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Andras Bikov,1,2 Peter Lange,3,4 Julie A Anderson,5 Robert D Brook,6 Peter MA Calverley,7 Bartolome R Celli,8 Nicholas J Cowans,9 Courtney Crim,10 Ian J Dixon,9 Fernando J Martinez,11 David E Newby,12 Julie C Yates,10 Jørgen Vestbo1,2 1Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK; 2Division of Infection, Immunity & Respiratory Medicine, University of Manchester, Manchester, UK; 3Medical Department, Herlev and Gentofte Hospital, Herlev, Denmark; 4Section of Epidemiology, Department of Public Health, University of Copenhagen, Copenhagen, Denmark; 5Research & Development, GlaxoSmithKline, Middlesex, UK; 6University of Michigan Health System, Ann Arbor, MI, USA; 7University of Liverpool, Department of Medicine, Clinical Sciences Centre, University Hospital Aintree, Liverpool, UK; 8Pulmonary and Critical Care Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA; 9Statistics & Programming, Veramed Ltd., Twickenham, UK; 10Research & Development, GlaxoSmithKline, Research Triangle Park, NC, USA; 11Division of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, NY, USA; 12British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UKCorrespondence: Andras Bikov 2nd Floor ERC Building, Wythenshawe Hospital, Southmoor Road, Manchester M23 9LT, UKTel +36203141599Fax +441612915730Email andras.bikov@gmail.comPurpose: Chronic obstructive pulmonary disease (COPD) is one of the leading causes of death worldwide. Impaired lung function is associated with heightened risk for death, cardiovascular events, and COPD exacerbations. However, it is unclear if forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) differ in predictive value.Patients and Methods: Data from 16,485 participants in the Study to Understand Mortality and Morbidity (SUMMIT) in COPD were analyzed. Patients were grouped into quintiles for each lung function parameter (FEV1 %predicted, FVC %predicted, FEV1/FVC). The four highest quintiles (Q2–Q5) were compared to the lowest (Q1) to assess their relationship with all-cause mortality, cardiovascular events, and moderate-to-severe and severe exacerbations. Cox-regression was used, adjusted for age, sex, ethnicity, body-mass index, smoking status, previous exacerbations, cardiovascular disease, treatment, and modified Medical Research Council dyspnea score.Results: Compared to Q1 (< 53.5% FEV1 predicted), increasing FEV1 quintiles (Q2 53.5– 457.5% predicted, Q3 57.5– 461.6% predicted, Q4 61.6– 465.8% predicted, and Q5 ≥ 65.8%) were all associated with significantly decreased all-cause mortality (20% (4– 34%), 28% (13– 40%), 23% (7– 36%), and 30% (15– 42%) risk reduction, respectively). In contrast, a significant risk reduction (21% (4– 35%)) was seen only between Q1 and Q5 quintiles of FVC. Neither FEV1 nor FVC was associated with cardiovascular risk. Increased FEV1 and FEV1/FVC quintiles were also associated with the reduction of moderate-to-severe and severe exacerbations while, surprisingly, the highest FVC quintile was related to the heightened exacerbation risk (28% (8– 52%) risk increase).Conclusion: Our results suggest that FEV1 is a stronger predictor for all-cause mortality than FVC in moderate COPD patients with heightened cardiovascular risk and that subjects with moderate COPD have very different risks.Keywords: airflow limitation, cardiovascular risk, exacerbation, lung function, lung volumes, death rate

Blood pressure (BP) is affected by many environmental factors including ambient temperature, altitude, latitude, noise, and air pollutants. Given their pervasiveness, it is plausible that such factors may also have an impact on hypertension prevalence and control rates. Health care providers should be aware that the environment can play a significant role in altering BP. Although not among the established modifiable risk factors (eg, obesity) for hypertension, reducing exposures when pertinent should be considered to prevent or control hypertension. The authors provide a concise review of the evidence linking diverse environmental factors with BP and suggest an approach for incorporating this knowledge into clinical practice. The authors propose using the term environmental hypertensionology to refer to the study of the effects of environmental factors on BP in clinical and research settings. [ABSTRACT FROM AUTHOR]

Arm size can affect the accuracy of blood pressure (BP) measurement, and "undercuffing" of large upper arms is likely to be a growing problem. Therefore, the authors investigated the relationship between upper arm and wrist readings. Upper arm and wrist circumferences and BP were measured in 261 consecutive patients. Upper arm auscultation and wrist BP was measured in triplicate, rotating measurements every 30 seconds between sites. Upper arm BP was 131.9+/-20.6/71.6+/-12.6 mm Hg in an obese population (body mass index, 30.6+/-6.6 kg/m(2)) with mean upper arm size of 30.7+/-5.1 cm. Wrist BP was higher (2.6+/-9.2 mm Hg and 4.9+/-6.6 mm Hg, respectively, P<.001); however, there was moderate concordance for the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) strata (kappa value=0.27-0.71), and the difference was >or=5 mm Hg in 72% of the patients. The authors conclude that there was poor concordance between arm and wrist BP measurement and found no evidence that "hidden undercuffing" was associated with obesity; therefore, they do not support routine use of wrist BP measurements. