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Introduction: Social support may influence illness incidence or recovery through effects on health-related behaviors, and one aspect is emotional support, which includes the offering of empathy, friendship, care, and trust along with information. While we have previously reported on the positive relationship of family and friend networks in risk reduction, our objective was to examine whether participation in formalized group activities was related to medication adherence post-stroke. Methods: Using Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) data, information regarding religious and nonreligious social activities was collected at baseline. The outcome variable was measured by the self-reported 8-item Morisky Medication Adherence Scale (MMAS-8; score 0-8). Medium/high adherence (MMAS-8≥6) at 6- and 12-months post-discharge was modeled against social activities separately using logistic regression adjusting for age, gender, race/ethnicity, education, family and friend networks, NIH stroke scale at admission, and the intervention. Results: Of the 541 participants who completed the baseline questionnaire, 286 and 344 had valid MMAS-8 scores for post 6-months and 12-months follow-up data collection. Medication adherence was poor among the participants. Only 44% for 6-months and 46% for 12-months had medium or high medication adherence. Participants going to nonreligious social events (n = 67, 21%) had higher odds of having medium/high medication adherence (OR = 3.08, 95% CI: 1.15-8.25) at 12-months. Discussion: Nonreligious social activities, including meetings of social clubs or other non-religious groups not relevant to work, were shown to be positively related to 12-months post-discharge medication adherence among stroke patients. Social activities may play an important role in emotional support and may be an opportunity for targeted secondary stroke prevention.

Introduction: Memory problems, a common cognitive issue, can have a negative influence on one’s ability to function and contributes to increased risk of secondary stroke. Objective: To examine the association between self-reported memory problems at 6 months and blood pressure control at 12 months post-stroke. Methods: This study utilized follow-up data from the Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) stroke risk factor reduction trial (n=226). Sample size was restricted to those who answered memory questions and had a 12-month blood pressure (BP) reading. Exclusion criteria for DESERVE included any significant memory disorder prior to the baseline stroke. Seven memory domain questions (Table 1) from the Stroke Impact Scale were used separately to assess the association with systolic BP, with control defined as ≤120mmHg, at 12 months in logistic regression models adjusted for race, gender, education, age, and intervention status. Models were additionally adjusted for 6-month BP control as a mediator. Results: Participants were almost equally white (28%), Black (33%), or Hispanic (34%) and 52% were female with a mean age of 65 (SD=13). About 25% had BP control at 6 or 12 months. Memory measures were not significantly associated with BP control prior to adjusting for BP control at 6 months. After adjusting for 6-month BP control, participants with less difficulty remembering things that people just told them (OR=1.69, 95% CI: 1.09, 2.63) or remembering to do things (OR=1.76, 95% CI:1.09, 2.86) had better odds of having their BP controlled at 12 months. Memory items 2 and 4-7 did not show an association with better BP control. Discussion: Stroke survivors who were better at remembering what people told them and remembering to do things were more likely to achieve blood pressure control 1-year post-stroke. Evaluating early memory post-stroke may be an important target for secondary prevention strategies and should be further researched.

Background: Social networks provide emotional and social support that may help prevent the onset of secondary stroke. Little is known about egocentric networks among stroke survivors and the type of support they provide. Objective: To develop an understanding of the supportive role alters or personal contacts provide to stroke survivors and gain insight of participants' egocentric network. Methods: Data obtained from the Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) trial, a skills-based, culturally tailored discharge educational intervention. Participants (n=552) identified up to 5 alters. Descriptive analyses were conducted to assess the relationship between participants and alters. Results: Approximately, 34% of participants identified as Non-Hispanic (NH) Black followed by Hispanic (33%), NH White (28%), NH Asian Pacific Islanders (API) (3%). Majority of participants (n=462, 83%) reported having at least one alter. Most participants with ≥1 alter (92%) indicated talking to alter every day or several times a week. Yet all with an alter stated that they can talk to alter about an important health problem or medical decision. Among participants (n=543, p=.002), NH Blacks (n=38, 45%) and Hispanic (n=33, 39%) were more likely to report no alters compared to NH White (n=14, 16%; Figure). Conclusions: Majority of participants reported having at least one person within their social network that they can talk to about their health problems. We are unable to determine if the first person that participants indicated may be the most influential person in health-related matters. The implications of these results may be relevant for future stroke interventions. Additional studies are needed to understand the type of influence alters have on stroke survivors in health-related behaviors and decisions that may help improve post-stroke outcomes. Further studies are also needed to assess health outcomes among isolated stroke patients by race.

Background: In the continuum of care for stroke survivors, racial-ethnic disparities are most prominent during post-stroke rehabilitation. This includes reintegration of stroke survivors to normal living, an important component in stroke rehabilitation and predicts stroke survivors’ participation in typical daily activities and post-stroke depression. We assessed the association between racial-ethnic factors and ability of survivors to reintegrate to normal living at one-year post stroke. Methods: Using data from the DESERVE (Discharge Educational Strategies for Reduction of Vascular Events) trial, we assessed reintegration to normal living (RNL) using the RNL index of 335 participants with acute stroke. Race and ethnicity were asked at baseline and the survivors’ RNL index was assessed at one-year follow-up. The RNL index was calculated from 11 questions rating survivor’s reintegration from 0-10 (no to complete integration). We used linear regression to assess variations in race-ethnicity on RNL index adjusting for intervention, age, sex, education, living arrangement, stroke history, and severity of recent stroke. Results: At baseline, 27.8% identified as Non-Hispanic (NH) white, 31.6% identified as NH black, 34.9% identified as Hispanic and 5.7% identified as NH other. Crude mean RNL index was greater in the intervention arm than the usual care arm for Hispanics and NH blacks (Figure). In adjusted models, NH whites (5.88, CI: -2.9,14.8) and NH Blacks (6.63, CI: -1.1,14.3) had higher RNL index compared to Hispanics. Conclusion: Racial-ethnic differences may play a clinically important role in reintegrating stroke survivors to normal living. Future interventions must be aimed at understanding fundamental causes of disparities that may lead to inequities in stroke survivors’ rehabilitation to better implement preventative strategies well before stroke incidence.

Introduction: Beliefs regarding ones’ control over their health can lie internally, influenced by their own actions, or externally, controlled by others or due to chance. Objective: To examine the association between health-related locus of control (HRLC) type and post-stroke disability, quality of life, and depression. Methods: This study utilized data from the Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) trial (n=552). Participants were categorized into three groups based on their highest Multidimensional Health Locus of Control (MHLC) score. The Stroke Impact Scale (SIS) was used to assess post-stroke disability and quality of life. Linear regression was used to identify differences in each SIS domain score between the three groups while adjusting for the intervention. Depression was defined as a Center for Epidemiological Studies Depression (CESD) score ≥16. Logistic regression was used to examine differences in depression between the three groups while adjusting for the intervention. Results: Of the 529 participants who completed the MHLC questionnaire at baseline, 179 (33.3%) were categorized into the internal group , 163 (30.8%) into the powerful others group, and 190 (35.9%) into the chance group. Of the 297 participants who completed the CESD questionnaires at 12 months, 163 (54.8%) scored ≥ 16. Participant’s mean scores for each SIS domain are reported in Table 1. For the SIS communication domain, the chance group’s mean score was 3.03 points lower than the powerful others group’s score (SE=1.39, p=.029). There were no statistically significant differences in scores for the other seven SIS domains or for depression between groups (Table 1). Discussion: External HRLC based on chance may be a predictor of communication difficulties in patients post-stroke. However, mean communication scores are skewed. Control beliefs are important in post-stroke recovery. More research is needed to validate these findings.

Introduction: Racial discrimination has existed for centuries in the US and contributes to disparities in stroke and stroke outcomes. Measures of structural racism have been used to quantify these disparities. Our objective was to determine if the efficacy of a skills-based intervention on blood pressure reduction in a cohort of mild/moderate strokes varied by historic redlining, the US Federal government’s sanctioned discrimination in mortgage risk assessment. Methods: The Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) intervention randomized 552 participants to a skills-based intervention or usual care. Participants addresses were geocoded and linked to federally sponsored Home Owners’ Loan Corporation (HOLC) color-coded maps from the 1930s. Participants residing in graded locations (n=279) were given weighted historic redlining scores (HRS) calculated using the proportion of 1930s HOLC residential security grades contained within 2010 census tract boundaries and a discrimination score based current lending practices. The change in systolic blood pressure was modeled linearly with generalized estimating equations used to account for clustering by site. Results: Participants were 34% Hispanic, 31% non-Hispanic Black, 28% non-Hispanic white, and 7% other race. The intervention was most efficacious in areas of persistent (Δ=6.05 mmHg reduction; p=0.003) and declining discrimination (Δ=11.08 mmHg reduction; p=0.007) versus usual care. In areas that were gentrifying, the intervention was least efficacious (Δ=7.33mmHg increase; p=0.022) and minimal in areas of no discrimination (Δ=0.054 mmHg reduction; p=0.903). Conclusions: Historic redlining practices are a form of structural racism that established geographic systems of disadvantage. The efficacy of interventions are impacted by underlying systems of disadvantage such that contextual factors beyond race must be considered when designing trials.

