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Background: Monolingual cognitive assessments are standard for bilinguals; the value of bilingual assessment is unknown. Since declines in animal naming accompany memory declines in dementia, we examined the association between bilingual animal naming and memory among bilingual Mexican American (MA) older adults., Methods: Bilingual MA (n = 155) completed the Harmonized Cognitive Assessment Protocol (HCAP) in a Texas community study. Regressions included HCAP memory score (English) as the outcome and English and Spanish animal naming trials as independent variables; demographics and language dominance were covariates., Results: English animal naming ( b = 0.06, P = 0.004) was more reliably associated with memory than Spanish ( b = 0.05, P = 0.06). Considered together, only English ( b = 0.05, P = 0.02) was associated with memory, not Spanish ( b = 0.01, P = 0.63). Conclusions: Spanish animal naming did not uniquely add to English animal naming in its association with memory among bilingual older MA., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Overcoming the heterogeneous mechanisms of metastasis and chemoresistance will improve outcomes for women with tubo-ovarian carcinomas (TOCs). CD44 expression has been shown to be associated with poor prognosis and advanced disease in TOCs. In addition, studies have shown a link between chemoresistance and CD44 pathways. Given the therapeutic implications of targeting CD44, this manuscript examines the biologic effects of a novel CD44 modulator, SPL-108, in TOCs., Materials and Methods: We assessed the effects of SPL-108 on chemosensitivity and migration in a panel of ovarian cancer cell lines with varied CD44 and MDR1 expression. In vitro experiments (cell viability assay, Western blot analysis, Calcein AM fluorescence assay, and migration assay) were carried out to determine the functional effects of SPL-108 in TOCs., Findings: Ovarian cancer cell lines OVCAR5 and OVCAR8 expressed higher protein levels of CD44 as demonstrated through Western Blot analysis. SPL-108 treatment significantly decreased the number of migrating cells in OVCAR8, OVCAR5 and OVCAR3 cell lines and migratory response was independent of CD44 expression. Treatment with SPL-108 led to significant accumulation of the MDR1 substrate Calcein in OVCAR5, OVCAR8 and OVCAR3 cells lines compared to verapamil treated positive control cells. Retention of Calcein after SPL-108 treatment was seen in cell lines with high MDR1 protein expression and no Calcein retention was seen in cells lacking MDR1 expression, suggesting SPL-108 inhibits MDR1., Conclusions: SPL-108 treatment has anti-metastatic properties and may play a role in chemoresistance in preclinical models of TOCs independent of CD44 expression. Ongoing in vitro and in vivo studies will help guide further clinical development of SPL-108., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: D.A.L had consulting/advisory role for Tesaro/GSK, Merck, received research funding to institution from Merck, Tesaro, Clovis Oncology, Regeneron, Agenus, Takeda, Immunogen, VBL Therapeutics, Genentech, Celsion, Ambry, Splash Pharmaceuticals. He also is a founder of Nirova BioSense, Inc. and Resident Diagnostics, Inc. D.A.L. is currently a full-time employee of Merck & Co., Inc. K.E.H reports that her spouse receives a salary from Strata Oncology., (Copyright © 2024. Published by Elsevier Inc.)

Background and Objectives: Mild cognitive impairment (MCI) affects up to 22% of US older adults aged 65 and older. Research suggests that physicians may recommend less cardiovascular disease (CVD) treatment for older adults with MCI due to assumptions about their preferences. To delve into the disparity between patient preferences and physician assumptions in CVD treatment recommendations, we conducted a multi-site qualitative study to explore the underlying reasons for this discrepancy, providing insights into potential communication barriers and strategies to enhance patient-physician relationships., Research Design and Methods: Employing a descriptive qualitative approach, we conducted interviews with 20 dyads, comprising older adults with MCI ( n = 11) and normal cognition NC ( n = 9), and their respective care partners. During these interviews, participants were prompted to reflect on physicians recommending fewer guideline-concordant CVD treatments to older adults with MCI than those with NC and physicians presuming that older adults with MCI desired less care or treatment in general than those with NC., Results: We identified three primary themes: (1) Most participants had negative reactions to the data that physicians might undertreat patients with MCI for CVD; (2) Participants suggested that physicians may undertreat patients with MCI due to physician assumptions about treatment effectiveness, patient prognosis, value, and treatment adherence, and (3) Participants proposed that physicians may elicit less input from patients with MCI about treatments because of negative physician assumptions about patient decision-making capacity and physician time limitations., Discussion and Implications: This study underscores the pressing need for person-centered communication and involvement of older adults with MCI and their care partners in the decision-making process to ensure that decisions are well-informed, reflecting patients' genuine preferences and values. Addressing these concerns has the potential to substantially enhance the quality of care and treatment outcomes for this vulnerable population, ultimately promoting their overall well-being., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Aim: The "2024 Guideline for the Primary Prevention of Stroke" replaces the 2014 "Guidelines for the Primary Prevention of Stroke." This updated guideline is intended to be a resource for clinicians to use to guide various prevention strategies for individuals with no history of stroke., Methods: A comprehensive search for literature published since the 2014 guideline; derived from research involving human participants published in English; and indexed in MEDLINE, PubMed, Cochrane Library, and other selected and relevant databases was conducted between May and November 2023. Other documents on related subject matter previously published by the American Heart Association were also reviewed., Structure: Ischemic and hemorrhagic strokes lead to significant disability but, most important, are preventable. The 2024 primary prevention of stroke guideline provides recommendations based on current evidence for strategies to prevent stroke throughout the life span. These recommendations align with the American Heart Association's Life's Essential 8 for optimizing cardiovascular and brain health, in addition to preventing incident stroke. We also have added sex-specific recommendations for screening and prevention of stroke, which are new compared with the 2014 guideline. Many recommendations for similar risk factor prevention were updated, new topics were reviewed, and recommendations were created when supported by sufficient-quality published data.

Background: Observational studies link high midlife systolic blood pressure to increased dementia risk. However, synthesis of evidence from randomized controlled trials has not definitively demonstrated that antihypertensive medication use reduces dementia risk. Here, we emulate target trials of antihypertensive medication initiation on incident dementia using three cohort studies, with attention to potential violations of necessary assumptions., Methods: We emulated trials of antihypertensive medication initiation on incident dementia using data from the Atherosclerosis Risk in Communities (ARIC) study, Cardiovascular Health Study (CHS), and Health and Retirement Study (HRS). We used data-driven methods to restrict participants to initiators and non-initiators with overlap in propensity scores and positive control outcomes to look for violations of positivity and exchangeability assumptions., Results: Analyses were limited by the small number of cohort participants who met eligibility criteria. Associations between antihypertensive medication initiation and incident dementia were inconsistent and imprecise (ARIC: HR = 0.30 [0.05, 1.93]; CHS: HR = 0.66 [0.27, 1.64]; HRS: HR = 1.09 [0.75, 1.59]). More stringent propensity score restriction had little effect on findings. Sensitivity analyses using a positive control outcome unexpectedly suggested antihypertensive medication initiation increased risk of coronary heart disease in all three samples., Conclusions: Positive control outcome analyses suggested substantial residual confounding in effect estimates from our target trials, precluding conclusions about the impact of antihypertensive medication initiation on dementia risk through target trial emulation. Formalized processes for identifying violations of necessary assumptions will strengthen confidence in target trial emulation and avoid inappropriate confidence in emulated trial results., Competing Interests: Conflicts of Interest:, (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To compare changes in cognitive trajectories after stroke between younger (18-64) and older (65+) adults, accounting for pre-stroke cognitive trajectories., Materials and Methods: Pooled cohort study using individual participant data from 3 US cohorts (1971-2019), the Atherosclerosis Risk In Communities Study (ARIC), Framingham Offspring Study (FOS), and REasons for Geographic And Racial Differences in Stroke Study (REGARDS). Linear mixed effect models evaluated the association between age and the initial change (intercept) and rate of change (slope) in cognition after compared to before stroke. Outcomes were global cognition (primary), memory and executive function., Results: We included 1,292 participants with stroke; 197 younger (47.2 % female, 32.5 % Black race) and 1,095 older (50.2 % female, 46.4 % Black race). Median (IQR) age at stroke was 59.7 (56.6-61.7) (younger group) and 75.2 (70.5-80.2) years (older group). Compared to the young, older participants had greater declines in global cognition (-1.69 point [95 % CI, -2.82 to -0.55] greater), memory (-1.05 point [95 % CI, -1.92 to -0.17] greater), and executive function (-3.72 point [95 % CI, -5.23 to -2.21] greater) initially after stroke. Older age was associated with faster declines in global cognition (-0.18 points per year [95 % CI, -0.36 to -0.01] faster) and executive function (-0.16 [95 % CI, -0.26 to -0.06] points per year for every 10 years of higher age), but not memory (-0.006 [95 % CI, -0.15 to 0.14]), after compared to before stroke., Conclusion: Older age was associated with greater post-stroke cognitive declines, accounting for differences in pre-stroke cognitive trajectories between the old and the young., Competing Interests: Declaration of competing interest Authors report funding from the NIH (Springer, Briceno, Burke, Aparicio), Agency for Healthcare Research and Quality (Burke), Alzheimer's Association (Aparicio), American Academy of Neurology (Aparicio), and the National Institute of Neurological Disorders and Stroke Intramural Research Program (Gottesman)., (Copyright © 2024. Published by Elsevier Inc.)

