Healthcare disparities in vascular surgery: A critical review.

Health disparities in vascular surgical care have existed for decades. Persons categorized as Black undergo a nearly twofold greater risk-adjusted rate of leg amputations. Persons categorized as Black, Latinx, and women have hemodialysis initiated via autogenous fistula less often than male persons categorized as White. Persons categorized as Black, Latino, Latina, or Latinx, and women are less likely to undergo carotid endarterectomy for symptomatic carotid stenosis and repair of abdominal aortic aneurysms. New approaches are needed to address these disparities. We suggest surgeons use data to identify groups that would most benefit from medical care and then partner with community organizations or individuals to create lasting health benefits. Surgeons alone cannot rectify the structural inequalities present in American society. However, all surgeons should contribute to ensuring that all people have access to high-quality vascular surgical care.

Black patients present with more severe vascular disease and a greater burden of risk factors than white patients at time of major vascular intervention.

BACKGROUND: Although many studies have demonstrated racial disparities after major vascular surgery, few have identified the reasons for these disparities, and those that did often lacked clinical granularity. Therefore, our aim was to evaluate differences in initial vascular intervention between black and white patients. METHODS: We identified black and white patients' initial carotid, abdominal aortic aneurysm (AAA), and infrainguinal peripheral artery disease (PAD) interventions in the Vascular Quality Initiative (VQI) registry from 2009 to 2014. We excluded nonblack or nonwhite patients as well as those with Hispanic ethnicity, asymptomatic PAD, or a history of prior ipsilateral interventions. We compared baseline characteristics and disease severity at time of intervention on a national and regional level. RESULTS: We identified 76,372 patients (9% black), including 35,265 carotid (5% black), 17,346 AAA (5% black), and 23,761 PAD interventions (18% black). For all operations, black patients were younger, more likely female, and had more insulin-dependent diabetes, hypertension, congestive heart failure, renal dysfunction, and dialysis dependence. Black patients were less likely to be on a statin before AAA (62% vs 69%; P < .001) or PAD intervention (61% vs 67%; P < .001) and also less likely to be discharged on an antiplatelet and statin regimen after these procedures (AAA, 60% vs 64% [P = .01]; PAD, 64% vs 67% [P < .001]). Black patients presented with more severe disease, including higher proportions of symptomatic carotid disease (36% vs 31%; P < .001), symptomatic or ruptured AAA (27% vs 16%; P < .001), and chronic limb-threatening ischemia (73% vs 62%; P < .001). Black patients more often presented with concurrent iliac artery aneurysms at the time of AAA repair (elective open AAA repair, 46% vs 26% [P < .001]; elective endovascular aneurysm repair, 38% vs 23% [P < .001]). CONCLUSIONS: Black patients present with more advanced disease at the time of initial major vascular operation. Efforts to control risk factors, identify and treat arterial disease in a timely fashion, and optimize medical management among black patients may provide opportunity to improve current disparities.

The Hachinski ischemic scale and cognition: the influence of ethnicity.

OBJECTIVE: cardiovascular burden is considered a risk factor for the development of cognitive dysfunction and dementia. While this link is well established in the literature, implementing this work in primary care settings remains a challenge. The goal of this study is to examine the utility of the Hachinski Ischemic Scale (HIS) in identifying cognitive dysfunction and diagnosis of mild cognitive impairment (MCI) in an ethnically diverse sample. METHODS: data were analysed on 517 participants (211 Mexican Americans and 306 non-Hispanic Whites) recruited from Project FRONTIER, a study of rural health. Neuropsychological measures were utilised to assess for cognitive functioning. RESULTS: among non-Hispanic Whites, HIS scores were significantly related to poorer performance on tasks of global cognition [B (SE) = -0.13 (0.06), P = 0.02], immediate memory [B (SE) = -0.85 (0.26), P < 0.001], attention [B (SE) = -1.6 (0.36), P < 0.001] and executive functioning [B (SE) = 0.46 (0.12), P < 0.001], and significantly predicted diagnosis of MCI [odds ratio (OR) = 1.4; 95% confidence interval (CI) = 1.2-1.6]. For Mexican Americans, HIS scores were significantly related to immediate memory [B (SE) = -0.78 (0.28), P = 0.01], attention [B (SE) = -0.74 (0.36), P = 0.04] and executive functioning [B (SE) = 0.37 (0.14), P = 0.01]; however, HIS scores were not significantly related to diagnosis of MCI in Mexican Americans (OR = 1.2, 95% CI = 0.96-1.4, P = 0.116). CONCLUSION: HIS scores were related to cognitive functioning; however, these results differed by ethnicity. It is possible that these findings indicate that vascular factors may increase risk for MCI among non-Hispanic Whites but not for Mexican Americans. These findings are consistent with past research that suggests risk factors for MCI may differ by ethnicity.

