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Introduction: Frailty is a state of decreased physiologic reserve associated with adverse treatment outcomes across surgical specialties. We sought to determine whether frailty affected patient outcomes after elective treatment (open microsurgical clipping or endovascular therapy [EVT]) of unruptured cerebral aneurysms (UCAs)., Methods: The National Readmissions Database was queried from 2010 to 2014 to identify patients who had a known UCA and underwent elective clipping or EVT. Frailty was assessed using the Johns Hopkins Adjusted Clinical Groups frailty indicator tool. Multivariable exact logistic regression analyses were conducted to assess the associations between frailty and the primary outcome variables of 30- and 90-day readmissions, complications, length of stay (LOS), and patient disposition., Results: Of 18,483 patients who underwent elective treatment for UCAs, 358 (1.9%) met the criteria for frailty. After adjusting for patient- and hospital-based factors, frailty (30-day: odds ratio [OR], 1.55; 95% confidence interval [CI], 1.11-2.17; P = 0.01; 90-day: OR, 1.47; 95% CI, 1.05-2.06; P = 0.02) and clipping versus EVT (30-day: OR, 2.12; 95% CI, 1.85-2.43; P < 0.000; 90-day: OR, 1.80; 95% CI, 1.59-2.03; P < 0.0001) were associated with increased readmission rates. Furthermore, frailty was associated with an increased rate of complications (surgical: OR, 2.91; 95% CI, 2.27-3.72; P < 0.0001; neurological: OR, 3.04; 95% CI, 2.43-3.81; P < 0.0001; major: OR, 2.75; 95% CI, 1.96-3.84; P < 0.0001), increased LOSs (incidence rate ratio, 3.08; 95% CI, 2.59-3.66; P < 0.0001), and an increased rate of nonroutine disposition (OR, 3.94; 95% CI, 2.91-5.34; P < 0.0001)., Conclusions: Frailty was associated with an increased likelihood of 30- and 90-day readmissions after elective treatment of UCAs. Frailty was notably associated with several postoperative complications, longer LOSs, and nonroutine disposition in the treatment of UCAs., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: This systematic review analyzes contemporary literature on racial/ethnic, insurance, and socioeconomic disparities within cerebrovascular surgery in the United States to determine areas for improvement., Methods: We conducted an electronic database search of literature published between January 1990 and July 2020 using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for studies analyzing a racial/ethnic, insurance, or socioeconomic disparity within adult cerebrovascular surgery., Results: Of 2873 articles screened for eligibility by title and abstract, 970 underwent full-text independent review by 3 authors. Twenty-seven additional articles were identified through references to generate a final list of 47 included studies for analysis. Forty-six were retrospective reviews and 1 was a prospective observational cohort study, thereby comprising Levels III and IV of evidence. Studies investigated carotid artery stenting (11/47, 23%), carotid endarterectomy (22/47, 46.8%), mechanical thrombectomy (8/47, 17%), and endovascular aneurysm coiling or surgical aneurysm clipping (20/47, 42.6%). Minority and underinsured patients were less likely to receive surgical treatment. Non-White patients were more likely to experience a postoperative complication, although this significance was lost in some studies using multivariate analyses to account for complication risk factors. White and privately insured patients generally experienced shorter length of hospital stay, had lower rates of in-hospital mortality, and underwent routine discharge. Twenty-five papers (53%) reported no disparities within at least one examined metric., Conclusions: This comprehensive contemporary systematic review demonstrates the existence of disparity gaps within the field of adult cerebrovascular surgery. It highlights the importance of continued investigation into sources of disparity and efforts to promote equity within the field., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Our goal was to systematically review the literature on racial/ethnic, insurance, and socioeconomic disparities in adult spine surgery in the United States and analyze potential areas for improvement., Methods: We conducted a database search of literature published between January 1990 and July 2020 using PRISMA guidelines for all studies investigating a disparity in any aspect of adult spine surgery care analyzed based on race/ethnicity, insurance status/payer, or socioeconomic status (SES)., Results: Of 2679 articles identified through database searching, 775 were identified for full-text independent review by 3 authors, from which a final list of 60 studies were analyzed. Forty-three studies analyzed disparities based on patient race/ethnicity, 32 based on insurance status, and 8 based on SES. Five studies assessed disparities in access to care, 15 examined surgical treatment, 35 investigated in-hospital outcomes, and 25 explored after-discharge outcomes. Minority patients were less likely to undergo surgery but more likely to receive surgery from a low-volume provider and experience postoperative complications. White and privately insured patients generally had shorter hospital length of stay, were more likely to undergo favorable/routine discharge, and had lower rates of in-hospital mortality. After discharge, white patients reported better outcomes than did black patients. Thirty-three studies (55%) reported no disparities within at least 1 examined metric., Conclusions: This comprehensive systematic review underscores ongoing potential for health care disparities among adult patients in spinal surgery. We show a need for continued efforts to promote equity and cultural competency within neurologic surgery., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Previous studies have noted the incidence of radiation-induced sarcomas (RIS) but have not investigated the relative risk (RR) of developing RIS based on primary tumor organ disease site. By examining data from the Surveillance, Epidemiology, and End Results (SEER) database, we hypothesized that breast cancer would have a higher incidence of RIS compared to seventeen other primary cancer sites., Methods: This was a retrospective cohort study that examined patients from SEER registries between 1973 and 2013. We included patients aged 18 years or older who were diagnosed with cancer and those diagnosed with a cancer who subsequently developed a sarcoma. We excluded patients with missing information on initial radiotherapy treatment or stage. RIS was defined as those who developed a secondary sarcoma near the site of their original malignancy and after a 24-month latency period., Results: Our patients had a mean age of 60 years and follow up time of 9.2 years. Breast cancer comprised the majority with 693,701(36.8%) patients of which 161 (0.02%) had a secondary sarcoma. Of the 359 patients with secondary sarcomas, 242 (67.4%) had RIS. Breast cancer had the highest number of RIS patients at 126 compared to all combined non-breast cancer sites at 116. The RR of RIS in breast cancer versus 19 other primary cancer sites was 1.21 (CI: 1.01-1.45, p < 0.03, adjusted for age at primary diagnosis, gender, and latency)., Conclusions: Our study demonstrated that breast cancer has a higher risk of developing RIS compared to other solid cancers., (Copyright © 2020 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Little is known about strategies for enrolling patients in home-based palliative care programs despite the need to conduct effectiveness studies of this emerging industry., Purpose: We used medical claims data from Accountable Care Organizations in California to identify patients for a randomized controlled trial of home-based palliative care. We report outcomes from this strategy and the implications for future research., Results: Claims data identified 1357 patients. Research assistants could not reach 986 patients (72.7%), usually because the phone calls went unanswered (38.5%) and many patients' phone numbers were missing or incorrect (16.3%). Of 371 patients reached, 163 opted out. Of 208 patients screened, 177 were ineligible for the trial. Just 10 patients were enrolled., Recommendations: Our findings suggest that medical claims data may not be useful for engaging patients potentially eligible for palliative care research trials. We recommend that alternative identification and recruitment strategies be considered., (Copyright © 2020 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: Quality of life is paramount in patients with advanced cancer and may be adversely affected by comorbid depression. We hypothesized that comorbid depression is associated with higher rates of postoperative complications, worse functional outcomes, and higher rates of readmission after craniotomy for resection of malignant intracranial tumors., Methods: The National Readmissions Database was queried from 2010 to 2014 to identify adult patients undergoing craniotomy for malignant brain tumor resection. The primary psychiatric disease assessed was major depressive disorder (MDD). Outcomes evaluated included neurologic or other major complications, incidence of nonroutine discharge, and unplanned readmission at 30 and 90 days., Results: Of the 57,621 craniotomies for malignant neoplasms included in the analysis, 11.32% of patients had clinically diagnosed MDD. The presence of MDD was associated with nonroutine discharge (odds ratio, 1.10-125; P < 0.0001) as well as higher rates of neurologic complications (odds ratio, 1.03-1.18; P = 0.003). No association between MDD and 30-day or 90-day readmissions was noted. Patients with major All Patient Refined Diagnosis Related Groups severity and index length of stay >7 days experienced higher rates of 30-day and 90-day readmissions., Conclusions: There is a clinically significant rate of comorbid MDD in patients with malignant intracranial tumors, and MDD is associated with worse perioperative outcomes. Given the wealth of behavioral and pharmaceutical therapies available, MDD is a modifiable risk factor in this cohort that clinicians should be vigilant in screening for and initiating appropriate treatment protocols., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To investigate potential health care discrepancies in patients with ruptured cerebral aneurysms undergoing microsurgical intervention., Methods: We retrospectively reviewed patients with ruptured intracranial aneurysms treated at our tertiary referral university hospital (UH) and safety net county hospital (CH) from 2010 to 2015. We identified 73 UH patients and 58 CH patients., Results: UH patients had shorter time duration between rupture and intervention (P < 0.001) and higher rates of intubation on admission (P = 0.01). Verapamil was more frequently used for clinical vasospasm in UH patients, at 0.13 (95% confidence