ImportanceYouths with sickle cell anemia (SCA) are at risk of pain crises, stroke, and early death. Complications can be reduced by the oral disease-modifying medication hydroxyurea, and in 2014, the National Heart, Lung, and Blood Institute published revised guidelines that hydroxyurea should be offered to youths aged 9 months and older with SCA regardless of disease severity.ObjectiveTo describe changes in hydroxyurea use among youths with SCA before and after release of the National Heart, Lung, and Blood Institute guidelines.Design, Setting, and ParticipantsThis cross-sectional study was conducted using administrative data from 2010 to 2018 from Michigan and New York State (NYS) Medicaid programs. The study population included youths aged 1 to 17 years with SCA enrolled in the Michigan or NYS Medicaid programs for at least 1 year (Michigan: 2010-2018; NYS: 2012-2018). Youths with SCA were identified using validated claims–based definitions. Data were analyzed from June to October 2020.Main Outcomes and MeasuresThe main outcome was hydroxyurea use characterized as mean annual counts of days’ supply of filled hydroxyurea prescriptions. Rates of hydroxyurea use over time were assessed using regression models (Michigan: zero-inflated negative binomial; NYS: negative binomial). Models included indicators for periods before and after guideline release.ResultsA total of 4302 youths with SCA (2236 males [52.0%]; 2676 born 2005-2017 [62.2%]; 150 Hispanic [3.5%], 2929 non-Hispanic Black [68.0%], and 389 non-Hispanic White [9.0%]) contributed 12 565 person-years. The mean (SD) annual days’ supply of hydroxyurea was 47.2 (93.6) days per youth in Michigan and 97.4 (137.0) days per youth in NYS. In Michigan, there was an increase in the odds of having nonzero days’ supply after the guidelines were released (odds ratio, 1.52; 95% CI, 1.07-2.14). In NYS, no change was seen in the mean days’ supply of filled hydroxyurea.Conclusions and RelevanceThese findings suggest that hydroxyurea was substantially underused among youths with SCA, despite establishment as the primary disease-modifying therapy for SCA, and that there was incomplete clinician or patient uptake of newly released guidelines. Results suggest that expanding use of hydroxyurea may require a multifaceted approach that includes addressing multiple system- and patient-level barriers.

Introduction: Racial disparities exist in stroke and stroke outcomes. However, the fundamental cause for these disparities are not biological differences, but structural racism. Using the Home Owners’ Loan Corporation (HOLC) ‘redlining’ scores, as indicator of structural lending practices from middle of the last century, we hypothesize that census tracts with high historic redlining are associated with higher stroke prevalence. Methods: Weighted historic redlining scores (HRS) were calculated using the proportion of 1930s HOLC residential security grades contained within 2010 census tract boundaries of Columbus, Ohio. Stroke prevalence (adults >=18) was obtained at the census tract-level from the CDC’s 500 Cities Project. Sociodemographic factors, as measured by census tract level information (American Community Survey 2014-2018), were considered mediators in the causal association between historic redlining (measured in 1936) and stroke prevalence (measured in 2017) and were not controlled for in regression analysis. The functional form of the association was non-linear, so stroke prevalence within quartiles of the HRS were compared using linear regression instead of a continuous score. Results: Higher HRS, representing greater redlining, were associated with greater prevalence of stroke when comparing the highest to the lowest quartile of HRS (Figure). Census tracts in the highest quartile of HRS had 1.48% higher stroke prevalence compared to those in the lowest quartile (95% CI: 0.23-2.74). No other interquartile differences were observed. Conclusions: Historic redlining practices are a form of structural racism that established geographic systems of disadvantage and consequently, poor health outcomes. Our findings demonstrate disparate stroke prevalence by degree of historic redlining in census tracts across Columbus, Ohio. While ecologic, this study demonstrates the need to acknowledge that racism, not race, drive stroke disparities.

Introduction: Presence of functional leptomeningeal collaterals has been found to be one of the key determinants of good outcomes. We evaluated the effects of certain environmental and physical factors in cerebral collateral circulation. Methods: After IRB approval, data was collected from prospective institutional Neurocritical Care and Stroke Registry. Stroke patients presenting with acute anterior circulation large vessel occlusion between May 2013 and August 2018 were included. Collaterals were graded based on CT-Angiogram and CT-Perfusion images obtained on presentation, by a blinded Neuroradiologist as good (grade 3-4) and poor (grades 0-2). Ohio air pollution data (2013-2018) were obtained from the US EPA and summarized as a single mean concentration by monitor. Strokes were geocoded and linked with the closest monitor. Odds of good (vs. poor) collateral grade were compared using BMI (linear), smoking status, antiplatelet medication use, and mean PM 2.5 concentration (cubic). Sensitivity analyses assessed additional adjustment by sex and change in NIHSS (admission to discharge). Results: A total of 73 strokes were analyzed with 48% male, mean BMI of 30.4 (SD=7.2), and 22% with good collateral grade. For each kg/m 2 greater BMI, the odds of having good collaterals (vs. poor) were 11% higher (OR: 1.11; 95%CI:1.01-1.22; p =0.029). Higher PM 2.5 concentrations were suggestive of lower odds of good collaterals ( p =0.124). Antiplatelet medication use (OR: 2.10; 95%CI:0.59-7.45) and smoking status (OR: 1.35; 95%CI:0.73-13.9) were not associated with the odds of having good collateral grade. After controlling for change in NIHSS and sex, higher BMI remained associated with good collateral grade (fig.1). Conclusions: Higher BMI was independently associated with higher odds of good collateral grade; this association needs to be explored in larger population taking other factors like age and medical comorbidities into account.

Aim To compare all-cause mortality, stroke recurrence and functional outcomes in people who have experienced stroke, with and without diabetes. Methods We captured data on population-based ischaemic strokes (2006-2012) in Nueces County, Texas. Data were collected from participant interviews and medical records. Differences in cumulative mortality and stroke recurrence risk by diabetes status were estimated at 30 days and 1 year using Cox models. Differences in 90-day functional outcomes (activities of daily living/instrumental activities of daily living score: range 1-4; higher scores worse) by diabetes status were assessed using Tobit regression. Effect modification by ethnicity was examined. Results There were 1301 ischaemic strokes, 46% with history of known diabetes. The median (interquartile range) age was 70 (58-81) years and 61% were Mexican American. People with diabetes were younger and more likely to be Mexican American compared with those without diabetes. After adjustment, diabetes predicted mortality (30-day hazard ratio 1.44, 95% CI 0.97-2.12; 1-year hazard ratio 1.47, 95% CI 1.09-1.97) but not stroke recurrence (1-year hazard ratio 1.27, 95% CI 0.78-2.07). People with diabetes had a worse functional outcome score that was explained by cardiovascular risk factors and pre-stroke factors. Diabetes was not associated with functional outcome in the fully adjusted model (final adjusted activities of daily living/instrumental activities of daily living score difference 0.11, 95% CI -0.07 to 0.30). Effect modification by ethnicity was not significant (P>0.3 for all models). Conclusions Diabetes was associated with higher mortality and worse functional outcome but not stroke recurrence. Interventions are needed to decrease the adverse outcomes associated with diabetes, particularly in Mexican-American people.

Introduction: There is substantial variability in current estimation and communication of stroke prognosis. Existing predictive models have focused on dichotomous outcomes (e.g. functional independence or not), though other outcomes may also be of importance to patients and families. Our objective was to create an ordinal prognostic model to predict the full range of functional outcome (modified Rankin Scale (mRS)) at 90 days after intracerebral hemorrhage. Methods: We used anonymized data from the Virtual International Stroke Trials Archive (VISTA), comprising individuals from both clinical trials and registries. The 90-day mRS was modeled using a proportional odds model. Potential predictors were selected a priori from available data including age, sex, comorbidities, and initial stroke severity. The best model was chosen based on fit statistics using a stepwise selection approach, internally validated using bootstrapping procedures, and externally validated using a population-based sample of 126 ICH cases from southeast Texas. Results: A total of 1097 ICH cases were used in model building, with 95% from clinical trials. Cases were 63% male, with an average age of 66.7 years (SD=12.0), a median stroke severity of 13 (NIHSS) and 23% had a history of stroke. The final predictive model included 6 variables (age, sex, NIHSS, AFIB, diabetes, and prior stroke) and discriminated well between mRS scores (c-statistic=0.743), with minor optimism after bootstrap resampling (corrected c-statistic=0.740). The model yielded good discrimination in the external data set (c-statistic=0.774). Examples of model output are shown in the Figure. Conclusions: This calibrated, internally and externally validated ordinal prognostic model to predict the full range of 90-day functional outcome will be tested as a part of an ongoing study to develop an educational decision support tool for stroke surrogate decision makers (NCT0342764).

