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Although prediction models for heart transplantation outcomes have been developed previously, a comprehensive benchmarking of survival machine learning methods for mortality prognosis in the most contemporary era of heart transplants following the 2018 donor heart allocation policy change is warranted. This study assessed seven statistical and machine learning algorithms–Lasso, Ridge, Elastic Net, Cox Gradient Boost, Extreme Gradient Boost Linear, Extreme Gradient Boost Tree, and Random Survival Forests in a post-policy cohort of 7,160 adult heart-only transplant recipients in the Scientific Registry of Transplant Recipients (SRTR) database who received their first transplant on or after October 18, 2018. A cross-validation framework was designed in mlr. Model performance was also compared in a seasonally-matched pre-policy cohort. In the post-policy cohort, Random Survival Forests and Cox Gradient Boost had the highest performances with C-indices of 0.628 and 0.627. The relative importance of some predictive variables differed between the pre-policy and post-policy cohorts, such as the absence of ECMO in the post-policy cohort. Survival machine learning models provide reasonable prediction of 1-year posttransplant mortality outcomes and continual updating of prediction models is warranted in the contemporary era. [ABSTRACT FROM AUTHOR]

Background: Alcohol intake is associated with breast cancer (BC) risk, but estimates of greatest public health relevance have not been quantified in large studies with long duration. Materials and Methods: In this prospective cohort study of 39,811 women (median 25 years follow-up), we examined the association between alcohol consumption and BC incidence and mortality with adjusted hazard ratios (HRs), cubic splines, absolute risks, number needed to harm (NNH), and population-attributable fractions. Results: We documented 2,830 cases of BC, including 237 BC deaths. Each additional alcoholic drink/day was associated with a 10% higher rate (HR = 1.10, 95% confidence intervals [CIs]: 1.04–1.16) of total BC in a linear manner (p = 0.0004). The higher rate was apparent for estrogen receptor (ER)+ (HR = 1.12, 95% CI: 1.06–1.18) but not ER− tumors (HR = 0.95, 95% CI: 0.82–1.10), with a statistically significant difference between these associations (p = 0.03). We constructed models comparing BC incidence among 100,000 women followed for 10 years. Compared to a scenario where all women rarely or never consumed alcohol, we expect 63.79 (95% CI: 58.35–69.24) more cases (NNH = 1,567) had all women consumed alcohol at least monthly and 278.66 (95% CI: 268.70–288.62) more cases (NNH = 358) had all women consumed >1 drink/day. Approximately 4.1% of BC cases were attributable to consumption exceeding one drink/month. Conclusion: Alcohol consumption is associated with a linear dose–response increase in BC incidence even within recommended limits of up to one alcoholic drink/day, at least for ER+ tumors. Our estimates of risk differences, attributable fraction, and NNH quantify the burden that alcohol consumption imposes on women in the general population. ClinicalTrials.gov Identifier: NCT00000479. [ABSTRACT FROM AUTHOR]

Background: There is a yet unmet opportunity to utilize data on taxes and individual behaviors to yield insight for analyzing studies involving alcohol and cigarette use. Objectives: To inform the direction and strength of their mutual associations by leveraging the fact that taxation can affect individual consumption, but individual consumption cannot affect taxation. Methods: We linked state-level data on cigarette and beer taxes in 2009–2020 with individual-level data on self-reported current cigarette and alcohol use from the Behavioral Risk Factor Surveillance System, a telephone survey by the Centers for Disease Control and Prevention that is representative of the population of each state in the United States. We constructed linear and logistic models to examine associations between a $1 increase in cigarette taxes per pack and a $1 increase in beer taxes per gallon and self-reported cigarette use and alcohol consumption (assessed as any current intake, average drinks/day, heavy drinking, and binge drinking), adjusting for survey year and individual characteristics. Results: Among 2,968,839,352 respondents (49% male), a $1 increase in beer taxes was associated with.003 (95% confidence interval [CI] −.013,.008) fewer drinks/day and lower odds of any drinking (odds ratio [OR] =.81 95%CI.80,.83), heavy drinking (OR =.96 95%CI.93,.99), binge drinking (OR =.82 95%CI.80,.83), and smoking (OR =.98 95%CI.96, 1.00). In contrast, a $1 increase in cigarette taxes was associated with lower odds of smoking (OR =.94 95%CI.94,.95) but.007 (95%CI.005,.010) more drinks/day, and higher odds of any drinking (OR = 1.10 95%CI 1.10, 1.11), heavy drinking (OR = 1.02 95%CI 1.01, 1.02), and binge drinking (OR =.82 95%CI.80,.83). Conclusion: Higher beer taxes were associated with lower odds of drinking and smoking, but higher cigarette taxes were associated with lower odds of smoking and higher alcohol consumption. These results suggest that alcohol intake may be a determinant of cigarette use rather than cigarette use as a determinant of alcohol intake. [ABSTRACT FROM AUTHOR]

Objective: To examine the relationship between habitual caffeinated beverage consumption and headache frequency, duration, and intensity in a prospective cohort of adults with episodic migraine. Background: Caffeine is a commonly ascribed headache trigger in adults with migraine and clinicians may counsel patients to avoid caffeinated beverages; however, few studies have examined this association. Methods: From March 2016 to August 2017, 101 adults with physician‐confirmed episodic migraine completed baseline questionnaires, including information about caffeinated beverage consumption. For 6 weeks, they reported headache onset, duration, and pain intensity (scale 0–100) on twice‐daily electronic diaries. Ninety‐seven participants completed data collection. We examined associations between self‐reported habitual caffeinated beverage consumption at baseline and headache outcomes prospectively captured over the following 6 weeks, adjusting for age, sex, and oral contraceptive use. Results: The adjusted mean headache days per month was similar among the 20 participants reporting no habitual intake (7.1 days, 95% confidence interval [CI] 5.1–9.2), the 65 participants reporting 1–2 servings/day (7.4 days, 95% CI 6.1–8.7), and the 12 participants reporting 3–4 servings/day (5.9 days, 95% CI 3.3–8.4). Similarly, mean headache duration (no servings/day: 8.6 h, 95% CI 3.8–13.3; 1–2 servings/day: 8.5 h, 95% CI 5.5–11.5; 3–4 servings/day: 8.8 h, 95% CI 2.3–14.9) and intensity (no servings/day: 43.8, 95% CI 37.0–50.5; 1–2 servings/day: 43.1, 95% CI 38.9–47.4; 3–4 servings/day: 46.5, 95% CI 37.8–55.3) did not differ across levels of caffeinated beverage intake, though estimates were imprecise. Conclusions: We found no association between habitual caffeinated beverage intake and headache frequency, duration, or intensity. These data do not support a recommendation that patients with episodic migraine should avoid consuming caffeine. Further research is needed to understand whether deviating from usual caffeine intake may trigger migraine attacks. Plain Language Summary: Some patients and doctors believe that caffeine causes migraine headaches. We studied 98 adults with migraine who reported how much caffeine they typically drink and tracked their headaches every day for six weeks, and we found that the number of caffeine drinks people drink daily was not linked to headache frequency, duration, or pain level. These results suggest that patients with episodic migraine do not have to avoid drinks with caffeine. [ABSTRACT FROM AUTHOR]

