Geographic Distribution of Social Service Resources for Stroke Survivors in Ohio Varies by Rurality.

BACKGROUND: Both social service resources and stroke prevalence vary by geography, and health care resources are scarcer in rural areas. We assessed whether distributions of resources relevant to stroke survivors were clustered around areas of the highest stroke prevalence in Ohio and whether this is varied by rurality using an ecological study design. METHODS: Census tract (CT)-level self-reported stroke prevalence estimates (Centers for Disease Control and Prevention PLACES-2019 Behavioral Risk Factor Surveillance System) were linked with sociodemographic and rurality data (2019 American Community Survey) and geographic density of resources in Ohio (2020 findhelp data). Resources were grouped into categories: housing, in-home, financial, transportation, education, and therapy. Negative binomial regression models estimated the mean number of resources within 25 miles and 30 minutes of a CT centroid and quartiles of stroke prevalence for each resource group by rurality status (rural, urban, and suburban). Models were sequentially adjusted for total population and CT demographics. RESULTS: In Ohio, stroke prevalence was 3.9% (0.4%-14.2%). The highest stroke prevalence quartile (versus lowest) was associated with fewer resources within 25 miles overall (resource ratio [RR], 0.57-0.98). The most pronounced disparities were in rural CT; rural CTs with the highest quartile stroke prevalence had fewer housing (RR, 0.49 [95% CI, 0.32-0.75]), in-home (RR, 0.31 [95% CI, 0.20-0.49]), and therapy (RR, 0.23 [95% CI, 0.13-0.43]) resources compared with those with the lowest quartile stroke prevalence (reference: mean, 1.2 housing, 5.1 in-home, and 4.9 therapy resources, respectively). Rural disparities no longer persisted after adjustment for federal poverty limit (rural: housing [RR, 0.69 (95% CI, 0.40-1.20)], in-home [RR, 0.65 (95% CI, 0.34-1.23)], and therapy [RR, 0.66 (95% CI, 0.33-1.32)]). CONCLUSIONS: Stroke social service resources are inversely distributed relative to stroke prevalence in Ohio, particularly in rural areas. This inverse link in rural Ohio is likely explained by geographic differences in poverty. Stroke-specific resource-related interventions may be needed and should consider the roles of rurality and poverty.

Changes in Hydroxyurea Use Among Youths Enrolled in Medicaid With Sickle Cell Anemia After 2014 Revision of Clinical Guidelines.

Importance: Youths with sickle cell anemia (SCA) are at risk of pain crises, stroke, and early death. Complications can be reduced by the oral disease-modifying medication hydroxyurea, and in 2014, the National Heart, Lung, and Blood Institute published revised guidelines that hydroxyurea should be offered to youths aged 9 months and older with SCA regardless of disease severity. Objective: To describe changes in hydroxyurea use among youths with SCA before and after release of the National Heart, Lung, and Blood Institute guidelines. Design, Setting, and Participants: This cross-sectional study was conducted using administrative data from 2010 to 2018 from Michigan and New York State (NYS) Medicaid programs. The study population included youths aged 1 to 17 years with SCA enrolled in the Michigan or NYS Medicaid programs for at least 1 year (Michigan: 2010-2018; NYS: 2012-2018). Youths with SCA were identified using validated claims-based definitions. Data were analyzed from June to October 2020. Main Outcomes and Measures: The main outcome was hydroxyurea use characterized as mean annual counts of days' supply of filled hydroxyurea prescriptions. Rates of hydroxyurea use over time were assessed using regression models (Michigan: zero-inflated negative binomial; NYS: negative binomial). Models included indicators for periods before and after guideline release. Results: A total of 4302 youths with SCA (2236 males [52.0%]; 2676 born 2005-2017 [62.2%]; 150 Hispanic [3.5%], 2929 non-Hispanic Black [68.0%], and 389 non-Hispanic White [9.0%]) contributed 12 565 person-years. The mean (SD) annual days' supply of hydroxyurea was 47.2 (93.6) days per youth in Michigan and 97.4 (137.0) days per youth in NYS. In Michigan, there was an increase in the odds of having nonzero days' supply after the guidelines were released (odds ratio, 1.52; 95% CI, 1.07-2.14). In NYS, no change was seen in the mean days' supply of filled hydroxyurea. Conclusions and Relevance: These findings suggest that hydroxyurea was substantially underused among youths with SCA, despite establishment as the primary disease-modifying therapy for SCA, and that there was incomplete clinician or patient uptake of newly released guidelines. Results suggest that expanding use of hydroxyurea may require a multifaceted approach that includes addressing multiple system- and patient-level barriers.

