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Context: The Asbestos Hazard Emergency Response Act (AHERA) became a law in 1986, and the US Environmental Protection Agency (USEPA) was mandated to promulgate rules to regulate the inspection, management, and abatement of asbestos-containing building materials (ACBM) in schools. This study describes 10 years (2008-2017) of AHERA compliance site inspection data conducted by the New Jersey Department of Health (NJDOH)., Objectives: To establish the level to which inspected NJ schools comply with AHERA regulations, to characterize compliance deficiencies including those that may lead to increased asbestos exposure risk to students and school employees, and to determine whether age, type, and geographic location of school impacted the likelihood of noncompliance., Design: Information collected during 456 unique inspections between 2008 and 2017 was analyzed., Setting and Participants: Inspections were conducted at public and private schools in New Jersey. These included elementary, middle, and high schools, as well as charter and vocational/technical schools., Main Outcome Measures: Descriptive statistics and multiple logistic regression modeling of 3 factors, school type, geographical region, and school age., Results: NJDOH inspectors found damage to friable ACBM in 50% (n = 229) of the schools and fiber release episodes in 27% of inspections (n = 121). The case of schools failing to attach warning labels on or immediately adjacent to ACBM was the most frequently noted compliance deficiency over the 10-year period. The modeling output showed that compliance was associated with the type of school and geographical region., Conclusions: Inspected schools during the 10-year period were in serious noncompliance with AHERA regulations. This included deficiencies that demonstrate a potential exposure to asbestos such as missing ACBM in management plans, damaged ACBM, lack of protection of short-term workers and custodial staff, and the identification of fiber release episodes. Modeling results of specific school characteristics can help direct limited resources to mitigate potential asbestos exposures., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background and Purpose: Magnetic resonance imaging (MRI) scans in the elderly commonly show white matter findings that may raise concerns. We sought to document incidence, manifestations, and predictors of worsening white matter grade on serial imaging., Methods: The Cardiovascular Health Study is a population-based, longitudinal study of 5888 people aged 65 years and older, of whom 1919 have had extensive initial and follow-up evaluations, including 2 MRI scans separated by 5 years. Scans were read without clinical information in standard side-by-side fashion to determine worsening white matter grade., Results: Worsening was evident in 538 participants (28%), mostly (85%) by 1 grade. Although similar at initial scan, participants with worsening white matter grade, compared with those without, experienced greater decline on modified Mini-Mental State examination and Digit-Symbol Substitution test (both P< or =0.001) after controlling for potential confounding factors, including occurrence of transient ischemic attack or stroke between scans. Independent predictors of worsening white matter grade included cigarette smoking before initial scan and infarct on initial scan. Otherwise, predictors differed according to white matter grade on initial scan. For low initial grade, increased age, increased diastolic blood pressure, increased high-density lipoprotein cholesterol, and decreased low-density lipoprotein cholesterol were associated with increased risk of worsening. For high initial grade, any cardiovascular disease and low ankle-arm index were associated with decreased risk of worsening, whereas use of diuretics and statins were associated with increased risk., Conclusions: Worsening white matter grade on serial MRI scans in elderly is common, is associated with cognitive decline, and has complex relations with cardiovascular risk factors.

Objective: To review the use of transcranial Doppler ultrasonography (TCD) and transcranial color-coded sonography (TCCS) for diagnosis., Methods: The authors searched the literature for evidence of 1) if TCD provides useful information in specific clinical settings; 2) if using this information improves clinical decision making, as reflected by improved patient outcomes; and 3) if TCD is preferable to other diagnostic tests in these clinical situations., Results: TCD is of established value in the screening of children aged 2 to 16 years with sickle cell disease for stroke risk (Type A, Class I) and the detection and monitoring of angiographic vasospasm after spontaneous subarachnoid hemorrhage (Type A, Class I to II). TCD and TCCS provide important information and may have value for detection of intracranial steno-occlusive disease (Type B, Class II to III), vasomotor reactivity testing (Type B, Class II to III), detection of cerebral circulatory arrest/brain death (Type A, Class II), monitoring carotid endarterectomy (Type B, Class II to III), monitoring cerebral thrombolysis (Type B, Class II to III), and monitoring coronary artery bypass graft operations (Type B to C, Class II to III). Contrast-enhanced TCD/TCCS can also provide useful information in right-to-left cardiac/extracardiac shunts (Type A, Class II), intracranial occlusive disease (Type B, Class II to IV), and hemorrhagic cerebrovascular disease (Type B, Class II to IV), although other techniques may be preferable in these settings.

