at time of enrollment. METHOD: The sample (N = 144) includes a diverse (47% White/non-Hispanic, 35% Black/African American, and 16% Latin/Hispanic) group of adults ranging from 55 to 93 years old. We used medical chart data to measure respondents' cognitive and health status, including chronic conditions and hospital use. Hearing status was measured once at the beginning of the 2-year review period. We used logistic regression and negative binomial hurdle models for analyses. We used latent class analysis (LCA) to explore the extent to which respondents cluster into a set of "health profiles" characterized by their hearing, cognitive status, and health conditions. RESULTS: We found that hearing loss is weakly associated with heart disease and diabetes and associated with cerebrovascular disease and falls; cognitive impairment is also associated with cerebrovascular disease and the number of falls. LCA indicates that respondents cluster into a variety of health profiles with a consistent pairing of hearing loss and depression. CONCLUSIONS: The results are largely consistent with associations reported in epidemiological studies that include age-related hearing loss. Of particular interest in this study is the LCA that suggested that all of the profiles associated with a high likelihood of hearing loss included a high risk of depression. The co-occurrence of these two factors highlights the need to identify and treat hearing loss in older adults, especially as part of the treatment plan for individuals with depressive symptoms.

Periodontal treatment and subsequent clinical outcomes and medical care costs: A retrospective cohort study.

INTRODUCTION: Periodontitis is a common oral disease associated with coronary artery disease (CAD), cerebrovascular disease (CBVD) and type 2 diabetes (T2D). We studied if periodontitis treatment improves clinical outcomes and reduces medical care costs in patients with CAD, CBVD or T2D. METHODS: We used clinic records and claims data from a health care system to identify patients with periodontitis and CAD, CBVD or T2D, and to assess periodontal treatments, hospitalizations, medical costs (total, inpatient, outpatient, pharmacy), glycated hemoglobin, cardiovascular events, and death following concurrent disease diagnoses. We compared clinical outcomes according to receipt of periodontal treatment and/or maintenance care in the follow-up period, and care costs according to treatment status within one year following concurrent disease diagnoses, while adjusting for covariates. The data were analyzed in 2019-21. RESULTS: We identified 9,503 individuals, 4,057 of whom were in the CAD cohort; 3,247 in the CBVD cohort; and 4,879 in the T2D cohort. Patients who were selected and elected to receive treatment and maintenance care were less likely to be hospitalized than untreated individuals (CAD: OR = 0.71 (95% CI: 0.55, 0.92); CBVD: OR = 0.73 (0.56, 0.94); T2D: OR = 0.80 (0.64, 0.99)). Selection to treatment and/or maintenance care was not significantly associated with cardiovascular events, mortality, or glycated hemoglobin change. Total care costs did not differ significantly between treated and untreated groups over 4 years. Treated patients experienced lower inpatient costs but higher pharmacy costs. CONCLUSIONS: Patients with periodontitis and CAD, CBVD or T2D who were selected and elected to undergo periodontal treatment or maintenance care had lower rates of hospitalizations, but did not differ significantly from untreated individuals in terms of clinical outcomes or total medical care costs.

Assessment of fibrinogen albumin ratio in patients with pregnancy-related cerebral venous thrombosis.

INTRODUCTION AND OBJECTIVE: Cerebral venous thrombosis (CVT) is a cerebrovascular disease observed more commonly in women of childbearing age. There is currently no biomarker used to predict the risk of CVT during the follow-up of pregnant/postpartum patients. In this context, the objective of this study is to investigate the importance of fibrinogen and albumin levels and fibrinogen-to-albumin ratio (FAR) values, which predispose to thromboembolism, in pregnant/postpartum patients. MATERIAL AND METHOD: The study sample consisted of 19 pregnant/postpartum patients with a diagnosis of CVT, 20 pregnant/postpartum patients without CVT. Albumin and fibrinogen levels and FAR values were compared between these two groups. RESULTS: Fibrinogen level was significantly higher in pregnant/postpartum CVT patients compared to pregnant/postpartum patients without CVT (p = 0.010). On the other hand, albumin level was significantly lower in pregnant/postpartum CVT patients compared to the other group (p = 0.010). Lastly, FAR level was significantly higher in pregnant/postpartum CVT patients compared to the other group (p = 0.011). There was no correlation between FAR values and modified Rankin score. CONCLUSION: The study findings indicated that high fibrinogen and low albumin levels and high FAR values are associated with an increased risk of CVT in pregnant/postpartum patients.