Financial Well-Being Among US Adults with Vascular Conditions: Differential Impacts Among Blacks and Hispanics.

Background: The ability to meet current and ongoing financial obligations, known as financial well-being (FWB), is not only associated with the likelihood of adverse health events but is also affected by unexpected health care expenditures. However, the relationship between FWB and common health outcomes is not well understood. Using data available in the Financial Well-Being Scale from the Consumer Financial Protection Bureau, we evaluated the impact of four vascular conditions-cardiovascular disease (CVD), stroke, high blood pressure (BP), and high cholesterol-on FWB and how these impacts varied between racial and ethnic groups. Methods: Using the Understanding America Survey-a nationally representative, longitudinal panel-we identified adults with self-reported diagnoses between 2014 and 2020 of high cholesterol, high BP, stroke, and CVD. We used stratified, longitudinal mixed regression models to assess the association between these diagnoses and FWB. Each condition was modeled separately and included sex, age, marital status, household size, income, education, race/ethnicity, insurance, body mass index, and an indicator of the condition. Racial and ethnic differentials were captured using group-condition interactions. Results: On average, Whites had the highest FWB Scale score (69.0, SD=21.8), followed by other races (66.7, SD=21.0), Hispanics (59.3, SD=21.6), and Blacks (56.2, SD=21.4). In general, FWB of individuals with vascular conditions was lower than that of those without, but the impact varied between racial and ethnic groups. Compared with Whites (the reference group), Blacks with CVD (-7.4, SD=1.0), stroke (-8.1, SD=1.5), high cholesterol (-5.7, SD=0.7), and high BP (6.1, SD=0.7) had lower FWB. Similarly, Hispanics with high BP (-3.0, SD=0.6) and CVD (-6.3, SD=1.3) had lower FWB. Income, education, insurance, and marital status were also correlated with FWB. Conclusions: These results indicated differences in the financial ramifications of vascular conditions among racial and ethnic groups. Findings suggest the need for interventions targeting FWB of individuals with vascular conditions, particularly those from minority groups.

Retrospective analysis of ethnic/racial disparities and excess vascular mortality associated with the COVID-19 pandemic.

The Sars coronavirus 2019 (COVID-19) pandemic has resulted in increased morbidity and mortality; however, there is limited understanding of how excess mortality is distributed among different racial and ethnic subgroups and vascular diseases. METHODS: We conducted a retrospective, cross-sectional study design using data from the United States (US) Center for Disease Control (CDC) Wide Ranging Online Data for Epidemiologic Research (Wonder) database. The database contains death certificate information for all US residents by cause of death as ascertained by the treating physician. We examined the trends of excess death by vascular disease specific mortality among different racial and ethnicity subgroups. Excess deaths were defined as the difference between observed numbers of deaths in specific time periods and the expected numbers of deaths in the same time periods. We compared mortality rates during the reference period of 2018-2019 (pre-pandemic) with the study period of 2020-2021 (pandemic years). We also compared excess mortality rates among racial and ethnic subgroups (Non-Hispanic white, Non-Hispanic Black, and Hispanic individuals). Vascular disease was categorized by administrative diagnostic codes (ICD10): Vascular disease (I26, I82, I70-73, I74) and its subtypes Arterial thrombosis (I74), venous thromboembolism (I26, I82) and atherosclerotic disease (I70-73). RESULTS: Compared to 2018-2019, there was a 1.3 % excess mortality associated with vascular disease, a 12.2 % excess mortality due to arterial thrombosis mortality, and an 8.0 % excess mortality due to thromboembolism in 2020-2021. Black individuals demonstrated higher excess vascular mortality (6.9 %) compared to white individuals (-0.3 %) P < .001, higher excess venous thromboembolism mortality (14.1 % vs 5.1 % P = 0.002) and higher atherosclerosis mortality (2.1 % vs -2.6 % P = 0.002). Hispanics compared to white individuals had higher excess vascular mortality (5.1 % vs -0.3 % P = 0.03) and excess venous thromboembolism mortality (24.2 % vs 5.1 % P < 0.001). CONCLUSION: The COVID-19 pandemic has led to a significant and persistent increase in vascular mortality. Excess mortality has disproportionately affected Black and Hispanic individuals compared to white individuals, highlighting the need for further studies to address and eliminate these health care disparities.