Examining trends in health care access measures among low-income adult smokers in Ohio: 2012-2019.

Smokers are more likely to be low-income with limited access to health services. Although Medicaid expansion under the Patient Protection and Affordable Care Act improved access to care for low-income adults, long-term trends in health care access among low-income smokers remain uncharacterized. The study evaluated changes in five access measures among low-income nonelderly (19-64) adults (N = 28976) across smoking status using pooled data from a statewide survey in Ohio covering pre- (i.e., 2012) and post-Medicaid expansion periods (2015, 2017, and 2019) guided by a comprehensive framework of health care access. We found improvements in some, but not all, health care access measures among low-income smokers in the post-Medicaid-expansion period compared to the pre-expansion period. Compared to 2012, the odds for unmet dental care needs declined in 2015 (aOR = 0.67, 95 % CI = 0.45-1.01), 2017 (aOR = 0.53, 95 % CI = 0.35-0.81), and 2019 (aOR = 0.65, 95 % CI = 0.40-1.05) (p trend < 0.001). Similarly, the odds for unmet other health care needs (i.e., medical exams and supplies) were lower in 2015 (aOR = 0.64, 95 % CI = 0.39-1.06), 2017 (aOR = 0.56, 95 % CI = 0.34-0.93), and 2019 (aOR = 0.47, 95 % CI = 0.27-0.83) (p trend < 0.001). Difficulty paying medical bills was also significantly lower in 2015 (aOR = 0.62, 95 % CI = 0.43-0.89), 2017 (aOR = 0.57, 95 % CI = 0.39-0.83) and 2019 (aOR = 0.57, 95 % CI = 0.37-0.87) (p trend < 0.001). While there was notable progress in measures of affordability (i.e., paying medical bills) as well as care availability and accommodation (i.e., unmet needs), there were no meaningful changes in the approachability of care (i.e., having a usual source of care).

Relation Between Smoking Status and Subjective Cognitive Decline in Middle Age and Older Adults: A Cross-Sectional Analysis of 2019 Behavioral Risk Factor Surveillance System Data.

BACKGROUND: Smoking status may influence subjective cognitive decline (SCD); however, few studies have evaluated this association. OBJECTIVE: To assess whether smoking status is associated with SCD among middle age and older adults, and to determine if this association is modified by sex at birth. METHODS: A cross-sectional analysis was conducted using data from the 2019 Behavioral Risk Factor Surveillance System (BRFSS) survey to analyze the relationship between SCD and smoking status (current, recent former, and remote former). Eligible respondents included participants 45 years of age or older who responded to the SCD and tobacco questions of interest. Survey-weighted Poisson regression models were employed to estimate the crude and adjusted prevalence ratios (cPR/aPR) and corresponding 95% confidence intervals (CI) of the association between smoking status and SCD. A Wald test was computed to determine the significance of the interaction term between smoking status and sex (α= 0.05). RESULTS: There were 136,018 eligible respondents, of which approximately 10% had SCD. There was a graded association between smoking and SCD, with the greatest prevalence of SCD among current smokers (aPR = 1.87; CI: 1.54, 2.28), followed by recent former smokers (aPR = 1.47; 95% CI: 1.02, 2.12), and remote former smokers (aPR = 1.11; 95% CI: 0.93, 1.33) each compared to never smokers. There was no evidence of effect modification by sex (p interaction = 0.73). CONCLUSION: The consistency of smoking as a risk factor for objective and subjective cognitive decline supports the need for future studies to further the evidence on whether changes to smoking status impacts cognition in middle age.

Historic redlining in Columbus, Ohio associated with stroke prevalence.