Background: High blood pressure (BP) increases recurrent stroke risk., Methods and Results: We assessed hypertension prevalence, treatment, control, medication adherence, and predictors of uncontrolled BP 90 days after ischemic or hemorrhagic stroke among 561 Mexican American and non-Hispanic White (NHW) survivors of stroke from the BASIC (Brain Attack Surveillance in Corpus Christi) cohort from 2011 to 2014. Uncontrolled BP was defined as average BP ≥140/90 mm Hg at 90 days poststroke. Hypertension was uncontrolled BP or antihypertensive medication prescribed or hypertension history. Treatment was antihypertensive use. Adherence was missing zero antihypertensive doses per week. We investigated predictors of uncontrolled BP using logistic regression adjusting for patient factors. Median (interquartile range) age was 68 (59-78) years, 64% were Mexican American, and 90% of strokes were ischemic. Overall, 94.3% of survivors of stroke had hypertension (95.6% Mexican American versus 92.0% non-Hispanic White; P =0.09). Of these, 87.9% were treated (87.3% Mexican American versus 89.1% non-Hispanic White; P =0.54). Among the total population, 38.3% (95% CI, 34.4%-42.4%) had uncontrolled BP. Among those with uncontrolled BP prescribed an antihypertensive, 84.5% reported treatment adherence (95% CI, 78.8%-89.3%). Uncontrolled BP 90 days poststroke was less likely in patients with stroke who had a primary care physician (adjusted odds ratio [aOR], 0.45 [95% CI, 0.24-0.83]; P =0.01), greater stroke severity (aOR per-1-point-higher National Institutes of Health Stroke Scale score, 0.96 [95% CI, 0.93-0.99]; P =0.02), or more depressive symptoms (aOR per-1-point-higher Personal Health Questionnaire Depression Scale-8 score, 0.95 [95% CI, 0.92-0.99] among those with a history of hypertension at baseline; P =0.009)., Conclusions: Greater than one third of survivors of stroke have uncontrolled BP at 90 days poststroke in this population-based study. Interventions are needed to improve BP control after stroke.

Background: Recent hypertension guidelines for the general population have included race-specific recommendations for antihypertensives, whereas current stroke-specific recommendations for antihypertensives do not vary by race. The impact of these guidelines on antihypertensive regimen changes over time, and if this has varied by prevalent stroke status, is unclear., Methods: The use of antihypertensive medications was studied cross-sectionally among self-identified Black and White participants, aged ≥45 years, with and without history of stroke, from the REGARDS study (Reasons for Geographic and Racial Differences in Stroke). Participants completed an in-home examination in 2003-2007 (visit 1) with/without an examination in 2013-2016 (visit 2). Stratified by prevalent stroke status, logistic regression mixed models examined associations between antihypertensive class use for visit 2 versus visit 1 and Black versus White individuals with an interaction adjusted for demographics, socioeconomic status, and vascular risk factors/vital signs., Results: Of 17 244 stroke-free participants at visit 1, Black participants had greater adjusted odds of angiotensin-converting enzyme inhibitor usage than White participants (odds ratio [OR], 1.51 [95% CI, 1.30-1.77]). This difference was smaller in the 7476 stroke-free participants at visit 2 (OR, 1.16 [95% CI, 1.08-1.25]). In stroke-free participants at visit 1, Black participants had lower odds of calcium channel blocker (CCB) usage than White participants (OR, 0.47 [95% CI, 0.41-0.55]), but CCB usage did not differ significantly between Black and White stroke-free participants at visit 2 (OR, 1.02 [95% CI, 0.95-1.09]). Among 1437 stroke survivor participants at visit 1, Black participants had lower odds of CCB use than White participants (OR, 0.34 [95% CI, 0.26-0.45]). In 689 stroke survivor participants at visit 2, CCB use did not differ between Black and White participants (OR, 0.80 [95% CI, 0.61-1.06])., Conclusions: Racial differences in the use of guideline-recommended antihypertensives decreased between 2003-2007 and 2013-2016 in stroke-free individuals. In stroke survivors, racial differences in CCB usage narrowed over the time periods. These findings suggest there is still a mismatch between race-specific hypertension guidelines and recent clinical practice., Competing Interests: Dr Royan receives salary support as an Assistant Editor at JAMA Network Open. Dr Long receives grant/contract support from the Centers for Disease Control and Prevention, the National Institutes of Health, Patient-Centered Outcomes Research Institute, and Amgen, and reports employment by West Virginia University. Dr Levine receives grant/contract support from the National Institutes of Health and compensation from Northwestern University for consultant services. Dr Gorelick receives consultant support from AbbVie and End Point Review Committee support from Bausch Health US, LLC, ICON Pharma, LabCorp (aka Lab Corporation), Pharmaceutical Research Associates, Sanofi and Genzyme US Companies, Takeda Pharmaceutical Company, and Union Chimique Belge (UCB). The other authors report no conflicts.

Background: Cannabis use may impair cognitive function (CF) differently in men and women, due to sex-specific differences in neurobiological mechanisms and environmental risk factors. Objective: Assess sex differences in the association between cumulative exposure to cannabis and cognitive performance in middle age. Methods: We studied participants from the Coronary Artery Risk Development in Young Adults (CARDIA) Study, including Black and White men and women 18-30 years old at baseline followed over 30 years. Our cross-sectional analysis of CF scores at year 30 was stratified by sex. We computed categories of cumulative exposure in "cannabis-years" (1 cannabis-year=365 days of use) from self-reported use every 2 to 5 years over 30 years. At years 25 and 30, we assessed CF with the Rey Auditory Verbal Learning Test (verbal memory), the Digit Symbol Substitution Test (processing speed), and the Stroop Interference Test (executive function). At year 30, additional measures included Category and Letter Fluency Test (verbal ability) and the Montreal Cognitive Assessment (global cognition). We computed standardized scores for each cognitive test and applied multivariable adjusted linear regression models for self-reported cumulative cannabis use, excluding participants who used cannabis within 24 h. In a secondary analysis, we examined the association between changes in current cannabis use and changes in CF between years 25 and 30. Results: By year 30, 1,352 men and 1,793 women had measures of CF; 87% ( N =1,171) men and 84% ( N =1,502) women reported ever cannabis use. Men had a mean cumulative use of 2.57 cannabis-years and women 1.29 cannabis-years. Self-reported cumulative cannabis use was associated with worse verbal memory in men (e.g., -0.49 standardized units [SU] for ≥5 cannabis-years of exposure; 95% CI=-0.76 to -0.23), but not in women (SU=0.02; 95% CI=-0.26 to 0.29). Other measures of CF were not associated with cannabis. Changes in current cannabis use between years 25 and 30 were not associated with CF in men or women. Conclusions: Self-reported cumulative cannabis exposure was associated with worse verbal memory in men but not in women. Researchers should consider stratified analyses by sex when testing the association between cannabis and cognition.

Background and Objectives: Late-life inflammation has been linked to dementia risk and preclinical cognitive decline, but less is known about early adult inflammation and whether this could influence cognition in midlife. We aimed to identify inflammation levels through early adulthood and determine association of these trajectories with midlife cognition., Methods: We used data from the Coronary Artery Risk Development in Young Adults study to identify inflammation trajectories (C-reactive protein [CRP] level <10 mg/L) over 18 years through early adulthood (age range 24-58) in latent class analysis and to assess associations with cognition 5 years after the last CRP measurement (age range 47-63). Six cognitive domains were evaluated from tests of verbal memory, processing speed, executive function, verbal and category fluency, and global cognition; poor cognitive performance was defined as a decline of ≥1 SD less than the mean on each domain. The primary outcome was poor cognitive performance. Logistic regression was used to adjust for demographics, smoking, alcohol use, physical activity, and APOE 4 status., Results: Among 2,364 participants, the mean (SD) age was 50.2 (3.5) years; 55% were female, and 57% were White. Three CRP trajectories emerged over 18 years: lower stable (45%), moderate/increasing (16%), and consistently higher (39%). Compared with lower stable CRP, both consistently higher (adjusted odds ratio [aOR] 1.67, 95% CI 1.23-2.26) and moderately/increasing (aOR 2.04, 95% CI 1.40-2.96) CRP had higher odds of poor processing speed; consistently higher CRP additionally had higher odds of poor executive function (aOR 1.36, 95% CI 1.00-1.88). For memory (moderately/increasing aOR 1.36, 95% CI 1.00-1.88; consistently higher aOR 1.18, 95% CI 0.90-1.54), letter fluency (moderately/increasing aOR 1.00, 95% CI 0.69-1.43; consistently higher aOR 1.05, 95% CI 0.80-1.39), category fluency (moderately/increasing aOR 1.16, 95% CI 0.82-1.63; consistently higher aOR 1.11, 95% CI 0.85-1.45), or global cognition (moderately/increasing aOR 1.16, 95% CI 0.82-1.63; consistently higher aOR 1.11, 95% CI 0.85-1.45), no association was observed., Discussion: Consistently higher or moderate/increasing inflammation starting in early adulthood may lead to worse midlife executive function and processing speed. Study limitations include selection bias due to loss to follow-up and reliance on CRP as the only inflammatory marker. Inflammation is important for cognitive aging and may begin much earlier than previously known.