interval [CI], 0.09-0.18) treatments per patient per day versus 0.077 (95% CI, 0.047-0.12) treatments per patient per day in CH patients, though there was no difference in delayed cerebral ischemia (P = 0.15). The majority of the CH cohort was uninsured (26.3%; UH 0%) or had Medicaid (59.7%; UH 35.2%) (P < 0.001). The UH had more dispositions to home or rehabilitation centers than the CH (82% vs. 67.3%; P = 0.04). After adjusting for disease severity, hospital stay, and insurance status, CH patients were 3.73 (95% CI, 1.25-12.14) times more likely to be discharged with a poor modified Rankin Scale score and 3.08 (95% CI, 1.04-9.61) times more likely to be discharged with a poor Glasgow Outcome Scale score compared with UH patients (P = 0.02 and P = 0.04, respectively)., Conclusions: Limited resource availability in a safety net hospital system could be a major driving force behind the health care discrepancy identified in our ruptured cerebral aneurysm population. Reallocation of resources to supplement advanced inpatient acute care technologies and, more importantly, post-acute care environments can narrow the outcomes gap., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Spontaneous intracerebral hemorrhage (ICH) comprises 10%-15% of strokes with a high mortality (40%) and low rates of functional independence within 6 months (25%). Minimally invasive parafascicular surgery has emerged as a potentially safer option for ICH management., Methods: Data from 25 patients who underwent channel-based ICH evacuation were retrospectively collected regarding demographics, clinical presentation, neuroimaging characteristics, follow-up modified Rankin Scale (mRS) score, Glasgow Coma Scale (GCS) score, and disposition., Results: Sixteen patients were male (64%) and 9 were female (36%), with a mean age of 52 years. There were 4 frontal, 1 occipital, and 20 basal ganglia hemorrhages; 15 (60%) showed intraventricular extension. Seventeen ICHs (68%) and 6 of 7 patient deaths (86%) were left sided. The mean volume was 46 cm 3 (range, 13.1-101.2 cm 3 ), and the mean clot reduction was 92%. Left-sided ICH (P = 0.014) and the presence of intraventricular hemorrhage (P = 0.038) were associated with worsened postoperative GCS score. Larger hemorrhages were associated with mortality (66 cm 3 vs. 38 cm 3 ; P < 0.005). With a mean follow-up time of 5 months, the median follow-up mRS score was 3.5 (vs. 4 preoperatively), and median follow-up GCS was 15 (vs. 10 preoperatively). Patients with higher postoperative mRS scores and lower postoperative GCS were more likely to die., Conclusions: BrainPath-mediated transsulcal approaches are associated with improved mRS and GCS scores, with low rates of residual hematoma, although further data are needed via controlled studies to determine the importance of hemorrhage location and size, timing of surgical intervention, and long-term patient outcomes., (Copyright © 2019. Published by Elsevier Inc.)

Acute changes in mental status represent a broad collection of symptoms used to describe disorders in mentation and level of arousal, including the more narrowly defined diagnoses of delirium and psychosis. A wide range of precipitating factors may be responsible for symptom onset including infection, intoxication, and metabolic disorders. Neurologic causes that may be detected on neuroimaging include stroke, traumatic brain injury, nonconvulsive seizure, central nervous system infection, tumors, hydrocephalus, and inflammatory disorders. Not infrequently, two or more precipitating factors may be found. Neuroimaging with CT or MRI is usually appropriate if the clinical suspicion for an acute neurological cause is high, where the cause of symptoms is not found on initial assessment, and for patients whose symptoms do not respond appropriately to management. There was disagreement regarding the appropriateness of neuroimaging in cases where a suspected, nonneurologic cause is found on initial assessment. Neuroimaging with CT is usually appropriate for patients presenting with delirium, although the yield may be low in the absence of trauma or a focal neurological deficit. Neuroimaging with CT or MRI may be appropriate in the evaluation of new onset psychosis, although the yield may be low in the absence of a neurologic deficit. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2019 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Although diabetes is a nationwide epidemic, US Latinos are a particularly vulnerable population. Culturally appropriate interventions can combat this disparity, especially those that increase social support. However, these interventions face significant cost and time barriers, which mHealth (mobile health) may overcome. This trial examines the benefit of adding social support to an existing text-message based, patient-focused mHealth intervention for emergency department patients with poorly controlled diabetes. Family members and friends of patients were randomized to mHealth augmented social support training (daily text-messages that synchronize with the patient messages) or a pamphlet based training (the same content mailed to their house.) We hypothesize that patients who received mHealth augmented social support will have a larger improvement in diabetes management (glycosylated hemoglobin or A1C) than those receiving standard support at six-months, and that improvement will be sustained at twelve-months. Secondary patient outcomes are clinical (weight, blood pressure), behavioral (medication adherence, self-care activities) and psychosocial (general and diabetes-specific social support, self-efficacy, diabetes-related distress, depression, fatalism and quality of life). We screened 2004 patients and enrolled 166 patient/supporter dyads. 