Black heart transplant recipients have a higher mortality rate than white recipients 6–12 months after transplant. Whether there are racial disparities in post-transplant stroke incidence and all-cause mortality following post-transplant stroke among cardiac transplant recipients is unknown. Using a nationwide transplant registry, we assessed the association between race and incident post-transplant stroke using logistic regression and the association between race and mortality among adults who survived a post-transplant stroke using Cox proportional hazards regression. We found no evidence of an association between race and the odds of post-transplant stroke (OR = 1.00, 95% CI: 0.83–1.20). The median survival time of those with a post-transplant stroke in this cohort was 4.1 years (95% CI: 3.0, 5.4). There were 726 deaths among the 1139 patients with post-transplant stroke, including 127 deaths among 203 Black patients and 599 deaths among 936 white patients. Among post-transplant stroke survivors, Black transplant recipients experienced a 23% higher rate of mortality compared to white recipients (HR = 1.23, 95% CI: 1.00–1.52). This disparity is strongest in the period beyond the first 6 months and appears to be mediated by differences in the post-transplant setting of care between Black and white patients. The racial disparity in mortality outcomes was not evident in the past decade. The improved survival of Black patients in the recent decade may reflect overall protocol improvements for heart transplant recipients irrespective of race, such as advancements in surgical techniques and immediate postoperative care as well as increased awareness about reducing racial disparities. [ABSTRACT FROM AUTHOR]

Heart transplant recipients develop cancer at two-times the rate compared to the general population. However, the incidence and mortality rates and the adjusted association between cancer and mortality remains unclear. We estimated the incidence and mortality rates and the adjusted association between developing cancer (any, skin, hematologic, and solid tumor subtypes) and the all-cause mortality rates among adult heart transplant recipients from the Scientific Registry of Transplant Recipients from October 1, 1987, until June 28, 2020. Among 51,597 adult heart transplant recipients, 13,191 (25.6%) were diagnosed with de novo malignancy throughout the follow-up period. The cumulative incidence cancer at years 1, 5, 10, and 20 was 3%, 16.4%, 32.8%, and 56.6%, respectively. Among those with cancer, the cumulative mortality was 17.5%, 42.3%, 65%, and 91% at years 1, 5, 10, and 20, respectively. The incidence rate of any de novo malignancy was 38.7 cases per 1000 person-years and the mortality rate (for those with cancer) was 115.2 cases per 1000 person-years. Compared to those without cancer, those with cancer had a higher adjusted mortality association [HR: 2.14 (2.07, 2.21)]. The strongest associations were estimated for pancreatic [10.63 (8.34, 13.54)], leukemia [8.06 (4.33, 15.00)], and esophagus [6.94 (5.43, 8.87)] malignancies. The association between de novo malignancies and mortality was higher in the earlier years of follow-up. Compared to not developing cancer, those with de novo malignancy have a 2-fold higher mortality rate, on average. The strength of the association varies by cancer subtype and by follow-up time. • The incidence rate of any de novo malignancy was 38.7 cases per 1000 person-years. • The mortality rate among those with cancer was 115.2 cases per 1000 person-years. • Heart transplant recipients who develop cancer have a 2-fold mortality rate. • The mortality rate varies by cancer subtype and by follow-up time after diagnosis. [ABSTRACT FROM AUTHOR]

Purpose: We aimed to evaluate the role of caffeinated beverage intake as a potential trigger of migraine headaches on that day or on the following day.Methods: In this prospective cohort study, 101 adults with episodic migraine completed electronic diaries every morning and evening. Ninety-eight participants completed at least 6 weeks of diaries in March 2016-October 2017. Every day, participants reported caffeinated beverage intake, other lifestyle factors, and the timing and characteristics of each migraine headache. We compared a participant's incidence of migraines on days with caffeinated beverage intake to the incidence of migraines among the same individual on days with no intake, accounting for day of week. We used conditional logistic regression to estimate odds ratios (OR) and 95% confidence intervals.Results: Among 98 participants (86 women, 12 men) with mean age 35.1 years, 83% white, and 10% Hispanic or Latino, the average age when headaches started was 16.3 years. In total, the participants reported 825 migraines during 4467 days of observation. There was a statistically significant nonlinear association between the number of caffeinated beverages and the odds of migraine headache occurrence on that day (P-quadratic trend = .024), though estimates for each level of intake were not statistically significant. The associations varied according to habitual intake and oral contraceptive use.Conclusions: There was a nonlinear association between caffeinated beverage intake and the odds of migraine headache occurrence on that day. This suggests that high levels of caffeinated beverage intake may be a trigger of migraine headaches on that day. [ABSTRACT FROM AUTHOR]

Background: Rather than identifying exposures and outcomes for research solely based on interests of medical professionals, there is a need for research that answers questions that are important to patients, so that they may make treatment decisions based on evidence that reflect their individual preferences. Objective: To identify exposures and outcomes of interest that could be studied with electronic health record data from inpatient care. Design, setting, participants: Mixed-methods analysis of semi-structured interviews administered in 2017 to 76 patients and 26 physicians who receive or provide care at Beth Israel Deaconess Medical Center in Boston, MA. Measurements: After conducting detailed semi-structured interviews about topics of interest that can be studied using electronic health records of inpatient care, we used an inductive approach to identify themes about the health care experience. Results: Participants reported concerns about adverse effects of medication changes, drug interactions, and surgery and other invasive procedures. The outcomes of greatest concern to them were in-hospital deaths and hospital-acquired infections. Participants commented on the importance of clear communication and information transfers, the hospital environment, accurate skills and knowledge, and upholding patient dignity and respect. Conclusion: Engaging patients and physicians in the research development process provided insight to the exposures and outcomes they consider important. Our questions about exposures and outcomes of interest were restricted to topics that could be studied with electronic health record data from inpatient care, but using a similar approach to elicit feedback about the health care experience could be used to glean insight for other areas of future research. [ABSTRACT FROM AUTHOR]

Objective: Acute high levels of anger and anxiety are associated with an elevated risk of myocardial infarction (MI) in the following two hours. MIs preceded by these acute negative emotions may also have a poor long-term prognosis, but information about high-risk patients is lacking. We examined whether young age and female sex are associated with MIs that are preceded by negative emotions and whether age and sex moderate the subsequent increased mortality risk following MI preceded by negative emotions.Methods: We conducted a secondary analysis of the Determinants of Myocardial Infarction Onset Study (N=2176, mean age=60.1±12.3years, 29.2% women). Anxiety and anger immediately prior to (0-2h) MI and the day before (24-26h) MI were assessed using a structured interview. Subsequent 10-year all-cause mortality was determined using the US National Death Index.Results: Anxiety during the 0-2h pre-MI period was associated with younger age (OR=0.98,95% CI=0.96-0.99 per year) and female sex (OR=1.50,95% CI=1.11-2.02). Anger in the 0-2h pre-MI period was also associated with younger age (OR=0.95,95% CI=0.94-0.96) but not with sex (OR=0.93,95% CI=0.67-1.28). During follow-up, 580 (26.7%) patients died. Mortality rate was higher if MI occurred immediately after high anxiety, particularly in patients ≥65years (HR=1.80,95% CI=1.28-2.54) vs. younger patients (HR=0.87,95% CI=0.55-1.40; p-interaction=0.015). Other interactions with sex or anger were not significant.Conclusions: Patients with high anxiety or anger levels in the critical 2-hour period prior to MI are younger than those without such emotional precipitants. In addition, pre-MI anxiety is associated with an elevated 10-year mortality risk in patients aged ≥65years. [ABSTRACT FROM AUTHOR]