Advancements in precision oncology over the past decades have led to new therapeutic interventions, but the efficacy of such treatments is generally limited by an adaptive process that fosters drug resistance 1 . In addition to genetic mutations 2 , recent research has identified a role for non-genetic plasticity in transient drug tolerance 3 and the acquisition of stable resistance 4,5 . However, the dynamics of cell-state transitions that occur in the adaptation to cancer therapies remain unknown and require a systems-level longitudinal framework. Here we demonstrate that resistance develops through trajectories of cell-state transitions accompanied by a progressive increase in cell fitness, which we denote as the 'resistance continuum'. This cellular adaptation involves a stepwise assembly of gene expression programmes and epigenetically reinforced cell states underpinned by phenotypic plasticity, adaptation to stress and metabolic reprogramming. Our results support the notion that epithelial-to-mesenchymal transition or stemness programmes-often considered a proxy for phenotypic plasticity-enable adaptation, rather than a full resistance mechanism. Through systematic genetic perturbations, we identify the acquisition of metabolic dependencies, exposing vulnerabilities that can potentially be exploited therapeutically. The concept of the resistance continuum highlights the dynamic nature of cellular adaptation and calls for complementary therapies directed at the mechanisms underlying adaptive cell-state transitions., (© 2024. The Author(s), under exclusive licence to Springer Nature Limited.)

Background: The large and increasing number of adults living with dementia is a pressing societal priority, which may be partially mitigated through improved population-level blood pressure (BP) control. We explored how tighter population-level BP control affects the incidence of atherosclerotic cardiovascular disease (ASCVD) events and dementia., Methods: Using an open-source ASCVD and dementia simulation analysis platform, the Michigan Chronic Disease Simulation Model, we evaluated how optimal implementation of 2 BP treatments based on the Eighth Joint National Committee recommendations and SPRINT (Systolic Blood Pressure Intervention Trial) protocol would influence population-level ASCVD events, global cognitive performance, and all-cause dementia. We simulated 3 populations (usual care, Eighth Joint National Committee based, SPRINT based) using nationally representative data to annually update risk factors and assign ASCVD events, global cognitive performance scores, and dementia, applying different BP treatments in each population. We tabulated total ASCVD events, global cognitive performance, all-cause dementia, optimal brain health, and years lived in each state per population., Results: Optimal implementation of SPRINT-based BP treatment strategy, compared with usual care, reduced ASCVD events in the United States by ≈77 000 per year and produced 0.4 more years of stroke- or myocardial infarction-free survival when averaged across all Americans. Population-level gains in years lived free of ASCVD events were greater for SPRINT-based than Eighth Joint National Committee-based treatment. Survival and years spent with optimal brain health improved with optimal SPRINT-based BP treatment implementation versus usual care: the average patient with hypertension lived 0.19 additional years and 0.3 additional years in optimal brain health. SPRINT-based BP treatment increased the number of years lived without dementia (by an average of 0.13 years/person with hypertension), but increased the total number of individuals with dementia, mainly through more adults surviving to advanced ages., Conclusions: Tighter BP control likely benefits most individuals but is unlikely to reduce dementia prevalence and might even increase the number of older adults living with dementia., Competing Interests: Disclosures None.

The impact of the COVID-19 pandemic on informal caregiving was examined in a Mexican American (MA) and Non-Hispanic White (NHW) population-based cohort. 395 participants age > 65 years were recruited via door-to-door and phone recruitment as part of the Brain Attack Surveillance in Corpus Christi-Cognitive (BASIC-C) project. Both recipients and caregivers answered questions regarding the recipient's health and the COVID-19 pandemic. 15% of caregivers saw their caregiving recipient less than before the pandemic and 18% saw their recipient more than before. 55% of caregivers reported a slight to severe impact of the pandemic on their caregiving, and 45% reported no impact. For most caregivers, their caregiving role did not change markedly during the pandemic. MA and NHW caregivers had similar survey responses., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Strategies to prevent or delay Alzheimer's disease and related dementias (AD/ADRD) are urgently needed, and blood pressure (BP) management is a promising strategy. Yet the effects of different BP control strategies across the life course on AD/ADRD are unknown. Randomized trials may be infeasible due to prolonged follow-up and large sample sizes. Simulation analysis is a practical approach to estimating these effects using the best available existing data. However, existing simulation frameworks cannot estimate the effects of BP control on both dementia and cardiovascular disease. This manuscript describes the design principles, implementation details, and population-level validation of a novel population-health microsimulation framework, the MIchigan ChROnic Disease SIMulation (MICROSIM), for The Effect of Lower Blood Pressure over the Life Course on Late-life Cognition in Blacks, Hispanics, and Whites (BP-COG) study of the effect of BP levels over the life course on dementia and cardiovascular disease. MICROSIM is an agent-based Monte Carlo simulation designed using computer programming best practices. MICROSIM estimates annual vascular risk factor levels and transition probabilities in all-cause dementia, stroke, myocardial infarction, and mortality in a nationally representative sample of US adults 18+ using the National Health and Nutrition Examination Survey (NHANES). MICROSIM models changes in risk factors over time, cognition and dementia using changes from a pooled dataset of individual participant data from 6 US prospective cardiovascular cohort studies. Cardiovascular risks were estimated using a widely used risk model and BP treatment effects were derived from meta-analyses of randomized trials. MICROSIM is an extensible, open-source framework designed to estimate the population-level impact of different BP management strategies and reproduces US population-level estimates of BP and other vascular risk factors levels, their change over time, and incident all-cause dementia, stroke, myocardial infarction, and mortality., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Burke et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: It is unclear how post-stroke cognitive trajectories differ by stroke type and ischemic stroke subtype. We studied associations between stroke types (ischemic, hemorrhagic), ischemic stroke subtypes (cardioembolic, large artery atherosclerotic, lacunar/small vessel, cryptogenic/other determined etiology), and post-stroke cognitive decline., Methods: This pooled cohort analysis from four US cohort studies (1971-2019) identified 1,143 dementia-free individuals with acute stroke during follow-up: 1,061 (92.8%) ischemic, 82 (7.2%) hemorrhagic, 49.9% female, 30.8% Black. Median age at stroke was 74.1 (IQR, 68.6, 79.3) years. Outcomes were change in global cognition (primary) and changes in executive function and memory (secondary). Outcomes were standardized as T-scores (mean [SD], 50 [10]); a 1-point difference represents a 0.1-SD difference in cognition. Median follow-up for the primary outcome was 6.0 (IQR, 3.2, 9.2) years. Linear mixed-effects models estimated changes in cognition after stroke., Results: On average, the initial post-stroke global cognition score was 50.78 points (95% CI, 49.52, 52.03) in ischemic stroke survivors and did not differ in hemorrhagic stroke survivors (difference, -0.17 points [95% CI, -1.64, 1.30]; P =0.82) after adjusting for demographics and pre-stroke cognition. On average, ischemic stroke survivors showed declines in global cognition, executive function, and memory. Post-stroke declines in global cognition, executive function, and memory did not differ between hemorrhagic and ischemic stroke survivors. 955 ischemic strokes had subtypes: 200 (20.9%) cardioembolic, 77 (8.1%) large artery atherosclerotic, 207 (21.7%) lacunar/small vessel, 471 (49.3%) cryptogenic/other determined etiology. On average, small vessel stroke survivors showed declines in global cognition and memory, but not executive function. Initial post-stroke cognitive scores and cognitive declines did not differ between small vessel survivors and survivors of other ischemic stroke subtypes. Post-stroke vascular risk factor levels did not attenuate associations., Conclusion: Stroke survivors had cognitive decline in multiple domains. Declines did not differ by stroke type or ischemic stroke subtype.

Importance: Stroke risk varies by systolic blood pressure (SBP), race, and ethnicity. The association between cumulative mean SBP and incident stroke type is unclear, and whether this association differs by race and ethnicity remains unknown., Objective: To examine the association between cumulative mean SBP and first incident stroke among 3 major stroke types-ischemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH)-and explore how these associations vary by race and ethnicity., Design, Setting, and Participants: Individual participant data from 6 US longitudinal cohorts (January 1, 1971, to December 31, 2019) were pooled. The analysis was performed from January 1, 2022, to January 2, 2024. The median follow-up was 21.6 (IQR, 13.6-31.8) years., Exposure: Time-dependent cumulative mean SBP., Main Outcomes and Measures: The primary outcome was time from baseline visit to first incident stroke. Secondary outcomes consisted of time to first incident IS, ICH, and SAH., Results: Among 40 016 participants, 38 167 who were 18 years or older at baseline with no history of stroke and at least 1 SBP measurement before the first incident stroke were included in the analysis. Of these, 54.0% were women; 25.0% were Black, 8.9% were Hispanic of any race, and 66.2% were White. The mean (SD) age at baseline was 53.4 (17.0) years and the mean (SD) SBP at baseline was 136.9 (20.4) mm Hg. A 10-mm Hg higher cumulative mean SBP was associated with a higher risk of overall stroke (hazard ratio [HR], 1.20 [95% CI, 1.18-1.23]), IS (HR, 1.20 [95% CI, 1.17-1.22]), and ICH (HR, 1.31 [95% CI, 1.25-1.38]) but not SAH (HR, 1.13 [95% CI, 0.99-1.29]; P = .06). Compared with White participants, Black participants had a higher risk of IS (HR, 1.20 [95% CI, 1.09-1.33]) and ICH (HR, 1.67 [95% CI, 1.30-2.13]) and Hispanic participants of any race had a higher risk of SAH (HR, 3.81 [95% CI, 1.29-11.22]). There was no consistent evidence that race and ethnicity modified the association of cumulative mean SBP with first incident stroke and stroke type., Conclusions and Relevance: The findings of this cohort study suggest that cumulative mean SBP was associated with incident stroke type, but the associations did not differ by race and ethnicity. Culturally informed stroke prevention programs should address modifiable risk factors such as SBP along with social determinants of health and structural inequities in society.