70% of patients are Spanish-speaking, 51% female, with a mean A1C of 10.8. We employed innovative measures to remotely enroll family members and support a bilingual population, which will assist other investigators in design of similar trials. The findings of our trial will have real-world applicability for clinicians, health system administrators, health educators and mHealth developers who aim to improve the health of this vulnerable population., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Visual loss can be the result of an abnormality anywhere along the visual pathway including the globe, optic nerve, optic chiasm, optic tract, thalamus, optic radiations or primary visual cortex. Appropriate imaging analysis of visual loss is facilitated by a compartmental approach that establishes a differential diagnosis on the basis of suspected lesion location and specific clinical features. CT and MRI are the primary imaging modalities used to evaluate patients with visual loss and are often complementary in evaluating these patients. One modality may be preferred over the other depending on the specific clinical scenario. Depending on the pattern of visual loss and differential diagnosis, imaging coverage may require targeted evaluation of the orbits and/or assessment of the brain. Contrast is preferred when masses and inflammatory processes are differential considerations. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2018 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Although the function of laminin in the basement membrane is known, the function of soluble "neuronal" laminin is unknown. Since laminin is neuroprotective, we determined whether the soluble laminin-1 induces signaling for neuroprotection via its 67KDa laminin-1 receptor (67LR). Treatment of Neuroscreen-1 (NS-1) cells with laminin-1 or YIGSR peptide, which corresponds to a sequence in laminin-1 β1 chain that binds to 67LR, induced a decrease in the cell-surface expression of 67LR and caused its internalization. Furthermore, intracellular cAMP-elevating agents, dibutyryl-cAMP, forskolin, and rolipram, also induced this internalization. Both soluble laminin-1 and YIGSR induced a sustained elevation of intracellular cAMP under defined conditions, suggesting a causal role of cAMP in the endocytosis of 67LR. This endocytosis was not observed in cells deficient in protein kinase A (PKA) nor in cells treated with either SQ 22536, an inhibitor for adenylyl cyclase, or ESI-09, an inhibitor for the exchange protein directly activated by cAMP (Epac). In addition, when internalization occurred in NS-1 cells, 67LR and adenylyl cyclase were localized in early endosomes. Under conditions in which endocytosis had occurred, both laminin-1 and YIGSR protected NS-1 cells from cell death induced by serum withdrawal. However, under conditions in which endocytosis did not occur, neither laminin-1 nor YIGSR protected these cells. Conceivably, the binding of laminin-1 to 67LR causes initial signaling through PKA and Epac, which causes the internalization of 67LR, along with signaling enzymes, such as adenylyl cyclase, into early endosomes. This causes sustained signaling for protection against cell death induced by serum withdrawal., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Diseases of the cerebral vasculature represent a heterogeneous group of ischemic and hemorrhagic etiologies, which often manifest clinically as an acute neurologic deficit also known as stroke or less commonly with symptoms such as headache or seizures. Stroke is the fourth leading cause of death and is a leading cause of serious long-term disability in the United States. Eighty-seven percent of strokes are ischemic, 10% are due to intracerebral hemorrhage, and 3% are secondary to subarachnoid hemorrhage. The past two decades have seen significant developments in the screening, diagnosis, and treatment of ischemic and hemorrhagic causes of stroke with advancements in CT and MRI technology and novel treatment devices and techniques. Multiple different imaging modalities can be used in the evaluation of cerebrovascular disease. The different imaging modalities all have their own niches and their own advantages and disadvantages in the evaluation of cerebrovascular disease. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Background: Patients with aneurysmal subarachnoid hemorrhage (aSAH) are susceptible to various medical complications, including ventriculostomy-associated infections (VAIs) in those who undergo external ventricular drain (EVD) placement. Many preventative strategies for VAIs have been used during the last 20 years, but their overall effect is unknown. Using the Nationwide (National) Inpatient Sample, we examined trends in VAI rates and mortality during a recent 12-year period in the aSAH population., Methods: In this retrospective analysis, data from the Nationwide Inpatient Sample was obtained from January 1, 2000, through December 31, 2011, using International Classification of Diseases, 9th Revision, Clinical Modification codes. After adjustment for age, sex, race, and subarachnoid severity, annual estimated event