Are there race-dependent endothelial cell responses to exercise?

African Americans have an endothelial dysfunction that likely contributes to their high prevalence of hypertension. Endothelial cell (EC) responses to stimuli could play a role in the development of endothelial dysfunction and hypertension. High physiological levels of vascular laminar shear stress can alter EC phenotype profoundly. It is not known whether there are race-dependent EC responses to laminar shear stress.

The relationship between carotid intima-media thickness and endogenous androgens in young women with polycystic ovary syndrome in Taiwan.

Polycystic ovary syndrome (PCOS) is a common and complex female endocrinopathy that is associated with multiple vascular risk factors. Our objective was to investigate the relationship between carotid intima-media thickness (CIMT) and endogenous androgens in young Taiwanese-Chinese women with PCOS. We measured CIMT with B-mode ultrasound in 42 young PCOS patients and 43 controls. Atherosclerosis-associated profiles and endocrinological parameters were also measured. The results showed that although Taiwanese-Chinese PCOS patients tend to possess more risk factors for atherosclerosis than controls, there was no evidence to support that they have a greater CIMT at this age. Furthermore, androstenedione appears to be inversely associated with CIMT.

Fetal growth and preterm birth influence cardiovascular risk factors and arterial health in young adults: the Cardiovascular Risk in Young Finns Study.

OBJECTIVE: Impaired fetal growth is associated with cardiovascular disease in adulthood. The mechanisms of this association remain poorly described. We aimed to determine the associations of impaired fetal growth and preterm birth with cardiovascular risk factors and arterial health in a large cohort of young adults. METHODS AND RESULTS: Carotid intima-media thickness, brachial flow-mediated dilatation and cardiovascular risk factors were compared between young adults (24-45 years) born at term with impaired fetal growth (birth weight <10th percentile; n=207), born preterm (<37 weeks' gestation; n=253), and a control group born at term with normal fetal growth (birth weight 50-90th percentile; n=835), in the Cardiovascular Risk in Young Finns study. Compared with controls, those with impaired fetal growth had elevated triglycerides (P=0.006), C-reactive protein (P=0.004), low-density lipoprotein cholesterol, systolic blood pressure (both P=0.06), and intima-media thickness and impaired flow-mediated dilatation (both P=0.02), the latter partially mediated by systolic blood pressure, C-reactive protein, and triglycerides. Those born preterm had higher intima-media thickness (P=0.005) and lower flow-mediated dilatation (P=0.03) compared with controls, although this was restricted to those with concurrent fetal growth restriction. CONCLUSIONS: Impaired fetal growth is associated with impaired endothelial function and elevated preclinical atherosclerosis in young adults, partly mediated by inflammation, blood pressure, and triglycerides. This association is most marked for those also born preterm.

A simple diabetes vascular severity staging instrument and its application to a Torres Strait Islander and Aboriginal adult cohort of north Australia.