BACKGROUND: Racial disparities exist in stroke and stroke outcomes. In an ecologic study, using the Home Owners' Loan Corporation (HOLC) "redlining" scores, as indicator of historic racialized lending practices, we hypothesized that census tracts with high historic redlining are associated with higher stroke prevalence. METHODS: Weighted historic redlining scores (HRS) were calculated using the proportion of 1930s HOLC residential security grades contained within 2010 census tract boundaries of Columbus, Ohio. Stroke prevalence (adults >=18) was obtained at the census tract-level from the CDC's 500 Cities Project. Sociodemographic census tract level data (American Community Survey 2014-2018) were considered mediators in the causal association between historic redlining and stroke prevalence and were not controlled for in regression analysis. HRS and stroke prevalence associations were evaluated with and without adjustment for proportion of census tract 65 years and older. RESULTS: Census tracts in the highest quartile of HRS (greater redlining) had 1.73% higher stroke prevalence compared to those in the lowest quartile (95% CI:0.41,3.05) adjusting for proportion 65 years and older. No other interquartile differences were observed. CONCLUSIONS: Historic redlining practices are a form of structural racism that established geographic systems of disadvantage and consequently, poor health outcomes. Our findings demonstrate disparate stroke prevalence by degree of historic redlining in census tracts across Columbus, Ohio.

Transferrin predicts trimethylamine-N-oxide levels and is a potential biomarker of cardiovascular disease.

INTRODUCTION: Trimethylamine-N-oxide (TMAO) is a circulating biomarker associated with cardiovascular disease (CVD). Production of TMAO is facilitated by gut microbiota and dependent on micronutrients such as choline, betaine, and L-carnitine, present in foods such as red meat and eggs. HYPOTHESIS: We sought to predict serum TMAO quartile levels among healthy individuals at increased risk of CVD using clinical data via an ordinal logistic model. METHODS: Data from participants (n = 127) enrolled in a longitudinal observational study on CVD were used to build a predictive model for TMAO using ordinal logistic regression with demographic variables and 40 other variables considered related to CVD risk. First, univariate models for each covariate were tested (with serum TMAO quartiles as the dependent variable), and only variables with P < 0.30 were evaluated further. Second, demographic variables (age, gender, white vs. non-white race) were included in a multivariable model with each previously identified independent variable controlling for potential confounding. Last, the final model included fixed demographics and candidates from the confounder-adjusted model with P < 0.10. RESULTS: Eight candidate variables were included in the final model, with only transferrin, high-density lipoprotein cholesterol (HDL-C) and race (white vs. non-white) showing significant associations with TMAO. Participants had 0.16 (Q2), 0.31 (Q3), and 0.20 (Q4) odds of being in a higher TMAO quartile compared with participants in the lowest transferrin quartile. Non-white participants had 2.92 times higher odds of being in the highest TMAO quartile compared to white individuals. Participants in the second quartile of HDL-C had 2.68 times higher odds of being in a higher TMAO quartile compared with participants in the lowest HDL-C quartile. CONCLUSIONS: Transferrin demonstrated a significant predictive association with TMAO and may represent a novel potential biomarker of increased CVD risk worthy of further study. These results warrant further examination of iron, metabolism, homeostasis, and gut microbiome to better understand and mitigate known increased CVD risk.

Motor vehicle-related electric scooter injuries in the US: A descriptive analysis of NEISS data.

INTRODUCTION: The introduction of scooter-share programs across the United States has led to an increased incidence of electronic scooter (e-scooter) injuries presenting to emergency departments (EDs). As legislation begins to push scooters from the sidewalk to the street, injuries resulting from collisions between e-scooters and motor vehicles are an important, but poorly characterized consideration. This study leverages data from a national injury surveillance system to characterize e-scooter versus motor vehicle collisions resulting in ED presentation. METHODS: This study utilizes data from the National Electronic Injury Surveillance System (NEISS). NEISS was queried for e-scooter-related injuries from January 1st, 2015 through December 31st, 2019. Injuries were characterized as motor vehicle-related (MV-involved) or non-motor-vehicle-related (MV-uninvolved) based on a manual review by the study investigators. Weighted tabular analyses were used to characterize both types of e-scooter injuries across demographic, diagnostic, and event-related factors. RESULTS: Over the study period an estimated 60,554 (95% CI: 37,525-84,594) injuries were treated in US EDs. Approximately 19% of these injuries involved motor vehicles. Those sustaining MV-involved injuries were significantly younger (p = 0.01), with a higher proportion of males injured (p = 0.01). Additionally, when compared to MV-uninvolved injuries, a significantly higher proportion of those with MV-involved injuries were admitted to the hospital for treatment (8.8% vs. 14.6%, p < 0.01). MV-involved injuries occurred primarily in the street (96.3%), while MV-uninvolved injuries were split across streets (44.0%), at one's home (~20%), and on public property (~20%) (p < 0.01). CONCLUSIONS: Electric scooter injuries involving a motor vehicle differed from those that did not across several key categories. As e-scooters and motor vehicles start to share the road more frequently, greater consideration should be made regarding how these two modes of transportation interact with each other. The promotion of thoughtful e-scooter legislation and infrastructure changes could help promote safer travel.