Background: Although some evidence shows that neighborhood deprivation is associated with greater subclinical atherosclerosis, prior studies have not identified what aspects of deprived neighborhoods were driving the association. Methods: We investigated whether social and physical neighborhood characteristics are related to the progression of subclinical atherosclerosis in 5950 adult participants of the MESA (Multi-Ethnic Study of Atherosclerosis) during a 12-year follow-up period. We assessed subclinical disease using coronary artery calcium (CAC). Neighborhood features examined included density of recreational facilities, density of healthy food stores, and survey-based measures of availability of healthy foods, walking environment, and social environment. We used econometric fixed-effects models to investigate how change in a given neighborhood exposure is related to simultaneous change in subclinical atherosclerosis. Results: Increases in density of neighborhood healthy food stores were associated with decreases in CAC (mean changes in CAC Agatston units per 1-SD increase in neighborhood exposures, −19.99; 95% confidence interval, −35.21 to −4.78) after adjustment for time-varying demographic confounders and computed tomography scanner type. This association remained similar in magnitude after additional adjustment for time-varying behavioral risk factors and depression. The addition of time-varying biomedical factors attenuated associations with CAC slightly (mean changes in CAC per 1-SD increase in neighborhood exposures, −17.60; 95% confidence interval, −32.71 to −2.49). Changes across time in other neighborhood measures were not significantly associated with within-person change in CAC. Conclusions: Results from this longitudinal study provide suggestive evidence that greater access to neighborhood healthy food resources may slow the development of coronary atherosclerosis in middle-aged and older adults.

Greater poststroke disability and U.S. employment policies may disadvantage minority stroke survivors from returning to work. We explored ethnic differences in return to work among Mexican Americans (MAs) and non-Hispanic whites (NHWs) working at the time of their stroke.Stroke patients were identified from the population-based BASIC (Brain Attack Surveillance in Corpus Christi) study from August 2011 to December 2013. Employment status was obtained at baseline and 90-day interviews. Sequential logistic regression models were built to assess ethnic differences in return to work after accounting for the following: (1) age (65 versus ≥65); (2) sex; (3) 90-day National Institutes of Health Stroke Scale (NIHSS); and (4) education (lower than high school versus high school or higher).Of the 729 MA and NHW stroke survivors who completed the baseline interview, 197 (27%) were working at the time of their stroke, of which 125 (63%) completed the 90-day outcome interview. Forty-nine (40%) stroke survivors returned to work by 90 days. MAs were less likely to return to work (OR = .45, 95% CI .22-.94) than NHWs. The ethnic difference became nonsignificant after adjusting for NIHSS (OR = .59, 95% CI .24-1.44) and further attenuated after adjusting for education (OR = .85, 95% CI .32- 2.22).The majority of stroke survivors did not return to work within 90 days of their stroke. MA stroke survivors were less likely to return to work after stroke than NHW stroke survivors which was due to their greater neurological deficits and lower educational attainment compared with that of NHW stroke survivors. Future work should focus on clinical and policy efforts to reduce ethnic disparities in return to work.

Women are more likely to live alone compared with men, and therefore have more difficulty activating emergency medical systems for stroke. The goal of this study was to examine the benefit of wearing medical alert devices to activate emergency medical systems for elderly women living alone. This was a randomized, controlled pilot trial. Women over 60 with at least 1 stroke risk factor were recruited from Southeast Michigan. Subjects received either a medical alert device or control. The primary outcome was change in health-related quality of life (HRQOL) from baseline to 90 days of wearing the device or control. A planned sample size of 320 could not be reached, and the trial was stopped at 265 women randomized prior to data examination. On average, the treatment group was older, reported lower prevalence of high cholesterol, and was less likely to complete follow-up. There was a nonsignificant smaller loss of healthy days in the past month in the intervention group (0.46) compared with the control group (2.23) (p = 0.213). Similarly, the secondary outcomes of changes in anxiety, depression, and changes in perceived isolation did not differ by treatment and control groups. This study did not establish improvement in HRQOL among women who wore the device compared with those that did not, nor the feasibility of a trial to study the efficacy of medical alert devices in elderly women. Newer devices that use cellular technology may be more accepted than the landline-based system used in this study.

Background and Purpose— Little is known about the relation between environment and stroke severity. We investigated associations between environmental exposures, including neighborhood socioeconomic disadvantage and short-term exposure to airborne particulate matter Methods— First-ever ischemic stroke cases were identified from the Brain Attack Surveillance in Corpus Christi project (2000–2012). Associations between pollutants, disadvantage, and National Institutes of Health Stroke Scale were modeled using linear and logistic regression with adjustment for demographics and risk factors. Pollutants and disadvantage were modeled individually, jointly, and with interactions. Results— Higher disadvantage scores and previous-day ozone concentrations were associated with higher odds of severe stroke. Higher levels of particulate matter P interaction =0.097). Conclusions— Air pollution exposures and neighborhood socioeconomic status may be important in understanding stroke severity. Future work should consider the multiple levels of influence on this important stroke outcome.

Background Stroke survivors’ risk of falls may be particularly sensitive to the environment due to deficits such as visuospatial neglect or homonymous hemianopia. We sought to identify the prevalence of falls among stroke survivors and investigate the possible role of the environment in falling. Materials and methods Data from the National Health and Aging Trends Study (NHATS), a nationally representative population of community-dwelling adults over 65, were used. We compared the prevalence of falling in the past month between stroke survivors and demographic and comorbidity matched controls using sequential Poisson regression models. Results The proportion of stroke survivors reporting a fall in the previous month was 18.8% compared to 10.8% among matched controls (PR: 1.74; 95% CI: 1.36–2.25). These differences were attenuated after adjusting for known confounders, mediators and aspects of the environment (PR: 1.17; 95% CI: 0.86–1.60). Indoor tripping hazards were associated with falls (PR: 1.24; 95% CI: 1.01–1.53). The association between stroke and falls was modified by neighborhood social disorder, such that in areas of low social disorder, falls in the previous month were more common in stroke survivors compared to non-stroke controls. Conclusions The difference in falls among stroke survivors and matched controls is largely explained by known risk factors and physical capacity. Indoor tripping hazards were associated with falls among stroke survivors and matched controls. Explanations of why the association between stroke and falls was protective in areas of high social disorder are unclear, but may warrant additional research.

ObjectiveWe investigated temporal trends in BMI, and assessed hypothesized predictors of trends including socio-economic position (SEP) and province-level economic development, in Argentina.DesignUsing multivariable linear regression, we evaluated cross-sectional patterning and temporal trends in BMI and examined heterogeneity in these associations by SEP and province-level economic development with nationally representative samples from Argentina in 2005 and 2009. We calculated mean annual changes in BMI for men and women to assess secular trends.ResultsWomen, but not men, exhibited a strong cross-sectional inverse association between SEP and BMI, with the lowest-SEP women having an average BMI 2·55 kg/m2greater than the highest-SEP women. Analysis of trends revealed a mean annual increase in BMI of 0·19 kg/m2and 0·15 kg/m2for women and men, respectively, with slightly greater increases occurring in provinces with greater economic growth. No significant heterogeneity in trends existed by individual SEP.ConclusionsBMI is increasing rapidly over time in Argentina irrespective of various sociodemographic characteristics. Higher BMI remains more common in women of lower SEP compared with those of higher SEP.

Background and Purpose— Acute stroke education has focused on stroke symptom recognition. Lack of education about stroke preparedness and appropriate actions may prevent people from seeking immediate care. Few interventions have rigorously evaluated preparedness strategies in multiethnic community settings. Methods— The Acute Stroke Program of Interventions Addressing Racial and Ethnic Disparities (ASPIRE) project is a multilevel program using a community-engaged approach to stroke preparedness targeted to underserved black communities in the District of Columbia. This intervention aimed to decrease acute stroke presentation times and increase intravenous tissue-type plasminogen activator utilization for acute ischemic stroke. Results— Phase 1 included (1) enhancement of focus of emergency medical services on acute stroke; (2) hospital collaborations to implement and enrich acute stroke protocols and transition District of Columbia hospitals toward primary stroke center certification; and (3) preintervention acute stroke patient data collection in all 7 acute care District of Columbia hospitals. A community advisory committee, focus groups, and surveys identified perceptions of barriers to emergency stroke care. Phase 2 included a pilot intervention and subsequent citywide intervention rollout. A total of 531 community interventions were conducted, reaching >10 256 participants; 3289 intervention evaluations were performed, and 19 000 preparedness bracelets and 14 000 stroke warning magnets were distributed. Phase 3 included an evaluation of emergency medical services and hospital processes for acute stroke care and a year-long postintervention acute stroke data collection period to assess changes in intravenous tissue-type plasminogen utilization. Conclusions— We report the methods, feasibility, and preintervention data collection efforts of the ASPIRE intervention. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00724555.