BACKGROUND: To develop an instrument that predicts diabetes-related vascular disease severity using routinely collected data on Australian Aboriginal and Torres Strait Islander adults with type 2 diabetes, in the absence of diabetes duration. METHODS: A complex diabetes severity classification system was simplified and adapted for use with an Australian Aboriginal and Torres Strait Islander adult population with type 2 diabetes in north Queensland. Detailed vascular health risks and morbidities were mapped to routinely collected measures. Individual-level health screening, hospital separation and mortality data were linked and used to plot mean monthly in-patient hospital cost and percent mortality by disease severity as defined by the newly developed instrument, to test construct validity. RESULTS: The revised instrument consists of four combined diabetes-related microvascular and macrovascular stages that range from least severe (stage 1) to severe irreversible vascular impairment (stage 4). When applied to data of an Aboriginal and Torres Strait Islander Australian population the instrument showed good construct validity, predicting higher hospital cost and mortality as vascular disease severity increased. CONCLUSIONS: This instrument discriminates between levels of diabetes-related vascular disease severity, displays good construct validity by predicting increased hospital cost and mortality with worsening severity and can be populated with routinely collected data. It may assist with future health service research and its use could be extended to practice settings for health care planning for diabetes management programs and monitoring vascular disease progression.

Differential endothelial cell gene expression by African Americans versus Caucasian Americans: a possible contribution to health disparity in vascular disease and cancer.

BACKGROUND: Health disparities and the high prevalence of cardiovascular disease continue to be perplexing worldwide health challenges. This study addresses the possibility that genetic differences affecting the biology of the vascular endothelium could be a factor contributing to the increased burden of cardiovascular disease and cancer among African Americans (AA) compared to Caucasian Americans (CA). METHODS: From self-identified, healthy, 20 to 29-year-old AA (n = 21) and CA (n = 17), we established cultures of blood outgrowth endothelial cells (BOEC) and applied microarray profiling. BOEC have never been exposed to in vivo influences, and their gene expression reflects culture conditions (meticulously controlled) and donor genetics. Significance Analysis of Microarray identified differential expression of single genes. Gene Set Enrichment Analysis examined expression of pre-determined gene sets that survey nine biological systems relevant to endothelial biology. RESULTS: At the highly stringent threshold of False Discovery Rate (FDR) = 0, 31 single genes were differentially expressed in AA. PSPH exhibited the greatest fold-change (AA > CA), but this was entirely accounted for by a homolog (PSPHL) hidden within the PSPH probe set. Among other significantly different genes were: for AA > CA, SOS1, AMFR, FGFR3; and for AA < CA, ARVCF, BIN3, EIF4B. Many more (221 transcripts for 204 genes) were differentially expressed at the less stringent threshold of FDR <.05. Using the biological systems approach, we identified shear response biology as being significantly different for AA versus CA, showing an apparent tonic increase of expression (AA > CA) for 46/157 genes within that system. CONCLUSIONS: Many of the genes implicated here have substantial roles in endothelial biology. Shear stress response, a critical regulator of endothelial function and vascular homeostasis, may be different between AA and CA. These results potentially have direct implications for the role of endothelial cells in vascular disease (hypertension, stroke) and cancer (via angiogenesis). Also, they are consistent with our over-arching hypothesis that genetic influences stemming from ancestral continent-of-origin could impact upon endothelial cell biology and thereby contribute to disparity of vascular-related disease burden among AA. The method used here could be productively employed to bridge the gap between information from structural genomics (for example, disease association) and cell function and pathophysiology.

Rationale, design, and baseline data of the Japanese Primary Prevention Project (JPPP)-a randomized, open-label, controlled trial of aspirin versus no aspirin in patients with multiple risk factors for vascular events.