Alzheimer's Disease and Related Disorders Prevalence Differs by Appalachian Residence in Ohio.

BACKGROUND: Areas within the Appalachian region may have a greater burden of under diagnosed Alzheimer's disease and related disorders (ADRD). OBJECTIVE: To estimate the prevalence of ADRD in the Appalachian counties of Ohio, and to determine if differences exist by geographic location (Appalachian/non-Appalachian and rural/urban) and across time among Medicare beneficiaries. METHODS: Centers for Medicare and Medicaid Services Public Use Files from 2007-2017 were used to estimate county-level ADRD prevalence among all fee-for-service beneficiaries in Ohio. Negative binomial regression was used to estimate prevalence overall, by Appalachian Regional Commission's Appalachian/non-Appalachian designation, and by rural/urban (Rural-Urban Continuum Codes) classification. Models were repeated, adjusting for county-level demographics and comorbidities. RESULTS: The prevalence of ADRD varied by both Appalachian residence and rural status (p = 0.008). Before adjustment by county-level demographics and comorbidities, the prevalence of ADRD in urban Appalachian counties was 1-3% lower than in urban non-Appalachian counties, while rural Appalachian counties had 2-3% higher prevalence compared to rural non-Appalachian counties. After adjustment, the differences between prevalence ratios were accentuated; the prevalence ratio was consistently higher for rural Appalachian counties, yet varied across the study period for urban counties (1.03 in 2007 to 0.97 in 2017). CONCLUSION: The results suggest a disparate burden of ADRD in Ohio with higher prevalence in rural Appalachian counties. This potential difference by Appalachian region is important to consider for availability of services and subsequent delivery of care. In order to better understand the disparity, further epidemiologic studies are necessary to better estimate the burden of ADRD.

Synergism of Short-Term Air Pollution Exposures and Neighborhood Disadvantage on Initial Stroke Severity.

BACKGROUND AND PURPOSE: Little is known about the relation between environment and stroke severity. We investigated associations between environmental exposures, including neighborhood socioeconomic disadvantage and short-term exposure to airborne particulate matter <2.5 µm and ozone, and their interactions with initial stroke severity. METHODS: First-ever ischemic stroke cases were identified from the Brain Attack Surveillance in Corpus Christi project (2000-2012). Associations between pollutants, disadvantage, and National Institutes of Health Stroke Scale were modeled using linear and logistic regression with adjustment for demographics and risk factors. Pollutants and disadvantage were modeled individually, jointly, and with interactions. RESULTS: Higher disadvantage scores and previous-day ozone concentrations were associated with higher odds of severe stroke. Higher levels of particulate matter <2.5 µm were associated with higher odds of severe stroke among those in higher disadvantage areas (odds ratio, 1.24; 95% confidence interval, 1.00-1.55) but not in lower disadvantage areas (odds ratio, 0.82; 95% confidence interval, 0.56-1.22; P interaction =0.097). CONCLUSIONS: Air pollution exposures and neighborhood socioeconomic status may be important in understanding stroke severity. Future work should consider the multiple levels of influence on this important stroke outcome.

The role of the environment in falls among stroke survivors.