Objective To estimate the incidence and prevalence of systemic lupus erythematosus (SLE) in a sociodemographically diverse southeastern Michigan source population of 2.4 million people. Methods SLE cases fulfilling the American College of Rheumatology classification criteria (primary case definition) or meeting rheumatologist-judged SLE criteria (secondary definition) and residing in Wayne or Washtenaw Counties during 2002–2004 were included. Case finding was performed from 6 source types, including hospitals and private specialists. Age-standardized rates were computed, and capture–recapture was performed to estimate underascertainment of cases. Results The overall age-adjusted incidence and prevalence (ACR definition) per 100,000 persons were 5.5 (95% confidence interval [95% CI] 5.0–6.1) and 72.8 (95% CI 70.8–74.8). Among females, the incidence was 9.3 per 100,000 persons and the prevalence was 128.7 per 100,000 persons. Only 7 cases were estimated to have been missed by capture–recapture, adjustment for which did not materially affect the rates. SLE prevalence was 2.3-fold higher in black persons than in white persons, and 10-fold higher in females than in males. Among incident cases, the mean ± SD age at diagnosis was 39.3 ± 16.6 years. Black SLE patients had a higher proportion of renal disease and end-stage renal disease (ESRD) (40.5% and 15.3%, respectively) as compared to white SLE patients (18.8% and 4.5%, respectively). Black patients with renal disease were diagnosed as having SLE at younger age than white patients with renal disease (mean ± SD 34.4 ± 14.9 years versus 41.9 ± 21.3 years; P = 0.05). Conclusion SLE prevalence was higher than has been described in most other population-based studies and reached 1 in 537 among black female persons. There were substantial racial disparities in the burden of SLE, with black patients experiencing earlier age at diagnosis, >2-fold increases in SLE incidence and prevalence, and increased proportions of renal disease and progression to ESRD as compared to white patients.

Background: A wide variety of racial and ethnic disparities in stroke epidemiology and treatment have been reported. Race-ethnic differences in initial stroke severity may be one important determinant of differences in the outcome after stroke. The overall goal of this study was to move beyond ethnic comparisons in the mean or median severity, and instead investigate ethnic differences in the entire distribution of initial stroke severity. Additionally, we investigated whether age modifies the relationship between ethnicity and initial stroke severity as this may be an important determinant of racial differences in the outcome after stroke. Methods: Ischemic stroke cases were identified from the population-based Brain Attack Surveillance in Corpus Christi (BASIC) project. National Institutes of Health Stroke Scale (NIHSS) was determined from the medical record or abstracted from the chart. Ethnicity was reported as Mexican American (MA) or non-Hispanic white (NHW). Quantile regression was used to model the distribution of NIHSS score by age category (45-59, 60-74, 75+) to test whether ethnic differences exist over different quantiles of NIHSS (5 percentile increments). Crude models examined the interaction between age category and ethnicity; models were then adjusted for history of stroke/transient ischemic attack, hypertension, atrial fibrillation, coronary artery disease, and diabetes. Results were adjusted for multiple comparisons. Results: There were 4,366 ischemic strokes, with median age 72 (IQR: 61-81), 55% MA, and median NIHSS of 4 (IQR: 2-8). MAs were younger, more likely to have a history of hypertension and diabetes, but less likely to have atrial fibrillation compared to NHWs. In the crude model, the ethnicity-age interaction was not statistically significant. After adjustment, the ethnicity-age interaction became significant at the 85th and 95th percentiles of NIHSS distribution. MAs in the younger age category (45-59) were significantly less severe by 3 and 6 points on the initial NIHSS than NHWs, at the 85th and 95th percentiles, respectively. However, in the older age category (75+), there was a reversal of this pattern; MAs had more severe strokes than NHWs by about 2 points, though not reaching statistical significance. Conclusions: There was no overall ethnic difference in stroke severity by age in our crude model. However, several potentially important ethnic differences among individuals with the most severe strokes were seen in younger and older stroke patients that were not explained by traditional risk factors. Age should be considered in future studies when looking at the complex distributional relationship between ethnicity and stroke severity.

Historically, recruitment of minority subjects for clinical research has been challenging. We developed culturally-tailored recruitment materials for a longitudinal, natural history study of intracerebral hemorrhage (ICH) and trained recruiting coordinators in cultural competence. Of 285 subjects meeting inclusion criteria, 158 (55% of those eligible) agreed to participate (60% of eligible Blacks vs. 45% of eligible non-Blacks, p..02). Of those enrolled, 138 (87%) agreed to participate in the genetic sub-study (86% of Blacks vs. 90% of non-Blacks enrolled, p..78). Of those subjects who refused enrollment, lack of interest in research (42%) was the most common reason given for the study as a whole. A higher rate of enrollment was achieved in Blacks vs. non-Blacks in this ICH clinical research study employing culturally tailored recruitment approaches and training of recruitment coordinators to overcome traditional recruitment barriers to research participation in minority patients.

Obstructive sleep apnea (OSA) is common after stroke and predicts poor outcomes. Continuous positive airway pressure (CPAP) treats OSA but is generally poorly tolerated by stroke patients. We assessed whether nasal expiratory positive airway pressure (EPAP), an alternative to CPAP, may be an effective option after acute stroke.We conducted a randomized, controlled, two-period crossover study in which each acute ischemic stroke patient received 1 night of EPAP and 1 night without EPAP while OSA was monitored with a validated device, the Watch-PAT 200. Linear repeated- measures analyses were conducted. Sample size calculations indicated that 18 subjects would be required to detect a 10-point or larger average reduction in the apnea-hypopnea index (AHI, the primary outcome), with use of EPAP, with power ≥ 80% and α = 0.05.Among the 19 subjects who completed the protocol, nasal EPAP treatment was associated with a nonsignificant absolute difference in AHI of -5.73 events/h in the primary analysis (p = 0.183, 95% confidence interval -14.4, 2.97) and a nonsignificant absolute difference in AHI of -5.43 events/h in the subgroup of patients who used nasal EPAP for ≥ 3 h (p = 0.314, 95% confidence interval -16.6, 5.76).This study suggests that EPAP is not an effective alternative to CPAP in acute stroke patients with OSA. Further work is needed to identify other more effective alternatives.ClinicalTrials.gov, ID: NCT01703663.

Objective To investigate the association between short-term changes in ambient pollution (particulate matter 2.5 ) and ozone (O 3 )) and the risk of recurrent ischemic stroke among individuals living in a bi-ethnic community. Methods We identified recurrent ischemic stroke cases from the population-based Brain Attack Surveillance in Corpus Christi (BASIC) project between 2000 and 2012. Associations between PM 2.5 (mean 24-h) and O 3 (maximal 8-h) levels, measured on the previous day, and odds of ischemic stroke were assessed using a time-stratified case-crossover design and modeled using conditional logistic regression. Results There were 317 recurrent ischemic strokes after excluding 41 strokes that occurred on days with missing air pollution data. Mean age was 72 years (SD=12) and median time to stroke recurrence was 1.1 years (IQR: 0.2–2.8 years). Median levels of PM 2.5 and O 3 over the study period were 7.7 μg/m 3 (IQR: 5.6–10.7 μg/m 3 ) and 35.2 ppb (IQR: 25.0–46.1 ppb), respectively. We observed no associations between previous-day PM 2.5 and O 3 and odds of recurrent stroke (OR=0.95 per 10 µg/m 3 of PM 2.5 , 95% CI: 0.71–1.28 and OR=0.97 per 10ppb of O 3 , 95% CI: 0.87–1.07) after adjusting for ambient temperature and relative humidity. Co-adjustment of both pollutants did not change the results. Conclusion We found no evidence of associations between previous-day air pollution levels and recurrent ischemic stroke. Research on the influence of air pollutants on risk of stroke recurrence is still in its infancy, and more research is necessary in studies that are adequately powered to understand the relation.