Objective: To examine whether vasomotor symptoms (VMS) and migraine headaches, hypothesized to be vasoactive conditions, are associated with greater risk for cardiovascular disease (CVD) events including strokes., Methods: We performed a secondary data analysis of a subset of women (n = 1,954) in the Coronary Artery Risk Development in Young Adults (CARDIA) study, a population-based cohort, which began data collection at 18 to 30 y of age. We examined whether migraine headaches and VMS trajectories (characterized as minimal, increasing, and persistent) at CARDIA year 15 examination were associated with higher risk of CVD events and stroke (both ischemic and hemorrhagic) using Cox proportional hazards regression models and adjustment for traditional CVD risk factors (age, cigarette use, and levels of systolic and diastolic blood pressure, fasting glucose, high- and low-density cholesterol, and triglycerides) and reproductive factors., Results: Among women with minimal VMS (n = 835), increasing VMS (n = 521), and persistent VMS (n = 598), there were 81 incident CVD events including 42 strokes. Women with histories of migraine and persistent VMS had greater risk of CVD (hazard ratio [HR], 2.25; 95% CI, 1.15-4.38) after adjustment for age, race, estrogen use, oophorectomy, and hysterectomy compared with women without migraine histories and with minimal/increasing VMS. After adjustment for CVD risk factors, these associations were attenuated (HR, 1.51; 95% CI, 0.73-3.10). Similarly, women with histories of migraine and persistent VMS had greater risk of stroke (HR, 3.15; 95% CI, 1.35-7.34), but these associations were attenuated after adjustment for CVD risk factors (HR, 1.70; 95% CI, 0.66-4.38)., Conclusions: Migraines and persistent VMS jointly associate with greater risk for CVD and stroke, although risk is attenuated with adjustment for traditional CVD risk factors., Competing Interests: Financial disclosure/conflicts of interest: None reported., (Copyright © 2024 by The Menopause Society.)

Background & Aims: Current approaches to managing digestive disease in older adults fail to consider the psychosocial factors contributing to a person's health. We aimed to compare the frequency of loneliness, depression, and social isolation in older adults with and without a digestive disease and to quantify their association with poor health., Methods: We conducted an analysis of Health and Retirement Study data from 2008 to 2016, a nationally representative panel study of participants 50 years and older and their spouses. Bivariate analyses examined differences in loneliness, depression, and social isolation among patients with and without a digestive disease. We also examined the relationship between these factors and health., Results: We identified 3979 (56.0%) respondents with and 3131 (44.0%) without a digestive disease. Overall, 60.4% and 55.6% of respondents with and without a digestive disease reported loneliness (P < .001), 12.7% and 7.5% reported severe depression (P < .001), and 8.9% and 8.7% reported social isolation (P = NS), respectively. After adjusting for covariates, those with a digestive disease were more likely to report poor or fair health than those without a digestive disease (odds ratio [OR], 1.25; 95% CI, 1.11-1.41). Among patients with a digestive disease, loneliness (OR, 1.43; 95% CI, 1.22-1.69) and moderate and severe depression (OR, 2.93; 95% CI, 2.48-3.47; and OR, 8.96; 95% CI, 6.91-11.63, respectively) were associated with greater odds of poor or fair health., Conclusions: Older adults with a digestive disease were more likely than those without a digestive disease to endorse loneliness and moderate to severe depression and these conditions are associated with poor or fair health. Gastroenterologists should feel empowered to screen patients for depression and loneliness symptoms and establish care pathways for mental health treatment., (Published by Elsevier Inc.)

Objectives: This study examines the associations of ethnicity, caregiver burden, familism, and physical and mental health among Mexican Americans (MAs) and non-Hispanic Whites (NHWs)., Methods: We recruited adults 65+ years with possible cognitive impairment (using the Montreal Cognitive Assessment score<26), and their caregivers living in Nueces County, Texas. We used weighted path analysis to test effects of ethnicity, familism, and caregiver burden on caregiver's mental and physical health., Results: 516 caregivers and care-receivers participated. MA caregivers were younger, more likely female, and less educated compared to NHWs. Increased caregiver burden was associated with worse mental (B = -0.53; p < .001) and physical health (B = -0.15; p = .002). Familism was associated with lower burden (B = -0.14; p = .001). MA caregivers had stronger familism scores (B = 0.49; p < .001)., Discussion: Increased burden is associated with worse caregiver mental and physical health. MA caregivers had stronger familism resulting in better health. Findings can contribute to early identification, intervention, and coordination of services to help reduce caregiver burden., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Given the tubal origin of high-grade serous ovarian cancer (HGSC), we sought to investigate intrauterine lavage (IUL) as a novel method of biomarker detection. IUL and serum samples were collected from patients with HGSC or benign pathology. Although CA-125 and HE4 concentrations were significantly higher in IUL samples compared to serum, they were similar between IUL samples from patients with HGSC vs benign conditions. In contrast, CA-125 and HE4 serum concentrations differed between HGSC and benign pathology ( P  =.002 for both). IUL and tumor samples from patients with HGSC were subjected to targeted panel sequencing and droplet digital PCR (ddPCR). Tumor mutations were found in 75 % of matched IUL samples. Serum CA-125 and HE4 biomarker levels allowed for better differentiation of HGSC and benign pathology compared to IUL samples. We believe using IUL for early detection of HGSC requires optimization, and current strategies should focus on prevention until early detection strategies improve., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: D.A.H. is a co-founder and officer with equity interest of Lime Therapeutics Inc., co-founder with equity interest of Selectin Therapeutics Inc. and Resident Diagnostics, Inc., and a member of the scientific advisory boards of Concarlo Therapeutics Inc., Nanorobotics Inc., and Mediphage Bioceuticals Inc. B.W. reports research funding by Repare Therapeutics, outside of the submitted work. E.S. reports honoraria from Dilon Technologies, Inc. D.A.L. is a full-time employee of Merck & Co., Inc. (Rahway, NJ, USA) and a co-founder with equity interest of Resident Diagnostics, Inc. N.A.R. reports grant funding from GRAIL paid to the institution. D.S.C. reports personal fees from Apyx Medical, Verthermia Inc., Biom 'Up, and AstraZeneca, as well as recent or current stock/options ownership of Apyx Medical, Verthemia, Intuitive Surgical, Inc., TransEnterix, Inc., Doximity, Moderna, and BioNTech SE. K.L.R. reports travel support from Intuitive Surgical. T.Y.S and M.F. have no conflicts of interest to report., (© 2024 The Authors. Published by Elsevier Inc.)

Purpose: To explore the risk factors and fundus imaging features of vitamin A deficiency retinopathy (VADR) in an academic tertiary referral center in Atlanta, GA, United States, and to propose guidance regarding diagnostic workup and management of affected patients., Design: Single-center retrospective case series., Subjects: Nine patients seen between 2015 and 2021 at the Emory Eye Center diagnosed with VADR., Methods: Retrospective chart review., Main Outcome Measures: Baseline serum retinol level, Snellen visual acuity, multimodal fundus imaging findings, and electroretinography findings., Results: Nine patients, 4 (44.4%) female, with a median (range) age of 68 (50-75) years were identified. The most common underlying etiologies for vitamin A deficiency included history of gastrointestinal surgery (55.6%), liver disease (44.4%), and nutritional depletion due to low-quality diet (44.4%). Only 1 (11.1%) patient had a history of bariatric surgery. Four (44.4%) patients were on some form of vitamin A supplementation before the diagnosis of VADR. Median (range) serum retinol level was 0.06 (< 0.06-0.19) mg/L. All patients had macular subretinal hyperreflective deposits resembling subretinal drusenoid deposits, although in some cases, these were scant and sparsely distributed. Six eyes of 3 patients with longstanding deficiency had defects in the external limiting membrane (ELM). Three of these eyes additionally had macular areas of complete retinal pigment epithelium and outer retinal atrophy (cRORA). Full-field electroretinography demonstrated severe rod dysfunction and mild to moderate cone system dysfunction. Many findings of VADR were reversible with vitamin A repletion. However, all eyes with ELM defects or cRORA had persistence or continued growth of these lesions., Conclusion: Vitamin A deficiency retinopathy is uncommon in the developed world. However, given that early intervention can lead to dramatic visual improvement and avoid potentially permanent retinal damage, retina specialists should be familiar with its clinical presentation. The presence of nyctalopia and subretinal hyperreflective deposits in a patient with a history of gastrointestinal surgery, liver disease, and/or poor diet can be suggestive of this diagnosis, even in the presence of ongoing vitamin A supplementation. Vitamin A supplementation can vary in route and dosage and can be tailored to the individual with serial testing of serum retinol., Financial Disclosure(s): The authors have no proprietary or commercial interest in any materials discussed in this article., (Published by Elsevier Inc.)