rates of VAI, in-hospital mortality, and hospital length of stay were calculated. Changes in these parameters during the study period were analyzed., Results: From years 2000 through 2011, there were 116,013 aSAH admissions, with EVD placement in 38,163 (32.9%) cases. In patients who underwent EVD placement, the mean annual rate of VAI was 7.3 per 100 patients, with no change during the 12-year period (absolute risk reduction per year of -0.05%, 95% confidence interval -0.22, 0.13). The mean mortality rate in this population was 19.8 per 100 patients, significantly declining over the study period (absolute risk reduction per year of -0.55%, 95% confidence interval -0.82, -0.29)., Conclusions: Despite numerous VAI-preventative strategies, the national VAI rate in aSAH patients has not changed; however, a reduction in mortality is suggested. Further studies are needed to determine how best to reduce VAIs, and to identify factors influencing observed trends in VAI and mortality., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives: To identify risk factors for and outcomes of surgical site infections and cellulitis after abdominal hysterectomies., Study Design: We used logistic regression analysis to analyze data from a case-control study of 1104 patients undergoing abdominal hysterectomies at a university hospital between Jan. 1, 2007 and Dec. 30, 2010., Results: Factors significantly associated with surgical site infections and with cellulitis were: pulmonary disease, operations done in Main Operating Room East, and seroma. Body mass index >35, no private insurance, and fluid and electrolyte disorders were risk factors for surgical site infections. The mean prophylactic dose of cefazolin was significantly higher for controls than for patients with surgical site infections. Preoperative showers with Hibiclens (Molnlycke Health Care US, LLC, Norcross, GA) and cefazolin prophylaxis were associated with a significantly decreased cellulitis risk. Surgical site infections and cellulitis were significantly associated with readmissions and return visits and surgical site infections were associated with reoperations., Conclusion: Preoperative showers, antimicrobial prophylaxis, surgical techniques preventing seromas, and the operating room environment may affect the risk of surgical site infections and cellulitis after abdominal hysterectomies., (Copyright © 2013 Mosby, Inc. All rights reserved.)

This study investigated the hypothesis that vascular risk factors are amyloidogenic. Participants were 43 persons, most with normal cognition or mild cognitive impairment. Vascular risk was quantified using the Framingham Coronary Risk Profile (FCRP) score. Cerebral amyloid was measured by [(11)C]Pittsburgh compound B (PIB) positron emission tomography (PET) and quantified with a Global PIB index, which is the average of distribution volume ratios in selected cortical regions of interest. In a bivariate model FCRP accounted for 16% of the variance in PIB index (p < 0.008) and the positive association remained significant controlling for age and sex. The effect of FCRP was independent of apolipoprotein E (APOE) genotype, which was also associated as expected with PIB. Carotid intima-media thickness was not associated with PIB index. Effects of individual FCRP component risk factors, cholesterol, and glycemic status on PIB index were all nonsignificant, suggesting an aggregate effect of risk factors. Although this is a correlational observation it may represent a causal relationship as there are multiple, plausible, amyloidogenic mechanisms of vascular risk factors., (Published by Elsevier Inc.)

Background: Hemostatic factors influenced by postmenopausal hormone therapy may contribute to atherosclerosis. The Estrogen in the Prevention of Atherosclerosis Trial (EPAT), a 2-year, randomized, double-blind, placebo-controlled trial, demonstrated reduced subclinical atherosclerosis progression measured by change in common carotid artery intima-media thickness (CIMT) with unopposed oral 17beta-estradiol., Objectives: To assess the effect of postmenopausal hormone therapy on the levels of several hemostatic factors, and the relationship between these factors and the progression of subclinical atherosclerosis., Patients and Methods: We measured tissue plasminogen activator (t-PA) antigen, factor (F) VII, D-dimer and albumin longitudinally, and plasminogen activator inhibitor type 1 (PAI-1) and fibrinogen at trial-end, in 186 postmenopausal women., Results: Estradiol vs. placebo was associated with greater FVII and lower t-PA, albumin, PAI-1 and fibrinogen (all P < or = 0.001), with no estradiol effect on D-dimer (P = 0.42). Only mean on-trial t-PA was positively associated with the absolute level of CIMT on-trial (r = 0.29, P < 0.0001), but this was attenuated with age and body mass index adjustment. No longitudinally measured hemostatic factor was associated with CIMT progression. However, higher CIMT during the trial was significantly related to increases in t-PA., Conclusions: These results confirm previous findings regarding estrogen's effect on hemostatic factors and show that albumin is negatively associated with estrogen therapy. These hemostatic factors did not account for the reduction of CIMT progression with 17beta-estradiol seen in EPAT. Atherosclerosis itself may affect levels of hemostatic factors (reverse causality), with subsequent involvement in atherosclerosis-associated thrombosis.