Background and Purpose: Diabetes mellitus (DM) is a well-established risk factor for ischemic stroke (IS), but the literature is inconsistent on the effect of DM on outcomes after IS. We sought to determine if DM increases the risk of mortality and recurrence after IS, and if these associations are greater in Mexican Americans (MA) than non-Hispanic whites (NHW). Methods: IS cases, all-cause mortality, and recurrent strokes were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) project (2006-2012). Sociodemographics and clinical data were obtained from medical records and interviews. Cumulative mortality and stroke recurrence risk were estimated at 30 days and 1 year using Kaplan-Meier analysis and Cox proportional hazards models. Effect modification by ethnicity was examined. Results: There were 1,301 IS cases, 46% with a history of DM, median age 70 (IQR: 58-81), and 61% MA. Patients with DM were younger and more likely to be MA compared to patients without DM. Risk of 30-day and 1-year mortality was 8.4% and 20.5% for those with DM and 9.5% and 20.8% for those without DM, respectively. Risk of 30-day and 1-year stroke recurrence was 1.2% and 7.5% for those with DM and 1.5% and 5.8% for those without DM, respectively. Unadjusted, DM was not a significant predictor of mortality or recurrence (see table). After adjustment, DM predicted mortality (30-day HR=1.58, 95% CI: 0.98-2.53; 1-year HR=1.48, 95% CI: 1.10-2.00) but not stroke recurrence (1-year HR=1.28, 95% CI: 0.78-2.08). Effect modification by ethnicity was not significant (p>0.2 for all models). Conclusions: Given that patients with DM were significantly younger than patients without DM, the crude association between DM and mortality revealed no difference. However, after accounting for age and other factors, patients with DM were 50% more likely to die at 1 year after IS compared to patients without DM.

Background: Recurrent strokes are associated with poor outcomes and mortality. Short-term ambient air pollution may be an important environmental risk factor for stroke recurrence. Although associations between air pollution and stroke risk have been observed, the evidence for short-term effects of air pollution on risk of stroke recurrence is in its infancy. We investigated the association between short-term changes in ambient pollution (particulate matter 2.5 ) and ozone (O 3 )) and the risk of recurrent ischemic stroke among individuals living in a bi-ethnic community. Methods: We identified recurrent ischemic stroke cases from the population-based Brain Attack Surveillance in Corpus Christi (BASIC) Project, an ongoing population-based stroke surveillance study in Nueces County, Texas, between 2000 and 2012. Associations between lags of 0 to 3 days PM 2.5 and O 3 levels and odds of ischemic stroke were assessed using a time-stratified case-crossover design. Conditional logistic regression models were used to calculate odds ratios (ORs) for a 10 unit change in exposure. Results: There were 317 recurrent ischemic strokes with mean age of 72 years (SD=12). Median levels of PM 2.5 and O 3 over the study period were 7.7μg/m 3 (IQR: 5.6-10.7μg/m 3 ) and 35.2ppb (IQR: 25.0-46.1ppb), respectively. No associations were observed across the different lagged exposures (0 to 3 days) after adjusting for ambient temperature and relative humidity (Figure). Co-adjustment of both pollutants results did not change the results. Conclusion: No association between PM 2.5 and O 3 and risk of recurrences was observed. Research on the influence of air pollutants on risk of recurrence is still in its infancy, and more research is needed to understand the relation.

Introduction: Previous studies exploring stroke caregiving have estimated that the average stroke survivor receives as many as 16 hours per week hours of informal caregiving at a societal cost of as much as $26.8 billion per year. However, these studies have focused on basic and instrumental activities of daily living, and have not included healthcare and transportation activities. We sought to determine whether, and at what cost, caregiving differs between stroke survivors and matched controls using an expanded definition of caregiving. Methods: A total of 892 stroke survivors were drawn from the 2011 wave of the National Health and Aging Trends Study (NHATS), a nationally representative survey of Medicare beneficiaries. One-to-one propensity matching was performed on demographics and comorbidities to create a sample of matched non-stroke controls. Caregivers were identified by detecting all helpers for NHATS respondents who had help with self-care or mobility activities or with household activities due to health or functioning. Stroke survivors and controls were compared using survey-weighted chi-square tests and Wald tests. The annual cost of caregiving was estimated using reported paid caregiving data and estimates of informal caregiving costs. Results: On average, stroke survivors received about 10 hours of additional caregiving per week compared to controls (22 hours vs. 12 hours, p Conclusion: Our expanded definition of caregiving suggests that prior studies may underestimate both the time and costs invested in caregiving to older stroke survivors.

Background: National data shows that African Americans (AA) are less likely to fall than whites. However, the reasons for this difference and whether it is true amongst stroke survivors are unknown. We hypothesized that AA stroke survivors fall less than white stroke survivors, and sought to understand which risk factors drive racial differences. Methods: Data from the 2011 wave of National Health and Aging Trends Study (NHATs), a nationally representative population of community-dwelling adults over 65, were used. We compared the prevalence of self-reported falling in the past year between AA and white stroke survivors using Poisson regression models. Models were adjusted for groups of variables that may predict race-based differences in falls: sociodemographic, comorbidity, capacity, fall risk factor, fall access, and environment. Race-specific predictive margins and prevalence ratios (PR) were calculated. Results: The sample included 806 stroke survivors; 581 white and 228 AA. AAs had lower income, physical and cognitive capacity, were less likely to be married, to go outside, to have osteoporosis, and lived in worse neighborhood environments compared to white stroke survivors. Unadjusted, prevalence of falling in the past year was similar comparing AA to whites (PR: 0.89, p=0.2). Adjustment for sociodemographic variables produced a marginal racial difference, which became statistically significant after adding physical and cognitive capacity measures (Table). After full adjustment, AA were 30% less likely to have reported a fall compared to whites (p=0.004). Conclusions: African American stroke survivors are significantly less likely to report falling in the previous year compared to whites. Differences in sociodemographics and capacity may be most influential, yet other factors did not account for differences in fall prevalence. Further study of falls among AA stroke survivors may provide insight to decrease falls among other racial/ethnic groups.

Introduction: Lost earnings are the largest driver of the projected $2.2 trillion in stroke costs over the next 4 decades. Mexican Americans (MA) are more likely to have a working age stroke and suffer greater post-stroke disability than non-Hispanic whites (NHW). Thus, we explored ethnic differences in post-stroke return to work and whether sociodemographics and stroke severity contribute to ethnic differences. Methods: Ischemic stroke patients were identified from the population-based Brain Attack Surveillance in Corpus Christi (BASIC) study from August 2011-December 2013. Employment status was obtained at baseline and 90-day interviews conducted with patients or proxies. Sequential logistic regression models were built to assess ethnic difference in return to work after accounting for: 1) age ( Results: Of the 729 MA and NHW stroke survivors who completed the baseline interview, 197 (27%) were working at the time of their stroke of which 125 completed the 90-day outcome interview. There were no ethnic differences in sex or the proportion over the age of 65. MAs had less education (5% vs. 24% college graduate, p Conclusion: MAs are less likely to return to work after stroke than NHWs. This finding is important given that MAs are younger and poorer at the time of their stroke suggesting a crucial public health problem. Future work should consider including return to work as part of patient centered outcomes and efforts to optimize stroke recovery.

Background and Purpose— Previous studies exploring stroke-related caregiving focused solely on informal caregiving and a relatively limited set of activities. We sought to determine whether, and at what cost, stroke survivors receive more care than matched controls using an expanded definition of caregiving and inclusion of paid caregivers. Methods— Data were drawn from the National Health and Aging Trends Study (NHATS), a nationally representative survey of Medicare beneficiaries. NHATS personnel conducted in-person interviews with respondents or proxies to determine the weekly hours of care received. We compared hours of assistance received between self-reported stroke survivors (n=892) and demography- and comorbidity-matched nonstroke controls (n=892). The annual cost of stroke caregiving was estimated using reported paid caregiving data and estimates of unpaid caregiving costs. Results— Of community-dwelling elderly stroke survivors, 51.4% received help from a caregiver. Stroke survivors received an average of 10 hours of additional care per week compared with demography- and comorbidity-matched controls (22.3 hours versus 11.8 hours; P Conclusions— Although stroke survivors are known to require considerable caregiving resources, our findings suggest that previous assessments may underestimate hours of care received and hence costs.

Disturbances in the self-concept are broadly recognized as a psychosocial risk factor in the etiology of the eating disorders and as such, have been identified an important focus in the eating disorder psychotherapies (for examples see Fairburn, Cooper & Shafran, 2003; Wonderlich et al, 2008). Yet despite the centrality of self-concept disturbances in theoretical models of the disorders, theoretically derived and empirically supported interventions that target changes in the self-concept as the mechanism of eating disorder symptom change and health recovery are lacking. In this paper, we report results of a randomized trial of a new psychotherapy for the eating disorders of anorexia nervosa (AN) and bulimia nervosa (BN), referred to as the identity intervention program (IIP). IIP is based on an empirically supported model that focuses on impairments in organizational properties of the total collection of self-cognitions, referred to as self-schemas, as a key determinant of the maladaptive attitudes and behaviors that characterize the disorders. The IIP seeks to build new positive self-schemas that are distinct and separate from other conceptions of the self in memory as the means to promote recovery and health. The trial examined whether IIP in combination with nutritional counseling would be more effective than supportive psychotherapy and nutritional counseling in reducing the attitudinal and behavioral symptoms that characterize the eating disorders and improving functional health and psychological well-being.

