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Tobacco burden is significantly greater among those insured by Medicaid, with a smoking prevalence about twice as high as the national average (28% vs. 15%). Over the past decade, smoking prevalence among those insured by Medicaid has remained relatively unchanged while overall smoking prevalence in the United States and among other insurance groups decreased. This indicates need for targeting tobacco control strategies to those insured by Medicaid. In response, the Vermont Tobacco Control Program (VTCP) set out to implement best practice by making its Medicaid cessation benefit more comprehensive and raising awareness and use of the benefit to support members in quitting. The VTCP collaborated with its Medicaid and health department leadership to implement this initiative, learning and adapting processes along the way. The VTCP identified a framework and considerations for programs implementing best practice to expand access and utilization of cessation supports. Elements of success include collaboration, data sharing, and promotion. As a result, the VTCP created an infrastructure that increases access, awareness, and use of cessation supports among Medicaid members and providers. Between 2013 and 2017, the quit ratio among Vermont Medicaid members increased from 8% to 13% and the smoking rate decreased from 36% to 31%.

Objective While there are several cognitive screening tests available for the detection of cortical dementias such as Alzheimer's disease (AD), these are rarely designed to be sensitive to vascular cognitive impairment (VCI). The Brief Memory and Executive Test (BMET) is a screening measure designed to be sensitive to the cognitive profile of both VCI and AD. This study investigated the ability of the BMET to detect AD, and to differentiate between VCI and AD. Methods This study included 150 patients, with either SVD, both with (n = 48) and without VCI (n = 51), or AD (N = 51) and 51 healthy controls. Participants were aged between 40 and 90 years of age and completed both the BMET and the MMSE. Results Receiver operator characteristic (ROC) curve analysis showed as before the BMET is a good predictor SVD. Additionally, the BMET was a good predictor of AD (AUC = 0.96) and performed at least as well as the MMSE (AUC = 0.92) when differentiating AD patients from healthy controls. The BMET had a sensitivity of 86% and specificity of 100% for detecting AD patients from control subjects. Using the difference in cognitive profile between the AD and VCI group, we developed an index score which correctly classified 76% of patients as either having VCI or AD. Conclusion The BMET is a brief and sensitive tool for the detection of cognitive impairment due to both SVD and AD and can be used to aid in the differentiation of the 2 diseases.

"Normal" age-related cognitive decline has been associated with cardiovascular risk factors. Framingham Vascular Age is age-normed cardiovascular risk which may help communicate risk to patients and identify those at relatively higher risk. We aim to assess the association between Framingham Vascular Age and cognition. 346 "healthy" participants (57±10 years) without neuropsychiatric disorders or clinical manifestations of cardiovascular disease were studied. Cognition was evaluated using the Brief Memory and Executive Test and Framingham Vascular Age was calculated. The association between Framingham Vascular Age and cognitive performance was determined through General Linear Models to control for covariates. Framingham Vascular age was associated with poorer Memory and Executive Function/Processing Speed indices (p= 0.019 and p

Background and Purpose— A variant in the histone deacetylase 9 ( HDAC9 ) gene is associated with large artery stroke. Therefore, inhibiting HDAC9 might offer a novel secondary preventative treatment for ischemic stroke. The antiepileptic drug sodium valproate (SVA) is a nonspecific inhibitor of HDAC9. We tested whether SVA therapy given after ischemic stroke was associated with reduced recurrent stroke rate. Methods— Data were pooled from 3 prospective studies recruiting patients with previous stroke or transient ischemic attack and long-term follow-up: the South London Stroke Register, The Vitamins to Prevent Stroke Study, and the Oxford Vascular Study. Patients receiving SVA were compared with patients who received antiepileptic drugs other than SVA using survival analysis and Cox Regression. Results— A total of 11 949 patients with confirmed ischemic event were included. Recurrent stroke rate was lower in patient taking SVA (17 of 168) than other antiepileptic drugs (105 of 530; log-rank survival analysis P =0.002). On Cox regression, controlling for potential cofounders, SVA remained associated with reduced stroke (hazard ratio=0.44; 95% confidence interval: 0.3–0.7; P =0.002). A similar result was obtained when patients taking SVA were compared with all cases not taking SVA (Cox regression, hazard ratio=0.47; 95% confidence interval: 0.29–0.77; P =0.003). Conclusions— These results suggest that exposure to SVA, an inhibitor of HDAC, may be associated with a lower recurrent stroke risk although we cannot exclude residual confounding in this study design. This supports the hypothesis that HDAC9 is important in the ischemic stroke pathogenesis and that its inhibition, by SVA or a more specific HDAC9 inhibitor, is worthy of evaluation as a treatment to prevent recurrent ischemic stroke.