Racial and Ethnic Disparities in Heart and Cerebrovascular Disease Deaths During the COVID-19 Pandemic in the United States.

BACKGROUND: Cardiovascular deaths increased during the early phase of the COVID-19 pandemic in the United States. However, it is unclear whether diverse racial/ethnic populations have experienced a disproportionate rise in heart disease and cerebrovascular disease deaths. METHODS: We used the National Center for Health Statistics to identify heart disease and cerebrovascular disease deaths for non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, and Hispanic individuals from March to August 2020 (pandemic period), as well as for the corresponding months in 2019 (historical control). We determined the age- and sex-standardized deaths per million by race/ethnicity for each year. We then fit a modified Poisson model with robust SEs to compare change in deaths by race/ethnicity for each condition in 2020 versus 2019. RESULTS: There were a total of 339 076 heart disease and 76 767 cerebrovascular disease deaths from March through August 2020, compared with 321 218 and 72 190 deaths during the same months in 2019. Heart disease deaths increased during the pandemic in 2020, compared with the corresponding period in 2019, for non-Hispanic White (age-sex standardized deaths per million, 1234.2 versus 1208.7; risk ratio for death [RR], 1.02 [95% CI, 1.02-1.03]), non-Hispanic Black (1783.7 versus 1503.8; RR, 1.19 [95% CI, 1.17-1.20]), non-Hispanic Asian (685.7 versus 577.4; RR, 1.19 [95% CI, 1.15-1.22]), and Hispanic (968.5 versus 820.4; RR, 1.18 [95% CI, 1.16-1.20]) populations. Cerebrovascular disease deaths also increased for non-Hispanic White (268.7 versus 258.2; RR, 1.04 [95% CI, 1.03-1.05]), non-Hispanic Black (430.7 versus 379.7; RR, 1.13 [95% CI, 1.10-1.17]), non-Hispanic Asian (236.5 versus 207.4; RR, 1.15 [95% CI, 1.09-1.21]), and Hispanic (264.4 versus 235.9; RR, 1.12 [95% CI, 1.08-1.16]) populations. For both heart disease and cerebrovascular disease deaths, Black, Asian, and Hispanic populations experienced a larger relative increase in deaths than the non-Hispanic White population (interaction term, P<0.001). CONCLUSIONS: During the COVID-19 pandemic in the United States, Black, Hispanic, and Asian populations experienced a disproportionate rise in deaths caused by heart disease and cerebrovascular disease, suggesting that these groups have been most impacted by the indirect effects of the pandemic. Public health and policy strategies are needed to mitigate the short- and long-term adverse effects of the pandemic on the cardiovascular health of diverse populations.

Assessment of cerebrovascular reserve with N-isopropyl-p-[123I]-iodoamphetamine time series analysis in patients with cerebrovascular disease.

ABSTRACT: Using N-isopropyl-p-[123I]-iodoamphetamine(123I-IMP) and single-photon emission computed tomography (SPECT), the relationship between cerebrovascular reserve and the 123I-IMP redistribution phenomenon was investigated.The 50 patients who matched the inclusion criteria were divided into control and ischemia groups, and the redistribution phenomenon was examined on resting images. The delayed images showed higher 123I-IMP accumulation in lesions in the middle cerebral artery(MCA) area and anterior cerebral artery(ACA) area, these watershed areas in the ischemia group than in the control group, confirming that the redistribution phenomenon exists with statistical significance (Wilcoxon test; control group vs ischemic group in the ACA area[P = .002], ACA-MCA watershed area(P = .014), MCA area(P = .025), and MCA-posterior cerebral artery(PCA) watershed area(P = .002). The patients were then divided into 4 types according to the Kuroda grading system, and the difference in the redistribution phenomenon was investigated between type III and the other 3 types.Compared with type I and type II, type III had a significantly lower rate of decrease in the radioisotope (RI) count, verifying the redistribution phenomenon (Student t test: type I vs type III in the ACA area(P = .008), ACA-MCA watershed area(P = .009), MCA area(P < .001), and MCA-PCA watershed area(P = .002); type II vs type III in the ACA area(P = .004), ACA-MCA watershed area(P = .2575), MCA area(P < .001), and MCA-PCA watershed area(P < .001). No significant difference between type III and type IV was observed in any area [(Student t test: type III vs type IV in the ACA area(P = .07), ACA-MCA watershed area(P = .38), MCA area(P = .05), and MCA-PCA watershed area(P = .24)].The redistribution phenomenon is associated with resting cerebral blood flow (CBF), but not necessarily with cerebral vascular reactivity (CVR).