Objectives: To identify independent predictors of and derive a risk score for acute hematogenous osteomyelitis (AHO) in children., Methods: We conducted a retrospective matched case-control study of children >90 days to <18 years of age undergoing evaluation for a suspected musculoskeletal (MSK) infection from 2017 to 2019 at 23 pediatric emergency departments (EDs) affiliated with the Pediatric Emergency Medicine Collaborative Research Committee. Cases were identified by diagnosis codes and confirmed by chart review to meet accepted diagnostic criteria for AHO. Controls included patients who underwent laboratory and imaging tests to evaluate for a suspected MSK infection and received an alternate final diagnosis., Results: We identified 1135 cases of AHO matched to 2270 controls. Multivariable logistic regression identified 10 clinical and laboratory factors independently associated with AHO. We derived a 4-point risk score for AHO using (1) duration of illness >3 days, (2) history of fever or highest ED temperature ≥38°C, (3) C-reactive protein >2.0 mg/dL, and (4) erythrocyte sedimentation rate >25 mm per hour (area under the curve: 0.892, 95% confidence interval [CI]: 0.881 to 0.901). Choosing to pursue definitive diagnostics for AHO when 3 or more factors are present maximizes diagnostic accuracy at 84% (95% CI: 82% to 85%), whereas children with 0 factors present are highly unlikely to have AHO (sensitivity: 0.99, 95% CI: 0.98 to 1.00)., Conclusions: We identified 10 predictors for AHO in children undergoing evaluation for a suspected MSK infection in the pediatric ED and derived a novel 4-point risk score to guide clinical decision-making., (Copyright © 2024 by the American Academy of Pediatrics.)

Background: Little information is available on the prevalence of cognitive impairment in Mexican American persons., Objective: To determine the prevalence of mild cognitive impairment (MCI) and dementia in those 65 years and older among Mexican American and non-Hispanic white individuals in a community., Methods: This was a population-based cohort study in Nueces County, Texas, USA. Participants were recruited using a random housing sample. The Harmonized Cognitive Assessment (HCAP) participant and informant protocol was performed after Montreal Cognitive Assessment (MoCA) screening. An algorithm was used to sort participants into diagnostic categories: no cognitive impairment, MCI, or dementia. Logistic regression determined the association of ethnicity with MCI and dementia controlling for age, gender, and education., Results: 1,901 participants completed the MoCA and 547 the HCAP. Mexican Americans were younger and had less educational attainment than non-Hispanic whites. Overall, dementia prevalence was 11.6% (95% CI 9.2-14.0) and MCI prevalence was 21.2% (95% CI 17.5-24.8). After adjusting for age, gender, and education level, there was no significant ethnic difference in the odds of dementia or MCI. Those with ≤11 compared with ≥16 years of education had much higher dementia [OR = 4.9 (95% CI 2.2-11.1)] and MCI risk [OR = 3.5 (95% CI 1.6-7.5)]., Conclusions: Dementia and MCI prevalence were high in both Mexican American and non-Hispanic white populations. Mexican American persons had double the odds of mild cognitive impairment and this was attenuated when age and educational attainment were considered. Educational attainment was a potent predictor of cognitive impairment.

Objective: The Harmonized Cognitive Assessment Protocol (HCAP) describes an assessment battery and a family of population-representative studies measuring neuropsychological performance. We describe the factorial structure of the HCAP battery in the US Health and Retirement Study (HRS)., Method: The HCAP battery was compiled from existing measures by a cross-disciplinary and international panel of researchers. The HCAP battery was used in the 2016 wave of the HRS. We used factor analysis methods to assess and refine a theoretically driven single and multiple domain factor structure for tests included in the HCAP battery among 3,347 participants with evaluable performance data., Results: For the eight domains of cognitive functioning identified (orientation, memory [immediate, delayed, and recognition], set shifting, attention/speed, language/fluency, and visuospatial), all single factor models fit reasonably well, although four of these domains had either 2 or 3 indicators where fit must be perfect and is not informative. Multidimensional models suggested the eight-domain model was overly complex. A five-domain model (orientation, memory delayed and recognition, executive functioning, language/fluency, visuospatial) was identified as a reasonable model for summarizing performance in this sample (standardized root mean square residual = 0.05, root mean square error of approximation = 0.05, confirmatory fit index = 0.94)., Conclusions: The HCAP battery conforms adequately to a multidimensional structure of neuropsychological performance. The derived measurement models can be used to operationalize notions of neurocognitive impairment, and as a starting point for prioritizing pre-statistical harmonization and evaluating configural invariance in cross-national research.

Objectives: To describe the proportion of pediatric mental health emergency department (MH-ED) visits across 5 COVID-19 waves in New York City (NYC) and to examine the relationship between MH-ED visits, COVID-19 prevalence, and societal restrictions., Methods: We conducted a time-series analysis of MH-ED visits among patients ages 5 to 17 years using the INSIGHT Clinical Research Network, a database from 5 medical centers in NYC from January 1, 2016, to June 12, 2022. We estimated seasonally adjusted changes in MH-ED visit rates during the COVID-19 pandemic, compared with predicted prepandemic levels, specific to each COVID-19 wave and stratified by mental health diagnoses and sociodemographic characteristics. We estimated associations between MH-ED visit rates, COVID-19 prevalence, and societal restrictions measured by the Stringency Index., Results: Of 686 500 ED visits in the cohort, 27 168 (4.0%) were MH-ED visits. The proportion of MH-ED visits was higher during each COVID-19 wave compared with predicted prepandemic trends. Increased MH-ED visits were seen for eating disorders across all waves; anxiety disorders in all except wave 3; depressive disorders and suicidality/self-harm in wave 2; and substance use disorders in waves 2, 4, and 5. MH-ED visits were increased from expected among female, adolescent, Asian race, high Child Opportunity Index patients. There was no association between MH-ED visits and NYC COVID-19 prevalence or NY State Stringency Index., Conclusions: The proportion of pediatric MH-ED visits during the COVID-19 pandemic was higher during each wave compared with the predicted prepandemic period, with varied increases among diagnostic and sociodemographic subgroups. Enhanced pediatric mental health resources are essential to address these findings., (Copyright © 2023 by the American Academy of Pediatrics.)

Importance: Requiring personalized genetic counseling may introduce barriers to cancer risk assessment, but it is unknown whether omitting counseling could increase distress., Objective: To assess whether omitting pretest and/or posttest genetic counseling would increase distress during remote testing., Design, Setting, and Participants: Making Genetic Testing Accessible (MAGENTA) was a 4-arm, randomized noninferiority trial testing the effects of individualized pretest and/or posttest genetic counseling on participant distress 3 and 12 months posttest. Participants were recruited via social and traditional media, and enrollment occurred between April 27, 2017, and September 29, 2020. Participants were women aged 30 years or older, English-speaking, US residents, and had access to the internet and a health care professional. Previous cancer genetic testing or counseling was exclusionary. In the family history cohort, participants had a personal or family history of breast or ovarian cancer. In the familial pathogenic variant (PV) cohort, participants reported 1 biological relative with a PV in an actionable cancer susceptibility gene. Data analysis was performed between December 13, 2020, and May 31, 2023., Intervention: Participants completed baseline questionnaires, watched an educational video, and were randomized to 1 of 4 arms: the control arm with pretest and/or posttest genetic counseling, or 1 of 3 study arms without pretest and posttest counseling. Genetic counseling was provided by phone appointments and testing was done using home-delivered saliva kits., Main Outcomes and Measures: The primary outcome was participant distress measured by the Impact of Event Scale 3 months after receiving the results. Secondary outcomes included completion of testing, anxiety, depression, and decisional regret., Results: A total of 3839 women (median age, 44 years [range 22-91 years]), most of whom were non-Hispanic White and college educated, were randomized, 3125 in the family history and 714 in the familial PV cohorts. In the primary analysis in the family history cohort, all experimental arms were noninferior for distress at 3 months. There were no statistically significant differences in anxiety, depression, or decisional regret at 3 months. The highest completion rates were seen in the 2 arms without pretest counseling., Conclusions and Relevance: In the MAGENTA clinical trial, omitting individualized pretest counseling for all participants and posttest counseling for those without PV during remote genetic testing was not inferior with regard to posttest distress, providing an alternative care model for genetic risk assessment., Trial Registration: ClinicalTrials.gov Identifier: NCT02993068.