Cerebral small vessel disease (SVD) is associated with deficits in working memory, with a relative sparing of long-term memory; function may be influenced by white matter microstructure. Working and long-term memory were examined in 106 patients with SVD and 35 healthy controls. Microstructure was measured in the uncinate fasciculi and cingula. Working memory was more impaired than long-term memory in SVD, but both abilities were reduced compared to controls. Regression analyses found that having SVD explained the variance in memory functions, with additional variance explained by the cingula (working memory) and uncinate (long-term memory). Performance can be explained in terms of integrity loss in specific white matter tract associated with mnemonic functions., Highlights • Working and long-term memory are both impaired in SVD compared to healthy adults. • SVD explained a significant proportion of the variance in both mnemonic functions. • Variance in working memory was explained by microstructure of the cingula. • Variance in long-term memory was explained by microstructure of the uncinate.

Objective: To determine whether MRI markers, including diffusion tensor imaging (DTI), can predict cognitive decline and dementia in patients with cerebral small vessel disease (SVD). Methods: In the prospective St George's Cognition and Neuroimaging in Stroke study, multimodal MRI was performed annually for 3 years and cognitive assessments annually for 5 years in a cohort of 99 patients with SVD, defined as symptomatic lacunar stroke and confluent white matter hyperintensities (WMH). Progression to dementia was determined in all patients. Progression of WMH, brain volume, lacunes, cerebral microbleeds, and a DTI measure (the normalized peak height of the mean diffusivity histogram distribution) as a marker of white matter microstructural damage were determined. Results: Over 5 years of follow-up, 18 patients (18.2%) progressed to dementia. A significant change in all MRI markers, representing deterioration, was observed. The presence of new lacunes, and rate of increase in white matter microstructural damage on DTI, correlated with both decline in executive function and global functioning. Growth of WMH and deterioration of white matter microstructure on DTI predicted progression to dementia. A model including change in MRI variables together with their baseline values correctly classified progression to dementia with a C statistic of 0.85. Conclusions: This longitudinal prospective study provides evidence that change in MRI measures including DTI, over time durations during which cognitive change is not detectable, predicts cognitive decline and progression to dementia. It supports the use of MRI measures, including DTI, as useful surrogate biomarkers to monitor disease and assess therapeutic interventions.

Background and Purpose— Cerebral autosomal-dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a monogenic form of cerebral small vessel disease leading to early-onset stroke and dementia, with younger patients frequently showing subclinical deficits in cognition. At present, there are no targeted cognitive screening measures for this population. However, the Brief Memory and Executive Test (BMET) and the Montreal Cognitive Assessment (MoCA) have shown utility in detecting cognitive impairment in sporadic small vessel disease. This study assesses the BMET and the MoCA as clinical tools for detecting mild cognitive deficits in CADASIL. Methods— Sixty-six prospectively recruited patients with CADASIL, and 66 matched controls completed the BMET, with a subset of these also completing the MoCA. Receiver operating characteristic curves were calculated to examine the sensitivity and specificity of clinical cutoffs for the detection of vascular cognitive impairment and reduced activities of daily living. Results— Patients with CADASIL showed more cognitive impairment overall and were poorer on both executive/processing and memory indices of the BMET relative to controls. The BMET showed good accuracy in predicting vascular cognitive impairment (85% sensitivity and 84% specificity) and impaired instrumental activities of daily living (92% sensitivity and 77% specificity). The MoCA also showed good predictive validity for vascular cognitive impairment (80% sensitivity and 78% specificity) and instrumental activities of daily living (75% sensitivity and 76% specificity). The most important background predictor of vascular cognitive impairment was a history of stroke. Conclusions— The results indicate that the BMET and the MoCA are clinically useful and sensitive screening measures for early cognitive impairment in patients with CADASIL.