BACKGROUND: Stroke survivors' risk of falls may be particularly sensitive to the environment due to deficits such as visuospatial neglect or homonymous hemianopia. We sought to identify the prevalence of falls among stroke survivors and investigate the possible role of the environment in falling. MATERIALS AND METHODS: Data from the National Health and Aging Trends Study (NHATS), a nationally representative population of community-dwelling adults over 65, were used. We compared the prevalence of falling in the past month between stroke survivors and demographic and comorbidity matched controls using sequential Poisson regression models. RESULTS: The proportion of stroke survivors reporting a fall in the previous month was 18.8% compared to 10.8% among matched controls (PR: 1.74; 95% CI: 1.36-2.25). These differences were attenuated after adjusting for known confounders, mediators and aspects of the environment (PR: 1.17; 95% CI: 0.86-1.60). Indoor tripping hazards were associated with falls (PR: 1.24; 95% CI: 1.01-1.53). The association between stroke and falls was modified by neighborhood social disorder, such that in areas of low social disorder, falls in the previous month were more common in stroke survivors compared to non-stroke controls. CONCLUSIONS: The difference in falls among stroke survivors and matched controls is largely explained by known risk factors and physical capacity. Indoor tripping hazards were associated with falls among stroke survivors and matched controls. Explanations of why the association between stroke and falls was protective in areas of high social disorder are unclear, but may warrant additional research.

Short-term exposures to ambient air pollution and risk of recurrent ischemic stroke.

OBJECTIVE: To investigate the association between short-term changes in ambient pollution (particulate matter <2.5µm in aerodynamic diameter (PM2.5) and ozone (O3)) and the risk of recurrent ischemic stroke among individuals living in a bi-ethnic community. METHODS: We identified recurrent ischemic stroke cases from the population-based Brain Attack Surveillance in Corpus Christi (BASIC) project between 2000 and 2012. Associations between PM2.5 (mean 24-h) and O3 (maximal 8-h) levels, measured on the previous day, and odds of ischemic stroke were assessed using a time-stratified case-crossover design and modeled using conditional logistic regression. RESULTS: There were 317 recurrent ischemic strokes after excluding 41 strokes that occurred on days with missing air pollution data. Mean age was 72 years (SD=12) and median time to stroke recurrence was 1.1 years (IQR: 0.2-2.8 years). Median levels of PM2.5 and O3 over the study period were 7.7µg/m3 (IQR: 5.6-10.7µg/m3) and 35.2 ppb (IQR: 25.0-46.1 ppb), respectively. We observed no associations between previous-day PM2.5 and O3 and odds of recurrent stroke (OR=0.95 per 10µg/m3 of PM2.5, 95% CI: 0.71-1.28 and OR=0.97 per 10ppb of O3, 95% CI: 0.87-1.07) after adjusting for ambient temperature and relative humidity. Co-adjustment of both pollutants did not change the results. CONCLUSION: We found no evidence of associations between previous-day air pollution levels and recurrent ischemic stroke. Research on the influence of air pollutants on risk of stroke recurrence is still in its infancy, and more research is necessary in studies that are adequately powered to understand the relation.

Change in Neighborhood Characteristics and Change in Coronary Artery Calcium: A Longitudinal Investigation in the MESA (Multi-Ethnic Study of Atherosclerosis) Cohort.

BACKGROUND: Although some evidence shows that neighborhood deprivation is associated with greater subclinical atherosclerosis, prior studies have not identified what aspects of deprived neighborhoods were driving the association. METHODS: We investigated whether social and physical neighborhood characteristics are related to the progression of subclinical atherosclerosis in 5950 adult participants of the MESA (Multi-Ethnic Study of Atherosclerosis) during a 12-year follow-up period. We assessed subclinical disease using coronary artery calcium (CAC). Neighborhood features examined included density of recreational facilities, density of healthy food stores, and survey-based measures of availability of healthy foods, walking environment, and social environment. We used econometric fixed-effects models to investigate how change in a given neighborhood exposure is related to simultaneous change in subclinical atherosclerosis. RESULTS: Increases in density of neighborhood healthy food stores were associated with decreases in CAC (mean changes in CAC Agatston units per 1-SD increase in neighborhood exposures, -19.99; 95% confidence interval, -35.21 to -4.78) after adjustment for time-varying demographic confounders and computed tomography scanner type. This association remained similar in magnitude after additional adjustment for time-varying behavioral risk factors and depression. The addition of time-varying biomedical factors attenuated associations with CAC slightly (mean changes in CAC per 1-SD increase in neighborhood exposures, -17.60; 95% confidence interval, -32.71 to -2.49). Changes across time in other neighborhood measures were not significantly associated with within-person change in CAC. CONCLUSIONS: Results from this longitudinal study provide suggestive evidence that greater access to neighborhood healthy food resources may slow the development of coronary atherosclerosis in middle-aged and older adults.