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Air pollution is associated with an increased risk for cardiovascular events. Many of the biological pathways involved could also promote diabetes mellitus (DM). We therefore investigated the association between DM prevalence and exposure to traffic-related air pollution (nitrogen dioxide [NO 2]). METHODS: Study participants were patients who attended two respiratory clinics in Hamilton (n = 5228) and Toronto (n = 2406). The diagnosis of DM was ascertained by linkage to administrative databases of the Ontario universal Health Insurance Plan for patients aged 40 years and above. Geographic Information systems methodology was used to assign individual estimates of NO2 based on a network of samplers in each city. Logistic regression was used to estimate the relations between NO2 exposures and the odds of DM diagnosis. RESULTS: After adjusting for age, body mass index, and neighborhood income there were positive effects in women on the odds ratio for DM for each 1 ppb NO2 exposure in Toronto (OR 1.055, 95% CI: 0.99 to 1.11) and Hamilton (OR 1.029, 95% CI: 0.98 to 1.08). In a meta-analytic model including both cities, there was a significant effect in women (OR = 1.04; 95% CI: 1.00 to 1.08). Across the inter-quartile range (approximately 4 ppb NO2) there was nearly a 17% increase in the odds of DM for women. There were no positive associations among men. CONCLUSIONS: Exposure to NO2, a marker of traffic-related air pollutants, was associated with DM prevalence among women. Exposure estimate errors in men may explain the apparent gender difference. These results suggest that common air pollutants are associated with DM and warrant more investigation to determine if this is a cause-and-effect relationship. [ABSTRACT FROM AUTHOR]

OBJECTIVE: This study sought to determine whether combined continuous ethinyl estradiol and norethindrone acetate, a postmenopausal hormone therapy (HT) combination designed to have fewer side effects than cyclical therapies and therapies using medroxyprogesterone acetate (MPA), could improve vascular endothelial function in postmenopausal women with risk factors for cardiovascular disease (CVD). METHODS: Eighteen postmenopausal women (mean age 62 +/- 11 years) participated in a randomized, placebo-controlled, crossover design trial of 10 microg estradiol/1 mg norethindrone acetate given once daily for 3 months, with a 1-month washout period between placebo and active treatment phases. Vascular reactivity was assessed at each phase of the study using high-frequency brachial artery ultrasound in response to flow-mediated hyperemia, cold pressor testing, and sublingual nitroglycerin. Markers of cardiovascular risk, including cholesterol levels, inflammatory markers, fibrinolytic markers, and solubilized adhesion molecules, were also measured at each phase. RESULTS: We found no significant difference in vascular reactivity measurements during active treatment with ethinyl estradiol/norethindrone acetate vs. placebo. C-reactive protein (CRP) levels increased significantly during active treatment, and high-density lipoprotein (HDL) levels decreased significantly. Vascular cell adhesion molecule-1 (VCAM-1) levels declined during active treatment. Plasminogen activator inhibitor-1 (PAI-1) levels were inversely correlated with flow-mediated hyperemic vascular reactivity, independent of active treatment or placebo phases. CONCLUSIONS: In this older postmenopausal population with at least one cardiovascular risk factor, treatment with combined continuous ethinyl estradiol and norethindrone acetate failed to improve vascular endothelial function. The agent's proinflammatory effect or subclinical atherosclerosis in this population may have contributed to this finding. [ABSTRACT FROM AUTHOR]

Cardiovascular disease is the leading cause of morbidity and mortality worldwide, with a substantial amount of health-care resources targeted towards its diagnosis and management. Environmental sustainability in cardiovascular care can have an important role in reducing greenhouse gas emissions and pollution and could be beneficial for improving health metrics and societal well-being and minimizing the cost of health care. In this Review, we discuss the motivations and frameworks for sustainable cardiovascular care with an emphasis on the reduction of the climate-related and environmental effects of cardiovascular care. We also provide an overview of greenhouse gas emissions related to the provision of health care, including their measurement and quantification, carbon accounting, carbon disclosures and climate effects. The principles of life-cycle assessment, waste prevention and circular economics in health care are discussed, and the emissions associated with various sectors of cardiovascular care as well as the rationale for prevention as a powerful approach to reduce these emissions are presented. Finally, we highlight the challenges in environmental sustainability and future directions as applicable to cardiovascular practice., (© 2024. Springer Nature Limited.)