Objective: When compared with other U.S. populations, African Americans have excess hypertension. Genetic variants in elements of the renin-angiotensin-aldosterone system (RAAS), namely the angiotensin-converting enzyme (ACE), aldosterone synthase (CYP11B2), and angiotensin II type 1 receptor (AGTR1) genes, have been associated with risk of hypertension in some populations., Methods: We genotyped the D/I polymorphism in the ACE gene, the C(-344)T polymorphism in the CYP11B2 gene, and the C(-535)T polymorphism in the AGTR1 gene among African American and Latino members of the Multiethnic Cohort Study (MEC) to determine their association with hypertension., Results: We observed no significant increase in the risk of hypertension for either African Americans or Latinos homozygous or heterozygous for the D allele of the ACE gene. Among African Americans we observed carriers of the (-344)T allele of CYP11B2 to be at increased risk of hypertension (versus CC genotype: TC genotype, OR = 1.66 [95% CI: 1.01-2.72]; TT genotype, OR = 1.74 [95% CI: 1.07-2.82]). There was also an increase in risk of hypertension associated with the AGTR1 T allele for African Americans (versus CC genotype: TC genotype, OR = 2.62 [95% CI: 1.46-4.72]; TT genotype, OR = 2.67 [95% CI: 1.51-4.74]). The associations observed with CYP11B2 and AGTR1 genotypes were not observed among Latinos., Conclusion: These data suggest that the (-535)T allele of AGTR1 and (-344)T allele of CYP11B2 may increase hypertension risk among African Americans but not among Latinos. Characterization of the linkage disequilibrium and haplotype patterns in the RAAS pathway genes will be crucial to understanding differences in hypertension susceptibility in these ethnic populations.

Purpose: The purpose of this study was to use emergency department data to estimate levels of morbidity and risk factors due to earthquake-related mechanisms of injury subsequent to an urban night-time earthquake., Methods: Data were abstracted from 4190 medical records for the month of January, 1994. Injuries attributable to the earthquake were identified through emergency department and medical records. These injuries were: (a) categorized by mechanism of injury; (b) assigned an injury severity score; and (c) linked to structural and geologic data. Proportional polytomous and dichotomous logistic regression were used to estimate risk of more severe injury associated with demographic characteristics, injury characteristics, structural characteristics, and geologic factors., Results: More severe earthquake-related injuries (serious versus moderate and moderate versus minor) were statistically significantly associated with patient age (> or = 60 years old), upper extremities, falling, multi-family structures, pre-1960 housing, and the 50th percentile of Peak Ground Acceleration, after adjusting for all other available demographic, injury, structural, and geologic characteristics., Conclusions: The current recommendation of 'duck, cover, and hold' might not be optimal during a nighttime earthquake, particularly if individuals are in the padded environment of the bed. Actions such as reaching for or catching objects, bracing, or holding onto perceived stable objects may increase risk for more serious injury. Alternate responses include assuming a tucked position (as in airline crashes) or staying in bed for non-ambulating people. Structural damage and structure size were not associated with more serious injuries, but structure use and age were, leading the authors to suspect that unmeasured socioeconomic factors might impact risk factors. The importance of including population demographic characteristics in hazard modeling is emphasized.