Cognitive Correlates of MRI-defined Cerebral Vascular Injury and Atrophy in Elderly American Indians: The Strong Heart Study.

OBJECTIVE: American Indians experience substantial health disparities relative to the US population, including vascular brain aging. Poorer cognitive test performance has been associated with cranial magnetic resonance imaging findings in aging community populations, but no study has investigated these associations in elderly American Indians. METHODS: We examined 786 American Indians aged 64 years and older from the Cerebrovascular Disease and its Consequences in American Indians study (2010-2013). Cranial magnetic resonance images were scored for cortical and subcortical infarcts, hemorrhages, severity of white matter disease, sulcal widening, ventricle enlargement, and volumetric estimates for white matter hyperintensities (WMHs), hippocampus, and brain. Participants completed demographic, medical history, and neuropsychological assessments including testing for general cognitive functioning, verbal learning and memory, processing speed, phonemic fluency, and executive function. RESULTS: Processing speed was independently associated with the presence of any infarcts, white matter disease, and hippocampal and brain volumes, independent of socioeconomic, language, education, and clinical factors. Other significant associations included general cognitive functioning with hippocampal volume. Nonsignificant, marginal associations included general cognition with WMH and brain volume; verbal memory with hippocampal volume; verbal fluency and executive function with brain volume; and processing speed with ventricle enlargement. CONCLUSIONS: Brain-cognition associations found in this study of elderly American Indians are similar to those found in other racial/ethnic populations, with processing speed comprising an especially strong correlate of cerebrovascular disease. These findings may assist future efforts to define opportunities for disease prevention, to conduct research on diagnostic and normative standards, and to guide clinical evaluation of this underserved and overburdened population.

The inpatient hospital burden of comorbidities in HCV-infected patients: A population-based study in two Italian regions with high HCV endemicity (The BaCH study).

BACKGROUND & AIMS: Hepatitis C (HCV) is associated with several extrahepatic manifestations, and estimates of the hospitalization burden related to these comorbidities are still limited. The aim of this study is to quantify the hospitalization risk associated with comorbidities in an Italian cohort of HCV-infected patients and to assess which of these comorbidities are associated with high hospitalization resource utilization. METHODS: Individuals aged 18 years and older with HCV-infection were identified in the Abruzzo's and Campania's hospital discharge abstracts during 2011-2014 with 1-year follow-up. Cardio-and cerebrovascular disease, diabetes and renal disease were grouped as HCV-related comorbidities. Negative binomial models were used to compare the hospitalization risk in patients with and without each comorbidity. Logistic regression model was used to identify the characteristics of being in the top 20% of patients with the highest hospitalization costs (high-cost patients). RESULTS: 15,985 patients were included; 19.9% had a liver complication and 48.6% had one or more HCV-related comorbidities. During follow-up, 36.0% of patients underwent at least one hospitalization. Liver complications and the presence of two or more HCV-related comorbidities were the major predictors of hospitalization and highest inpatient costs. Among those, patients with cardiovascular disease had the highest risk of hospitalization (Incidence Rate Ratios = 1.42;95%CI:1.33-1.51) and the highest likelihood of becoming high-cost patients (Odd Ratio = 1.37;95%CI:1.20-1.57). CONCLUSION: Beyond advanced liver disease, HCV-related comorbidities (especially cardiovascular disease) are the strongest predictors of high hospitalization rates and costs. Our findings highlight the potential benefit that early identification and treatment of HCV might have on the reduction of hospitalization costs driven by extrahepatic conditions.

How Do Patients with Chronic Diseases Make Usage Decisions regarding Mobile Health Monitoring Service?

