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The aim of this 4-year observational study is to analyze the outcomes of stroke patients treated with direct mechanical thrombectomy (dMT) compared to bridging therapy (BT) (intravenous thrombolysis [IVT] + BT) based on 3-month outcomes, in real clinical practice in the "Stroke Belt" of Southern Europe. In total, 300 patients were included (41.3% dMT and 58.6% BT). The frequency of direct referral to the stroke center was similar in the dMT and BT group, whereas the time from onset to groin was longer in the BT group (median 210 [IQR 160–303] vs. 399 [IQR 225–675], p = 0.001). Successful recanalization (TICI 2b-3) and hemorrhagic transformation were similar in both groups. The BT group more frequently showed excellent outcomes at 3 months (32.4% vs. 15.4%, p = 0.004). Multivariate analysis showed that BT was independently associated with excellent outcomes (OR 2.7. 95% CI,1.2–5.9, p = 0.02) and lower mortality (OR 0.36. 95% CI 0.16–0.82, p = 015). Conclusions: Compared with dMT, BT was associated with excellent functional outcomes and lower 3-month mortality in this real-world clinical practice study conducted in a region belonging to the “Stroke Belt” of Southern Europe. Given the disparity of results on the benefit of BT in the current evidence, it is of vital importance to analyze the convenience of its use in each health area.

The aim of this 4-year observational study is to analyze the outcomes of stroke patients treated with direct mechanical thrombectomy (dMT) compared to bridging therapy (BT) (intravenous thrombolysis [IVT] + BT) based on 3-month outcomes, in real clinical practice in the "Stroke Belt" of Southern Europe. In total, 300 patients were included (41.3% dMT and 58.6% BT). The frequency of direct referral to the stroke center was similar in the dMT and BT group, whereas the time from onset to groin was longer in the BT group (median 210 [IQR 160–303] vs. 399 [IQR 225–675], p = 0.001). Successful recanalization (TICI 2b-3) and hemorrhagic transformation were similar in both groups. The BT group more frequently showed excellent outcomes at 3 months (32.4% vs. 15.4%, p = 0.004). Multivariate analysis showed that BT was independently associated with excellent outcomes (OR 2.7. 95% CI,1.2–5.9, p = 0.02) and lower mortality (OR 0.36. 95% CI 0.16–0.82, p = 015). Conclusions: Compared with dMT, BT was associated with excellent functional outcomes and lower 3-month mortality in this real-world clinical practice study conducted in a region belonging to the “Stroke Belt” of Southern Europe. Given the disparity of results on the benefit of BT in the current evidence, it is of vital importance to analyze the convenience of its use in each health area.

Objective To evaluate the trends in cardiovascular, ischemic heart disease (IHD), stroke, and heart failure mortality in the stroke belt in comparison with the rest of the United States. Patients and Methods We evaluated the nationwide mortality data of all Americans from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database from 1999 to 2018. Cause-specific deaths were identified in the stroke belt and nonstroke belt populations using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes. The relative percentage gap was estimated as the absolute difference computed relative to nonstroke belt mortality. Piecewise linear regression and age-period-cohort modeling were used to assess, respectively, the trends and to forecast mortality across the 2 regions. Results The cardiovascular mortality rate (per 100,000 persons) was 288.3 (95% CI, 288.0 to 288.6; 3,684,273 deaths) in the stroke belt region and 251.2 (95% CI, 251.0 to 251.3; 13,296,164 deaths) in the nonstroke belt region. In the stroke belt region, age-adjusted mortality rates due to all cardiovascular causes (average annual percentage change [AAPC] in mortality rates, −2.4; 95% CI, −2.8 to −2.0), IHD (AAPC, −3.8; 95% CI, −4.2 to −3.5), and stroke (AAPC, −2.8; 95% CI, −3.4 to −2.1) declined from 1999 to 2018. A similar decline in cardiovascular (AAPC, −2.5; 95% CI, −3.0 to −2.0), IHD (AAPC, −4.0; 95% CI, −4.3 to −3.7), and stroke (AAPC, −2.9; 95% CI, −3.2 to −2.2) mortality was seen in the nonstroke belt region. There was no overall change in heart failure mortality in both regions (PAAPC>.05). The cardiovascular mortality gap was 11.8% in 1999 and 15.9% in 2018, with a modest reduction in absolute mortality rate difference (~7 deaths per 100,000 persons). These patterns were consistent across subgroups of age, sex, race, and urbanization status. An estimated 101,953 additional cardiovascular deaths need to be prevented from 2020 to 2025 in the stroke belt to ameliorate the gap between the 2 regions. Conclusion Despite the overall decline, substantial geographic disparities in cardiovascular mortality persist. Novel approaches are needed to attenuate the long-standing geographic inequalities in cardiovascular mortality in the United States, which are projected to increase.