Background: The public health relevance of daily Air Quality Index (AQI) activity guidelines for the general adult public in the United States to prevent atherosclerotic cardiovascular disease (ASCVD) events is questionable., Objectives: The purpose of the study was to explore the utility of a policy tailoring activity guidance to calculated ASCVD risk rather than uniform recommendations to the general adult public as currently provided., Methods: We calculated the number needed to treat (NNT) to prevent one ASCVD event per day by following activity recommendations across 10-year ASCVD risk scores (1% to 20%). Second, we modeled the benefits of tailoring recommendations to ASCVD risk., Results: The NNT decreased as ASCVD risk and/or AQI levels increased. At AQIs up to 151 (68% of days with AQIs above moderate in the United States), the NNTs remained untenably high (>2.7-55.3 million) across ASCVD risk. Under unhealthy conditions (AQIs 151-200), 28% of elevated AQIs, NNTs <1 million could be achieved by current guidance (15% exposure reduction), but only among the highest-risk individuals (ASCVD 18% to 20%) on the most polluted days (AQIs 192-200). Tailoring guidance to ASCVD risk could yield NNTs <1 million at risk thresholds of 7.5% and 10% if activity restrictions were more stringent (35% to 50% exposure reductions) during unhealthy conditions., Conclusions: ASCVD risk has a major influence on the NNT to prevent cardiovascular events by following AQI guidance. It may be possible for a future policy to improve the utility of AQI activity guidance for the general adult public by tailoring activity recommendations to ASCVD risk., Competing Interests: This study was supported by grant funding from the National Institutes of Environmental Health (1R35ES031702-01A1). The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2024 The Authors.)

Background: Persistent mineralocorticoid receptor activation is a pathologic response in type 2 diabetes and chronic kidney disease. Whereas mineralocorticoid receptor antagonists are beneficial in reducing cardiovascular complications, direct mechanistic pathways for these effects in humans are lacking., Methods: The MAGMA trial (Mineralocorticoid Receptor Antagonism Clinical Evaluation in Atherosclerosis) was a randomized, double-blind, placebo-controlled trial in patients with high-risk type 2 diabetes with chronic kidney disease (not receiving dialysis) on maximum tolerated renin-angiotensin system blockade. The primary end point was change in thoracic aortic wall volume, expressed as absolute or percent value (ΔTWV or ΔPWV), using 3T magnetic resonance imaging at 12 months. Secondary end points were changes in left ventricle (LV) mass; LV fibrosis, measured as a change in myocardial native T1; and 24-hour ambulatory and central aortic blood pressures. Tertiary end points included plasma proteomic changes in 7596 plasma proteins using an aptamer-based assay., Results: A total of 79 patients were randomized to placebo (n=42) or 25 mg of spironolactone daily (n=37). After a modified intent-to-treat, including available baseline data of study end points, patients who completed the trial protocol were included in the final analyses. At the 12-month follow-up, the average change in PWV was 7.1±10.7% in the placebo group and 0.87±10.0% in the spironolactone group ( P =0.028), and ΔTWV was 1.2±1.7 cm 3 in the placebo group and 0.037±1.9 cm 3 in the spironolactone group ( P =0.022). Change in LV mass was 3.1±8.4 g in the placebo group and -5.8±8.4 g in the spironolactone group ( P =0.001). Changes in LV T1 values were significantly different between the placebo and spironolactone groups (26.0±41.9 ms in the placebo group versus a decrease of -10.1±36.3 ms in the spironolactone group; P =6.33×10 -4 ). Mediation analysis revealed that the spironolactone effect on thoracic aortic wall volume and myocardial mass remained significant after adjustment for ambulatory and central blood pressures. Proteomic analysis revealed a dominant effect of spironolactone on pathways involving oxidative stress, inflammation, and leukocyte activation., Conclusions: Among patients with diabetes with moderate to severe chronic kidney disease at elevated cardiovascular risk, treatment with spironolactone prevented progression of aortic wall volume and resulted in regression of LV mass and favorable alterations in native T1, suggesting amelioration of left-ventricular fibrosis., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02169089., Competing Interests: Dr Connelly holds the Keenan Chair in Research Leadership at St Michael’s Hospital and University of Toronto.