Objectives: The increasing population of patients with chronic diseases generates great challenge of chronic disease management. The occurrence of mobile health monitoring service (MHMS) is beneficial to chronic disease prevention and health promotion. The objective of this study is to investigate how patients with chronic diseases make usage decisions on MHMS. Study Design: A survey. Methods: 213 respondents with chronic diseases were asked to rate their level of health severity, negative health emotions, and health uncertainty avoidance. SmartPLS was used to test the measurement model. Results: Of 213 research respondents, 159 of them have one chronic disease, while 54 have more than one such disease. Perceived health severity of patients with chronic diseases positively influences MHMS usage intentions, while negative health emotions do not. Health uncertainty avoidance strengthens the effect of health severity but weakens the effect of negative health emotions on MHMS usage intentions. Conclusion: Patients with chronic diseases have a unique decision-making process regarding MHMS usage in which their special health-related factors and tendencies play a critical role in determining behavioral intentions.

Assessment of risk factors for cerebrovascular disease among the elderly in Beijing: A 23-year community-based prospective study in China.

INTRODUCTION: There are few studies on how lifestyle factors and mental conditions modulate the cerebrovascular diseases (CBVD) mortality risk are rare in the Asian elderly. AIM: To comprehensively assess the impact of lifestyle factors and mental conditions on the mortality risk of CBVD among the Chinese older adults. MATERIAL AND METHODS: This community-based prospective cohort study was based on the Beijing Longitudinal Study of Aging. We included 2101 participants aged ≥55 years who were interviewed in August 1992 and followed until December 2015. Baseline sociodemographic variables, lifestyle behaviors, and medical conditions were collected using a standard questionnaire. In addition, biochemical parameters, the Activities of Daily Living (ADL) scale, Center for Epidemiological Studies Depression (CES-D) scale, and Mini-Mental State Examination (MMSE) were performed. Hazard ratio (HR) and 95% confidence intervals (CI) was estimated from the competing risk model. RESULTS: During the follow-up period, 576 (27.42%) CBVD events were documented. Multivariable analysis showed that hypertension (HR = 2.331, 95% CI = 1.652-3.288,P < 0.001), depression (HR=2.331, 95% CI=1.652-3.288, P < 0.001), cognitive impairment (HR=1.382, 95% CI=1.132-1.689, P < 0.001), and coronary heart diseases (HR=1.360, 95% CI=1.095-1.689, P = 0.005) were independently associated with CBVD, while body mass index, fasting blood glucose, triglycerides, drinking, and smoking were not associated with CBVD (all P > 0.05). CONCLUSIONS: Males were at higher risk of CBVD than females. Age, gender, hypertension, cognitive impairment, and depression were associated with CBVD among the elderly in Beijing, China.

Total small vessel disease burden and brain network efficiency in cerebral amyloid angiopathy.

BACKGROUND: Cerebral amyloid angiopathy (CAA) is associated with hemorrhagic and nonhemorrhagic markers small vessel disease (SVD). A composite score to quantify the total burden of SVD on MRI specifically for CAA patients was recently developed. Brain network alterations related to individual MRI markers of SVD in CAA were demonstrated. OBJECTIVES: Considering diffusion based network measures sensitive to detect different relevant SVD-related brain injury, we investigated if increased overall SVD injury on MRI corresponds to worse global brain connectivity in CAA. METHODS: Seventy-three patients (79.5% male, mean age 70.58±8.22years) with a diagnosis CAA were considered. SVD markers in total MRI SVD score included: lobar cerebral microbleeds, cortical superficial siderosis (cSS), white matter hyperintensities (WMH) and centrum semiovale-enlarged perivascular spaces. Diffusion imaging based network reconstruction was made. The associations between total MRI SVD score and global network efficiency (GNE) were analyzed. RESULTS: A modest significant inverse correlation between total MRI SVD score and GNE existed (p=0.013; R2=0.07). GNE was related with the presence of cSS and moderate-severe WMHs. CONCLUSIONS: An increased burden of SVD neuroimaging markers corresponds to more reductions in global brain connectivity, implying a possible cumulative effect of overall SVD markers on disrupted physiology. GNE was related with some components of the score, specifically cSS and moderate-severe WMHs.

Comparative effectiveness of antihypertensive drugs in nondiabetic patients with hypertension: A population-based study.