Although hypertension is a contributing factor to higher stroke occurrence in the Stroke Belt, little is known about post‐stroke hypertension medication use in Stroke Belt residents. Through the use of national Behavioral Risk Factor Surveillance System surveys from 2015, 2017, and 2019; we compared unadjusted and adjusted estimates of post‐stroke hypertension medication use by Stroke Belt residence status. Similar levels of post‐stroke hypertension medication use were observed between Stroke Belt residents (OR: 1.09, 95% CI: 0.89, 1.33) and non‐Stroke Belt residents. After adjustment, Stroke Belt residents had 1.14 times the odds of post‐stroke hypertension medication use (95% CI: 0.92, 1.41) compared to non‐Stroke Belt residents. Findings from this study suggest that there is little difference between post‐stroke hypertension medication use between Stroke Belt and non‐Stroke Belt residents. However, further work is needed to assess whether use of other non‐medicinal methods of post‐stroke hypertension control differs by Stroke Belt residence status.

Background and Purpose: The impact of the coronavirus disease 2019 (COVID-19) pandemic on stroke systems has not been systematically evaluated. Our study aims to investigate trends in telestroke consults during the pandemic. Methods: We did retrospective chart review of consecutive patients seen through a telestroke network in South Carolina from March 2019 to April 2020. We dichotomized patients to preCOVID-19 pandemic (March 2019 to February 2020) and during COVID-19 pandemic (March to April 2020). Results: A total of 5852 patients were evaluated during the study period, 613 (10.5%) were seen during the pandemic. The median number of weekly consults dropped from 112 to 77 during the pandemic, P =0.002. There was no difference in baseline features; however, Black patients were less likely to present with strokes during the pandemic (13.9% versus 29%, P ≤0.002). Conclusions: The COVID-19 pandemic has led to a significant drop in telestroke volume. The impact seems to disproportionately affect Black patients.

Introduction A reduction of the hospitalization and reperfusion treatments was reported during COVID-19 pandemic. However, high variability in results emerged, potentially due to logistic paradigms adopted. Here, we analyze stroke code admissions, hospitalizations, and stroke belt performance for ischemic stroke patients in the metropolitan Bologna region, comparing temporal trends between 2019 and 2020 to define the impact of COVID-19 on the stroke network. Methods This retrospective observational study included all people admitted at the Bologna Metropolitan Stroke Center in timeframes 1 March 2019–30 April 2019 (cohort-2019) and 1 March 2020–30 April 2020 (cohort-2020). Diagnosis, treatment strategy, and timing were compared between the two cohorts to define temporal trends. Results Overall, 283 patients were admitted to the Stroke Center, with no differences in demographic factors between cohort-2019 and cohort-2020. In cohort-2020, transient ischemic attack (TIA) was significantly less prevalent than 2019 (6.9% vs 14.4%, p = .04). Among 216 ischemic stroke patients, moderate-to-severe stroke was more represented in cohort-2020 (17.8% vs 6.2%, p = .027). Similar proportions of patients underwent reperfusion (45.9% in 2019 vs 53.4% in 2020), although a slight increase in combined treatment was detected (14.4% vs 25.4%, p = .05). Door-to-scan timing was significantly prolonged in 2020 compared with 2019 (28.4 ± 12.6 vs 36.7 ± 14.6, p = .03), although overall timing from stroke to treatment was preserved. Conclusion During COVID-19 pandemic, TIA and minor stroke consistently reduced compared to the same timeframe in 2019. Longer stroke-to-call and door-to-scan times, attributable to change in citizen behavior and screening at hospital arrival, did not impact on stroke-to-treatment time. Mothership model might have minimized the effects of the pandemic on the stroke care organization.