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: Exposure to fine particulate matter (<2.5 um, particulate matter with an aerodynamic diameter <2.5 microns [PM 2.5 ]) has been implicated in atherogenesis. Limited data in animal studies suggest that PM 2.5 exposure leads to myocardial fibrosis and increased incidence of heart failure (HF). Whether PM 2.5 is associated with adverse outcomes in patients with preexisting HF has not been widely studied., Methods and Results: In this retrospective cohort study, Medicare patients hospitalized with first HF between 2013 and 2020 were identified from the Medicare Provider Analysis and Review Part A 100% files. Patients were linked with integrated estimates of ambient PM 2.5 obtained at 1×1 km using the zip code of participants' residence. The study outcomes were all-cause death, HF, and all-cause readmissions burden. A total of 2 599 525 patients were included in this study, with 6 321 731 person-years of follow-up. Mean PM 2.5 was 7.3±1.7 μg/m 3 . Each interquartile range of PM 2.5 was associated with 0.9% increased hazard of all-cause death, 4.5% increased hazard of first HF readmission, 3.1% increased risk of HF hospitalization burden, and 5.2% increase in all-cause readmission burden, after adjusting for 11 sociodemographic and medical factors. Subgroup analyses showed that the effects were more pronounced at levels <7 μg/m 3 and in patients aged <75 years, Asians, and those residing in rural areas., Conclusions: Ambient air pollution is associated with higher risk of adverse events in Medicare beneficiaries with established HF. These associations persist below the National Air Quality Standards (12 μg/m 3 ), supporting that no threshold effect exists for health effects of air pollution exposure.

Hypertensive emergencies cause substantial morbidity and mortality, particularly when acute organ injury is present. Careful and effective strategies to reduce blood pressure and diminish the effects of pressure-mediated injury are essential. While the selection of specific antihypertensive medications varies little across different forms of hypertensive emergencies, the intensity of blood pressure reduction to the target pressure differs substantially. Treatment hinges on balancing the positive effects of lowering blood pressure with the potential for negative effects of organ hypoperfusion in patients with altered autoregulatory mechanisms. When patients do not have acute organ injury in addition to severe hypertension, they benefit from a conservative, outpatient approach to blood pressure management. In all cases, long term control of blood pressure is paramount to prevent recurrent hypertensive emergencies and improve overall prognosis. This review discusses the current evidence and guidelines on the evaluation and management of hypertensive emergency., Competing Interests: Competing interests: We have read and understood the BMJ policy on declaration of interests and have no relevant interests to declare., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Urban environments contribute substantially to the rising burden of cardiometabolic diseases worldwide. Cities are complex adaptive systems that continually exchange resources, shaping exposures relevant to human health such as air pollution, noise, and chemical exposures. In addition, urban infrastructure and provisioning systems influence multiple domains of health risk, including behaviors, psychological stress, pollution, and nutrition through various pathways (eg, physical inactivity, air pollution, noise, heat stress, food systems, the availability of green space, and contaminant exposures). Beyond cardiometabolic health, city design may also affect climate change through energy and material consumption that share many of the same drivers with cardiometabolic diseases. Integrated spatial planning focusing on developing sustainable compact cities could simultaneously create heart-healthy and environmentally healthy city designs. This article reviews current evidence on the associations between the urban exposome (totality of exposures a person experiences, including environmental, occupational, lifestyle, social, and psychological factors) and cardiometabolic diseases within a systems science framework, and examines urban planning principles (eg, connectivity, density, diversity of land use, destination accessibility, and distance to transit). We highlight critical knowledge gaps regarding built-environment feature thresholds for optimizing cardiometabolic health outcomes. Last, we discuss emerging models and metrics to align urban development with the dual goals of mitigating cardiometabolic diseases while reducing climate change through cross-sector collaboration, governance, and community engagement. This review demonstrates that cities represent crucial settings for implementing policies and interventions to simultaneously tackle the global epidemics of cardiovascular disease and climate change., Competing Interests: Disclosures None.