The authors compared the effectiveness of thiazide diuretic (TD), angiotensin-converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), and calcium channel blocker (CCB) monotherapies for the treatment of nondiabetic hypertension using MarketScan Databases 2010-2014. Multivariable Cox regression models assessed whether the addition of a new antihypertensive drug, treatment discontinuation, or switch and major cardiovascular or cerebrovascular events varied across groups. A total of 565 009 patients started monotherapy with ACEIs (43.6%), CCBs (23.6%), TDs (18.8%), or ARBs (14.0%). Patients who took TDs had a higher risk for either drug addition or discontinuation than patients who took ACEIs (hazard ratio [HR], 0.69 [95% CI, 0.68-0.70] vs HR, 0.81 [95% CI, 0.80-0.81]), ARBs (HR, 0.67 [95% CI, 0.66-0.68] vs HR, 0.66 [95% CI, 0.65-0.67]), and CCBs (HR, 0.85 [95% CI, 0.84-0.87] vs HR, 0.94 [95% CI, 0.93-0.95]). Conversely, patients who took TDs experienced a lower risk of clinical events compared with patients who took ACEIs (HR, 1.24 [95% CI, 1.15-1.33]), ARBs (HR, 1.28 [95% CI, 1.18-1.39]), and CCBs (HR, 1.35 [95% CI, 1.25-1.46]). Our results provide a strong rationale for choosing TDs as first-line monotherapy for the control of hypertension.

Montreal cognitive assessment and analysis of related factors for cognitive impairment in patients with chronic cerebral circulation insufficiency.

BACKGROUND: Chronic cerebral circulation insufficiency (CCCI) refers to cerebral dysfunctions that lead to cerebral vascular pathological changes. Our aim is to identify factors related to cognitive impairment in CCCI. METHODS: CCCI patients (n=102) were assessed with the Montreal cognitive assessment (MoCA) to analyze cognitive impairment. Patients were divided into two groups according to MoCA scores: (1) cognitive dysfunction and (2) normal cognitive function. We compared the clinical information with univariate and multivariate logistic regression analyses and identified major risk factors related to cognitive impairment in CCCI. RESULTS: Age (p=0.007, OR=3.768, χ2=7.173), leukoaraiosis (p=0.002, OR=6.231, χ2=9.478), a history of hypertension (p=0.021, OR=3.078, χ2=5.307), a history of hyperlipidemia (p=0.016, OR=3.429, χ2=5.795), and the number of vascular risk factors (p=0.019, χ2=9.921) were related to cognitive impairment by univariate analysis. Age (p=0.070, OR=2.689, 95% CI=0.923±7.837) and leukoaraiosis (p=0.012, OR=4.531, 95% CI=1.401±14.667) were significant by multivariate logistic regression analysis. Age (r=-0.585, p<0.01) had a marked negative correlation with MoCA scores. There were significant differences in the MoCA subscale scores, including visuospatial and executive capacity (p<0.01), attention and calculation (p<0.01), and delayed recall (p<0.01), in patients with different degrees of leukoaraiosis. Patients with CCCI had a higher incidence of cognitive impairment (78.4%). CONCLUSIONS: Changes in visuospatial and executive capacity, delayed recall, and language function represent cognitive manifestations in CCCI. Age and leukoaraiosis have the strongest effects on cognitive impairment morbidity and can aggravate cognitive impairment.

Design and methods of the NiCK study: neurocognitive assessment and magnetic resonance imaging analysis of children and young adults with chronic kidney disease.