Objectives. To review critical contributions from the Nurses' Health Study (NHS) on alcohol consumption and health outcomes. Methods. We performed a narrative review of NHS (1980-2012) and NHS II (1989-2011) publications. Results. Using detailed information on self-reported alcohol drinking patterns obtained approximately every 4 years combined with extensive information on diet, lifestyle habits, and physician-diagnosed health conditions, NHS investigators have prospectively examined the risks and benefits associated with alcohol consumption. Moderate intake, defined as up to 1 drink a day, is associated with a lower risk of hypertension, myocardial infarction, stroke, sudden cardiac death, gallstones, cognitive decline, and all-cause mortality. However, even moderate intake places women at higher risk for breast cancer and bone fractures, and higher intake increases risk for colon polyps and colon cancer. Conclusions. Regular alcohol intake has both risks and benefits. In analyses using repeated assessments of alcohol over time and deaths from all causes, women with low to moderate intake and regular frequency (> 3 days/week) had the lowest risk of mortality compared with abstainers and women who consumed substantially more than 1 drink per day. [ABSTRACT FROM AUTHOR]

Background: Although considerable research describes the cardiovascular effects of habitual moderate and heavy alcohol consumption, the immediate risks following alcohol intake have not been well characterized. Based on its physiological effects, alcohol may have markedly different effects on immediate and long-term risk.Methods and Results: We searched CINAHL, Embase, and PubMed from inception to March 12, 2015, supplemented with manual screening for observational studies assessing the association between alcohol intake and cardiovascular events in the following hours and days. We calculated pooled relative risks and 95% confidence intervals for the association between alcohol intake and myocardial infarction, ischemic stroke, and hemorrhagic stroke using DerSimonian and Laird random-effects models to model any alcohol intake or dose-response relationships of alcohol intake and cardiovascular events. Among 1056 citations and 37 full-text articles reviewed, 23 studies (29 457 participants) were included. Moderate alcohol consumption was associated with an immediately higher cardiovascular risk that was attenuated after 24 hours, and even protective for myocardial infarction and hemorrhagic stroke (≈2-4 drinks: relative risk=30% lower risk) and protective against ischemic stroke within 1 week (≈6 drinks: 19% lower risk). In contrast, heavy alcohol drinking was associated with higher cardiovascular risk in the following day (≈6-9 drinks: relative risk=1.3-2.3) and week (≈19-30 drinks: relative risk=2.25-6.2).Conclusions: There appears to be a consistent finding of an immediately higher cardiovascular risk following any alcohol consumption, but, by 24 hours, only heavy alcohol intake conferred continued risk. [ABSTRACT FROM AUTHOR]

In cohort and case-control studies, confounding that arises as a result of differences in the distribution of determinants of the outcome between exposure groups leading to non-exchangeability are addressed by restriction, matching or with statistical models. In case-only studies, this issue is addressed by comparing each individual with his/herself. Although case-only designs use self-matching and only include individuals who develop the outcome of interest, issues of non-exchangeability are identical to those that arise in traditional case-control and cohort studies. In this review, we describe one type of case-only design, the case-crossover design, and discuss how the concept of exchangeability can be used to understand issues of confounding, carryover effects, period effects and selection bias in case-crossover studies. [ABSTRACT FROM AUTHOR]

Abstract: Background: Although there is evidence that anxiety and anger are associated with a higher risk of cardiovascular events, studies examining the relationship between these stressors and prognosis following myocardial infarction have been mixed. Methods: We conducted a prospective cohort study of 1968 participants (average age 60.2 years, 30.6% women) in the Determinants of Myocardial Infarction Onset Study recruited at the time of admission for myocardial infarction between 1989 and 1996. We used the state anxiety and anger subscales of the State-Trait Personality Inventory. Participants were followed for all-cause mortality through December 31, 2007 using the National Death Index. We constructed multivariable Cox proportional hazards models adjusted for demographic, behavioral, and clinical confounders and calculated hazard ratios (HR) and 95% confidence intervals (CI) to examine the relationship between high levels of anxiety and anger and all-cause mortality. Results: Over 10 years of follow-up, 525 participants died. Compared with those scoring lower, an anxiety score >90th percentile was associated with a 1.31-times (95% CI, 0.93-1.84) higher mortality rate. The association was apparent in the first 3 years (HR 1.78; 95% CI 1.08-2.93), but not thereafter. Likewise, an anger score >90th percentile was associated with a 1.25-times (95% CI, 0.87-1.80) higher mortality rate. The association was higher in the first 3 years (HR 1.58; 95% CI, 0.91-2.74) than in subsequent years, but it was not statistically significant during either follow-up period. Conclusions: In this study of myocardial infarction survivors, a high level of anxiety was associated with all-cause mortality, with the strongest association in the first 3 years of follow-up. [Copyright &y& Elsevier]

The aim of the present study was to explore the association between outbursts of anger and acute myocardial infarction (AMI) risk. Outbursts of anger are associated with an abrupt increase in cardiovascular events; however, it remains unknown whether greater levels of anger intensity are associated with greater levels of AMI risk or whether potentially modifiable factors can mitigate the short-term risk of AMI. We conducted a case-crossover analysis of 3,886 participants from the multicenter Determinants of Myocardial Infarction Onset Study, who were interviewed during the index hospitalization for AMI from 1989 to 1996. We compared the observed number and intensity of anger outbursts in the 2 hours preceding AMI symptom onset with its expected frequency according to each patient's control information, defined as the number of anger outbursts in the previous year. Of the 3,886 participants in the Determinants of Myocardial Infarction Onset Study, 1,484 (38%) reported outbursts of anger in the previous year. The incidence rate of AMI onset was elevated 2.43-fold (95% confidence interval 2.01 to 2.90) within 2 hours of an outburst of anger. The association was consistently stronger with increasing anger intensities (p trend <0.001). In conclusion, the risk of experiencing AMI was more than twofold greater after outbursts of anger compared with at other times, and greater intensities of anger were associated with greater relative risks. Compared with nonusers, regular β-blocker users had a lower susceptibility to heart attacks triggered by anger, suggesting that some drugs might lower the risk from each anger episode. [ABSTRACT FROM AUTHOR]

There is increasing interest in evaluating the association between specific fine-particle (particles with aerodynamic diameters less than 2.5 µm; PM2.5) constituents and adverse health outcomes rather than focusing solely on the impact of total PM2.5. Because PM2.5 may be related to both constituent concentration and health outcomes, constituents that are more strongly correlated with PM2.5 may appear more closely related to adverse health outcomes than other constituents even if they are not inherently more toxic. Therefore, it is important to properly account for potential confounding by PM2.5 in these analyses. Usually, confounding is due to a factor that is distinct from the exposure and outcome. However, because constituents are a component of PM2.5, standard covariate adjustment is not appropriate. Similar considerations apply to source-apportioned concentrations and studies assessing either short-term or long-term impacts of constituents. Using data on 18 constituents and data from 1,060 patients admitted to a Boston medical center with ischemic stroke in 2003–2008, the authors illustrate several options for modeling the association between constituents and health outcomes that account for the impact of PM2.5. Although the different methods yield results with different interpretations, the relative rankings of the association between constituents and ischemic stroke were fairly consistent across models. [ABSTRACT FROM PUBLISHER]