Objectives: In addition to neuropsychological difficulties, patients with cerebral small vessel disease (SVD) can have reduced activities of daily living and a poorer quality of life compared to healthy adults. The Brief Memory and Executive Test (BMET), is a cognitive screening tool designed to be sensitive to the neuropsychological profile of patients with SVD. While the BMET is sensitive to the cognitive consequences of SVD, it is unclear how well scores on this measure relate to functional outcomes. The aims of this study are to investigate the relationship between scores on the BMET and functional outcomes (activities of daily living and quality of life) in SVD, and to compare this with other commonly used cognitive screening tools. Methods: This study included 184 participants with SVD (mean age=63.2; SD=9.9) and 299 healthy controls (mean age=62.4; SD=13.8) who were tested using the BMET, Montreal Cognitive Assessment (MoCA), Mini-Mental State Examination (MMSE), Stroke Specific - Quality of Life Scale (SS-QoL), Geriatric Depression Scale (GDS), and measures of both instrumental activities of daily living (IADL) and basic activities of daily living (BADL). Results: After controlling for covariates the scores on the BMET, but not the MoCA or MMSE, were significantly related to poorer IADL and quality of life in the SVD group. In addition to the BMET scores, symptoms of depression were found to be significant associated with functional outcome. Conclusion: These results support the clinical utility of using of the BMET, in combination with a standardized depression questionnaire, during the early assessment of patients with SVD. (JINS, 2016, 22, 1–9)

A common cause of neuropsychological impairment in older adults is cerebral small vessel disease (SVD), but little is known as to whether lack of awareness of neuropsychological impairment is a feature of this clinical condition. In this study, we investigated awareness deficits in a well-phenotyped population of patients with SVD (n= 45; 21 with defined concomitant neuropsychological impairment) and made comparisons with 24 Alzheimer's disease (AD) patients and a further 80 control participants. Awareness of performance on a range of neuropsychological measures was examined based on the Brief Memory and Executive Test Battery (BMET) (Brookes, Hannesdottir, Lawrence, Morris, & Markus, 2012), exploring the relationship between awareness and memory and executive function. The results revealed significant awareness deficits in both the SVD and AD groups. When splitting the SVD group into those with or without concomitant neuropsychological impairment, only those with neuropsychological impairment showed reduced awareness. For the SVD group, executive function was significantly correlated with awareness but memory was not. By comparison, memory was significantly correlated with awareness in the AD group, with executive function showing a trend but remaining non-significant. The results show that lack of awareness of deficit is a clinical feature of SVD and indicate that there are distinct neuropsychological associations with awareness deficit for SVD and AD.

Background: cerebral small vessel disease (SVD) is the most common cause of vascular cognitive impairment (VCI). Despite this, there is a paucity of rapid simple screening tools to identify cognitive impairment in SVD and differentiate it from other common dementia types. Objective: to validate a new screening test for cognitive impairment in SVD, the Brief Memory and Executive Test (BMET) battery, and examine its ability to detect SVD and differentiate it from Alzheimer's disease (AD). Subjects: 45 patients with SVD, 27 patients with AD and 80 normal controls. Methods: the BMET includes brief tests of executive functioning and processing speed, with comparative tests of memory and orientation. Group discrimination was calculated using discriminant function analysis. Results: the BMET took an average of 10 min to administer. It showed high sensitivity (91%) and specificity (85%) in differentiating SVD patients with cognitive impairment from AD patients. As a comparison the mini-mental state examination had lower sensitivity (63%) and specificity (62%). Conclusions: the BMET is a simple and quick to administer clinical tool for the detection of VCI in SVD and its differentiation from AD impairment. Further multicentre studies are required to evaluate and compare it with other existing screening tests.