ImportanceIn the last two decades, hypertension control in the U.S. population has not improved, and there are widening disparities. Less is known, however, about progress in reducing hospitalizations related to hypertensive emergencies.ObjectivesTo describe trends in national hospitalization rates for hypertensive emergencies, overall and by demographic and geographical subgroups.Design, Setting and, ParticipantsSerial cross-sectional analysis of Medicare fee-for-service beneficiaries aged 65 years or older between 1999 and 2019 using Medicare denominator and inpatient files.Main Outcome and MeasuresTrends in hospitalization for hypertensive emergencies, overall and by specific subgroups.ResultsThe sample consisted of 397,238 individual Medicare fee-for-service beneficiaries. From 1999 through 2019, the annual hospitalization rates for hypertensive emergencies increased significantly from 51.5 to 125.9 per 100,000 beneficiary-years; this increase was most pronounced among the following subgroups: adults ≥85 years (66.8 to 274.1), females (64.9 to 160.1), Blacks (144.4 to 369.5), and Medicare-Medicaid insured (dual eligible, 93.1 to 270.0). Across all subgroups, Black adults had the highest hospitalization rate in 2019, and there was a significant increase in the differences in hospitalizations between Blacks and Whites from 1999 to 2019. Marked geographic variation was also present, with the highest hospitalization rates in the South (so-called “Stroke Belt”). Among 3,143 counties and county-equivalents included in the study, less than 1% of counties either had no change (n=7) or decreased (n=20) hospitalization rates since 1999. Among patients hospitalized for a hypertensive emergency, the observed 30-day all-cause mortality rate decreased from 2.6% to 1.7% and 30-day all-cause readmission rate decreased from 15.7% to 11.8%.Conclusions and RelevanceAmong Medicare fee-for-service beneficiaries aged 65 years or older, hospitalization rates for hypertensive emergencies increased substantially and significantly from 1999 to 2019. Black adults had the largest increase in hospitalization rates across age, sex, race, and dual-eligible strata. There was significant national variation, with the highest rates generally in the South.KEY POINTSQuestionHow have hospitalization rate for hypertensive emergencies among US adults aged 65 years and older changed between 1999 and 2019 and are there any differences across demographic and geographical subgroups?FindingsIn this serial cross-sectional study that included 397,238 individual Medicare fee-for-service beneficiaries, there was a marked increase in hospitalization rates for hypertensive emergencies from 1999 to 2019, and this increase was most pronounced among Black adults across age, sex, race, and dual-eligible strata. Significant national variation was observed, with the highest hospitalization rates generally in the South.MeaningBetween 1999 and 2019, hospitalization rates for hypertensive emergencies increased substantially and differences across demographic and geographic subgroups persisted.

Purpose of Review A review of American history is presented to understand how public policy has contributed to a disproportionate burden of disease in members of underrepresented groups. A review of research conducted in the Stroke Belt provides an opportunity to examine more closely traditional and non-traditional risk factors in an effort to consider strategies for change. Recent Findings A diverse physician workforce has been offered as a way of improving care for our increasingly diverse populace. Given the expected increased prevalence of stroke in communities of color and the impact of stress from discrimination on health, proactive strategies to promote inclusion and equity to support diversity in perioperative neuroscience is warranted. Summary Public policy rooted in structural racism has left marginalized groups economically and educationally disadvantaged with less access to health care. Mistrust and fear from ongoing discrimination compels the neuroscience community to broaden their approach for developing a more reassuring and supportive educational environment for patients and trainees.