Background--Acute psychological stress is associated with an abrupt increase in the risk of cardiovascular events. Intense grief in the days after the death of a significant person may trigger the onset of acute myocardial infarction (MI), but this relationship has not been systematically studied. Methods and Results--We conducted a case-crossover analysis of 1985 participants from the multicenter Determinants of Myocardial Infarction Onset Study interviewed during index hospitalization for an acute MI between 1989 and 1994. We compared the observed number of deaths in the days preceding M1 symptom onset with its expected frequency based on each patient's control information, defined as the occurrence of deaths in the period from 1 to 6 months before infarction. Among the 1985 subjects, 270 (13.6%) experienced the loss of a significant person in the prior 6 months, including 19 within 1 day of their MI. The incidence rate of acute MI onset was elevated 21.1-fold (95% confidence interval, 13.1-34.1) within 24 hours of the death of a significant person and declined steadily on each subsequent day. The absolute risk of MI within 1 week of the death of a significant person is 1 excess MI per 1394 exposed individuals at low (5%) 10-year MI risk and 1 per 320 among individuals at high (20%) 10-year risk. Conclusions--Grief over the death of a significant person was associated with an acutely increased risk of MI in the subsequent days. The impact may be greatest among individuals at high cardiovascular risk. [ABSTRACT FROM AUTHOR]

Despite extensive research on the emergence of and treatments for methicillin-resistant Staphylococcus aureus (MRSA), prior studies have not rigorously evaluated the impact of methicillin resistance on the overall incidence of S. aureus infections. Yet, there are direct clinical and research implications of determining whether methicillin-susceptible S. aureus (MSSA) infection rates remain stable in the face of increasing MRSA prevalence or whether MSSA will be replaced over time. A synthesis of prior studies indicates that the emergence of healthcare-associated MRSA (HA-MRSA) and community-associated MRSA (CA-MRSA) has led to an increase in the overall incidence of S. aureus infections, with MRSA principally adding to, rather than replacing, MSSA. However, colonization with CA-MRSA may at least partially replace colonization with MSSA. So far, evidence indicates that MSSA still accounts for many infections. Therefore, eradication of MRSA alone is not sufficient to address the public health burden of S. aureus. [ABSTRACT FROM PUBLISHER]

The article discusses evidences on the association of behavioral, psychosocial and environmental triggers and cardiovascular outcomes as well as relates on the common underlying pathophysiology of the triggers. It states that triggers can lower threshold for cardiac electric instability and can elicit procoagulatory hemostatic alterations. It asserts that increased physical activity can trigger cardiovascular events and asserts that there is lower risk among patients who are sexually active.

Regular physical activity is known to decrease the risk of cardiovascular disease, but the risk of ischemic stroke immediately following moderate or vigorous physical activity remains unclear. The authors evaluated the risk of acute ischemic stroke immediately following physical activity and examined whether the risk was modified by regular physical activity. In a multicenter case-crossover study, the authors interviewed 390 ischemic stroke patients (209 men, 181 women) at 3 North American hospitals between January 2001 and November 2006. Physical activity during the hour before stroke symptoms arose was compared with usual frequency of physical activity over the prior year. Of the 390 subjects, 21 (5%) reported having engaged in moderate or vigorous physical activity during the hour before ischemic stroke onset, and 6 subjects had lifted an object weighing at least 50 pounds (≥23 kg) during that hour. The rate ratio for ischemic stroke was 2.3 (95% confidence interval (CI): 1.5, 3.7; P < 0.001) for moderate or vigorous physical activity in the previous hour and 2.6 (95% CI: 1.1, 5.9; P = 0.02) for lifting 50 pounds or more. People who reported engaging in moderate or vigorous physical activity at least 3 times per week experienced a 2-fold increased risk (95% CI: 1.2, 3.3) with each bout of physical activity, as compared with a 6.8-fold risk (95% CI: 2.5, 18.8) among more sedentary subjects (P for homogeneity = 0.03). [ABSTRACT FROM PUBLISHER]

Background: Among patients with acute ischemic stroke, impaired kidney function has been shown to increase the mortality risk, but the shape of this relationship has not been evaluated in detail. Methods: We estimated the glomerular filtration rate (eGFR) at the time of hospitalization in 1,175 consecutive patients hospitalized with acute ischemic stroke at the Beth Israel Deaconess Medical Center and examined the shape of the association between eGFR and all-cause mortality. Results: There were 508 deaths during a median follow-up of 40.3 months, resulting in a ‘U’-shaped relationship between eGFR and all-cause mortality. The curve was relatively flat between 75 and 110 ml/min/1.73 m2 but increased sharply at lower and higher levels of eGFR (test for nonlinearity: p < 0.0001). Conclusions: Among patients with acute ischemic stroke, a reduced or highly elevated eGFR at hospital admission is associated with a higher mortality rate compared to patients with moderate levels of eGFR. Copyright © 2009 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Objectives/Background: Despite the high prevalence of sleep disturbance, stress, and depressive symptoms among patients with episodic migraine, there has been limited prospective research examining how these comorbid symptoms relate to future headache risk. Methods: We conducted an a priori secondary analysis of a prospective cohort study of 98 adults with episodic migraine recruited through Harvard‐affiliated medical centers and local college student clinics in Boston, MA. At baseline, participants completed validated questionnaires on sleep quality, stress, and depressive symptoms. Over the next 6 weeks, they recorded headaches on twice‐daily diaries. We conducted time‐to‐event analyses to evaluate whether these baseline symptoms were associated with headache recurrence. Results: At baseline, 45/98 (46%) participants had poor sleep quality, 51/98 (52%) reported moderate/high stress levels, and 18/98 (18%) had high depressive symptom scores. Over 4,406 person‐days, we observed 823 discrete headaches. In multivariable models, the hazard ratios for headache recurrence were: 1.22 (95% CI 1.02, 1.46) for people with baseline poor sleep, 1.12 (95% CI 0.93, 1.35) for those with baseline moderate/high stress compared to lower levels, and 1.31 (95% CI 1.05, 1.65) for the combination of poor sleep and moderate/high stress compared to the combination of good sleep and low stress. There was no association between depression scores and headache risk. Conclusion: Among patients with episodic migraine, poor sleep was associated with a higher rate of headache recurrence over the next 6 weeks, especially among those with coexisting moderate/high stress. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the association of routine exercise with headache frequency, intensity, and duration among adults with episodic migraine (EM). Background: A comprehensive management plan for EM must aim at reducing disability and cost of care; to do so requires optimizing acute and preventive medications, and behavior changes. Prophylactic medication use is associated with adverse events and contraindications with comorbidities. Aerobic exercise is reported to decrease migraine frequency. However, no study has evaluated a potential synergistic relation between regular exercise and preventive medication use among patients with EM. Design and Methods: This was a secondary analysis of data from a prospective cohort study of adults with EMs. In that study, adults with EM (using International Classification of Headache Disorders‐3 criteria confirmed by study physicians) were recruited from three academic medical centers in Boston, MA. At baseline, participants provided information on exercise, clinical and demographic characteristics, and lifestyle behaviors. We prospectively collected daily information on headaches and health behavior over at least 6 weeks using electronic questionnaires from 94 participants. We assessed the association between baseline self‐reported moderate‐vigorous exercise at least three times per week, at baseline, and prospectively recorded headache frequency, intensity, and duration. We further assessed whether these associations differed by the prevalent use of prophylactic migraine medication. Results: Data from 94 of 98 eligible participants were used in the analysis as 4 participants had missing data on routine exercise frequency or intensity at baseline. On average, patients who reported moderate‐vigorous exercise at least three times per week at enrollment had 1.5 fewer headache days per month (−1.5 headache days/month; 95% confidence interval [CI] −3.1 to 0.1) compared to less exercise; this was not statistically significant (p = 0.066). The association between exercise and headache days per month varied by baseline use of migraine prophylaxis (p‐value of interaction = 0.009). Among those who reported regular use of migraine prophylaxis, a report of moderate‐vigorous exercise at least three times per week was associated with 5.1 fewer headache days (−5.1: 95% CI −8.2 to −2.0; p = 0.001) compared to those who reported lower levels of exercise. However, among those not using migraine prophylaxis, we observed only 0.4 fewer headache days per month (−0.4: 95% CI −2.2 to 1.3; p = 0.636) associated with moderate‐vigorous exercise at least three times/week, a result that was not statistically significant. There was no association of self‐reported moderate‐vigorous exercise at least three times a week with headache intensity or duration. Conclusion: In patients with EM, those who reported moderate‐vigorous exercise at least three times per week had fewer headache days per month, though not statistically significant. This association was significantly stronger in those who used prophylactic medication for migraines. Exercise appeared not to be associated with the severity or duration of headaches. Routine moderate‐vigorous exercise may be an important adjunctive strategy for improving headache burden in patients eligible for migraine prophylaxis. [ABSTRACT FROM AUTHOR]