From 2004 to 2008, in four U.S. test markets, Planned Parenthood Federation of America implemented Real Life. Real Talk.®, an initiative designed to foster open, honest, and balanced communication about sex and health among parents/caregivers, their children, and the general public. Funded by private donors and foundations, including the Ford Foundation, Real Life. Real Talk, combined community organizing and collaboration, education, community events, and promotion in an intervention that addressed the entire marketing mix. Through building local grassroots partnerships and providing a host of coordinated local educational events, including repeated offerings of Sex Ed for Parents™, Real Life. Real Talk. sought to reduce the public's level of shame, intolerance, and avoidance and, subsequently, to increase openness, acceptance, and engagement about issues of sexual health. Parents who participated in Sex Ed for Parents reported that these events were useful, and nearly all participating parents said they would recommend Sex Ed for Parents to a friend. Results from community-wide surveys show modest program awareness and several promising trends that correspond with the goals of the initiative. Real Life. Real Talk. is an example of community-level social marketing that evolved for continual improvement. Real Life. Real Talk. maintained an iterative design and implementation process. It allowed each community to embrace engagement on its own terms, and, as a result, each community contributed unique cultural elements.

Prism adaptation, in which the participant adapts to prismatic glasses that deflect vision laterally, is a specific test of cerebellar function. Fourteen dyslexic children (mean age 13.5 years); 14 children with developmental coordination disorder (DCD): 6 of whom had comorbid dyslexia; and 12 control children matched for age and IQ underwent prism adaptation (assessed by clay throwing accuracy to a 16.7 degrees visual displacement). All 8 DCD children, 5 of the 6 children with comorbid DCD and dyslexia and 10 of the 14 dyslexic children showed an impaired rate of adaptation, thereby providing strong evidence of impaired cerebellar function in DCD and developmental dyslexia. Taken together with other emerging evidence of overlap between developmental disorders, these findings highlight the importance of complementing research on the individual disorders with research on the commonalities between the disorders.

In order to assess the relationship between cerebellar deficits and dyslexic tendencies in a non-clinical sample, 27 primary school children aged 8-9 completed a cerebellar soft signs battery and were additionally assessed for reading age, sequential memory, picture arrangement and knowledge of common sequences. An average measure of the soft signs data established a single construct which we treated as our primary index of cerebellar function. Overall cerebellar function was significantly correlated with reading age, picture arrangement and knowledge of common sequences even when IQ was partialled out. Graphical representation of our data indicated a continuous rather than discrete distribution for each measure. Results are discussed in terms of the CDH and continuum approaches to dyslexia.

OBJECTIVES: Cognitive impairment, predominantly affecting processing speed and executive function, is an important consequence of cerebral small vessel disease (SVD). To date, few longitudinal studies of cognition in SVD have been conducted. We determined the pattern and rate of cognitive decline in SVD and used the results to determine sample size calculations for clinical trials of interventions reducing cognitive decline.METHODS: 121 patients with MRI confirmed lacunar stroke and leukoaraiosis were enrolled into the prospective St George's Cognition And Neuroimaging in Stroke (SCANS) study. Patients attended one baseline and three annual cognitive assessments providing 36 month follow-up data. Neuropsychological assessment comprised a battery of tests assessing working memory, long-term (episodic) memory, processing speed and executive function. We calculated annualized change in cognition for the 98 patients who completed at least two time-points.RESULTS: Task performance was heterogeneous, but significant cognitive decline was found for the executive function index (pCONCLUSIONS: The pattern of cognitive decline seen in SVD over three years is consistent with the pattern of impairments at baseline. Rates of decline were slow and sample sizes would need to be large for clinical trials aimed at halting decline beyond initial diagnosis using cognitive scores as an outcome measure. This emphasizes the importance of more sensitive surrogate markers in this disease.