Background Dietary patterns and associations with incident heart failure (HF) are not well established in the United States. Objectives The purpose of this study was to determine associations of 5 dietary patterns with incident HF hospitalizations among U.S. adults. Methods The REGARDS (REasons for Geographic and Racial Differences in Stroke) trial is a prospective cohort of black and white adults followed from 2003 to 2007 through 2014. Inclusion criteria included completion of a food frequency questionnaire and no baseline coronary heart disease or HF. Five dietary patterns (convenience, plant-based, sweets, Southern, and alcohol/salads) were derived from principal component analysis. The primary endpoint was incident HF hospitalization. Results This study included 16,068 participants (mean age 64.0 ± 9.1 years, 58.7% women, 33.6% black participants, 34.0% residents of the stroke belt). After a median of 8.7 years of follow-up, 363 participants had incident HF hospitalizations. Compared with the lowest quartile, the highest quartile of adherence to the plant-based dietary pattern was associated with a 41% lower risk of HF in multivariable-adjusted models (hazard ratio: 0.59; 95% confidence interval: 0.41 to 0.86; p = 0.004). Highest adherence to the Southern dietary pattern was associated with a 72% higher risk of HF after adjusting for age, sex, and race and for other potential confounders (education, income, region of residence, total energy intake, smoking, physical activity, and sodium intake; hazard ratio: 1.72; 95% confidence interval: 1.20 to 2.46; p = 0.005). However, the association was attenuated and no longer statistically significant after further adjusting for body mass index in kg/m2, waist circumference, hypertension, dyslipidemia, diabetes mellitus, atrial fibrillation, and chronic kidney disease. No statistically significant associations were observed with incident HF with reduced or preserved ejection fraction hospitalizations and the dietary patterns. No associations were observed with the other 3 dietary patterns. Conclusions Adherence to a plant-based dietary pattern was inversely associated with incident HF risk, whereas the Southern dietary pattern was positively associated with incident HF risk.

Purpose We examined the association of Stroke Belt birth state with late-life cognition in The Study of Healthy Aging in African Americans (STAR). Methods STAR enrolled 764 Black Americans ages 50+ who were long-term Kaiser Permanente Northern California members. Participants completed Multiphasic Health Check-ups (MHC; 1964–1985) where early-life overweight/obesity, hypertension, diabetes, and hyperlipidemia were measured. At STAR (2018), birth state, self-reported early-life socioeconomic status (SES), and executive function, verbal episodic memory, and semantic memory scores were collected. We used linear regression to examine the association between Stroke Belt birth and late-life cognition adjusting for birth year, gender, and parental education. We evaluated early-life SES and cardiovascular risk factors (CVRF) as potential mechanisms. Results Twenty-seven percent of participants were born in the Stroke Belt with a mean age of 69 (standard deviation = 9) at STAR. Stroke Belt birth was associated with worse late-life executive function (β [95% confidence interval]: −0.18 [−0.33, −0.02]) and semantic memory (−0.37 [−0.53, −0.21]), but not verbal episodic memory (−0.04 [−0.20, 0.12]). Adjustment for SES and CVRF attenuated associations of Stroke Belt birth with cognition (executive function [−0.05 {−0.25, 0.14}]; semantic memory [−0.28 {−0.49, −0.07}]). Conclusions Black Americans born in the Stroke Belt had worse late-life cognition than those born elsewhere, underscoring the importance of early-life exposures on brain health.