Objective: Given the lack of studies examining the associations between daily weather and air pollution with nightly objective sleep over multiple weeks, we quantified these associations in a prospective cohort of healthy participants with episodic migraine.Methods: Ninety-eight participants completed daily electronic diaries and wore an actigraph for an average of 45 ds, and a total 4406 nights of data were collected. Nightly sleep characteristics including duration, wake after sleep onset (WASO), and efficiency were assessed using wrist actigraphy. Daily weather parameters and air pollution levels were collected from local weather station and ground-level air quality monitors. We used linear fixed effects models adjusting for participant, day of the week, and day of the year (for weather analysis), and additionally adjusted for temperature and relative humidity (for air pollution analysis).Results: The participants were 35 ± 12 yrs old and 86 were women. A 10 °F higher daily average temperature was associated with 0.88 (95% CI: 0.06, 1.70) minutes longer WASO and 0.14% (95% CI: -0.01%, 0.30%) lower sleep efficiency on that night. A 14 parts per billion (ppb) (interquartile range) higher daily maximum eight-h ozone was associated with 7.51 (95% CI: 3.23, 11.79) minutes longer sleep duration on that night. Associations did not differ between cold (October-March) and warm (April-September) seasons.Conclusions: Higher daily ozone was associated with longer sleep duration and modest associations were observed between higher temperature and lower WASO and lower efficiency. [ABSTRACT FROM AUTHOR]

Background: Coffee intake and heavy physical exertion are triggers of acute myocardial infarction (AMI). It is hypothesized that their triggering effects can be modified by genetic variation. Methods: The study population consisted of incident cases (n=1354 for coffee intake, and n=1101 for heavy physical exertion) of nonfatal AMI recruited in Costa Rica between 1994 and 2004. Coffee intake and heavy physical exertion were assessed with validated questionnaires. Blood samples were collected and genotyping was conducted. We used a case-crossover design to estimate the relative risks (RRs) and 95% confidence intervals (CIs) of AMI associated with each trigger stratified by the genotypes of each SNP included. Chi-square tests of homogeneity of RR across genotypic strata were used to assess effect modification by genetic factors. We included SNPs from both candidate genes (candidate SNPs) and previous genome-wide association studies (GWAS SNPs) related to the pathophysiological pathways of the triggering effects. Specifically, the candidate SNPs were from select genes related to sympathetic nervous system, renin-angiotensin system, caffeine metabolism, and habitual coffee consumption. The GWAS SNPs were those previously found to be associated with AMI/coronary artery disease, lipid metabolism, blood pressure, heart rate, blood coagulation, matrix metalloproteinase, and adhesion molecules. A p-value of 0.05 was considered statistically significant at first. We then performed Bonferroni correction and false discovery rate (FDR) adjustment to account for multiple testing. Results: Among the SNPs associated with AMI/coronary artery disease, rs10483853 significantly modified the triggering effect of coffee, and rs10507130 was significant for heavy physical exertion. Among the SNPs associated with blood pressure, rs935334 was significant for both triggers. Among the SNPs associated with heart rate, rs9398652, rs1541010 and rs1395479 were significant for coffee intake, and rs17287293 and rs223116 were significant for heavy physical exertion. Among the SNPs associated with blood coagulation, rs4460176, rs565229, and rs12367822 were significant for coffee intake, and rs2731672, rs10489087, rs647316, rs2138852, rs1473247, rs12367822 and rs1671152 were significant for heavy physical exertion. The two SNPs associated with serum matrix metalloproteinase (rs11225434 and rs495366) both significantly modified the triggering effect of heavy physical exertion. No SNPs remained statistically significant after Bonferroni correction or FDR adjustment. Conclusions: We identified several potential genetic modifiers of the triggering effects of coffee intake and heavy physical exertion on AMI. Among them, heart rate and blood coagulation traits appeared to be more important. Replication studies in other populations will help confirm and expand our findings. [ABSTRACT FROM AUTHOR]

Background: Roughly, a fourth of all placental abruption cases have an acute aetiologic underpinning, but the causes of acute abruption are poorly understood. Studies indicate that symptoms of stress, depression, and anxiety during pregnancy may be associated with a higher risk of abruption.Objective: We examined the rate of abruption in the 2 hours immediately following outbursts of anger.Methods: In a multicentre case-crossover study, we interviewed 663 women diagnosed with placental abruption admitted to one of the seven Peruvian hospitals between January 2013 and August 2015. We asked women about outbursts of anger before symptom onset and compared this with their usual frequency of anger during the week before abruption.Results: The rate of abruption was 2.83-fold (95% confidence interval [CI] 1.85, 4.33) higher in the 2 hours following an outburst of anger compared with other times. The rate ratio (RR) was lower for women who completed technical school or university (RR 1.38, 95% CI 0.52, 3.69) compared to women with secondary school education or less (RR 3.73, 95% CI 2.32, 5.99, P-homogeneity = .07). There was no evidence that the association between anger episodes and abruption varied by hypertensive disorders of pregnancy (ie preeclampsia/ eclampsia) or antepartum depressive symptoms.Conclusion: There was a higher rate of abruption in the 2 hours following outbursts of anger compared with other times, providing potential clues to the aetiologic mechanisms of abruption of acute onset. [ABSTRACT FROM AUTHOR]