Background Cognitive impairment is common in patients with cerebral small vessel disease, but is not well detected using common cognitive screening tests which have been primarily devised for cortical dementias. We developed the Brief Memory and Executive Test (BMET); a rapid screening measure sensitive to the impaired executive function and processing speed characteristic of small vessel disease (SVD). To assess the BMET’s validity for general use, we evaluated it when administered by non-psychologists in a multicentre study and collected control data to derive normative scores. Methods Two-hundred participants with SVD, defined as a clinical lacunar stroke and a corresponding lacunar infarct on MRI, and 303 healthy controls aged between 40–90 years old were recruited. The BMET, as well as the Montreal Cognitive Assessment (MoCA) and Mini Mental State Examination (MMSE), were performed. Overall, 55 SVD participants underwent repeat testing at 3 months to assess the BMET test-retest reliability. Results Administering the BMET took a mean (SD) of 12.9 (4.7) in cases and 9.5 (2.6) minutes in controls. Receiver Operator Curve analysis showed the BMET was a good predictor of cognitive impairment in SVD (AUC = 0.94) and performed significantly better than both the MoCA (AUC = 0.77) and the MMSE (AUC = 0.70). Using a cut-off score of 13, the BMET had a sensitivity of 93% and specificity of 76% for detecting cognitive impairment in SVD. Conclusions The BMET is a brief and sensitive tool for the detection of cognitive impairment in patients with SVD. Electronic supplementary material The online version of this article (doi:10.1186/s12916-015-0290-y) contains supplementary material, which is available to authorized users.

Patterns of verbal fluency deficits have been explored across different neurodegenerative disorders. This study sought to investigate the specific pattern of verbal fluency performance in cerebral small vessel disease (SVD), which is the most common cause of vascular cognitive impairment, and compare this with Alzheimer's disease (AD). Participants with SVD (n = 45), AD (n = 24) and healthy controls (n = 80) completed assessments of semantic and phonemic fluency. Mixed-model analyses of covariance were used to compare performance on the different fluency tasks between the groups, and a discriminant function analysis was conducted to examine group differentiation. The SVD group was impaired in both fluency tasks when compared to the controls. In contrast, the AD group displayed impairment in semantic fluency only. Discriminant function analysis revealed that fluency scores correctly classified 80% of SVD patients and 92% of AD patients. The pattern of performance observed in the SVD group may reflect deficits in executive function and processing speed impacting equivalently on semantic and phonemic fluency. The differences between the SVD and AD groups highlighted in this study may be useful for distinguishing between these conditions. (JINS, 2014, 20, 1–9)

Objective To investigate the relationships between executive dysfunction, awareness deficits and perceptions of quality of life (QOL) in patients with cerebral small vessel disease (SVD). Method We tested neuropsychological function with simultaneous measurement of awareness performance in 125 participants. Forty-five were carefully phenotyped patients with SVD, defined as a lacunar stroke with corresponding infarct on neuroimaging; and 80 were age-matched controls, providing a normal comparison for neuropsychological measures. Patients also completed the Stroke-Specific Quality of Life Scale. In patients with SVD, the impact of executive dysfunction on awareness and QOL was examined simultaneously using structural equation modeling. Results A simple regression indicated a positive relationship between awareness and QOL. However, when executive function was added to the model, the results showed strong relationships between executive function and awareness, and executive function and QOL, but no direct relationship between awareness and QOL. Conclusion Our results show that the main neuropsychological symptom associated with SVD, namely, executive dysfunction, may predict both reductions in awareness and QOL. However, there is no direct impact of awareness deficits on QOL in patients with SVD, when executive function is included in the model.

A common cause of neuropsychological impairment in older adults is cerebral small vessel disease (SVD), but little is known as to whether lack of awareness of neuropsychological impairment is a feature of this clinical condition. In this study, we investigated awareness deficits in a well-phenotyped population of patients with SVD (n= 45; 21 with defined concomitant neuropsychological impairment) and made comparisons with 24 Alzheimer's disease (AD) patients and a further 80 control participants. Awareness of performance on a range of neuropsychological measures was examined based on the Brief Memory and Executive Test Battery (BMET) (Brookes, Hannesdottir, Lawrence, Morris,Markus, 2012), exploring the relationship between awareness and memory and executive function. The results revealed significant awareness deficits in both the SVD and AD groups. When splitting the SVD group into those with or without concomitant neuropsychological impairment, only those with neuropsychological impairment showed reduced awareness. For the SVD group, executive function was significantly correlated with awareness but memory was not. By comparison, memory was significantly correlated with awareness in the AD group, with executive function showing a trend but remaining non-significant. The results show that lack of awareness of deficit is a clinical feature of SVD and indicate that there are distinct neuropsychological associations with awareness deficit for SVD and AD.