Nearly 56% of the global population lives in cities, with this number expected to increase to 6.6 billion or >70% of the world's population by 2050. Given that cardiometabolic diseases are the leading causes of morbidity and mortality in people living in urban areas, transforming cities and urban provisioning systems (or urban systems) toward health, equity, and economic productivity can enable the dual attainment of climate and health goals. Seven urban provisioning systems that provide food, energy, mobility-connectivity, housing, green infrastructure, water management, and waste management lie at the core of human health, well-being, and sustainability. These provisioning systems transcend city boundaries (eg, demand for food, water, or energy is met by transboundary supply); thus, transforming the entire system is a larger construct than local urban environments. Poorly designed urban provisioning systems are starkly evident worldwide, resulting in unprecedented exposures to adverse cardiometabolic risk factors, including limited physical activity, lack of access to heart-healthy diets, and reduced access to greenery and beneficial social interactions. Transforming urban systems with a cardiometabolic health-first approach could be accomplished through integrated spatial planning, along with addressing current gaps in key urban provisioning systems. Such an approach will help mitigate undesirable environmental exposures and improve cardiovascular and metabolic health while improving planetary health. The purposes of this American Heart Association policy statement are to present a conceptual framework, summarize the evidence base, and outline policy principles for transforming key urban provisioning systems to heart-health and sustainability outcomes.

Importance: Reducing exposure to fine particulate matter (<2.5 μm [PM2.5]) air pollution improves cardiopulmonary morbidity and mortality. However, the public health relevance of air quality index (AQI) activity guidelines under present-day environmental conditions in the US has not been critically assessed., Objective: To evaluate the public health relevance of following PM2.5 AQI activity guidance in preventing serious atherosclerotic cardiovascular disease (ASCVD) and pulmonary events among adults in the US., Design, Setting, and Participants: This cross-sectional modeling study involved the general adult population and sensitive individuals as designated by the US Environmental Protection Agency (EPA), including adults with preexisting ASCVD or lung disease (asthma or chronic obstructive pulmonary disease). The study was conducted between August 1, 2023, and January 31, 2024., Exposures: Daily AQI strata for PM2.5 and the corresponding activity recommendations., Main Outcomes and Measures: The main outcome was the number needed to treat (NNT) per day by following activity guidance across daily AQI strata to prevent 1 serious ASCVD or pulmonary event among relevant populations. To calculate PM2.5-induced excess disease event rates per day, estimated baseline disease-specific daily event rates for each group were multiplied by the increase in risks due to PM2.5 levels at each AQI stratum. The number of events prevented per day was calculated by multiplying each excess disease event rate by the percentage in exposure reduction plausibly incurred by following population-specific activity guidance at each AQI level. The NNT is the reciprocal of the number of events prevented., Results: The NNT to prevent ASCVD events was high for the general population and for patients with ASCVD across all AQI strata. The range of values was comparatively lower to prevent pulmonary events among adults with lung disease. During most days (96%) when activity recommendations were promulgated due to elevated PM2.5 (AQI, 101-200), the NNT to prevent a serious disease event remained very high for the general population (>18 million), patients with ASCVD (approximately 1.6-5 million), and adults with lung disease (approximately 66 000-202 000)., Conclusions and Relevance: These findings suggest that existing PM2.5 AQI activity recommendations are of questionable public health relevance in present-day conditions and merit consideration for updating to improve their potential effectiveness.

Competing Interests: Disclosures None.

The Global Burden of Disease assessment estimates that 20% of global type 2 diabetes cases are related to chronic exposure to particulate matter (PM) with a diameter of 2·5 μm or less (PM 2·5 ). With 99% of the global population residing in areas where air pollution levels are above current WHO air quality guidelines, and increasing concern in regard to the common drivers of air pollution and climate change, there is a compelling need to understand the connection between air pollution and cardiometabolic disease, and pathways to address this preventable risk factor. This Review provides an up to date summary of the epidemiological evidence and mechanistic underpinnings linking air pollution with cardiometabolic risk. We also outline approaches to improve awareness, and discuss personal-level, community, governmental, and policy interventions to help mitigate the growing global public health risk of air pollution exposure., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Competing Interests: Disclosures R.D. Brook is a consultant for Alnylam Pharmaceuticals. The other authors report no conflicts.