Introduction: The Southeastern United States, known as the “the stroke belt,” has the highest stroke mortality rate in the country. One possible reason is the high proportion of its residents living in rural areas. Studies suggest stroke care is worse for patients living in rural areas, and they are less likely to receive acute stroke therapy (intravenous thrombolysis or endovascular therapy), leading to worse outcomes. We compared 90-day modified Rankin Score (mRS) between patients living in urban versus rural areas who received acute stroke therapy. Methods: We performed a retrospective analysis of a tertiary care academic hospital in the Southeastern US, the University of Alabama at Birmingham. Patients admitted with imaging-confirmed ischemic stroke and had acute stroke therapy between 2014 and 2018 were included for analysis. Individuals were classified as rural or urban dwelling based on US Department of Agriculture’s 2010 Rural-Urban Commuting Area Codes. Clinical and demographic characteristics were collected from the chart. Stepwise logistic regression models were performed with these variables to compare good (mRS 0-1) vs poor (mRS 2-6) functional outcomes. Results: There were 232 patients included in the study (185 urban, and 47 rural). There were no significant differences between groups in age (urban 64.5±15.1; rural 66.2±14.7), gender (urban: 56% male 44% female, rural: 51% male 49% female), or proportion of African-Americans (33% of urban group and 25% of rural group). Mean baseline NIH stroke scale was higher in rural patients than urban (17.0 vs 14.8 respectively, p-value=0.03.). In logistical regression models for good functional outcome (mRS 0-1) at 90-days, analysis of factors including rural/urban status, gender, age, insurance, transfer, and acute stroke therapy, revealed only older age as a significant factor (OR 0.97, 95% CI 0.95-0.99). Conclusions: Our study demonstrated no significant differences in functional outcome between patients from urban and rural locations after receiving acute therapy for treating ischemic stroke. Importantly, only older age predicted poor functional outcome at 90 days. Our study demonstrates that patients from rural areas can recover similarly to those from urban areas.

Background and Purpose: Intracerebral hemorrhage (ICH) accounts for around 10% of stroke, but carries 50% of stroke mortality. ICH characteristics and prognostic factors specific to the Stroke Belt are not well defined by race. Methods: Records of patients admitted to the University of Alabama Hospital with ICH from 2017 to 2019 were reviewed. We examined the association of demographics; clinical and radiographic features including stroke severity, hematoma volume, and ICH score; and transfer status with in-hospital mortality and discharge functional status for a biracial population including Black and White patients. Independent predictors of in-hospital mortality and functional outcome were examined using logistic regression. Results: Among the 275 ICH cases included in this biracial analysis, Black patients (n = 114) compared to White patients (n = 161) were younger (60.6 vs. 71.4 years, P < 0.0001), more often urban (81% vs. 64%, P < 0.01), more likely to have a history of hypertension (87% vs. 71%, P < 0.01), less often transferred (44% vs. 74%, P < 0.01), and had smaller median initial hematoma volumes (9.1 vs. 12.6 mL, P = 0.041). On multivariable analysis, Glasgow Coma Scale (GCS) for White patients (OR 13.0, P < 0.0001), hyperlipidemia for Black patients (OR 13.9, P = 0.019), and ICH volume for either race (Black patients: OR 1.05, P = 0.03 and White patients: OR 1.04, P < 0.01) were independent predictors of in-hospital mortality. Conclusions: Hypertension is more prevalent among Black ICH patients in the Stroke Belt. The addition of hyperlipidemia to the ICH score model improved the prediction of mortality for Black ICH patients. No differences in in-hospital mortality or poor functional outcome were observed by race.

The Southern dietary pattern, derived within the REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort, is characterised by high consumption of added fats, fried food, organ meats, processed meats and sugar-sweetened beverages and is associated with increased risk of several chronic diseases. The aim of the present study was to identify characteristics of individuals with high adherence to this dietary pattern. We analysed data from REGARDS, a national cohort of 30 239 black and white adults ≥45 years of age living in the USA. Dietary data were collected using the Block 98 FFQ. Multivariable linear regression was used to calculate standardised beta coefficients across all covariates for the entire sample and stratified by race and region. We included 16 781 participants with complete dietary data. Among these, 34·6 % were black, 45·6 % male, 55·2 % resided in stroke belt region and the average age was 65 years. Black race was the factor with the largest magnitude of association with the Southern dietary pattern (Δ = 0·76 sd, P < 0·0001). Large differences in Southern dietary pattern adherence were observed between black participants and white participants in the stroke belt and non-belt (stroke belt Δ = 0·75 sd, non-belt Δ = 0·77 sd). There was a high consumption of the Southern dietary pattern in the US black population, regardless of other factors, underlying our previous findings showing the substantial contribution of this dietary pattern to racial disparities in incident hypertension and stroke.