BACKGROUND: Chronic kidney disease is strongly linked to neurocognitive deficits in adults and children, but the pathophysiologic processes leading to these deficits remain poorly understood. The NiCK study (Neurocognitive Assessment and Magnetic Resonance Imaging Analysis of Children and Young Adults with Chronic Kidney Disease) seeks to address critical gaps in our understanding of the biological basis for neurologic abnormalities in chronic kidney disease. In this report, we describe the objectives, design, and methods of the NiCK study. DESIGN/METHODS: The NiCK Study is a cross-sectional cohort study in which neurocognitive and neuroimaging phenotyping is performed in children and young adults, aged 8 to 25 years, with chronic kidney disease compared to healthy controls. Assessments include (1) comprehensive neurocognitive testing (using traditional and computerized methods); (2) detailed clinical phenotyping; and (3) multimodal magnetic resonance imaging (MRI) to assess brain structure (using T1-weighted MRI, T2-weighted MRI, and diffusion tensor imaging), functional connectivity (using functional MRI), and blood flow (using arterial spin labeled MRI). Primary analyses will examine group differences in neurocognitive testing and neuroimaging between subjects with chronic kidney disease and healthy controls. Mechanisms responsible for neurocognitive dysfunction resulting from kidney disease will be explored by examining associations between neurocognitive testing and regional changes in brain structure, functional connectivity, or blood flow. In addition, the neurologic impact of kidney disease comorbidities such as anemia and hypertension will be explored. We highlight aspects of our analytical approach that illustrate the challenges and opportunities posed by data of this scope. DISCUSSION: The NiCK study provides a unique opportunity to address key questions about the biological basis of neurocognitive deficits in chronic kidney disease. Understanding these mechanisms could have great public health impact by guiding screening strategies, delivery of health information, and targeted treatment strategies for chronic kidney disease and its related comorbidities.

Chronic cerebrospinal venous insufficiency: pitfalls and perils of sonographic assessment.

OBJECTIVES: Duplex sonography has been proposed as a diagnostic modality for detection of chronic cerebrovascular venous insufficiency, a recently proposed hypothesis of multiple sclerosis (MS) pathogenesis. We reviewed potential challenges of duplex sonography for diagnosis of chronic cerebrovascular venous insufficiency and used interim pooled data from a study aimed to apply cerebrovascular venous insufficiency criteria to a group of patients with MS and control patients without MS. METHODS: Duplex sonography for chronic cerebrovascular venous insufficiency was performed in patients with MS and controls. Extracranial and deep cerebral veins were studied by using a published chronic cerebrovascular venous insufficiency protocol and criteria. Comparative imaging was performed to explore how physiologic factors and imaging techniques could affect key parameters. The effects of varying definitions on fulfilling chronic cerebrovascular venous insufficiency diagnostic criteria were also explored. RESULTS: Forty-two patients were enrolled. Twenty-five (60%) had a reduction in internal jugular vein cross-sectional area by 50% or more, cross-sectional area of 0.3 cm(2) or less, and/or a B-mode abnormality. No patients had reflux longer than 0.88 seconds in both sitting and supine positions, the presence of duplex sonographic reflux on transcranial Doppler imaging, or a larger internal jugular vein cross-sectional area in the sitting versus supine position. Fourteen patients (33.3%) had either a flap or septum, and 1 had a web. Collateral veins to the vertebral veins were identified in 14 of 42 patients (33.3%). The use of transcranial Doppler imaging versus quality Doppler profiles resulted in fewer patients meeting criteria for chronic cerebrovascular venous insufficiency. CONCLUSIONS: There are several important variables, including physiologic, technical, and criterion definitions, in the application of sonographic assessment of chronic cerebrovascular venous insufficiency that may affect diagnostic accuracy.

Practical implications of the migraine cardio- and cerebrovascular association: unmet needs of patients.

BACKGROUND: Numerous studies have described a relationship between migraine and stroke, and there is emerging evidence that migraine is also associated with cardiovascular disease. The combination of migraine and both cerebrovascular and cardiovascular disease has implications for therapy. METHODS: We conducted a review of the modifications in medical therapy in patients with comorbid migraine and cardio- and cerebrovascular disorders based on publications from the last 15 years. RESULTS: Some drugs are contraindicated to treat migraine attacks (ergots, triptans) or for migraine prevention in patients after transient ischemic attack (TIA)/ischemic stroke. Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated in patients with cerebral bleeding. Some drugs for the treatment of acute migraine attacks are contraindicated in patients with symptomatic coronary heart disease. CONCLUSIONS: Given the large number of patients with comorbid migraine and cardiovascular as well as cerebrovascular disease, there is an unmet need to treat these patients.

Rates of and factors associated with infection in 200 909 Medicare implantable cardioverter-defibrillator implants: results from the National Cardiovascular Data Registry.