BACKGROUND: Prevention of atherosclerotic disease has become an important public health priority in Japan due to the aging of the population and changes in diet and lifestyle factors. METHODS: The Japanese Primary Prevention Project (JPPP) is a multicenter, open-label, randomized, parallel-group trial that is evaluating primary prevention with low-dose aspirin in Japanese patients aged 60 to 85 years with hypertension, dyslipidemia, or diabetes mellitus. The study cohort will be followed for a mean of 4 years. The primary end point is a composite of death from cardiovascular causes (including fatal myocardial infarction [MI], fatal stroke, and other cardiovascular death), nonfatal stroke (ischemic or hemorrhagic), and nonfatal MI. Key secondary end points include a composite of cardiovascular death, nonfatal stroke, nonfatal MI, transient ischemic attack, angina pectoris, or arteriosclerotic disease requiring surgery or intervention; each component of the primary end point; noncerebrovascular and noncardiovascular death; and extracranial hemorrhage requiring transfusion or hospitalization. End point assessment is done by a central adjudication committee that is blinded to treatment assignments. RESULTS: Enrollment began in March 2005 and was completed in June 2007. A total of 14,466 patients were randomly allocated to receive enteric-coated aspirin, 100 mg/d, or no aspirin. At randomization, the study cohort had a mean (SD) age of 70.6 (6.2) years; 57.8% were women, 85.0% had hypertension, 71.7% had dyslipidemia, and 33.9% had diabetes. In the study cohort, 80.4% of patients had > or =3 risk factors. CONCLUSION: The JPPP is the largest primary prevention trial of aspirin in a Japanese population that is investigating whether the benefit of aspirin in reducing risk of vascular events outweighs any bleeding risk in elderly patients with multiple risk factors.

Don't all veins look alike? Comprehensively attending to diversity within the vascular surgical specialty.

Prior research has established diversity as a topic of empirical analysis in the vascular surgery literature. Building on the work of previously published articles on diversity in the Journal of Vascular Surgery and elsewhere, this article engages in a broad discussion of diversity in two interrelated arenas: educational/workplace diversity and culturally competent care. Interdisciplinary review of the literature indicates that diversity is often thought of as an end-state to be accomplished. A more fruitful way to encompass the changing aspects of diversity work is to think of diversity as a set of processes that can be adjusted based on a set of interrelated goals that matter differently to different groups. In considering diversity as a process, an approach to diversity emerges that considers both independent effects of gender and race/ethnicity as well as interactive effects between the two variables to address future trends in medical education. Such trends are diagnosed and multiple courses of intervention are offered as reasonable options for future efforts. A comprehensive definition of diversity will be established in order to encompass two different arenas in which diversity concerns arise: educational diversity and culturally competent patient care. Second, a discussion of the rationales for attention to diversity among vascular surgeons will provide different avenues into a conversation about diversity in the profession. In so doing, three successful efforts will be briefly discussed: the Ohio State University's MED-Path program, the Keck School of Medicine's chair-centered approach to diversity in residency training, and the American Association of Orthopedic Surgeons' (AAOS) approach to culturally competent care.

Uninsured South Florida vascular surgery patients are less likely to receive optimal medical management than their insured counterparts.

OBJECTIVE: Vascular disease is the most prevalent condition in patients aged >60 years, leading to increasing complications associated with their comorbid conditions. Poor medical compliance could be one reason why the rate of complications may be higher in this patient population, particularly the uninsured. This study was conducted to better assess rates of medication compliance in vascular surgical patients. METHODS: Consecutive patients seen in vascular clinics at a busy tertiary academic center were prospectively studied. Physicians and physician assistants used a standardized questionnaire to collect patient data and evaluated patients for coexisting medical conditions and medication use. Optimal medical therapy was defined according to the 2006 American Heart Association (AHA)/American College of Cardiology (ACC) "Guidelines for Secondary Prevention for Atherosclerotic Vascular Disease." Data were analyzed using multivariate regression. RESULTS: During the 4-month study period, 180 consecutive patients (47% men) were seen in vascular surgery clinics. Most patients (79%) were nonsmokers and only 21% admitted to smoking. Comorbid conditions surveyed included hypertension in 141, diabetes mellitus in 56, coronary artery disease in 24, hypercholesterolemia in 89, and chronic renal failure in 13; of these, 61% were insured and 39% had no insurance. Overall, only 31% of all patients were receiving adequate medical therapy for their comorbid conditions, and about 66% were receiving suboptimal medical treatment for their vascular disease. Uninsured patients were less likely (19%) than insured patients (39%) to receive optimal medical therapy (P = .012). Lack of insurance was a predictor of suboptimal medical therapy for hypertension (odds ratio [OR], 3.13; 95% confidence interval [CI], 1.20-8.16; P = .016), hypercholesterolemia (OR, 5.1; 95% CI, 1.87-13.88; P = .001), peripheral arterial disease (OR, 13.32; 95% CI, 2.84-62.54, P < .001), and any disease overall (OR, 2.43; 95% CI, 1.21-4.88, P = .012). Overall, men and women were equally likely (68%) to receive suboptimal medical therapy; however, women were significantly more likely to be undertreated for coronary artery disease (OR, 0.022; 95% CI, 0.0017-0.293; P < .001). CONCLUSIONS: Compliance with optimal medical therapy for secondary risk factor management amongst our vascular surgery patients is low. Uninsured patients are less likely to receive optimal medical therapy than their insured counterparts. This survey provides sobering statistics regarding medical compliance in our population. This issue deserves further study and may indirectly affect outcomes in minority groups that are disproportionately represented in our uninsured patients.