Care Received by Elderly US Stroke Survivors May Be Underestimated.

BACKGROUND AND PURPOSE: Previous studies exploring stroke-related caregiving focused solely on informal caregiving and a relatively limited set of activities. We sought to determine whether, and at what cost, stroke survivors receive more care than matched controls using an expanded definition of caregiving and inclusion of paid caregivers. METHODS: Data were drawn from the National Health and Aging Trends Study (NHATS), a nationally representative survey of Medicare beneficiaries. NHATS personnel conducted in-person interviews with respondents or proxies to determine the weekly hours of care received. We compared hours of assistance received between self-reported stroke survivors (n=892) and demography- and comorbidity-matched nonstroke controls (n=892). The annual cost of stroke caregiving was estimated using reported paid caregiving data and estimates of unpaid caregiving costs. RESULTS: Of community-dwelling elderly stroke survivors, 51.4% received help from a caregiver. Stroke survivors received an average of 10 hours of additional care per week compared with demography- and comorbidity-matched controls (22.3 hours versus 11.8 hours; P<0.01). We estimate that the average annual cost for caregiving for an elderly stroke survivor is ≈$11 300 or ≈$40 billion annually, for all elderly stroke survivors, of which $5000 per person, or $18.2 billion annually, is specific to stroke. CONCLUSIONS: Although stroke survivors are known to require considerable caregiving resources, our findings suggest that previous assessments may underestimate hours of care received and hence costs.

Expiratory Positive Airway Pressure for Sleep Apnea after Stroke: A Randomized, Crossover Trial.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) is common after stroke and predicts poor outcomes. Continuous positive airway pressure (CPAP) treats OSA but is generally poorly tolerated by stroke patients. We assessed whether nasal expiratory positive airway pressure (EPAP), an alternative to CPAP, may be an effective option after acute stroke. METHODS: We conducted a randomized, controlled, two-period crossover study in which each acute ischemic stroke patient received 1 night of EPAP and 1 night without EPAP while OSA was monitored with a validated device, the Watch-PAT 200. Linear repeated- measures analyses were conducted. Sample size calculations indicated that 18 subjects would be required to detect a 10-point or larger average reduction in the apnea-hypopnea index (AHI, the primary outcome), with use of EPAP, with power ≥ 80% and α = 0.05. RESULTS: Among the 19 subjects who completed the protocol, nasal EPAP treatment was associated with a nonsignificant absolute difference in AHI of -5.73 events/h in the primary analysis (p = 0.183, 95% confidence interval -14.4, 2.97) and a nonsignificant absolute difference in AHI of -5.43 events/h in the subgroup of patients who used nasal EPAP for ≥ 3 h (p = 0.314, 95% confidence interval -16.6, 5.76). CONCLUSIONS: This study suggests that EPAP is not an effective alternative to CPAP in acute stroke patients with OSA. Further work is needed to identify other more effective alternatives. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT01703663.

Mexican Americans are Less Likely to Return to Work Following Stroke: Clinical and Policy Implications.