Background: There are wide variations in the gender makeup of speakers at national pediatric emergency medicine (PEM) conferences with no significant change in recent years., Objective: Gender disparities exist among national speakers and award recipients. PEM represents the intersection of pediatrics, a female-dominated specialty with approximately 58% women, and emergency medicine, a male-dominated specialty. We describe the proportion of women speakers and award recipients at two national PEM conferences, the American Academy of Pediatrics (AAP) Section on Emergency Medicine (SOEM) and the Advanced PEM Assembly (APEMA), to the AAP National Conference & Exhibition (NCE), a national pediatric conference., Methods: Data from SOEM and APEMA, obtained from 2016 to 2021 were compared to the 2021 NCE. Invited speakers, abstract presenters, and award recipients were identified. Gender was determined by searching each individual's name for self-identification. Gender proportions were compared across conferences, speaker type, and year., Results: Compared to the NCE, a significantly smaller proportion of women were invited speakers at APEMA (NCE 59.9% vs. APEMA 38.8%, p < 0.001), but similar proportions of women were invited speakers (53.9%, p = 0.178) and awardees at SOEM (50% vs. 50%, p = 1.0). A larger number of women were SOEM abstract presenters than invited speakers (63.3% vs. 53.9%, p = 0.041). Between 2016 and 2021, the proportion of women invited speakers (SOEM, p = 0.744; APEMA, p = 0.947) or abstract presenters (SOEM, p = 0.632) did not significantly change., Conclusions: Compared to NCE, women are underrepresented as speakers at APEMA, but not at SOEM. Abstract presenters are more likely to be women compared to invited speakers. While awards appear equally distributed, recipients do not mirror the proportion of women in PEM. Conference organizers and leaders in PEM should ensure gender equity in national recognition., (© 2023 Society for Academic Emergency Medicine.)

Background: Individuals with Alzheimer's disease and Alzheimer's disease-related dementias may lose the ability to drive safely as their disease progresses. Little is known about driving prevalence in older Latinx and non-Hispanic White (NHW) individuals. We investigated the prevalence of driving status among individuals with cognitive impairment in a population-based cohort., Methods: This was a cross-sectional analysis of the cohort BASIC-Cognitive study in a community of Mexican American (MA) and NHW individuals in South Texas. Participants scored ≤25 on the Montreal Cognitive Assessment (MoCA), indicating a likelihood of cognitive impairment. Current driving status was assessed by the Harmonized Cognitive Assessment Protocol informant interview. Logistic regression was used to assess driving versus non-driving adjusted for pre-specified covariates. Chi-square and Mann-Whitney U tests were used to compare NHW and MA differences in driving outcomes from the American Academy of Neurology (AAN) questions for evaluating driving risk in dementia., Results: There were 635 participants, 77.0 mean age, 62.4% women, and 17.3 mean MoCA. Of these, 360 (61.4%) were current drivers with 250 of 411 (60.8%) MA participants driving, and 121 of 190 (63.70%) NHW participants driving (p = 0.50). In fully adjusted models age, sex, cognitive impairment, language preference, and Activities of Daily Living scores were significant predictors for the likelihood of driving (p < 0.0001). Severity of cognitive impairment was inversely associated with odds of driving, but this relationship was not found in those preferring Spanish language for interviews. Around one-third of all caregivers had concerns about their care-recipient driving. There were no significant differences in MA and NHW driving habits and outcomes from the AAN questionnaire., Conclusions: The majority of participants with cognitive impairment were currently driving. This is a cause for concern for many caregivers. There were no significant ethnic driving differences. Associations with current driving in cognitively impaired persons require further research., (© 2023 The American Geriatrics Society.)

Background: Clinical guidelines recommend that older patients (65+) with mild cognitive impairment (MCI) and early-stage dementia receive similar guideline-concordant care after cardiovascular disease (CVD) events as those with normal cognition (NC). However, older patients with MCI and dementia receive less care for CVD and other conditions than those with NC. Whether physician recommendations for guideline-concordant treatments after two common CVD events, acute myocardial infarction (AMI) and acute ischemic stroke (stroke), differ between older patients with NC, MCI, and early-stage dementia is unknown., Objective: To test the influence of patient cognitive status (NC, MCI, early-stage dementia) on physicians' recommendations for guideline-concordant treatments for AMI and stroke., Design: We conducted two parallel, randomized survey studies for AMI and stroke in the US using clinical vignettes where the hypothetical patient's cognitive status was randomized between physicians., Participants: The study included cardiologists, neurologists, and generalists who care for most patients hospitalized for AMI and stroke., Main Measures: The primary outcome was a composite quality score representing the number of five guideline-concordant treatments physicians recommended for a hypothetical patient after AMI or stroke., Key Results: 1,031 physicians completed the study (58.5% response rate). Of 1,031 respondents, 980 physicians had complete information. After adjusting for physician factors, physicians recommended similar treatments after AMI and stroke in hypothetical patients with pre-existing MCI (adjusted ratio of expected composite quality score, 0.98 [95% CI, 0.94, 1.02]; P = 0.36) as hypothetical patients with NC. Physicians recommended fewer treatments to hypothetical patients with pre-existing early-stage dementia than to hypothetical patients with NC (adjusted ratio of expected composite quality score, 0.90 [0.86, 0.94]; P < 0.001)., Conclusion: In these randomized survey studies, physicians recommended fewer guideline-concordant AMI and stroke treatments to hypothetical patients with early-stage dementia than those with NC. We did not find evidence that physicians recommend fewer treatments to hypothetical patients with MCI than those with NC., (© 2023. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Objective: To examine the differences in opioid prescribing by cognitive status following common elective surgical procedures among Medicare beneficiaries., Background: Older individuals commonly experience changes in cognition with age. Although opioid prescribing is common after surgery, differences in opioid prescribing after surgery by cognitive status are poorly understood., Methods: We conducted a retrospective analysis of patients ≥65 years participating in the Health and Retirement Study (HRS) linked with Medicare claims data who underwent surgeries between January 2007 and November 2016 and had cognitive assessments before the index operation. Cognitive status was defined as normal cognition, mild cognitive impairment (MCI), or dementia. Outcomes assessed were initial perioperative opioid fill rates, refill rates, and high-risk prescriptions fill rates. The total amount of opioids filled during the 30-day postdischarge period was also assessed. Adjusted rates were estimated for patient factors using the Cochran-Armitage test for trend., Results: Among the 1874 patients included in the analysis, 68% had normal cognition, 21.3% had MCI, and 10.7% had dementia. Patients with normal cognition (58.1%) and MCI (54.5%) had higher initial preoperative fill rates than patients with dementia (33.5%) ( P < 0.001). Overall, patients with dementia had similar opioid refill rates (21%) to patients with normal cognition (24.1%) and MCI (26.5%) ( P = 0.322). Although prior opioid exposure did not differ by cognitive status ( P = 0.171), among patients with high chronic preoperative use, those with dementia had lower adjusted prescription sizes filled within 30 days following discharge (281 OME) than patients with normal cognition (2147 OME) and MCI (774 OME) ( P < 0.001; P = 0.009 respectively). Among opioid-naive patients, patients with dementia also filled smaller prescription sizes (97 OME) compared to patients with normal cognition (205 OME) and patients with MCI (173 OME) ( P < 0.001 and P = 0.019, respectively)., Conclusions: Patients with dementia are less likely to receive postoperative prescriptions, less likely to refill prescriptions, and receive prescriptions of smaller sizes compared to patients with normal cognition or MCI. A cognitive assessment is an additional tool surgeons can use to determine a patient's individualized postoperative pain control plan., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objectives: Patients with multisystem inflammatory disease in children (MIS-C) are at risk of developing shock. Our objectives were to determine independent predictors associated with development of delayed shock (≥3 hours from emergency department [ED] arrival) in patients with MIS-C and to derive a model predicting those at low risk for delayed shock., Methods: We conducted a retrospective cross-sectional study of 22 pediatric EDs in the New York City tri-state area. We included patients meeting World Health Organization criteria for MIS-C and presented April 1 to June 30, 2020. Our main outcomes were to determine the association between clinical and laboratory factors to the development of delayed shock and to derive a laboratory-based prediction model based on identified independent predictors., Results: Of 248 children with MIS-C, 87 (35%) had shock and 58 (66%) had delayed shock. A C-reactive protein (CRP) level greater than 20 mg/dL (adjusted odds ratio [aOR], 5.3; 95% confidence interval [CI], 2.4-12.1), lymphocyte percent less than 11% (aOR, 3.8; 95% CI, 1.7-8.6), and platelet count less than 220,000/uL (aOR, 4.2; 95% CI, 1.8-9.8) were independently associated with delayed shock. A prediction model including a CRP level less than 6 mg/dL, lymphocyte percent more than 20%, and platelet count more than 260,000/uL, categorized patients with MIS-C at low risk of developing delayed shock (sensitivity 93% [95% CI, 66-100], specificity 38% [95% CI, 22-55])., Conclusions: Serum CRP, lymphocyte percent, and platelet count differentiated children at higher and lower risk for developing delayed shock. Use of these data can stratify the risk of progression to shock in patients with MIS-C, providing situational awareness and helping guide their level of care., Competing Interests: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Understanding concordance between informants' and cognitively impaired participants' information reporting is crucial for Alzheimer's and Alzheimer's-related dementia studies., Methods: The Brain Attack Surveillance in Corpus Christi-Cognitive is a community-based cohort study. Households in Nueces County, Texas, USA, were randomly identified. 330 dyads of participants and their named informants answered questions. Models were generated to examine which predictors, including age, gender, ethnicity, cognitive function, and relationship to informant, influenced answer discordance., Results: For demographic items, female participants and participants with spouses/partners as informants had significantly less discordance, with incidence rate rations (IRRs) of 0.65 (CI = 0.44, 0.96) and 0.41 (CI = 0.23, 0.75), respectively. For health items, better cognitive function of the participant was associated with less discordance, with an IRR of 0.85 (CI = 0.76, 0.94)., Conclusions: Demographic information concordance is most associated with gender and informant-participant relationship. Level of cognitive function is most associated with concordance for health information., Clinicaltrials: gov identifier NCT03403257., (© 2023. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Importance: The magnitude of cognitive change after incident myocardial infarction (MI) is unclear., Objective: To assess whether incident MI is associated with changes in cognitive function after adjusting for pre-MI cognitive trajectories., Design, Setting, and Participants: This cohort study included adults without MI, dementia, or stroke and with complete covariates from the following US population-based cohort studies conducted from 1971 to 2019: Atherosclerosis Risk in Communities Study, Coronary Artery Risk Development in Young Adults Study, Cardiovascular Health Study, Framingham Offspring Study, Multi-Ethnic Study of Atherosclerosis, and Northern Manhattan Study. Data were analyzed from July 2021 to January 2022., Exposures: Incident MI., Main Outcomes and Measures: The main outcome was change in global cognition. Secondary outcomes were changes in memory and executive function. Outcomes were standardized as mean (SD) T scores of 50 (10); a 1-point difference represented a 0.1-SD difference in cognition. Linear mixed-effects models estimated changes in cognition at the time of MI (change in the intercept) and the rate of cognitive change over the years after MI (change in the slope), controlling for pre-MI cognitive trajectories and participant factors, with interaction terms for race and sex., Results: The study included 30 465 adults (mean [SD] age, 64 [10] years; 56% female), of whom 1033 had 1 or more MI event, and 29 432 did not have an MI event. Median follow-up was 6.4 years (IQR, 4.9-19.7 years). Overall, incident MI was not associated with an acute decrease in global cognition (-0.18 points; 95% CI, -0.52 to 0.17 points), executive function (-0.17 points; 95% CI, -0.53 to 0.18 points), or memory (0.62 points; 95% CI, -0.07 to 1.31 points). However, individuals with incident MI vs those without MI demonstrated faster declines in global cognition (-0.15 points per year; 95% CI, -0.21 to -0.10 points per year), memory (-0.13 points per year; 95% CI, -0.22 to -0.04 points per year), and executive function (-0.14 points per year; 95% CI, -0.20 to -0.08 points per year) over the years after MI compared with pre-MI slopes. The interaction analysis suggested that race and sex modified the degree of change in the decline in global cognition after MI (race × post-MI slope interaction term, P = .02; sex × post-MI slope interaction term, P = .04), with a smaller change in the decline over the years after MI in Black individuals than in White individuals (difference in slope change, 0.22 points per year; 95% CI, 0.04-0.40 points per year) and in females than in males (difference in slope change, 0.12 points per year; 95% CI, 0.01-0.23 points per year)., Conclusions: This cohort study using pooled data from 6 cohort studies found that incident MI was not associated with a decrease in global cognition, memory, or executive function at the time of the event compared with no MI but was associated with faster declines in global cognition, memory, and executive function over time. These findings suggest that prevention of MI may be important for long-term brain health.