Background Mexican Americans have increased risks of stroke and lower fractures compared with non-Hispanic whites, but little is known about poststroke fracture risk in Mexican Americans. The objective of this study was to describe poststroke fracture risk in a bi-ethnic population and to compare risk by ethnicity. Methods In the Brain Attack Surveillance in Corpus Christi Project, strokes were identified through hospital surveillance (2000-2004) and validated by neurologists (n = 2389). Inpatient claims for fractures were ascertained (2000-2004) and cross-referenced with strokes. Survival free from fracture (any and hip) poststroke was estimated and compared by ethnicity. Cox regression was used to test the association of ethnicity and fracture risk adjusted for confounders. Interaction terms for ethnicity and age were considered. Results The mean age was 71 years (SD, 13 yrs); 54% were Mexican American and 52% were women. The mean follow-up was 4 years. There were 105 fractures (33% of the hips). Survival free of any fracture and of hip fracture did not differ by ethnicity. Increasing age, female gender, intracerebral hemorrhage, and greater stroke severity were associated with risk of any fracture, but ethnicity was not. Ethnicity was associated with risk of hip fracture, but this association was modified by age ( P = .02), where Mexican Americans were protected from hip fractures at younger but not older ages. Conclusions Stroke patients were at high risk for fractures, with a 10% risk at 5 years. Mexican Americans were protected from hip fractures at younger but not older ages. Both elderly Mexican Americans and non-Hispanic whites should be targeted for poststroke fracture prevention.

We measured antimullerian hormone (AMH), a marker of ovarian reserve, in women with lupus treated with cyclophosphamide (CYC) (group I), CYC plus gonadotropin-releasing hormone agonist (GnRH-a) (group II) or neither (group III). We hypothesized that AMH would be diminished in women exposed to CYC versus women receiving adjunctive GnRH-a treatment or no CYC exposure.Forty-eight premenopausal lupus patients were retrospectively divided into three treatment groups: CYC alone (group I, n = 11), CYC + GnRH-a (group II, n = 10) and neither (group III, n = 27). Serum AMH levels between groups were compared using a nonparametric test (Wilcoxon rank-sum). Multiple linear regression adjusting for age was performed.AMH (ng/mL) levels at the last collection were significantly lower in group I versus group III (mean ± SD: 0.18 ± 0.20 group I vs 1.33 ± 1.59 group III; p = 0.015), and versus group II (mean ± SD: 0.86 ± 1.06; p = 0.018). When centered on age 30 years, average AMH levels for group I, group II and group III were 0.20, 0.44 and 1.00, respectively. When adjusted for age, AMH between all groups was significantly different (p0.0001).Posttreatment AMH levels were significantly higher among patients receiving CYC + GnRH-a compared to CYC alone, suggesting that GnRH-a coadministration mitigates CYC-induced ovarian injury.

Background: Stroke outcome studies often combine cases of intracerebral hemorrhage (ICH) and ischemic stroke (IS). These studies of mixed stroke typically ignore computed tomography (CT) findings for ICH cases, though the impact of omitting these traditional predictors of ICH mortality is unknown. We investigated the incremental impact of ICH CT findings on mortality prediction model performance. Methods: Cases of ICH and IS (2000–2003) were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) project. Base models predicting 30-day mortality included demographics, stroke type, and clinical findings (National Institutes of Health Stroke Scale (NIHSS) +/– Glasgow Coma Scale (GCS)). The impact of adding CT data (volume, intraventricular hemorrhage, infratentorial location) was assessed with the area under the curve (AUC), unweighted sum of squared residuals (Ŝ), and integrated discrimination improvement (IDI). The model assessment was performed first for the mixed case of IS and ICH, and then repeated for ICH cases alone to determine whether any lack of improvement in model performance with CT data for mixed stroke type was due to IS cases naturally forming a larger proportion of the total sample than ICH. Results: A total of 1,256 cases were included (86% IS, 14% ICH). Thirty-day mortality was 16% overall (11% for IS; 43% for ICH). When both clinical scales (NIHSS and GCS) were included, none of the model performance measures showed improvement with the addition of CT findings whether considering IS and ICH together (ΔAUC: 0.002, 95% CI –0.01, 0.02; ΔŜ: –3.0, 95% CI –9.1, 2.6; IDI: 0.017, 95% CI –0.004, 0.05) or considering ICH cases alone (ΔAUC: 0.02, 95% CI –0.02, 0.08; ΔŜ: –2.0, 95% CI –9.7, 3.4; IDI 0.065, 95% CI –0.03, 0.21). If NIHSS was the only clinical scale included, there was still no improvement in AUC or Ŝ when CT findings were added for the sample with IS/ICH combined (ΔAUC: 0.005, 95% CI –0.01, 0.02; ΔŜ: –5.0, 95% CI –11.6, 1.0) or for ICH cases alone (ΔAUC: 0.05, 95% CI –0.002, 0.11; ΔŜ: –4.2, 95% CI –11.5, 2.3). However, IDI was improved when NIHSS was the only clinical scale for IS/ICH combined (IDI: 0.029, 95% CI 0.002, 0.065) and ICH alone (IDI: 0.12, 95% CI 0.005, 0.26). Conclusions: Excluding ICH CT findings had only minimal impact on mortality prediction model performance whether examining ICH and IS together or ICH alone. These findings have important implications for the design of clinical studies involving ICH patients.

Background and Purpose— We sought to describe the association of spirituality, optimism, fatalism, and depressive symptoms with initial stroke severity, stroke recurrence, and poststroke mortality. Methods— Stroke cases from June 2004 to December 2008 were ascertained in Nueces County, TX. Patients without aphasia were queried on their recall of depressive symptoms, fatalism, optimism, and nonorganizational spirituality before stroke using validated scales. The association between scales and stroke outcomes was studied using multiple linear regression with log-transformed National Institutes of Health Stroke Scale and Cox proportional hazards regression for recurrence and mortality. Results— Six hundred sixty-nine patients participated; 48.7% were women. In fully adjusted models, an increase in fatalism from the first to third quartile was associated with all-cause mortality (hazard ratio, 1.41; 95% CI, 1.06–1.88) and marginally associated with risk of recurrence (hazard ratio, 1.35; 95% CI, 0.97–1.88), but not stroke severity. Similarly, an increase in depressive symptoms was associated with increased mortality (hazard ratio, 1.32; 95% CI, 1.02–1.72), marginally associated with stroke recurrence (HR, 1.22; 95% CI, 0.93–1.62), and with a 9.0% increase in stroke severity (95% CI, 0.01–18.0). Depressive symptoms altered the fatalism–mortality association such that the association of fatalism and mortality was more pronounced for patients reporting no depressive symptoms. Neither spirituality nor optimism conferred a significant effect on stroke severity, recurrence, or mortality. Conclusions— Among patients who have already had a stroke, self-described prestroke depressive symptoms and fatalism, but not optimism or spirituality, are associated with increased risk of stroke recurrence and mortality. Unconventional risk factors may explain some of the variability in stroke outcomes observed in populations and may be novel targets for intervention.

Background and Purpose— Few patients arrive early enough at hospitals to be eligible for emergent stroke treatment. There may be barriers specific to underserved, urban populations that need to be identified before effective educational interventions to reduce delay times can be developed. Methods— A survey of respondents' likely action in a hypothetical stroke situation was given to 253 community volunteers in the catchment areas of a large urban community hospital. Concurrently, 100 structured interviews were conducted in the same hospital with patients with acute stroke or a proxy. Results— In this predominantly urban, black population, if faced with a hypothetical stroke, 89% of community volunteers surveyed said they would call 911 first, and few felt any of the suggested potential barriers applied to them. However, only 12% of patients with stroke interviewed actually called 911 first (OR, 63.9; 95% CI, 29.5 to 138.2). Instead, 75% called a relative/friend. Eighty-nine percent of patients with stroke reported significant delay in seeking medical attention, and almost half said the reason for the delay was thinking the symptoms were not serious and/or they would self-resolve. For those arriving by ambulance, only 25% did so because they thought it would be faster, whereas 35% cited having no other transportation options. Conclusions— In this predominantly black urban population, although 89% of community volunteers report the intent of calling 911 during a stroke, only 12% of actual patients with stroke did so. Further research is needed to determine and conquer the barriers between behavioral intent and actual behavior to call 911 for witnessed stroke.