BACKGROUND: Greater poststroke disability and U.S. employment policies may disadvantage minority stroke survivors from returning to work. We explored ethnic differences in return to work among Mexican Americans (MAs) and non-Hispanic whites (NHWs) working at the time of their stroke. METHODS: Stroke patients were identified from the population-based BASIC (Brain Attack Surveillance in Corpus Christi) study from August 2011 to December 2013. Employment status was obtained at baseline and 90-day interviews. Sequential logistic regression models were built to assess ethnic differences in return to work after accounting for the following: (1) age (<65 versus ≥65); (2) sex; (3) 90-day National Institutes of Health Stroke Scale (NIHSS); and (4) education (lower than high school versus high school or higher). RESULTS: Of the 729 MA and NHW stroke survivors who completed the baseline interview, 197 (27%) were working at the time of their stroke, of which 125 (63%) completed the 90-day outcome interview. Forty-nine (40%) stroke survivors returned to work by 90 days. MAs were less likely to return to work (OR = .45, 95% CI .22-.94) than NHWs. The ethnic difference became nonsignificant after adjusting for NIHSS (OR = .59, 95% CI .24-1.44) and further attenuated after adjusting for education (OR = .85, 95% CI .32- 2.22). CONCLUSIONS: The majority of stroke survivors did not return to work within 90 days of their stroke. MA stroke survivors were less likely to return to work after stroke than NHW stroke survivors which was due to their greater neurological deficits and lower educational attainment compared with that of NHW stroke survivors. Future work should focus on clinical and policy efforts to reduce ethnic disparities in return to work.

Ethnic differences in ambient air pollution and risk of acute ischemic stroke.

OBJECTIVES: To investigate the association between short-term changes in ambient pollution (particulate matter <2.5 µm in aerodynamic diameter (PM2.5) and ozone (O3)) and the risk of ischemic stroke among individuals living in a bi-ethnic community and whether this association is modified by ethnicity. METHODS: We identified incident ischemic stroke cases from the population-based Brain Attack Surveillance in Corpus Christi (BASIC) project between 2000 and 2012. Associations between PM2.5 (mean 24-h) and O3 (maximal 8-h) levels, measured on the same-day and lags of 1-3 days, and odds of ischemic stroke were assessed using a time-stratified case-crossover design and modeled using conditional logistic regression. We explored race/ethnicity (Mexican American versus non-Hispanic white) as a modifier by including interaction terms in the models. RESULTS: There were 2948 ischemic strokes with median age 71 years (IQR: 59-80). We observed no overall associations between the air pollutants and odds of ischemic stroke at any lag. When stratified by ethnicity, higher O3 was consistently associated with greater odds of ischemic stroke for non-Hispanic whites, but not for Mexican Americans. Higher PM2.5 was generally associated with lower odds of ischemic stroke for non-Hispanic whites but modestly greater odds for Mexican Americans. CONCLUSION: Ethnic differences in the associations between ischemic stroke and short-term exposures to O3 and PM2.5 were suggested indicating that further study in diverse populations may be warranted.

Ethnic Differences in Poststroke Quality of Life in the Brain Attack Surveillance in Corpus Christi (BASIC) Project.

BACKGROUND AND PURPOSE: Mexican Americans (MAs) have an increased risk of stroke and experience worse poststroke disability than non-Hispanic whites, which may translate into worse poststroke quality of life (QOL). We assessed ethnic differences in poststroke QOL, as well as potential modification of associations by age, sex, and initial stroke severity. METHODS: Ischemic stroke survivors were identified through the biethnic, population-based Brain Attack Surveillance in Corpus Christi (BASIC) Project. Data were collected from medical records, baseline interviews, and 90-day poststroke interviews. Poststroke QOL was measured at ≈90 days by the validated short-form stroke-specific QOL in 3 domains: overall, physical, and psychosocial (range, 0-5; higher scores represent better QOL). Tobit regression was used to model associations between ethnicity and poststroke QOL scores, adjusted for demographics, clinical characteristics, and prestroke cognition and function. RESULTS: Among 290 eligible stroke survivors (66% MA, 34% non-Hispanic whites, median age=69 years), median scores for overall, physical, and psychosocial poststroke QOL were 3.3, 3.8, and 2.7, respectively. Poststroke QOL was lower for MAs than non-Hispanic whites both overall (mean difference, -0.30; 95% confidence interval, -0.59, -0.01) and in the physical domain (mean difference, -0.47; 95% confidence interval, -0.81, -0.14) after multivariable adjustment. No ethnic difference was found in the psychosocial domain. Age modified the associations between ethnicity and poststroke QOL such that differences were present in older but not in younger ages. CONCLUSIONS: Disparities exist in poststroke QOL for MAs and seem to be driven by differences in older stroke patients. Targeted interventions to improve outcomes among MA stroke survivors are urgently needed.

High rate of microbleed formation following primary intracerebral hemorrhage.