While there is consistent evidence that episodes of physical exertion are associated with an immediately higher risk of acute ischemic vascular events, the risk of placental abruption immediately following episodes of physical exertion has not been studied. In a multicenter case-crossover study, we interviewed 663 women with placental abruption at 7 Peruvian hospitals between January 2013 and August 2015. We asked women about physical exertion in the hour before symptom onset and compared this with their frequency of physical exertion over the prior week. Compared with times with light or no exertion, the risk of placental abruption was 7.8 (95% confidence interval (CI): 5.5, 11.0) times greater in the hour following moderate or heavy physical exertion. The instantaneous incidence rate ratio of placental abruption within an hour of moderate or heavy physical exertion was lower for women who habitually engaged in moderate or heavy physical activity more than 3 times per week in the year before pregnancy (rate ratio (RR) = 3.0, 95% CI: 1.6, 5.9) compared with more sedentary women (RR = 17.3, 95% CI: 11.3, 26.7; P for homogeneity < 0.001), and the rate ratio was higher among women with preeclampsia/eclampsia (RR = 13.6, 95% CI: 7.0, 26.2) than among women without (RR = 6.7, 95% CI: 4.4, 10.0; P for homogeneity = 0.07). [ABSTRACT FROM AUTHOR]

Objective: To examine the association between exposure to psychological (anger, anxiety) and physical (high activity levels, coffee consumption) challenge immediately prior to myocardial infarction (MI) as risk indicator of mortality at 10- year follow-up. Methods: Participants of the Determinants of Myocardial Infarction Onset Study (N=2176, mean age 60.1±12.5 yrs, 29.2% women) were interviewed to assess exposure to several potential triggers immediately prior to MI, including anger, anxiety, physical activity and coffee. All-cause mortality was assessed using the National Death Index for 10 years follow-up. We constructed Cox proportional hazards models with 95% confidence intervals to examine the relationship between exposure to these potential triggers in the 2 hours prior to MI onset and the rate of all-cause mortality, adjusting for demographic and clinical characteristics. Results: Exposure to anger, anxiety, physical activity or coffee consumption prior to MI was associated with a 30% higher mortality rate over 10 years (HR=1.30, 95%CI=1.06-1.59, p=0.011) compared to patients who were not exposed to any of these potential triggers. This association was stronger for the first 3 years of follow-up (HR=1.59, 95%CI=1.16-2.19, p=0.004) and weaker for years 3 to 10 (HR=1.14, 95%CI=0.88-1.48, p=0.32). In separate analyses for each exposure, there was a higher mortality rate associated with anxiety (HR=1.44, 95%CI=1.09- 1.91, p=0.010) and a suggestion of a higher rate for anger (HR=1.33, 95%CI=0.97- 1.81, p=0.075), but no association for physical activity or coffee consumption. Sensitivity analyses showed stronger associations for women than men, and patients aged 65 and older compared to younger patients. Discussion: MI following episodes of anger, anxiety, physical activity or coffee consumption is associated with higher all-cause mortality in the following 10 years. This association was strongest for anxiety and slightly lower for anger but there was no evidence of a higher mortality rate among MI patients reporting physical activity or coffee consumption immediately prior to MI. [ABSTRACT FROM AUTHOR]

A response by Mostofsky and Mittleman to a letter to the editor about their article "Modeling the Association Between Particle Constituents of Air Pollution and Health Outcomes" in the August 2012 issue is presented.

Background: Psychotropic drugs increase the risk of falls, but they are still frequently prescribed to treat behavioral symptoms associated with dementia in the nursing home. We examined whether there is an acute increased risk of falls in the days following a change to an antipsychotic or benzodiazepine drug prescription.Methods: We collected information on 594 long-stay nursing home residents from two facilities who fell at least once between September 1, 2010 and May 31, 2013. Psychotropic drug changes were ascertained from the facilities' computerized medication administration log. We used the case-crossover design to compare the frequency of antipsychotic and benzodiazepine drug changes during the days before a fall with the frequency of drug changes at more remote times.Results: Mean age was 87.5 years, and 75.1% were female. The risk of falls was higher in the 24 hours following benzodiazepine initiation compared with other times (odds ratio [OR] 3.79, 95% confidence interval [CI] 1.10, 13.00). There was no clear difference in risk following antipsychotic initiation (OR 2.42, CI 0.58, 10.06), but this could be due to the small sample size. Stopping a benzodiazepine was associated with a significantly reduced fall risk (OR 0.26, 95% CI 0.08-0.91).Conclusions: Benzodiazepines pose an immediate threat to fall risk, whereas it is less clear if antipsychotics also pose an immediate risk. Nursing home staff should be particularly vigilant in the days following the new prescription for a benzodiazepine in an effort to prevent injury. [ABSTRACT FROM AUTHOR]

To examine the association between healthcare-related regrets and sleep difficulties among nurses and physicians, we surveyed 240 nurses and 220 physicians at the University Hospitals of Geneva. Regret intensity and regret coping were measured using validated scales. Sleep difficulties were measured using the Insomnia Severity Index (ISI), and an additional question assessed the frequency of sleeping pill use. After controlling for sex, profession, years of experience, rate of employment, and depression as well as for all other regret-related variables, the following variables remained significantly associated with self-rated severity of insomnia: regret intensity (slope = 1.32, p = 0.007, 95%CI: [0.36; 2.29], std. coefficient = 0.16) and maladaptive (e.g., rumination) emotion-focused coping (slope = 1.57, p = 0.002, 95%CI: [0.60; 2.55], std. coefficient = 0.17) remained significant predictors of self-rated insomnia severity. If these cross-sectional associations represent causal effects, the development of regret-management programs may represent a promising approach to mitigating sleep difficulties of healthcare professionals. [ABSTRACT FROM AUTHOR]

The authors evaluated hospitalization cost offset of hostility management group therapy for patients with coronary heart disease (CHD) from a previously published randomized controlled trial (Y. Gidron, K. Davidson, & I. Bata, 1999). Twenty-six male patients with myocardial infarction or unstable angina were randomized to either 2 months of cognitive-behavioral group therapy or an information (control) session. Therapy patients had a shorter average length of hospital stay (n = 13, M = 0.38 days, SD = 0.96) than did control patients (n = 13, M = 2.15 days, SD = 2.6), t(15.2) = -2.29, p = .04, over 6 months following therapy. The average hospitalization costs were significantly lower for therapy patients (M = $245, SD = $627) than for control patients (M = $1,333, SD = $1,609), t(15.6) = -2.27, p = .04. The cost-offset ratio is calculated by dividing the $1,088 of hospitalization savings by the $560 of therapy expense ($1.00:$1.94), indicating that for every $1.00 spent on therapy, there is an approximate savings of $2.00 in hospitalization costs in the following 6 months. These findings support the hospitalization cost offset of hostility-reduction in CHD patients. [ABSTRACT FROM AUTHOR]

The article offers information on attribution of sleep disturbances as a trigger of migraine has conducted a prospective cohort study adults with episodic migraine to examine the bidirectional, temporal associations between migraine onset and sleep duration, quality, and fragmentation. Topics include the strong bidirectional associations between sleep duration and quality and next-day migraine, and the clinicians should avoid attributing migraine attacks solely to sleep problems.