Changing demographics in patients with vascular disease.

The United States population with vascular disease has changed dramatically during the past 2 decades, with large increases in the proportion of Hispanic, African American, and other minority patients. Not only has the number of these patients increased, but the types and distribution of vascular disease in minority populations is also different from that encountered in non-Hispanic whites. Although genetic makeup accounts for some of these differences, access to vascular care is also an important determinant, with many minority patients presenting late in the course of the disease process. These factors create significant challenges for the vascular specialists caring for these patients. The vascular surgery workforce is composed of >90% white men and does not currently represent the changes in the population of patients with vascular disease. In addition, women with vascular disease comprise up to 50% of many vascular surgery practices. In many parts of the country, Hispanics and African Americans outnumber non-Hispanic whites with vascular disease. Yet, women and minority physicians are still significantly under-represented in the field of vascular surgery. This year's E. Stanley Crawford Critical Issues Forum at the Society for Vascular Surgery meeting addressed the disconnect between the vascular surgery workforce and the patients whom we serve. This article reviews the projected demographic changes in the population of the United States, which supports the need for training a vascular surgery workforce that is more diverse. This article also reviews the current status of minority and female representation in medical schools, surgical training programs, and vascular surgery programs in the United States.

Spontaneous Coronary Artery Dissection: Clinical Characteristics, Management, and Outcomes in a Racially and Ethnically Diverse Community-Based Cohort.

CONTEXT: Spontaneous coronary artery dissection (SCAD) is a cause of acute coronary syndrome, which predominantly affects healthy women; however, few data define this vulnerable population. OBJECTIVE: To identify demographic and clinical characteristics of patients with SCAD and determine outcomes in a community-based cohort. DESIGN: Retrospective cohort study of patients with SCAD at Kaiser Permanente Northern California during a 10-year period. We compared 111 SCAD cases with 333 healthy, matched controls. MAIN OUTCOME MEASURES: Predisposing factors, treatment modalities, and inhospital and late outcomes. RESULTS: Patients with SCAD had a mean age (standard deviation) of 48.1 (11) years; 92.8% were women, and 49.5% were nonwhite. Of women, 9% were peripartum. Fibromuscular dysplasia was identified in 21.8% of femoral angiograms obtained. With conditional logistic regression, only pregnancy and hyperlipidemia were associated with SCAD compared with controls. Fifty-five patients (49.5%) were successfully treated without revascularization; of the 54 who had urgent percutaneous coronary intervention, 2 required coronary artery bypass grafting for SCAD extension. During a median follow-up of 2.6 years, major adverse cardiovascular events occurred in 8.1% of patients. Pregnancy-related SCAD was not associated with worsened outcomes. However, Emergency Department visits or hospitalizations because of recurrent chest pain occurred frequently for 54% of patients with SCAD. CONCLUSION: The study cohort is comparable to published SCAD cohorts, but notable for a racially and ethnically diverse population. Compared with the controls, only pregnancy and hyperlipidemia were associated with SCAD. For the SCAD cases, major adverse cardiovascular events occurred in 8.1%, and race did not influence outcomes.

A population-based analysis of the health experience of African Nova Scotians.