BACKGROUND: We sought to investigate the frequency of microbleed development following intracerebral hemorrhage in a predominantly African-American population and to identify predictors of new microbleed formation. AIMS AND/OR HYPOTHESIS: To investigate the frequency and predictors of new microbleeds following intracerebral hemorrhage. METHODS: The DECIPHER study was a prospective, longitudinal, magnetic resonance-based cohort study designed to evaluate racial/ethnic differences in risk factors for microbleeds and to evaluate the prognostic impact of microbleeds in this intracerebral hemorrhage population. We evaluated new microbleed formation in two time periods: from baseline to 30 days and from 30 days to year 1. RESULTS: Of 200 subjects enrolled in DECIPHER, 84 had magnetic resonance imaging at all required time points to meet criteria for this analysis. In the baseline to day 30 analysis, 11 (13·1%) had new microbleeds, compared with 25 (29·8%) in the day 30 to year 1 analysis. Logistic regression analysis demonstrated that baseline number of microbleeds [odds ratio 1·05 (95% confidence interval 1·01, 1·08), P = 0·01] was associated with new microbleed formation at 30 days. A logistic regression model predicting new microbleed at one-year included baseline number of microbleeds [odds ratio 1·05 (1·00, 1·11), P = 0·046], baseline age [odds ratio 1·05 (1·00, 1·10), P = 0·04], and white matter disease score [odds ratio 1·18 (0·96, 1·45). P = 0·115]. Overall, 28 of 84 (33·3%) intracerebral hemorrhage subjects formed new microbleeds at some point in the first year post-intracerebral hemorrhage. CONCLUSIONS: We found that one-third of intracerebral hemorrhage subjects in this cohort surviving one-year developed new microbleeds, which suggests a dynamic and rapidly progressive vasculopathy. Future studies are needed to examine the impact of new microbleed formation on patient outcomes.

The Women Independently Living Alone with a Medical Alert Device (WILMA) trial.

Women are more likely to live alone compared with men, and therefore have more difficulty activating emergency medical systems for stroke. The goal of this study was to examine the benefit of wearing medical alert devices to activate emergency medical systems for elderly women living alone. This was a randomized, controlled pilot trial. Women over 60 with at least 1 stroke risk factor were recruited from Southeast Michigan. Subjects received either a medical alert device or control. The primary outcome was change in health-related quality of life (HRQOL) from baseline to 90 days of wearing the device or control. A planned sample size of 320 could not be reached, and the trial was stopped at 265 women randomized prior to data examination. On average, the treatment group was older, reported lower prevalence of high cholesterol, and was less likely to complete follow-up. There was a nonsignificant smaller loss of healthy days in the past month in the intervention group (0.46) compared with the control group (2.23) (p = 0.213). Similarly, the secondary outcomes of changes in anxiety, depression, and changes in perceived isolation did not differ by treatment and control groups. This study did not establish improvement in HRQOL among women who wore the device compared with those that did not, nor the feasibility of a trial to study the efficacy of medical alert devices in elderly women. Newer devices that use cellular technology may be more accepted than the landline-based system used in this study.

Temporal trends in BMI in Argentina by socio-economic position and province-level economic development, 2005-2009.

OBJECTIVE: We investigated temporal trends in BMI, and assessed hypothesized predictors of trends including socio-economic position (SEP) and province-level economic development, in Argentina. DESIGN: Using multivariable linear regression, we evaluated cross-sectional patterning and temporal trends in BMI and examined heterogeneity in these associations by SEP and province-level economic development with nationally representative samples from Argentina in 2005 and 2009. We calculated mean annual changes in BMI for men and women to assess secular trends. RESULTS: Women, but not men, exhibited a strong cross-sectional inverse association between SEP and BMI, with the lowest-SEP women having an average BMI 2.55 kg/m(2) greater than the highest-SEP women. Analysis of trends revealed a mean annual increase in BMI of 0.19 kg/m(2) and 0.15 kg/m(2) for women and men, respectively, with slightly greater increases occurring in provinces with greater economic growth. No significant heterogeneity in trends existed by individual SEP. CONCLUSIONS: BMI is increasing rapidly over time in Argentina irrespective of various sociodemographic characteristics. Higher BMI remains more common in women of lower SEP compared with those of higher SEP.