Background: Lower socioeconomic status (SES) has been associated with hypertension; however, the mediators and moderators of this association remain understudied. We examined the mediation effect of psychological distress on the link between lower SES and self-reported hypertension and the racial and sex moderation effects., Methods: We analyzed the data collected from 2009 to 2019 among adults from the Panel Study of Income Dynamics (PSID). Lower SES was defined as one of 3 indicators: education ≤12 years, unemployed, or individual annual income <$27,800. Psychological distress was assessed using the Kessler K6 scale. Cox proportional hazard regression was conducted. Mediation analyses were performed using the PROCESS macro., Results: In the sample of heads of family who did not have self-reported hypertension in 2009 (N = 6,214), the mean age was 41 years, 30.6% were female, 32.9% were African American. The cumulative incidence of self-reported hypertension was 29.8% between 2009 and 2019. Cox proportional hazard regression analysis showed that after controlling for covariates, lower SES (score > 0 vs. score = 0) was associated with self-reported hypertension (hazard ratio = 1.27, 95% confidence interval = 1.14-1.42). SES had indirect effect on self-reported hypertension through psychological distress and the indirect effect (0.02 in females, 0.01 in males, P < 0.05) was moderated by sex but not by race., Conclusions: The association of SES and self-reported hypertension was mediated by psychological distress and sex moderated the mediation effect. Interventions focused on reducing contributors to SES and psychological stress should be considered to reduce hypertension risk., (© The Author(s) 2023. Published by Oxford University Press on behalf of American Journal of Hypertension, Ltd. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Determine how positive BPPV findings in adolescents and young adults following concussion impacted the total number of treatments required and time until discharge., Setting: Outpatient physical therapy clinic., Participants: 167 individuals who were diagnosed with concussion or brain injury., Design: Retrospective chart review., Main Measures: Total number of treatments and days until discharge were compared for various BPPV diagnoses (anterior canal, posterior canal, horizontal canal, and combination) and for individuals with and without BPPV., Results: Fifty-one out of 167 cases (30.54%) were diagnosed with BPPV. The total number of treatments provided was statistically different across BPPV diagnoses (P = .004). However, days until discharge were not statistically different between BPPV diagnoses (P = .28). There was no significant difference between time to discharge between those with BPPV (median = 21 days, range = 7-126) and those without (median = 28 days, range = 7-84 days; P = .23, r = 0.09)., Conclusion: To optimize outcomes, including symptom resolution and return to sport and/or work, early identification of BPPV and subsequent intervention should be prioritized for individuals who have concussion symptoms that suggest vestibular dysfunction., Competing Interests: Declaration of competing interest None, (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Increased particulate matter <2.5 μm (PM 2.5 ) air pollution is associated with adverse cardiovascular outcomes. However, its impact on patients with prior coronary artery bypass grafting (CABG) is unknown., Objectives: The purpose of this study was to evaluate the association between major adverse cardiovascular events (MACE) (defined as myocardial infarction, stroke, or cardiovascular death) and air pollution after CABG., Methods: We linked 26,403 U.S. veterans who underwent CABG (2010-2019) nationally with average annual ambient PM 2.5 estimates using residential address. Over a 5-year median follow-up period, we identified MACE and fit a multivariable Cox proportional hazard model to determine the risk of MACE as per PM 2.5 exposure. We also estimated the absolute potential reduction in PM 2.5 attributable MACE simulating a hypothetical PM 2.5 lowered to the revised World Health Organization standard of 5 μg/m 3 ., Results: The observed median PM 2.5 exposure was 7.9 μg/m 3 (IQR: 7.0-8.9 μg/m 3 ; 95% of patients were exposed to PM 2.5 above 5 μg/m 3 ). Increased PM 2.5 exposure was associated with a higher 10-year MACE rate (first tertile 38% vs third tertile 45%; P  < 0.001). Adjusting for demographic, racial, and clinical characteristics, a 10 μg/m 3 increase in PM 2.5 resulted in 27% relative risk for MACE (HR: 1.27, 95% CI: 1.10-1.46; P  < 0.001). Currently, 10% of total MACE is attributable to PM 2.5 exposure. Reducing maximum PM 2.5 to 5 μg/m 3 could result in a 7% absolute reduction in 10-year MACE rates., Conclusions: In this large nationwide CABG cohort, ambient PM 2.5 air pollution was strongly associated with adverse 10-year cardiovascular outcomes. Reducing levels to World Health Organization-recommended standards would result in a substantial risk reduction at the population level., Competing