Previous research suggests that stressors may trigger the onset of acute cardiovascular disease (CVD) events within hours to days, but there has been limited research around sociopolitical events such as presidential elections. Among adults ≥18 y of age in Kaiser Permanente Southern California, hospitalization rates for acute CVD were compared in the time period immediately prior to and following the 2016 presidential election date. Hospitalization for CVD was defined as an inpatient or emergency department discharge diagnosis of acute myocardial infarction (AMI) or stroke using International Classification of Diseases, 10th revision codes. Rate ratios (RR) and 95% confidence intervals (CIs) were calculated comparing CVD rates in the 2 d following the 2016 election to rates in the same 2 d of the prior week. In a secondary analysis, AMI and stroke were analyzed separately. The rate of CVD events in the 2 d after the 2016 presidential election (573.14 per 100,000 person-years [PY]) compared to the rate in the window prior to the 2016 election (353.75 per 100,000 PY) was 1.62 times higher (95% CI 1.17, 2.25). Results were similar across sex, age, and race/ethnicity groups. The RRs were similar for AMI (RR 1.67, 95% CI 1.00, 2.76) and stroke (RR 1.59, 95% CI 1.03, 2.44) separately. Transiently heightened cardiovascular risk around the 2016 election may be attributable to sociopolitical stress. Further research is needed to understand the intersection between major sociopolitical events, perceived stress, and acute CVD events. [ABSTRACT FROM AUTHOR]

Migraine is a common recurrent headache disorder affecting 14% American adults. Although weather and air pollution are often reported by patients with migraine as precipitating factors, previous studies have had mixed results. We prospectively collected migraine headache onset data using electronic questionnaires from 98 adults with episodic migraine in the Greater Boston area (2016–2017). Each participant was followed for an average of 45 days for a total of 4406 days of observation. Temperature, relative humidity, and barometric pressure data were obtained from local weather station. Daily average fine particulate matter, daily maximum 1-hour sulfur dioxide, daily maximum 1-hour nitrogen dioxide, daily maximum 8-hour ozone, and daily maximum 8-hour carbon monoxide from local air pollution monitors. We conducted a repeated measures analysis using fixed effects logistic regression models. In the models we adjusted for day of week, a natural cubic spline term of day of the year with 4 degrees of freedom, and a participant identifier. We additionally adjusted for linear terms of temperature and relative humidity in the air pollution analyses. We also applied logistic regression models with generalized estimating equation (GEE) and autoregressive correlation structure in the sensitivity analysis. The mean age was 35 years and 88% were women. Mean temperature was 56.9 °F, relative humidity 67.3%, and fine particulate matter 7.3 μg/m3. Higher relative humidity was associated with higher odds of migraine headache, but the association was only observed in warm season (April–September). Higher levels of daily maximum 8-hour ozone and daily maximum 8-hour carbon monoxide appeared to be associated with higher odds of migraine headache onset in cold season (October–March). Although the associations for ozone and relative humidity were attenuated and no longer statistically significant in the overall GEE analysis, the differing associations by season remained. We found that higher relative humidity was associated with higher odds of migraine headache onset in warm season, and traffic-related gaseous pollutants may be associated with higher odds of migraine headache onset in cold season. • Migraine is a common recurrent headache disorder affecting 14% American adults. • Weather and air pollution are often reported as precipitating factors by patients. • We prospectively collected migraine headache data using daily electronic diaries. • Relative humidity is associated with migraine headache onset in warm season. • Traffic-related pollutants are associated with migraine headache onset in cold season. [ABSTRACT FROM AUTHOR]

Background: Physical exertion and caffeine consumption are associated with acute myocardial infarction (MI). However, physical exertion and caffeine consumption have not been examined as immediate triggers of MI in low and middle-income countries. Objective: Using a self-matched case-crossover design, we examined the acute risk of MI in the hour following episodes of physical exertion, caffeinated coffee, and tea consumption among MI survivors in Thailand. Methods: A total of 506 Thai participants (women = 191, men = 315) were interviewed between 2014 and 2017 after sustaining an acute MI. We compared each subject’s exposure to physical exertion and consumption of caffeine- containing beverages in the hour preceding the onset of MI with the subject’s expected usual frequency in the prior year to calculate relative risks (RRs) and 95% confidence intervals (95%CIs). Results: Of the 506 participants, 47 (9.3%) engaged in moderate or heavy physical exertion, 6 (1.2%) consumed tea, and 21 (4.2%) consumed coffee within the hour before MI. The relative risk of MI after moderate or heavy physical exertion was 3.0 (95% CI 2.2–4.2) compared to periods of no exertion, with a higher risk among more sedentary participants compared to active participants. Compared to times with no caffeinated beverage consumption, there was a higher risk of MI in the hour following consumption of caffeinated tea (RR = 3.7; 95%CI: 1.5–9.3) and coffee (RR = 2.3; 95%CI: 1.4–3.6). Conclusion: Physical exertion, coffee and tea consumption were associated with a higher risk of MI in the subsequent hour compared to times when the participants were sedentary or did not consume caffeinated beverages. Our study identifies high-risk populations for targeted screening and intervention to prevent acute MI. [ABSTRACT FROM AUTHOR]

Background: Long-term exposure to ambient air pollution has been associated with impaired cognitive function and vascular disease in older adults, but little is known about these associations among people with concerns about memory loss.Objective: To examine associations between exposures to fine particulate matter and residential proximity to major roads and markers of small vessel disease.Methods: From 2004-2010, 236 participants in the Massachusetts Alzheimer's Disease Research Center Longitudinal Cohort participated in neuroimaging studies. Residential proximity to major roads and estimated 2003 residential annual average of fine particulate air pollution (PM2.5) were linked to measures of brain parenchymal fraction (BPF), white matter hyperintensities (WMH), and cerebral microbleeds. Associations were modeled using linear and logistic regression and adjusted for clinical and lifestyle factors.Results: In this population (median age [interquartile range] = 74 [12], 57% female) living in a region with median 2003 PM2.5 annual average below the current Environmental Protection Agency (EPA) standard, there were no associations between living closer to a major roadway or for a 2μg/m3 increment in PM2.5 and smaller BPF, greater WMH volume, or a higher odds of microbleeds. However, a 2μg/m3 increment in PM2.5 was associated with -0.19 (95% Confidence Interval (CI): -0.37, -0.005) lower natural log-transformed WMH volume. Other associations had wide confidence intervals.Conclusions: In this population, where median 2003 estimated PM2.5 levels were below the current EPA standard, we observed no pattern of association between residential proximity to major roads or 2003 average PM2.5 and greater burden of small vessel disease or neurodegeneration. [ABSTRACT FROM AUTHOR]

Background Residential proximity to green space has been associated with physical and mental health benefits, but whether green space is associated with post-stroke survival has not been studied. Methods Patients ≥21 years of age admitted to the Beth Israel Deaconess Medical Center (BIDMC) between 1999 and 2008 with acute ischemic stroke were identified. Demographics, presenting symptoms, medical history and imaging results were abstracted from medical records at the time of hospitalization for stroke onset. Addresses were linked to average Normalized Difference Vegetation Index, distance to roadways with more than 10,000 cars/day, and US census block group. Deaths were identified through June 2012 using the Social Security Death Index. Results There were 929 deaths among 1645 patients with complete data (median follow up: 5 years). In multivariable Cox models adjusted for indicators of medical history, demographic and socioeconomic factors, the hazard ratio for patients living in locations in the highest quartile of green space compared to the lowest quartile was 0.78 (95% Confidence Interval: 0.63–0.97) (p-trend=0.009). This association remained statistically significant after adjustment for residential proximity to a high traffic road. Conclusions Residential proximity to green space is associated with higher survival rates after ischemic stroke in multivariable adjusted models. Further work is necessary to elucidate the underlying mechanisms for this association, and to better understand the exposure–response relationships and susceptibility factors that may contribute to higher mortality in low green space areas. [ABSTRACT FROM AUTHOR]