Goals: Evidence suggests that patients with mild cognitive impairment (MCI) receive fewer treatments for acute ischemic stroke and other cardiovascular diseases than patients with normal cognition. Little is known about how patient and care partner preferences for ischemic stroke treatment differ between the patient population with MCI and the population with normal cognition. This study aimed to understand how patient MCI diagnosis influences patient and care partner decision-making for acute ischemic stroke treatments., Methods: Multi-center qualitative study using in-person semi-structured interviews with 20 MCI and normal cognition patient-care partner dyads using a standard guide. The present study reports results on patient and care partner preferences for a clinical vignette patient to receive three non-invasive treatments (intravenous tissue plasminogen activator, inpatient rehabilitation, and secondary preventive medications) and two invasive treatments (feeding tube and carotid endarterectomy) after acute ischemic stroke. We used qualitative content analysis to identify themes., Findings: We identified three major themes: (1) Patients with MCI desired non-invasive treatments after stroke, similar to patients with normal cognition and for similar reasons; (2) Patients with MCI expressed different preferences than patients with normal cognition for two invasive treatments after stroke: carotid endarterectomy and feeding tube placement; and (3) Patients with MCI expressed more skepticism of the stroke treatment options and less decisiveness in decision-making than patients with normal cognition., Conclusions: These results suggest that patient MCI diagnosis may contribute to differences in patient and care partner preferences for invasive treatments after stroke, but not for non-invasive treatments., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflicts of interest., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Importance: Incident stroke is associated with accelerated cognitive decline. Whether poststroke vascular risk factor levels are associated with faster cognitive decline is uncertain., Objective: To evaluate associations of poststroke systolic blood pressure (SBP), glucose, and low-density lipoprotein (LDL) cholesterol levels with cognitive decline., Design, Setting, and Participants: Individual participant data meta-analysis of 4 US cohort studies (conducted 1971-2019). Linear mixed-effects models estimated changes in cognition after incident stroke. Median (IQR) follow-up was 4.7 (2.6-7.9) years. Analysis began August 2021 and was completed March 2023., Exposures: Time-dependent cumulative mean poststroke SBP, glucose, and LDL cholesterol levels., Main Outcomes and Measures: The primary outcome was change in global cognition. Secondary outcomes were change in executive function and memory. Outcomes were standardized as t scores (mean [SD], 50 [10]); a 1-point difference represents a 0.1-SD difference in cognition., Results: A total of 1120 eligible dementia-free individuals with incident stroke were identified; 982 (87.7%) had available covariate data and 138 (12.3%) were excluded for missing covariate data. Of the 982, 480 (48.9%) were female individuals, and 289 (29.4%) were Black individuals. The median age at incident stroke was 74.6 (IQR, 69.1-79.8; range, 44.1-96.4) years. Cumulative mean poststroke SBP and LDL cholesterol levels were not associated with any cognitive outcome. However, after accounting for cumulative mean poststroke SBP and LDL cholesterol levels, higher cumulative mean poststroke glucose level was associated with faster decline in global cognition (-0.04 points/y faster per each 10-mg/dL increase [95% CI, -0.08 to -0.001 points/y]; P = .046) but not executive function or memory. After restricting to 798 participants with apolipoprotein E4 (APOE4) data and controlling for APOE4 and APOE4 × time, higher cumulative mean poststroke glucose level was associated with a faster decline in global cognition in models without and with adjustment for cumulative mean poststroke SBP and LDL cholesterol levels (-0.05 points/y faster per 10-mg/dL increase [95% CI, -0.09 to -0.01 points/y]; P = .01; -0.07 points/y faster per 10-mg/dL increase [95% CI, -0.11 to -0.03 points/y]; P = .002) but not executive function or memory declines., Conclusions and Relevance: In this cohort study, higher poststroke glucose levels were associated with faster global cognitive decline. We found no evidence that poststroke LDL cholesterol and SBP levels were associated with cognitive decline.

Competing Interests: Disclosure: The authors declare no conflict of interest.