Interests: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Background: The Reducing Air Pollution in Detroit Intervention Study (RAPIDS) was designed to evaluate cardiovascular health benefits and personal fine particulate matter (particulate matter < 2.5 μm in diameter, PM 2.5 ) exposure reductions via portable air filtration units (PAFs) among older adults in Detroit, Michigan. This double-blind randomized crossover intervention study has shown that, compared to sham, air filtration for 3 days decreased 3-day average brachial systolic blood pressure by 3.2 mmHg. The results also showed that commercially available HEPA-type and true HEPA PAFs mitigated median indoor PM 2.5 concentrations by 58% and 65%, respectively. However, to our knowledge, no health intervention study in which a significant positive health effect was observed has also evaluated how outdoor and indoor PM 2.5 sources impacted the subjects. With that in mind, detailed characterization of outdoor and indoor PM 2.5 samples collected during this study and a source apportionment analysis of those samples using a positive matrix factorization model were completed. The aims of this most recent work were to characterize the indoor and outdoor sources of the PM 2.5 this community was exposed to and to assess how effectively commercially available HEPA-type and true HEPA PAFs were able to reduce indoor and outdoor PM 2.5 source contributions. Methods: Approximately 24 h daily indoor and outdoor PM 2.5 samples were collected on Teflon and Quartz filters from the apartments of 40 study subjects during each 3-day intervention period. These filters were analyzed for mass, carbon, and trace elements. Environmental Protection Agency Positive Matrix Factorization (PMF) 5.0 was utilized to determine major emission sources that contributed to the outdoor and indoor PM 2.5 levels during this study. Results: The major sources of outdoor PM 2.5 were secondary aerosols (28%), traffic/urban dust (24%), iron/steel industries (15%), sewage/municipal incineration (10%), and oil combustion/refinery (6%). The major sources of indoor PM 2.5 were organic compounds (45%), traffic + sewage/municipal incineration (14%), secondary aerosols (13%), smoking (7%), and urban dust (2%). Infiltration of outdoor PM 2.5 for sham, HEPA-type, and true HEPA air filtration was 79 ± 24%, 61 ± 32%, and 51 ± 34%, respectively. Conclusions: The results from our study showed that intervention with PAFs was able to significantly decrease indoor PM 2.5 derived from outdoor and indoor PM 2.5 sources. The PAFs were also able to significantly reduce the infiltration of outdoor PM 2.5 . The results of this study provide insights into what types of major PM 2.5 sources this community is exposed to and what degree of air quality and systolic blood pressure improvements are possible through the use of commercially available PAFs in a real-world setting.

We examine a 12-min video-recorded interaction among a patient (KN) in a disordered state of consciousness (DOC) and a speech language pathologist clinician (CL) that takes place in a medical rehabilitation setting. The video is a demonstration of how caregivers could use a clinical assessment to observe their loved one's behavior to communicate potential behavioral changes to healthcare professionals. The purpose of this paper is to make visible the communication practices used by participants that may not be obvious to researchers, medical rehabilitation practitioners, and clinical assessment developers. We use phenomenological, linguistic and conversation analytic approaches to analyze the interaction. We found that KN demonstrates multiple conversational competencies, some (but not all) of which are acknowledged by CL, and most of which are not directly addressed by the assessment scoring criteria. For example, KN demonstrates conversational competency by responding non-verbally to CL's prompts from the assessment protocol and following along with the unspoken rules of discourse. He does this primarily through gaze, which broadcasts the focus of his attention and actively signals his participation in the conversation. Though KN does not always respond correctly to CL's questions, he nevertheless demonstrates implicit conversational competencies during turns of talk such as returning to 'neutral' position which signals the completion of a turn of talk. KN's conversational competencies may be missed by CL and the assessment protocol but we argue that they are important in understanding KN's capacity. Our analyses show that competency is not simply a performance by one person who appropriately and correctly responds to a series of questions in a prescribed time frame. Competence is a collaborative achievement among participants, co-produced in situ, and influenced by linguistic and cultural habits of talk and epistemic norms that privilege clinical knowledge and expertise., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Bullous pemphigoid (BP) has been associated with dipeptidyl peptidase-4 inhibitor (DDP-4i) use in patients with diabetes mellitus (DM). The prevalence and association of DM in BP patients independent of DPP-4i use has not been investigated by meta-analysis. To perform a systematic review and meta-analysis on the association between diabetes and bullous pemphigoid. The goal was to determine the prevalence and pooled odds ratio of BP patients with DM in the absence of DDP-4i use compared to the general population prevalence of diabetes mellitus. OVID Medline, EMBASE, Cochrane Central and Web of Science were searched for relevant studies published from inception to April 2020. Case-control, case-series, cohort, and cross-sectional studies that included the association of BP and DM without DDP-4i's, in any language. PRISMA guidelines were followed for data extraction and the Newcastle-Ottawa Scale for risk of bias evaluation. Three reviewers independently performed data extraction. Pooled odds ratio and prevalence were calculated using the random effects model. The odds ratio and prevalence of BP patients with DM. Overall, 8 studies out of 856 identified publications through data base searches were included. The pooled prevalence of diabetes in patients with BP was 20.0% [95% CI 14%-26%; p = 0.00]. Within the comparative non-BP control population, 13% had diabetes. BP patients were more likely to have diabetes compared to a control population without BP [OR 2.10, 95% CI 1.22-3.60; p = 0.01]. This study found that twice the number of BP patients have DM (20%) compared to the general population reported as 10.5%, warranting monitoring of blood glucose levels in BP patients who may have yet undeclared or undiagnosed DM when initiating systemic steroids., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Fine particulate matter (PM 2.5 ) air pollution is a leading contributor to the global burden of cardiovascular disease (CVD). One important underlying mechanism is an increase in blood pressure (BP). A growing number of studies have reported a beneficial effect of portable air cleaners (PACs) on systolic and diastolic BP; SBP and DBP. We conducted an updated systematic review and meta-analysis of studies using true versus sham mode filtration reporting the effects on BP. Of 214 articles identified up to February 5, 2023, seventeen (from China, USA, Canada, South Korea and Denmark) enrolling approximately 880 participants (484 female) met the inclusion criteria for meta-analyses. Aside from studies conducted in China, research on PACs and BP has been conducted in relatively low pollution settings. Mean indoor PM 2.5 concentrations during the active and sham mode purification were 15.9 and 41.2 µg/m 3 , respectively. The mean efficiency of PACs against indoor PM 2.5 was 59.8 % (ranging from 23 % to 82 %). True mode filtration was associated with a pooled mean difference of - 2.35 mmHg (95 % confidence interval [CI]: - 4.5, - 0.2) and - 0.81 mmHg (95 % CI: - 1.86, 0.24) in SBP and DBP, respectively. After removing the studies with high risk of bias, the magnitude of the pooled benefits on SBP and DBP increased to - 3.62 mmHg (95 % CI: - 6.69, - 0.56) and - 1.35 mmHg (95 % CI: - 2.29, - 0.41), respectively. However, there are several barriers to the use of PACs, specifically in low- and middle-income countries (LMICs), such as the initial purchase cost and filter replacements. There may be several avenues to help overcome these economic burdens and improve cost effectiveness, such as implementing government or other subsidized programs to distribute PACs targeting vulnerable and higher-risk individuals. We propose that environmental health researchers and healthcare providers should be better trained to educate the public regarding the use of PACs to reduce the impacts of PM 2.5 on cardiometabolic diseases globally., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. It should be noted that Ryan W. Allen has conducted studies using PACs purchased at a discounted rate from Woongjin-Coway., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Traffic noise and air pollution are environmental stressors found to increase risk for cardiovascular events. The burden of disease attributable to environmental stressors and cardiovascular disease globally is substantial, with a need to better understand the contribution of specific risk factors that may underlie these effects. Epidemiological observations and experimental evidence from animal models and human controlled exposure studies suggest an essential role for common mediating pathways. These include sympathovagal imbalance, endothelial dysfunction, vascular inflammation, increased circulating cytokines, activation of central stress responses, including hypothalamic and limbic pathways, and circadian disruption. Evidence also suggests that cessation of air pollution or noise through directed interventions alleviates increases in blood pressure and intermediate surrogate pathways, supporting a causal link. In the second part of this review, we discuss the current understanding of mechanisms underlying and current gaps in knowledge and opportunities for new research., Competing Interests: Disclosures None.