BACKGROUND: People of African descent living in Britain and the United States have higher rates of morbidity from chronic disease than among the general population. We investigated whether the same applied to people of African descent living in a Canadian province. METHODS: We used administrative data to calculate 10-year cumulative incidence rate ratios for the period 1996-2005 for treated circulatory disease, diabetes mellitus and psychiatric disorders in Preston (population 2425), a community of predominantly African Nova Scotians. We used data for the province of Nova Scotia as a whole as the population reference standard. We also calculated 10-year incidence rate ratios for visits to family physicians and specialists and for admissions to hospital. We compared these findings with those in 7 predominantly white communities in Nova Scotia with otherwise similar socio-economic characteristics. RESULTS: In the province as a whole, we identified 787,787 incident cases for the 3 disease groups over the 10-year period. Incidence rate ratios for the community of interest relative to the provincial population were significantly elevated for the 3 diseases: circulatory disease (1.19, 95% CI 1.08-1.29), diabetes (1.43, 95% CI 1.21-1.64) and psychiatric disorders (1.13, 95% CI 1.06-1.20). Incidence rate ratios in the community of interest were also higher than those in the comparison communities. Visits to family physicians and specialists for circulatory disease and diabetes were similarly elevated, but the pattern was less clear for visits for psychiatric disorders and hospital admissions. INTERPRETATION: African Nova Scotians had higher morbidity levels associated with treated disease, which could not be explained by socio-economic characteristics, recent immigration or language. Apart from psychiatric disorders, use of specialist services was consistent with morbidity. Further study is needed to investigate the relative contribution of genetic, biological, behavioural, psychosocial and environmental factors.

Race and risk of maternal vascular malperfusion lesions in the placenta.

INTRODUCTION: The biological mechanisms that underlie racial disparities in placenta-mediated pregnancy complications remain unknown. Placental evidence of maternal vascular malperfusion (MVM), a common pathologic feature of these outcomes, represents hypoxic-ischemic damage to the placenta. We sought to separately estimate the risk of MVM and individual lesions associated with maternal race. METHODS: This was a retrospective cohort study of black and white women with singleton live births and placental pathology data at Magee-Womens Hospital during 2008-2012 (n = 15,581). MVM consisted of ≥1 individual lesions: low placental weight, decidual vasculopathy, accelerated villous maturation, infarcts, and fibrinoid deposition. We separately compared the incidence of MVM and individual lesions in black and white women using logistic regression with generalized estimating equations. RESULTS: After adjusting for covariates, black women had increased risks of MVM (aOR 1.14, 95% CI 1.05-1.23), low placental weight (aOR 1.41, 95% CI 1.28-1.55), and decidual vasculopathy (aOR 1.58, 95% CI 1.36-1.83), also observed in uncomplicated, preterm, and term births. Conversely, black women had decreased risk of infarcts (aOR 0.84, 95% CI 0.75-0.95) compared with white women, also observed in uncomplicated and full-term births. Race was not associated with accelerated villous maturation or fibrinoid deposition. Inverse probability weighting to account for potential selection bias generated similar results. DISCUSSION: Our findings suggest that excess risks of MVM, specifically low placental weight and decidual vasculopathy in black women may be due to a pathological susceptibility to an underlying high-risk vascular phenotype. The clinical significance of race differences in the occurrence of infarcts warrants further investigation.

Cognitive status, stroke symptom reports, and modifiable risk factors among individuals with no diagnosis of stroke or transient ischemic attack in the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study.

BACKGROUND AND PURPOSE: Vascular disorders that increase risk for stroke may be accompanied by decrements in cognitive functioning and by stroke symptoms in the absence of diagnosed stroke or transient ischemic attack. This study evaluates relationships among cognitive status, stroke symptom reports, and cardiovascular and behavioral factors. METHODS: REasons for Geographic and Racial Differences in Stroke (REGARDS), a prospective population study of stroke incidence, assesses stroke risk with telephone interviews and in-home physicals. Excluding subjects with a history of stroke or transient ischemic attack, this analysis includes 14,566 black and white men and women > or =45 years of age. Incremental logistic models examine baseline relationships among cognitive status (Six-item Screener scores), stroke symptom reports, demographics, health behaviors, cardiovascular indices, and depressive symptoms. RESULTS: A history of stroke symptoms was related to impaired cognitive status after adjusting for age, gender, race, and education but not after adjusting for poor health behaviors, vascular risk factors, and depressive symptoms. Odds of experiencing a stroke symptom increased 35% with each of five modifiable factors (hypertension, diabetes, smoking, lack of exercise, depressive symptoms), and odds of cognitive impairment increased an additional 12% with each modifiable factor. Lifelong abstinence from alcohol, lack of exercise, and depressive symptoms were independently related to impaired cognitive status. CONCLUSIONS: The increased likelihood of cognitive impairment among subjects reporting stroke symptoms in the absence of a diagnosed stroke or transient ischemic attack suggests that such symptoms are not benign and may warrant clinical evaluation that includes a cognitive assessment. Future studies that include brain imaging may clarify the etiology of these symptoms.