Background Living near major roadways has been associated with increased risk of cardiovascular events, but little is known about its impact on renal function. Methods We calculated the estimated glomerular filtration rate (eGFR) for 1103 consecutive Boston-area patients hospitalised with confirmed acute ischaemic stroke between 1999 and 2004. We used linear regression to evaluate the association between eGFR and categories of residential distance to major roadway (0 to ≤50, >50 to ≤100, >100 to ≤200, >200 to ≤400, >400 to ≤1000 and >1000 m) adjusting for age, sex, race, smoking, comorbid conditions, treatment with ACE inhibitor and neighbourhood-level socioeconomic characteristics. In a second analysis, we considered the log of distance to major roadway as a continuous variable. Results Patients living closer to a major roadway had lower eGFR than patients living farther away (Ptrend=0.01). Comparing patients living 50 m versus 1000 m from a major roadway was associated with a 3.9 ml/min/1.73 m2 lower eGFR (95% CI 1.0 to 6.7; p=0.007): a difference comparable in magnitude to the reduction in eGFR observed for a 4-year increase in age in population-based studies. The magnitude of this association did not differ significantly across categories of age, sex, race, history of hypertension, diabetes or socioeconomic status. Conclusions Living near a major roadway is associated with lower eGFR in a cohort of patients presenting with acute ischaemic stroke. If causal, these results imply that exposures associated with living near a major roadway contribute to reduced renal function, an important risk factor for cardiovascular events. [ABSTRACT FROM AUTHOR]

Background: Acute psychological stress is associated with an abrupt increase in the risk of cardiovascular events. Intense grief in the days after the death of a significant person may trigger the onset of acute myocardial infarction (MI), but this relationship has not been systematically studied.Methods and Results: We conducted a case-crossover analysis of 1985 participants from the multicenter Determinants of Myocardial Infarction Onset Study interviewed during index hospitalization for an acute MI between 1989 and 1994. We compared the observed number of deaths in the days preceding MI symptom onset with its expected frequency based on each patient's control information, defined as the occurrence of deaths in the period from 1 to 6 months before infarction. Among the 1985 subjects, 270 (13.6%) experienced the loss of a significant person in the prior 6 months, including 19 within 1 day of their MI. The incidence rate of acute MI onset was elevated 21.1-fold (95% confidence interval, 13.1-34.1) within 24 hours of the death of a significant person and declined steadily on each subsequent day. The absolute risk of MI within 1 week of the death of a significant person is 1 excess MI per 1394 exposed individuals at low (5%) 10-year MI risk and 1 per 320 among individuals at high (20%) 10-year risk.Conclusions: Grief over the death of a significant person was associated with an acutely increased risk of MI in the subsequent days. The impact may be greatest among individuals at high cardiovascular risk. [ABSTRACT FROM AUTHOR]

Numerous studies have found that depression was a strong independent risk factor for incident coronary heart disease (CHD), with increasing risk in those with higher levels of depressive symptoms. The association between measures of inflammation (C-reactive protein, interleukin-6, and soluble intracellular adhesion molecule-1), depressive symptoms, and CHD incidence was examined in 1,794 subjects of the population-based Canadian Nova Scotia Health Survey. There were 152 incident CHD events (8.5%; 141 nonfatal, 11 fatal) during the 15,514 person-years of observation (incidence rate 9.8 events/1,000 person-years). Depression and inflammation were correlated at baseline and each significantly predicted CHD in separate models. When both risk factors were in the same model, each remained significant. The association between depressed group by the Center for Epidemiological Studies-Depression scale (score ≥10 vs 0 to 9) and CHD incidence (hazard rate 1.60, 95% confidence interval 1.12 to 2.27) was not reduced by the addition of inflammatory markers to the model (hazard rate 1.59, 95% confidence interval 1.12 to 2.26). Findings were similar after adjustment for aspirin, lipid-lowering medication, or antidepressant use, and the association did not vary by gender, smoking status, age, obesity, cardiovascular medication use, or antidepressant use. In conclusion, increased inflammation explained only a very small proportion of the association between depression and incident CHD. [Copyright &y& Elsevier]

Background:The white coat effect can lead to overdiagnosis of hypertension and unnecessary pharmacologic treatment. Mechanisms underlying the white coat effect remain poorly understood but are critical to improving the accuracy of clinic blood pressure measurement. Purpose: This study investigated whether perceived hypertension status was associated with state anxiety levels during a clinic visit and the magnitude of the white coat effect, independent of true blood pressure status. Methods: This observational study included 214 normotensive and mildly hypertensive participants who were 18 to 80 years old, had no cardiac history, and were willing to discontinue antihypertensive medications for 8 weeks. Participants underwent 36�hr ambulatory blood pressure monitoring and physician blood pressure measurement. Outcome measures were state anxiety reported during the clinic visit and the white coat effect. Results: An analysis of covariance indicated that participants who perceived themselves as hypertensive reported greater state anxiety (p�<�.001) and showed larger white coat effects (ps�<�.01) compared with those who perceived themselves as normotensive. True hypertension status based on ambulatory blood pressure was not related to either outcome. Anxiety accounted for approximately 19% of the association between perceived hypertension status and the white coat effect. Conclusions:These findings suggest that the perception of being hypertensive is associated with greater anxiety during clinic blood pressure measurement and a larger white coat effect, independent of the true blood pressure level. Anxiety appears to be a mechanism by which perceived hypertension status contributes to the white coat effect. [ABSTRACT FROM AUTHOR]

Background: Residential proximity to green space has been associated with physical and mental health benefits, but whether green space is associated with post-stroke survival is not well understood. Methods: We identified patients ≥21 years of age admitted to the Beth Israel Deaconess Medical Center (BIDMC) between April 1, 1999 and October 31, 2008 with neurologist-confirmed acute ischemic stroke. Demographics, presenting symptoms, medical history and imaging results were abstracted from medical records at the time of hospitalization for stroke onset. The time of stroke symptom onset or time last seen normal was documented by the attending stroke neurologist at the time of hospital presentation. Participant addresses were geocoded and linked to average Normalized Difference Vegetation Index (NDVI) derived from satellite-based estimates within a 250x250m grid (July 2000-2012), distance to roadways with more than 10,000 cars/day, and 2000 US census block group. We identified deaths through June 2012 using the Social Security Death Index (SSDI). Results: We observed 929 deaths among 1,645 patients with complete data (median follow up: 5 years). In multivariable Cox models adjusted for indicators of medical history and demographic and socioeconomic factors, patients living in locations in the lowest quartile of green space had 28% higher rate of post-stroke mortality (95% Confidence Interval (CI): 4% to 59%) than those living in the highest quartile of green space (p-trend=0.009). This association remained significant after adjustment for residential proximity to a high traffic road. Conclusions: Residential proximity to green space is associated with higher rates of survival after ischemic stroke in multivariable adjusted models. Further work is necessary to elucidate the underlying mechanisms for this association and to better understand susceptibility factors that may contribute to greater mortality in low green space areas. [ABSTRACT FROM AUTHOR]