Background and Purpose— Mexican Americans (MAs) have an increased risk of stroke and experience worse poststroke disability than non-Hispanic whites, which may translate into worse poststroke quality of life (QOL). We assessed ethnic differences in poststroke QOL, as well as potential modification of associations by age, sex, and initial stroke severity. Methods— Ischemic stroke survivors were identified through the biethnic, population-based Brain Attack Surveillance in Corpus Christi (BASIC) Project. Data were collected from medical records, baseline interviews, and 90-day poststroke interviews. Poststroke QOL was measured at ≈90 days by the validated short-form stroke-specific QOL in 3 domains: overall, physical, and psychosocial (range, 0–5; higher scores represent better QOL). Tobit regression was used to model associations between ethnicity and poststroke QOL scores, adjusted for demographics, clinical characteristics, and prestroke cognition and function. Results— Among 290 eligible stroke survivors (66% MA, 34% non-Hispanic whites, median age=69 years), median scores for overall, physical, and psychosocial poststroke QOL were 3.3, 3.8, and 2.7, respectively. Poststroke QOL was lower for MAs than non-Hispanic whites both overall (mean difference, −0.30; 95% confidence interval, −0.59, −0.01) and in the physical domain (mean difference, −0.47; 95% confidence interval, −0.81, −0.14) after multivariable adjustment. No ethnic difference was found in the psychosocial domain. Age modified the associations between ethnicity and poststroke QOL such that differences were present in older but not in younger ages. Conclusions— Disparities exist in poststroke QOL for MAs and seem to be driven by differences in older stroke patients. Targeted interventions to improve outcomes among MA stroke survivors are urgently needed.

To investigate the association between short-term changes in ambient pollution (particulate matter2.5 μm in aerodynamic diameter (PM2.5) and ozone (O3)) and the risk of ischemic stroke among individuals living in a bi-ethnic community and whether this association is modified by ethnicity.We identified incident ischemic stroke cases from the population-based Brain Attack Surveillance in Corpus Christi (BASIC) project between 2000 and 2012. Associations between PM2.5 (mean 24-h) and O3 (maximal 8-h) levels, measured on the same-day and lags of 1-3 days, and odds of ischemic stroke were assessed using a time-stratified case-crossover design and modeled using conditional logistic regression. We explored race/ethnicity (Mexican American versus non-Hispanic white) as a modifier by including interaction terms in the models.There were 2948 ischemic strokes with median age 71 years (IQR: 59-80). We observed no overall associations between the air pollutants and odds of ischemic stroke at any lag. When stratified by ethnicity, higher O3 was consistently associated with greater odds of ischemic stroke for non-Hispanic whites, but not for Mexican Americans. Higher PM2.5 was generally associated with lower odds of ischemic stroke for non-Hispanic whites but modestly greater odds for Mexican Americans.Ethnic differences in the associations between ischemic stroke and short-term exposures to O3 and PM2.5 were suggested indicating that further study in diverse populations may be warranted.

Background We sought to investigate the frequency of microbleed development following intracerebral hemorrhage in a predominantly African-American population and to identify predictors of new microbleed formation. Aims and/or hypothesis To investigate the frequency and predictors of new microbleeds following intracerebral hemorrhage. Methods The DECIPHER study was a prospective, longitudinal, magnetic resonance-based cohort study designed to evaluate racial/ethnic differences in risk factors for microbleeds and to evaluate the prognostic impact of microbleeds in this intracerebral hemorrhage population. We evaluated new microbleed formation in two time periods: from baseline to 30 days and from 30 days to year 1. Results Of 200 subjects enrolled in DECIPHER, 84 had magnetic resonance imaging at all required time points to meet criteria for this analysis. In the baseline to day 30 analysis, 11 (13·1%) had new microbleeds, compared with 25 (29·8%) in the day 30 to year 1 analysis. Logistic regression analysis demonstrated that baseline number of microbleeds [odds ratio 1·05 (95% confidence interval 1·01, 1·08), P = 0·01] was associated with new microbleed formation at 30 days. A logistic regression model predicting new microbleed at one-year included baseline number of microbleeds [odds ratio 1·05 (1·00, 1·11), P = 0·046], baseline age [odds ratio 1·05 (1·00, 1·10), P = 0·04], and white matter disease score [odds ratio 1·18 (0·96, 1·45). P = 0·115]. Overall, 28 of 84 (33·3%) intracerebral hemorrhage subjects formed new microbleeds at some point in the first year post-intracerebral hemorrhage. Conclusions We found that one-third of intracerebral hemorrhage subjects in this cohort surviving one-year developed new microbleeds, which suggests a dynamic and rapidly progressive vasculopathy. Future studies are needed to examine the impact of new microbleed formation on patient outcomes.

Background: Stroke risk and severity are patterned by neighborhood socioeconomic disadvantage (ND). Air pollution may also influence stroke severity through biologic mechanisms. We sought to identify potential synergistic effects of ND and air pollution on initial stroke severity in a large population-based stroke study. Methods: We identified incident ischemic stroke cases from the BASIC project from 2000-2012. NIH Stroke Scale (NIHSS) was determined from the medical record or abstracted. Particulate matter (PM2.5) and ozone (O3) data were obtained from a state website. An ND score was created for census tracts (proxy for neighborhood) of residence using 12 Census variables. The association between pollutants, ND, and NIHSS was modeled continuously (NIHSS score) and dichotomously (upper quartile (≥7) vs. lower quartiles ( Results: A total of 3,035 ischemic strokes occurred; mean age was 70 (SD=13), 51% female and 53% Mexican American. The difference from the 10th to 90th percentile of the ND score (more disadvantage) was associated with a 24% (95% CI: 0.98 - 1.57) higher odds of severe stroke (Table). Higher previous-day O3 levels were associated with both continuous NIHSS and severe stroke in single and dual exposure models; these associations were not modified by ND. Larger associations between PM2.5 and severe stroke were found for those in higher ND areas than those in lower ND areas (p=0.03). Same-day PM2.5 was not associated with continuous NIHSS nor modified by ND. Conclusion: Synergistic effects of air pollution and ND score on stroke severity existed; increases in PM2.5 were associated with greater odds of severe stroke as ND increased.

Despite rapid economic growth during the last half of the twentieth century, gender inequality has remained high in Korea. Using data from the 2001 Korean National Health and Nutrition Examination Survey (KNHANES), previous research found that gender differences in sociostructural and psychosocial factors contributed to a substantial female excess in poor self-rated health. To the extent that women’s overall social status relative to men has improved over time in Korea, it is possible that the gender gap in perceived health has decreased. This study used repeated cross-sectional KNHANES data from 2001-2012 to examine temporal trends in gender differences in self-rated health. In age-adjusted models, we found no significant trend in the female excess of poor self-rated health among respondents aged 25-44 (p=0.685). In contrast, we found a statistically significant downward trend among those aged 45-64 (p

Background: Lack of education about stroke preparedness and needed action, particularly in underserved communities may prevent seeking timely care. Aim: To evaluate the Acute Stroke Program of Interventions Addressing Racial and Ethnic Disparities (ASPIRE) project. Methods: ASPIRE is a multi-level program [individual/community, hospital, EMS] using a community-engaged approach to stroke preparedness targeted to underserved black DC communities. The aim is to decrease acute stroke (AS) presentation times and increase intravenous tissue plasminogen activator (IV tPA) use. Phase 1 included 1) Enhancement of EMS focus on AS; 2) Implementation/enrichment of AS protocols to move DC hospitals to Primary Stroke certification; 3) Pre-intervention (PRE) AS patient data collection in all 7 acute care DC hospitals; 4) Focus group/survey identification of barriers to emergency stroke care to create a culturally tailored intervention. Phase 2 was a 1 year city-wide intervention. Phase 3 was 1 year post-intervention (POST) acute stroke data collection to assess changes in IV tPA use and AS presentation time. We compare PRE vs. POST AS parameters among ischemic stroke cases that arrived within 168 hours of stroke onset, excluding hospital transfers (n=84). We performed logistic regression models for AS arrival ≤ 3 hours. Results: Phase 1 identified 687 ischemic stroke cases, 85% black, 58% women; 56% ≥ 65 yrs. Phase 2 conducted 531 community interventions for 10,256+ participants; performed 3,289 intervention evaluations; distributed 19,000 preparedness bracelets and 14,000 stroke warning magnets. In Phase 3, we identified 684 ischemic stroke cases, 79% black, 58% women; 56% ≥ 65 yrs. We report significant increases in AS arrival time ≤ 3 hours (14% to 27%; p Conclusion: ASPIRE shows significant success increasing the proportion of AS arrivals to ED ≤ 3 hours and increasing IV tPA utilization. Culturally tailored community interventions can be effective in increasing stroke preparedness in underserved urban communities.