The vascular effects of metabolic impairment clusters in subjects of different ethnicities.

BACKGROUND: Although metabolic syndrome affects vascular function, the impact of individual impairments and their clustering is unclear. OBJECTIVE: To assess the vascular impact of metabolic impairments before they reach treatment thresholds in different ethnic groups. METHODS: Metabolic variables, inflammatory markers, endothelium dependent vasodilatation (EDV) and carotid intima media thickness (CIMT) were measured in population samples of 82 Caucasians and 78 matched Afro-Caribbeans with no vascular disease. Insulin resistance was assessed using homeostasis model assessment (HOMA-IR). EDV was measured as the change in the height of the inflection point of the digital volume pulse following intravenous infusion of 5 mcg/min of albuterol (DeltaRIDeltaLB). Regression models were used to investigate the independent effects of metabolic impairment clusters and their interaction with ethnicity on EDV and CIMT. RESULTS: HOMA-IR (2.4-3.8, p < 0.0001), IL-6 levels (1.1-2.8 pg/mL, p = 0.02) and CIMT (0.71-0.83 mm, p = 0.009) increased whereas in DeltaRIBASELINE (77.6-72.9 percentage points, p < 0.0001) and DeltaRIDeltaLB (15.5-7.1 percentage points, p < 0.0001) decreased with the number of metabolic impairments present. DeltaRIDeltaLB decreased by 1.6 (95% CI 0.2-3.7) percentage points and CIMT increased by 0.06 (95% CI 0.02-0.10) mm for each metabolic impairment present after adjusting for age, gender, ethnicity and HOMA-IR. There were significant interactions between Afro-Caribbean ethnicity and metabolic impairments for IL-6 (p = 0.037) and DeltaRIDeltaLB (p = 0.002). CONCLUSIONS: Clustering of metabolic impairments is associated with inflammatory activation, impaired EDV and increased CIMT even before reaching treatment thresholds for individual impairments. This effect was more marked in Afro-Caribbean subjects.

Impaired endothelial function in healthy African-American adolescents compared with Caucasians.

OBJECTIVE: To determine whether African-American adolescents have endothelial dysfunction compared with Caucasians and whether differences are a result of differences in insulin sensitivity calculated from total glucose (S(I)) or secretion. STUDY DESIGN: Thirty-three Caucasian (13.6 +/- 2.6 years of age; body mass index [BMI] 21.6 +/- 4.4 kg/m2 mean +/- SD) and 25 African-American (13.3 +/- 2.9 years of age; BMI 24.0 +/- 4.4 kg/m2) adolescents were studied. Forearm blood flow (FBF; plethysmography) was measured before and after 5 minutes of arterial occlusion. S(I) and acute insulin response to glucose (AIRG) were measured using intravenous glucose tolerance tests and minimal modeling. RESULTS: Baseline FBF did not differ between races. Postocclusion FBF was lower in African-Americans (17.2 +/- 1.2 vs 22.6 +/- 1.2 mL/dL/minute, P = .006). AIRG was higher in African-Americans (6050 +/- 940 vs 2410 +/- 30 microU minute/mL, P = .001). Pubertal stage had no effect. S(I) did not differ by race or pubertal stage. In African-Americans, percent fall in FVR following arterial occlusion correlated (r = 0.67, P = .001) with log AIRG. No relationships were found between percent fall in FVR and S(I) in either race. CONCLUSION: African-American adolescents have decreased endothelial function. This may be a result of increased insulin secretion. Endothelial dysfunction in African-American adolescents may predispose to cardiovascular and type II diabetes.