Background Cerebral small vessel disease causes lacunar stroke, and more recently has been implicated as a cause of depression. Factors causing reduced quality of life in small vessel disease, including the relative contributions of disability and depressive symptoms, remain uncertain. Methods One hundred patients with small vessel disease and 55 controls completed the Stroke-Specific Quality of Life scale. The protocol was repeated in 40 patients with the young-onset genetic form of small vessel disease, cerebral autosomal dominant arteriopathy with sub-cortical infarcts and leukoencephalopathy, and 35 controls. Disability, activities of daily living, cognition and depression were measured. Results Quality of life was significantly lower in small vessel disease versus controls: mean (standard deviation), 196·8 (35·2) vs. 226·8 (15·3), P < ·0001. Depressive symptoms were the major predictor of quality of life, explaining 52·9% of variance. The only other independent predictor was disability, explaining an additional 18·4%. A similar pattern was found in the young-onset genetic group, with reduced quality of life 202·0 (29·7) vs. controls 228·6 (13·1) P < ·0001, and depressive symptoms accounting for 42·2% of variance. Disability explained an additional 17·6%. Relationships between depression and quality of life, and disability and quality of life were independent of one another. Conclusions Depressive symptoms, often unrecognized, are a major determinant of reduced quality of life in small vessel disease. They account for greater reduction than, and are independent of, disability. This relationship may reflect the proposed causal association between white matter disease and depression. Treatment of depressive symptoms might significantly improve quality of life in small vessel disease.

Balance difficulties are an enduring feature of dyslexia research, however results have been inconsistent. We propose that between-study heterogeneity may be attributable to variability in balance tasks, balance measurement, participant age, and inclusion of comorbid disorders such as ADHD. This study attempted to clarify these issues, employing quantitative, continuous measures of balance and blindfolded balance, and using both adult and child participants without comorbid ADHD. Eighty-seven individuals participated: dyslexic adults (n = 17), matched adult controls (n = 30), dyslexic children (n = 16) and matched child controls (n = 24). The study found significant balance deficits for the child dyslexic group in the eyes-open task and a result approaching significance in the blindfolded task. By contrast, the adult dyslexic group showed significant deficits in the blindfolded task only. This result is interpreted in terms of lack of sensitivity of the non-blindfolded balance task for adults, owing to ceiling effects. This highlights the need for the use of age-appropriate tests, and may explain some of the heterogeneity in the literature. It is concluded that there is a significant incidence of balance difficulties in children and adults with dyslexia, even for those without comorbid attention deficit.

Three major 'neural systems', specialized for different types of information processing, are the sensory, declarative, and procedural systems. It has been proposed (Trends Neurosci., 30(4), 135-141) that dyslexia may be attributable to impaired function in the procedural system together with intact declarative function. We provide a brief overview of the increasing evidence relating to the hypothesis, noting that the framework involves two main claims: first that 'neural systems' provides a productive level of description avoiding the underspecificity of cognitive descriptions and the overspecificity of brain structural accounts; and second that a distinctive feature of procedural learning is its extended time course, covering from minutes to months. In this article, we focus on the second claim. Three studies-speeded single word reading, long-term response learning, and overnight skill consolidation-are reviewed which together provide clear evidence of difficulties in procedural learning for individuals with dyslexia, even when the tasks are outside the literacy domain. The educational implications of the results are then discussed, and in particular the potential difficulties that impaired overnight procedural consolidation would entail. It is proposed that response to intervention could be better predicted if diagnostic tests on the different forms of learning were first undertaken.