Background: Brain injury during early childhood may disrupt key periods of neurodevelopment. Most research regarding mild traumatic brain injury (mTBI) has focused on school-age children. We sought to characterize the incidence and healthcare utilization for mTBI in young children presenting to U.S. emergency departments (ED)., Methods: The Nationwide Emergency Department Sample was queried for children age 0-6 years with mTBI from 2016 to 2019. Patients were excluded for focal or diffuse TBI, drowning or abuse mechanism, death in the ED or hospital, Injury Severity Score > 15, neurosurgical intervention, intubation, or blood product transfusion., Results: National estimates included 1,372,291 patient visits: 63.5% were two years or younger, 57.5% were male, and 69.4% were injured in falls. The most common head injury diagnosis was "unspecified injury of head" (83%); this diagnosis decreased in frequency as age increased, in favor of a concussion diagnosis. Most patients were seen at low pediatric volume EDs (64.5%) and non-children's hospital EDs (86.2%), and 64.9% were seen at a non-teaching hospital. Over 98% were treated in the ED and discharged home. Computed tomography of the head and cervical spine were performed in 18.7% and 1.6% of patients, respectively, less often at children's hospitals (OR = 0.55, 95%CI = 0.41-0.76 for head and OR = 0.19, 95%CI = 0.11-0.34 for cervical spine). ED charges resulted in $540-681 million annually, and more than half of patients utilized Medicaid., Conclusions: Early childhood mTBI is prevalent and results in high financial burden in the U.S. There is wide variation in diagnostic coding and computed tomography scanning amongst EDs. More focused research is needed to identify optimal diagnostic tools and management strategies., Competing Interests: Declaration of Competing Interest The authors report no conflicts of interest related to this article., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs)., Methods: The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains., Results: Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics., Conclusions: The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Objectives: We examined whether cognitive trajectories from 0-3 months after stroke differ between Mexican Americans (MAs) and non-Hispanic white (NHW) adults., Materials and Methods: The sample included 701 participants with ischemic stroke (62% MA; 38% NHW) from the population-based stroke surveillance study, the Brain Attack Surveillance in Corpus Christi (BASIC) Project, between 2008-2013. The outcome was the modified Mini Mental State Examination (3MSE, range 0-100 lower scores worse). Linear mixed effects models were utilized to examine the association between ethnicity and cognitive trajectories from 0-3 months following stroke, adjusting for confounders., Results: MAs were younger, had lower educational attainment, and fewer had health insurance than NHWs (all p< 0.01). A smaller proportion of MAs were rated by informants as exhibiting pre-stroke cognitive decline than NHW (p < .0.05). After accounting for confounders, MAs demonstrated lower cognitive performance at post-stroke baseline and at 3-months following stroke (-2.00; 95% CI =-3.92, -0.07). Cognitive trajectories from 0-3 months following stroke were indicative of modest cognitive recovery (increase of 0.034/day, 95% CI =0.030-0.036) and did not differ between MAs and NHWs (p = 0.68)., Conclusion: We found no evidence that cognitive trajectories in the first three months following stroke differed between MAs and NHWs. MAs demonstrated lower cognitive performance shortly after stroke and at three months following stroke compared to NHWs. Further research is needed to identify factors contributing to ethnic disparities in cognitive outcomes after stroke., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: Clinical trials conducted before the introduction of modern medical management to prevent stroke demonstrated that carotid endarterectomy (CEA) and carotid artery stenting (CAS) prevent stroke following transient ischemic attack (TIA). We compared the cost-effectiveness of CEA, CAS, and modern medical management in two secular settings of medical management in individuals with incident TIA and type 2 diabetes., Methods: Using simulation modeling, our base-case analyses were performed from the healthcare sector perspective over a 20-year time horizon with an annual 3% discount rate applied to both costs and quality-adjusted life years (QALYs). Outcomes depended on age, sex, biomarkers associated with cardiovascular risk, and treatment effects based on a validated model of type 2 diabetes. Our simulation population was drawn from the National Health and Nutrition Examination Survey (NHANES) 2014 cohort. Costs for modern medical management were based on average wholesale prices, and revascularization costs were derived from published literature. One-way and probabilistic sensitivity analyses were conducted., Results: Compared to all other strategies, historical medical management plus CEA was either cost-saving or cost-effective at a threshold of $100,000 per QALY gained. Modern medical management was cost-effective compared to historical medical management without revascularization at a $100,000 acceptability threshold. However, both revascularization approaches (plus medical management) were cost-saving compared to modern medical management alone., Conclusion: Among individuals requiring carotid revascularization, carotid endarterectomy is the cost-effective strategy to treat individuals with type 2 diabetes following a TIA. For individuals for whom revascularization is contraindicated, modern medical therapy is cost-effective., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: The Omicron variant of SARS-CoV-2 has a predilection for the upper airways, causing symptoms such as sore throat, hoarse voice, and stridor., Objective: We describe a series of children with COVID-19-associated croup in an urban multicenter hospital system., Methods: We conducted a cross-sectional study of children ≤18 years of age presenting to the emergency department during the COVID-19 pandemic. Data were extracted from an institutional data repository comprised of all patients who were tested for SARS-CoV-2. We included patients with a croup diagnosis by International Classification of Diseases, 10th revision code and a positive SARS-CoV-2 test within 3 days of presentation. We compared demographics, clinical characteristics, and outcomes for patients presenting during a pre-Omicron period (March 1, 2020-December 1, 2021) to the Omicron wave (December 2, 2021-February 15, 2022)., Results: We identified 67 children with croup, 10 (15%) pre-Omicron and 57 (85%) during the Omicron wave. The prevalence of croup among SARS-CoV-2-positive children increased by a factor of 5.8 (95% confidence interval 3.0-11.4) during the Omicron wave compared to prior. More patients were ≥6 years of age in the Omicron wave than prior (19% vs. 0%). The majority were not hospitalized (77%). More patients ≥6 years of age received epinephrine therapy for croup during the Omicron wave (73% vs. 35%). Most patients ≥6 years of age had no croup history (64%) and only 45% were vaccinated against SARS-CoV-2., Conclusion: Croup was prevalent during the Omicron wave, atypically affecting patients ≥6 years of age. COVID-19-associated croup should be added to the differential diagnosis of children with stridor, regardless of age. © 2022 Elsevier Inc., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background and Objectives: There are disparities in the prevalence of obesity by race, and the relationship between obesity and cognitive decline is unclear. The objective of this study was to determine whether obesity is independently associated with cognitive decline and whether the association between obesity and cognitive decline differs in Black and White adults. We hypothesized that obesity is associated with greater cognitive decline compared with normal weight and that the effect of obesity on cognitive decline is more pronounced in Black adults compared with their White counterparts., Methods: We pooled data from 28,867 participants free of stroke and dementia (mean, SD: age 61 [10.7] years at the first cognitive assessment, 55% female, 24% Black, and 29% obese) from 6 cohorts. The primary outcome was the annual change in global cognition. We performed linear mixed-effects models with and without time-varying cumulative mean systolic blood pressure (SBP) and fasting plasma glucose (FPG). Global cognition was set to a t-score metric (mean 50, SD 10) at a participant's first cognitive assessment; a 1-point difference represents a 0.1 SD difference in global cognition across the 6 cohorts. The median follow-up was 6.5 years (25th percentile, 75th percentile: 5.03, 20.15)., Results: Obese participants had lower baseline global cognition than normal-weight participants (difference in intercepts, -0.36 [95% CI, -0.46 to -0.17]; p < 0.001). This difference in baseline global cognition was attenuated but was borderline significant after accounting for SBP and FPG (adjusted differences in intercepts, -0.19 [95% CI, -0.39 to 0.002]; p = 0.05). There was no difference in the rate of decline in global cognition between obese and normal-weight participants (difference in slope, 0.009 points/year [95% CI, -0.009 to 0.03]; p = 0.32). After accounting for SBP and FPG, obese participants had a slower decline in global cognition (adjusted difference in slope, 0.03 points/year slower [95% CI, 0.01 to 0.05]; p < 0.001). There was no evidence that race modified the association between body mass index and global cognitive decline ( p = 0.34)., Discussion: These results suggest that obesity is associated with lower initial cognitive scores and may potentially attenuate declines in cognition after accounting for BP and FPG., (Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

Introduction: Rural versus urban living is a social determinant of cognitive health. We estimated the association of rural versus urban residence in the USA with incident cognitive impairment (ICI) and assessed effect heterogeneity by sociodemographic, behavioral, and clinical factors., Methods: The Reasons for Geographic and Racial Differences in Stroke Study (REGARDS) is a population-based prospective observational cohort of 30,239 adults, 57% female, 36% Black, aged 45+ years, sampled from 48 contiguous states in the USA in 2003-2007. We analyzed 20,878 participants who at baseline were cognitively intact with no history of stroke and had ICI assessed on average 9.4 years later. We classified participants' home addresses at baseline as urban (population ≥50,000), large rural (10,000-49,999), or small rural (≤9,999) by Rural-Urban Commuting Area codes. We defined ICI as ≥1.5 SD below the mean on at least 2 of the following tests: word list learning, word list delayed recall, and animal naming., Results: Participants' home addresses were 79.8% urban, 11.7% large rural, and 8.5% small rural. ICI occurred in 1,658 participants (7.9%). Small rural residents had higher odds of ICI than urban residents, adjusted for age, sex, race, region, and education (OR = 1.34 [95% CI: 1.10, 1.64]), and after further adjustment for income, health behaviors, and clinical characteristics (OR = 1.24 [95% CI: 1.02, 1.53]). Former smoking versus never, nondrinking versus light alcohol drinking, no exercise versus ≥4 times/week, CES-D depressive symptom score of 2 versus 0, and fair versus excellent self-rated health had stronger associations with ICI in small rural areas than in urban areas. For example, in urban areas, lack of exercise was not associated with ICI (OR = 0.90 [95% CI: 0.77, 1.06]); however, lack of exercise combined with small rural residence was associated with 1.45 times the odds of ICI compared with ≥4 bouts of exercise/week in urban areas (95% CI: 1.03, 2.03). Overall, large rural residence was not associated with ICI; however, black race, hypertension, and depressive symptoms had somewhat weaker associations with ICI, and heavy alcohol drinking a stronger association with ICI, in large rural areas than in urban areas., Conclusion: Small rural residence was associated with ICI among USA adults. Further research to better understand why rural residents are at higher risk for developing ICI and mechanisms to ameliorate that risk will support efforts to advance rural public health., (© 2023 S. Karger AG, Basel.)

Background: People with mild cognitive impairment (MCI) receive fewer guideline-concordant treatments for cardiovascular disease (CVD) than people with normal cognition (NC)., Objective: To understand physician perspectives on why patients with MCI receive fewer CVD treatments than patients with NC., Methods: As part of a mixed-methods study assessing how patient MCI influences physicians' decision making for acute myocardial infarction (AMI) and stroke treatments, we conducted a qualitative study using interviews of physicians. Topics included participants' reactions to data that physicians recommend fewer CVD treatments to patients with MCI and reasons why participants think fewer CVD treatments may be recommended to this patient population., Results: Participants included 22 physicians (8 cardiologists, 7 neurologists, and 7 primary care physicians). Most found undertreatment of CVD in patients with MCI unreasonable, while some participants thought it could be considered reasonable. Participants postulated that other physicians might hold beliefs that could be reasons for undertreating CVD in patients with MCI. These beliefs fell into four main categories: 1) patients with MCI have worse prognoses than NC, 2) patients with MCI are at higher risk of treatment complications, 3) patients' cognitive impairment might hinder their ability to consent or adhere to treatment, and 4) patients with MCI benefit less from treatments than NC., Conclusion: These findings suggest that most physicians do not think it is reasonable to recommend less CVD treatment to patients with MCI than to patients with NC. Improving physician understanding of MCI might help diminish disparities in CVD treatment among patients with MCI.