Background: Ethnic differences in stroke severity may vary by age or be explained by differences in risk factors (e.g. atrial fibrillation (Afib), diabetes). Our goal was to investigate ethnic differences in initial stroke severity. Methods: Ischemic stroke cases were identified from the population-based BASIC project. NIHSS was determined from the medical record or abstracted from the chart. Ethnicity was ascertained from the medical records and reported as Mexican American (MA) or non-Hispanic white (NHW). Quantile regression was used to model the distribution of NIHSS by age group (45-59, 60-74, 75+) to test whether ethnic differences exist over different quantiles of NIHSS (5% increments). Crude models were run to examine the interaction between age group and ethnicity; models were then adjusted for hypertension, Afib, coronary artery disease, and diabetes. Results were adjusted for multiple comparisons across 19 quantiles (5 to 95%). Results: There were 4,366 ischemic strokes, with median age 72 years (IQR: 61-81), 55% MA and median NIHSS of 4 (IQR: 2-8). In the crude model, in younger (45-59) and older (75+) age groups, MAs had one point higher NIHSS than NHWs at the median and for some lower quantiles (all p Conclusion: Ethnic differences in initial stroke severity varied by age. Age should be considered when looking at race/ethnic differences in severity.

Background: We previously reported racial differences in neurocognitive outcomes assessed 1 year after primary ICH in the DiffErenCes in the Imaging of Primary Hemorrhage based on Ethnicity or Race (DECIPHER) study.. We now analyze MR imaging findings associated with cognitive impairment in this cohort. Methods: Inclusion criteria were primary ICH, age >18, MRI at baseline, neurocognitive outcomes measured at 30 days and 1 year. Domains assessed included memory, executive function, attention, verbal fluency, depression and functional outcome. African American normative data were used to establish cut-points. The following variables were evaluated on MRI: evidence of prior stroke, hemorrhage volume and location, presence of microbleeds, and severity of white matter disease (WMD). Independent t- tests, chi-square, or Fisher’s exact tests were used as appropriate to compare differences between groups at 30 days and 1 year. Results: Of 192 subjects enrolled, mean age was 59 ± 13 years, 47% were female, and 76 % were black. Mean NIHSS was 10 (median 7). Neurocognitive outcomes were available for 144 subjects at 30 days and 126 at 1 year. Significant impairment was observed for all domains at each interval: memory (30 days 90%, 1 year 86%), verbal fluency (30 days 83%, 1 year 74%), attention (30 days 50%, 1 year 52%), and executive function (30 days 51%, 1 year 54%). Dementia was present in 22% at 30 days and 13% at 1 year. At 1 Year, hemorrhage location was not significantly associated with cognitive impairment, however, evidence of prior stroke was associated with impaired executive function (p6 associated with impaired memory (p 2 (p Conclusion: While the overall rates of neurocognitive and functional impairment decreased over time significant effects of primary ICH persist at 1 year and are associated with MR imaging findings of underlying vascular small vessel injury, including the presence of microbleeds and white matter disease.

Background: Racial disparities in ischemic stroke incidence have been found in previous studies with blacks having higher rates compared to whites. Recent data has suggested a decrease in stroke incidence but not necessarily a decrease in race differentials. We sought to document incidence of ischemic stroke and explore race-ethnic differentials in the urban, Washington, DC metro area. METHODS: ASPIRE is a multi-dimensional intervention with a three-pronged approach (community, hospital, EMS) to acute stroke preparedness targeted to increase IV tPA utilization in underserved black communities in DC. Using a comprehensive active and passive surveillance strategy including stroke admission alerts, stroke champions, admission/discharge data and chart review, the ASPIRE research team prospectively identified all hospitalized incident ischemic strokes between January 2008 and July 2012. Direct age-adjusted rates were estimated using age specific proportions from the 2010 census of the DC population for each sex, gender and race subgroup. RESULTS: Over 4.5 years, we captured 691 incident ischemic strokes: mean age 67 yrs +/- 15 yrs; 79% were blacks; and 55% females. Over 45% of the incident ischemic strokes occurred in black-females. Risk factors including hypertension (79%), diabetes (39%), and current smoking (28%) were significantly greater for blacks than whites. The age-adjusted average annual incidence rate per 100,000 was 226 overall: 171 for blacks, 45 for whites; 65 for black-males; 19 for white-males; 106 for black-females; and 26 for white-females CONCLUSION: We report significant racial disparities in the incidence of hospitalized ischemic in the DC metro area despite potential undercounting of non-hospitalized stroke cases, and potential competing mortalities in black men (ie. ICH, homicide, AIDS). This continued excess burden of ischemic stroke, particularly in black females, highlights the ongoing importance of projects such as ASPIRE to continue education and preparedness among those with increased risk.

BACKGROUND: There is sparse data about the nature of race-ethnic disparities in the acute stroke setting including differentials in stroke preparedness. The aim of this analysis was to explore race-ethnic differentials in time to arrival for acute stroke in a racial and ethnically diverse urban setting. METHODS: ASPIRE is a multi-dimensional intervention program (community, hospital, and EMS) for acute stroke preparedness targeted to increase IV tPA utilization in underserved black communities in the DC metro area. We prospectively identified stroke admissions and EMS utilization including acute stroke arrival time parameters for the 6 month pre and post intervention periods. Cox proportional hazards models were used to examine predictors of arrival time. Proportionality of the hazards was checked. RESULTS: In the 6 month pre-intervention period, data was collected on 943 stroke cases; 53% female; 74% black; mean age 67 yrs. Of the subjects from the pre-intervention period with arrival times less than 48 hrs, the median arrival time to the emergency department (ED) was 9 hours; 20% presented under 3 hours. In multivariable Cox PH models, subjects were 38% more likely to arrive earlier if they had arrived by EMS (HR: 1.38, 95%CI: 1.21-1.58). Black subjects were 25% less likely to arrive earlier (HR: 0.75, 95%CI: 0.60-0.93), but this effect was dampened over time (p=0.03). The model included the interaction between black race and time and adjusted for insurance status, risk factors (hypertension and diabetes), gender, age and prior stroke. Ina gender by race analysis, there was a trend towards black women being less likely to arrive earlier to the ED (HR 0.78, 95% CI 0.6 -1.0). However, overall, there was no race-ethnic interaction with arrival by EMS. CONCLUSIONS: Contrary to the perceived perception by the community suggesting there is a disparity in EMS utilization by the black DC community, we found no overall significant racial difference in EMS utilization for acute stroke. While there was a trend towards delayed overall arrival in black females, this was independent of EMS utilization.

Background and Purpose— Hypertension is the most important risk factor associated with intracerebral hemorrhage. We explored racial differences in blood pressure (BP) control after intracerebral hemorrhage and assessed predictors of BP control at presentation, 30 days, and 1 year in a prospective cohort study. Methods— Subjects with spontaneous intracerebral hemorrhage were identified from the DiffErenCes in the Imaging of Primary Hemorrhage based on Ethnicity or Race (DECIPHER) Project. BP was compared by race at each time point. Multivariable linear regression was used to determine predictors of presenting mean arterial pressure, and longitudinal linear regression was used to assess predictors of mean arterial pressure at follow-up. Results— A total of 162 patients were included (mean age, 59 years; 53% male; 77% black). Mean arterial pressure at presentation was 9.6 mm Hg higher in blacks than whites despite adjustment for confounders ( P =0.065). Fewer than 20% of patients had normal BP (P =0.331), blacks were more likely than whites to have Stage I/II hypertension at 1 year ( P =0.036). Factors associated with lower mean arterial pressure at follow-up in multivariable analysis were being married at baseline ( P =0.032) and living in a facility (versus personal residence) at the time of BP measurement ( P =0.023). Conclusions— Long-term BP control is inadequate in patients after intracerebral hemorrhage, particularly in blacks. Further studies are needed to understand the role of social support and barriers to control to identify optimal approaches to improve BP in this high-risk population.

Background In white populations, age seems to modify the effect of sex on stroke risk, and compared with men, women are protected from stroke until approximately age 75 to 85 years, after which the protection is lost or reversed. Compared with non-Hispanic whites (NHWs), Mexican Americans (MAs) are at higher risk of stroke; however, age- and sex-specific stroke incidence data are currently not available for this population. Objective This study was performed to compare the age-specific sex differences in stroke risk in MAs and NHWs. Methods Data were derived from the BASIC (Brain Attack Surveillance in Corpus Christi) Project, a population-based stroke surveillance study conducted in Nueces County Texas. Incident strokes (n = 2421, including ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage) that occurred between January 1, 2000 and May 25, 2007 in individuals aged 45 years or older were included in the analysis. Poisson regression using the generalized additive models framework was used to analyze the relationship between sex, age (5-year intervals), and race/ethnicity (NHW or MA) and incident stroke risk. Results Among both NHWs and MAs aged 45 to 79 years, men were at higher risk of stroke than women were. The magnitude of increased stroke risk in men compared with women diminished with age, and after age 79 years, no sex difference in stroke risk was observed. Conclusions Reasons for the loss of protection from stroke in aging women of all races/ethnicities are not fully understood, and further study is warranted.