B-mode ultrasound has gained popularity as a non-invasive method for direct visualization of superficial vessels. With B-mode ultrasound, arterial stiffness can be directly measured since image acquisition of the arterial wall thickness and vessel diameter can be obtained simultaneously in a dynamic fashion throughout the cardiac cycle. Recently, a method was developed to measure carotid arterial diameter and intima-media thickness (IMT) from B-mode images that utilizes computerized edge tracking-multiframe image processing that automatically measures arterial diameter and IMT in multiple sequential frames spanning several cardiac cycles. To evaluate this method, replicate B-mode common carotid artery ultrasound examinations and blood pressure measurements were obtained in 24 subjects 1-2 weeks apart. Approximately 80 sequential frames spanning two cardiac cycles were analyzed from each ultrasound examination to obtain maximum arterial diameter (D(max)), minimum arterial diameter (D(min)), and IMT using a computerized edge detection method. The intraclass correlations of D(max), D(min), and IMT were 0.97-0.99 and the mean absolute difference for these measurements were 0.03-0.11 mm. The coefficient of variation for D(max) and D(min) were 1.28 and 1.18%, respectively. The intraclass correlation for several standard arterial stiffness indices, Peterson's elastic modulus, Young's modulus, arterial distensibility, compliance, and the beta stiffness index ranged between 0.84 and 0.89. Additionally, it was determined that averaging IMT over five frames centered at D(min) reduced single frame IMT measurement variability by 27% (P=0.005) compared with IMT measured from a single frame corresponding to D(min). Comparison of the phasic relationship of D(max) and D(min) measured from the B-mode ultrasound image with the simultaneously recorded electrocardiogram (ECG) signal in the 24 subjects, provided a more accurate method of frame selection for arterial diameter extrema independent of the ECG signal. The method of computerized edge detection-sequential multiframe image processing presented in this paper represents a technological advance for image analysis of B-mode ultrasound images of common carotid arterial dimensions that is highly reproducible and directly applicable to noninvasive imaging of atherosclerosis.

Few studies have examined the correlation between change in carotid artery intima-media thickness (IMT) and change in coronary artery disease. In the Cholesterol Lowering Atherosclerosis Study, current nonsmoking men with coronary artery disease were randomized to colestipol-niacin or placebo. Among 133 subjects with baseline and on-trial coronary angiography and carotid ultrasonography, colestipol-niacin treatment significantly reduced progression of atherosclerosis by both end point measures (2-year average change in percent diameter stenosis by coronary angiography and rate of change in carotid IMT). Significant correlations between change in common carotid artery IMT and quantitative coronary angiographic measures of change were evident over all coronary artery lesions, and in mild/moderate (<50% diameter stenosis), but not severe (>/=50% diameter stenosis) coronary artery lesions. In mild/moderate lesions, correlations with change in common carotid IMT were: percent diameter stenosis (r=0.28, P=0.002), minimum lumen diameter (r=-0.28, P=0.002), and vessel edge roughness (r=0.25, P=0.003). While measures obtained by carotid ultrasonography and coronary angiography are correlated, they each assess different aspects of atherosclerosis change.

The Monitored Atherosclerosis Regression Study (MARS) was a randomized, double-blind, placebo-controlled angiographic trial of lipid-lowering therapy in subjects with coronary artery disease. Subjects were counseled to follow a low-fat, low-cholesterol diet. At every clinic visit, data were obtained on body weight, dietary intake, alcohol consumption, and tobacco use. Semiannual determinations of early preintrusive atherosclerosis were made with high-resolution B-mode ultrasonography of the carotid artery intima-media thickness (IMT). We evaluated the effects of lifestyle modification (diet, alcohol, smoking, and weight loss) on the rate of carotid artery IMT progression on the 94 subjects randomly assigned to the placebo group. Dietary cholesterol, insoluble fiber, body mass index, and smoking were significant predictors of the annual rate of carotid artery IMT progression (P < 0.05). For subjects experiencing IMT progression, increased intakes of monounsaturated fat relative to saturated fat and stearic acid (18:0) consumption were significant predictors of a reduction in the annual rate of carotid artery IMT progression; for subjects experiencing IMT regression, male sex was a significant predictor of a reduction in the annual rate of carotid artery IMT regression. Modifications reducing body mass index by 5 kg/m2, quitting a 10 cigarette/d smoking habit, and reducing dietary cholesterol intake by 100 mg/d on average would reduce the annual rate of carotid wall IMT progression by 0.13 mm/y, which is equivalent to the maximum rate of IMT progression observed in the MARS placebo group. Progression of early preintrusive atherosclerosis can be reduced and overall regression can occur with dietary and lifestyle modification.