Background and Purpose: An easily administered questionnaire and algorithm classifying transient ischemic attacks (TIAs) or strokes, and also their distribution, could be invaluable for identifying endpoints in epidemiologic studies or clinical trials of prevention and therapy of cerebral ischemia. The Asymptomatic Carotid Atherosclerosis Study (ACAS) devised a symptom-based questionnaire and algorithm for detecting events in the trial. The purpose of this study was to determine sensitivity, specificity, and agreement rates of the questionnaire and algorithm against diagnoses of a panel of cerebrovascular disease authorities., Methods: Three hundred eighty-one men and women at eight medical centers reported symptoms of stroke, TIA, or other neurologic illness. The questionnaire was administered by trained interviewers and the responses were analyzed using the algorithm. A standardized neurologic examination was performed by a neurologist. Data were submitted to two or more external reviewers. Sensitivity, specificity, and the kappa statistic (kappa) were used to evaluate the relationship between the algorithm and the external reviewers' diagnosis., Results: Of the 381 reviews, 196 were diagnosed as TIA or stroke by the external panel. The algorithm's agreement with the diagnosis of TIA or stroke was 80.1%, and kappa was 0.60. Sensitivity was 87.8%, and specificity was 71.9%., Conclusion: While statistical agreement rates depend on the method of sample selection, the algorithm has a high agreement with an external panel of experts and is a sensitive tool for event detection. The lower specificity indicates that careful neurologic evaluation may be required to confirm or refute events identified by the screening algorithm.

Rationale and Objectives: The authors determine the reliability of centralized versus noncentralized (site-based) measurement of angiographic stenosis of patients enrolled into the multicenter, prospective, Asymptomatic Carotid Atherosclerosis Study by angiographic studies., Methods: Percent agreements and correlations of 244 masked and prospectively interpreted angiograms were calculated for comparison of centralized and noncentralized readers measuring the percent carotid stenosis from the same angiographic studies. Univariate summary statistics for differences in percent stenoses were calculated for these readings., Results: Agreement between readings were 88.5% and 91.8% with kappa statistics of 0.77 and 0.73 for > or = 60% and > or = 80% stenosis, respectively, for comparison of 33 centers to the designated central reader. Comparison between the designated central reader and a second central reader derived percent agreements of 85.0% and 86.5% with kappa statistics of 0.69 and 0.41 for > or = 60% and > or = 80% stenoses, respectively, for arteries selected from the original group. Hence, agreement was slightly better between the enrolling centers and the designated central reader than between the two central readers., Conclusions: Both centralized and noncentralized (site-based) methods of angiographic measurement of stenosis are equally reliable for large, prospective, masked, multicenter trials when quality control measures are instituted to ensure uniform application of eligibility criteria.

Background: HMG CoA reductase inhibitors (or statins), a new class of lipid-lowering compounds, have raised expectations for more widespread use than that of the older lipid-lowering drugs. Not only are they more effective in lowering LDL cholesterol, but they are better tolerated as well. No data exist concerning the effect of statins on early carotid atherosclerosis and clinical events in men and women who have moderately elevated LDL cholesterol levels but are free of symptomatic cardiovascular disease., Methods and Results: Lovastatin (20 to 40 mg/d) or its placebo was evaluated in a double-blind, randomized clinical trial with factorial design along with warfarin (1 mg/d) or its placebo. This report is limited to the lovastatin component of the trial. Daily aspirin (81 mg/d) was recommended for everyone. Enrollment included 919 asymptomatic men and women, 40 to 79 years old, with early carotid atherosclerosis as defined by B-mode ultrasonography and LDL cholesterol between the 60th and 90th percentiles. The 3-year change in mean maximum intimal-medial thickness (IMT) in 12 walls of the carotid arteries was the primary outcome; change in single maximum IMT and incidence of major cardiovascular events were secondary outcomes. LDL cholesterol fell 28%, from 156.6 mg/dL at baseline to 113.1 mg/dL at 6 months (P < .0001), in the lovastatin groups and was largely unchanged in the lovastatin-placebo groups. Among participants not on warfarin, regression of the mean maximum IMT was seen after 12 months in the lovastatin group compared with the placebo group; the 3-year difference was statistically significant (P = .001). A larger favorable effect of lovastatin was observed for the change in single maximum IMT but was not statistically significant (P = .12). Five lovastatin-treated participants suffered major cardiovascular events--coronary heart disease mortality, nonfatal myocardial infarction, or stroke--versus 14 in the lovastatin-placebo groups (P = .04). One lovastatin-treated participant died, compared with eight on lovastatin-placebo (P = .02)., Conclusions: In men and women with moderately elevated LDL cholesterol, lovastatin reverses progression of IMT in the carotid arteries and appears to reduce the risk of major cardiovascular events and mortality. Results from ongoing large-scale clinical trials may further establish the clinical benefit of statins.

We describe a 68-year-old man with invasive transitional cell carcinoma of the bladder metastatic to the dura who presented with complex partial status epilepticus (CPSE). To our knowledge, the association of CPSE and dural metastases has not been previously reported.