BACKGROUND: The rate of implantable cardioverter-defibrillator (ICD) infections has been increasing faster than that of implantation. We sought to determine the rate and predictors of ICD infection in a large cohort of Medicare patients. METHODS AND RESULTS: Cases submitted to the ICD Registry from 2006 to 2009 were matched to Medicare fee-for-service claims data using indirect patient identifiers. ICD infections occurring within 6 months of hospital discharge after implantation were identified by ICD-9 codes. Logistic regression was used to examine factors associated with risk of ICD infection. Of 200 909 implants, 3390 patients (1.7%) developed an ICD infection. The infection rate was 1.4%, 1.5%, and 2.0% for single, dual, and biventricular ICDs, respectively (P<0.001). Generator replacement had a higher rate compared with initial implant (1.9% versus 1.6%, P<0.001). The factors associated with infection were adverse event during implant requiring reintervention (odds ratio [OR], 2.692; 95% confidence interval [CI], 2.304-3.145), previous valvular surgery (OR, 1.525; 95% CI, 1.375-1.692), reimplantation for device upgrade, malfunction, or manufacturer advisory (OR, 1.354; 95% CI, 1.196-1.533), renal failure on dialysis (OR, 1.342; 95% CI, 1.123-1.604), chronic lung disease (OR, 1.215; 95% CI, 1.125-1.312), cerebrovascular disease (OR, 1.172; 95% CI, 1.076-1.276), and warfarin (OR, 1.155; 95% CI, 1.060-1.257). CONCLUSIONS: Patients who developed an ICD infection were more likely to have had peri-ICD implant complications requiring early reintervention, previous valve surgery, device replacement for reasons other than battery depletion, and increased comorbidity burden. Efforts should be made to carefully consider when to reenter the pocket at any time other than battery replacement.

Enrollment of racially/ethnically diverse participants in traumatic brain injury trials: effect of availability of exception from informed consent.

BACKGROUND: The Final Rule regulations were developed to allow exception from informed consent (EFIC) to enable clinical trial research in emergency settings where major barriers exist for informed consent. There is little known evidence of the effect of the Final Rule in minority enrollment in clinical trials, particularly in traumatic brain injury (TBI) trials. A clinical trial funded by the National Institute of Neurological Disorders and Stroke was conducted to study the effects of erythropoietin on cerebral vascular dysfunction and anemia in subjects with TBI. There were periods of time when EFIC was and was not available for enrollment into the study. PURPOSE: To explore the effect of EFIC availability on TBI trial enrollment of minority versus non-minority subjects. METHODS: Minority status of screened (n = 289) and enrolled (n = 191) TBI subjects was determined for this study. We tested for the presence of a minority and EFIC availability interaction in a multiple logistic regression model after controlling for EFIC and minority group main effects and other covariates. RESULTS: An interaction between the availability of EFIC minority and non-minority enrollment was not detected (odds ratio = 1.22; 95% confidence interval (CI) = 0.29-5.16). LIMITATIONS: Our study was conducted at a single site, and the CI for the EFIC and minority interaction term was wide. Therefore, a small interaction effect cannot be ruled out. CONCLUSION: EFIC increased the odds of being enrolled regardless of minority status.

Vascular cognitive impairment: most useful subtests of the Montreal Cognitive Assessment in minor stroke and transient ischemic attack.

BACKGROUND/AIMS: Cognitive impairment is frequent in cerebrovascular disease but often remains undetected. The Montreal Cognitive Assessment (MoCA) has been proposed in this context. Our aim was to evaluate the MoCA and its subtests in cerebrovascular disease. METHODS: We assessed 386 consecutive patients with minor stroke (National Institutes of Health Stroke Score <4) or transient ischemic attack at 3 months. The MoCA and the modified Rankin Scale (mRS) were administered. Computed tomography (CT) scans were assessed for stroke and white matter changes. An unfavorable functional outcome was defined as mRS >1. RESULTS: The prevalence of cognitive impairment (cutoff of 26) was 55% using the MoCA and 13% using the MMSE. In a multivariate analysis, MoCA <26 was associated with the outcome (OR 3.00, CI 1.78-5.03), as were remote lacunar stroke on CT and white matter changes of at least moderate severity. Five subtests (5-word recall, word list generation, trail-making, abstract reasoning and cube copy) formed an optimal short MoCA with 6/10 or less showing a sensitivity of 91% and a specificity of 83%. CONCLUSION: This study extends the utility of the MoCA to milder forms of cerebrovascular disease. The MoCA is associated with the 3-month functional outcome. Five subtests may constitute an optimal brief tool in vascular cognitive impairment.