The Monitored Atherosclerosis Regression Study was a double-blind, 2-year, placebo-controlled, randomized, serial angiographic trial which tested reduction of low density lipoprotein-cholesterol with monotherapy using lovastatin on the progression of coronary atherosclerosis. Angiographic outcome was evaluated both by a panel of human readers who visually inspected matched film pairs to arrive at a global change score and by automated computerized vessel edge finding and lesion measurement (quantitative coronary angiography, QCA). In this paper, we model the association between QCA measures of coronary artery lesion change and the panel-based global change score. QCA measures included: per-patient changes in percent diameter stenosis and minimum lumen diameter averaged over all lesions; per-patient changes in average diameter and percent involvement averaged over all segments; the numbers of progressing and regressing lesions and new total occlusions; and the development of any new lesions. We found that when evaluating coronary artery lesion change, panelists evaluate changes in percent diameter stenosis for both low grade (< 50% diameter stenosis at baseline) and high grade (> or = 50% diameter stenosis at baseline) lesions as well as new total occlusions and the number of progressing lesions. Although computerized quantification of the size of a lesion at baseline and as an endpoint may be a more precise measure than that by human panel interpretation, QCA fails to incorporate many other important aspects of coronary angiographic change visualized over the entire coronary artery tree by a panel of human interpreters. Thus, the global change score provides a "multiple endpoint" for coronary angiographic trials which does not suffer from the problems of statistical analysis and interpretation of multiple hypothesis tests which usually accompany true multiple endpoint measures. Choice of either or both endpoints in preparing angiographic trials depends on careful consideration of the desired information as well as the cost of carrying out the endpoint analysis.

Background: Major therapeutic decisions are made by patients with information and guidance provided by their physicians. The values patients place on different outcomes and the risks they are willing to accept are important factors in making these decisions. New beneficial therapies associated with potentially serious complications are now available for some blinding diseases. The authors aim to determine the maximum amount of risk of stroke and death persons would accept to recover vision., Methods: Standardized survey of adults with normal vision., Results: Thirty-nine percent and 37% of surveyed adults would accept some risk of stroke and death, respectively, to triple the chances of recovering 20/100 visual acuity in one eye when binocular. More than 80% of persons would accept these risks if they were monocular. Maximum risk scores were significantly higher in the monocular case scenarios than in binocular case scenarios. Medical students and eye physicians were more likely to accept risk than persons with high school or university educational backgrounds., Conclusions: The value persons place on vision when weighed against the risk of stroke or death varies considerably. More persons are willing to accept life-threatening risks if they are monocular. The reasons physicians and medical students are more likely to accept serious risks to improve vision than nonphysicians is unclear. Further studies are needed to determine how physicians' values effect the patient decision-making processes.

A new method to measure carotid intima-media thickness (IMT) from B-mode ultrasound images was developed that utilizes automatic tracking of the lumen-intima and media-adventitia echoes. Phantom studies and human replicate studies under typical clinical protocols for common carotid IMT measurement were carried out to assist in evaluation of the method. A lucite step wedge phantom was used to show that incorporation of sub-pixel interpolation to locate echo boundaries allowed detection of changes in the echo separation that were 5-10 times smaller than the axial resolution of the ultrasound transducer. For average IMT measured in the distal common carotid artery (CCA) wall in 24 subjects scanned twice within 60 days, mean absolute difference was 0.036 mm with a standard deviation of 0.045 mm. Replicate scans obtained 1 week apart of eight subjects by three sonographers showed the intersonographer variability was 5.4%. In another study of 12 subjects scanned every 4 months for 48 months, the root mean square deviation of the IMT measurements from a linear regression line was 0.030 mm. These data indicate that the method is equally precise over short intervals (60 days) and over long intervals (48 months). The new automated computerized edge tracking method presented in this paper represents an advance for image analysis of B-mode ultrasound images of common carotid IMT with measurement variability substantially reduced (2 to 4 times) compared with currently available manual methods.

Although lexical semantic deficits are postulated to play a prominent role in the anomia of Alzheimer's disease, it is unclear whether the primary disturbance is one of lexical access or one of lexical semantic loss. Response consistency on a naming task is one means of evaluating the underlying source of naming impairment. Access dysfunction usually implies variable word-finding difficulty, while a theory of lexical loss predicts that many word names would be consistently unavailable. Nineteen Alzheimer's disease patients were administered a visual confrontation naming task (the Boston Naming Test) on two occasions 6 months apart. Eighty percent of errors occurred consistently at both times; only 20% of errors occurred on only one occasion. Response consistency occurred significantly more often than expected under the assumption of no response consistency. Findings support the hypothesis that anomia in Alzheimer's disease is in part due to a loss of lexical semantic information.