[Objective] Spain’s so-called Stroke Belt is an area with high prevalence of vascular disease. We aimed to determine the prevalence of undetected obstructive sleep apnea–hypopnea syndrome (OSAHS) among patients with acute ischemic stroke (AIS) in southern Spain., [Methods] We conducted a cross-sectional study at the Virgen Macarena University Hospital Stroke Unit during 2018 to 2019. We included patients, [Results] Seventy-two patients were included. The median participant age was 72 years. Mean body mass index was 27.07 kg/m2, and 40.28% were daily alcohol drinkers. Hypertension, atrial fibrillation, ischemic cardiomyopathy, and previous stroke were detected in 63.9%, 11.1%, 15.3%, and 17.6% of patients, respectively. Polygraphy was feasible in 91.38% of patients. The prevalence of OSAHS was 84.72% (apnea–hypopnea index ≥5). Patients with moderate and severe OSAHS were more likely to be obese and to have a larger neck circumference and facial palsy. The diagnostic criteria of central sleep apnea syndrome were met in only 1.38% of patients., [Conclusions] The high prevalence of OSAHS found in the Spanish Stroke Belt justifies further investigation and development of a screening program as a strategy to identify patients with undetected OSAHS., The authors disclosed receipt of the following financial support for the research, authorship and/or publication of this article: This work was supported by the Neurovascular Research Group, part of the Cooperative Cerebrovascular Disease Research Network (INVICTUS+) (RD16/0019/0015).

Objective: As compared to whites, the black population develops hypertension (HTN) at an earlier age, has a greater frequency and severity of HTN, and has poorer control of blood pressure (BP). Traditional practices and treatment efforts have had minor impact on these disparities, with over a 2-fold higher death rate currently for blacks as compared to whites. The University of Mississippi Medical Center (UMC) is located in the southeastern US and the Stroke Belt, which has higher rates of HTN and related diseases as compared to the rest of the country.Methods: We retrospectively analyzed the UMC's Research Data Warehouse, containing >30 million electronic health records from >900,000 patients to determine the initial BP response following the first prescribed antihypertensive drug.Results: There were 5,973 white (45% overall HTN prevalence) and 10,731 black (57% overall HTN prevalence) patients who met criteria for the study. After controlling for age, BMI, and drug dosage, black males were overall less likely to have controlled BP (defined as < 140/90 mmHg) and were associated with smaller falls in BP as compared to whites and black females. Blockers of the renin-angiotensin system (RAS) failed to significantly improve odds of HTN control vs. the untreated group in black patients. However, our data suggests that these drugs do provide significant benefit in blacks when combined with THZ, as compared to untreated and as compared to THZ alone.Conclusion: These data support the use of a single-pill formulation with ARB or ACE inhibitor with a thiazide in blacks for initial first-line HTN therapy and suggests that HTN treatment strategies should consider both race and gender. Our study gives a unique insight into initial antihypertensive responses in actual clinical practice and could have an impact in BP control efficiency in a state with prevalent socioeconomic and racial disparities.

Background Stroke is a chronic cardiovascular disease that puts major stresses on U.S. health and economy. The prevalence of stroke exhibits a strong geographical pattern at the state-level, where a cluster of southern states with a substantially higher prevalence of stroke has been called the stroke belt of the nation. Despite this recognition, the extent to which key neighborhood characteristics affect stroke prevalence remains to be further clarified. Methods We generated a new neighborhood health data set at the census tract level on nearly 27,000 tracts by pooling information from multiple data sources including the CDC’s 500 Cities Project 2017 data release. We employed a two-stage modeling approach to understand how key neighborhood-level risk factors affect the neighborhood-level stroke prevalence in each state of the US. The first stage used a state-of-the-art Bayesian machine learning algorithm to identify key neighborhood-level determinants. The second stage applied a Bayesian multilevel modeling approach to describe how these key determinants explain the variability in stroke prevalence in each state. Results Neighborhoods with a larger proportion of older adults and non-Hispanic blacks were associated with neighborhoods with a higher prevalence of stroke. Higher median household income was linked to lower stroke prevalence. Ozone was found to be positively associated with stroke prevalence in 10 states, while negatively associated with stroke in five states. There was substantial variation in both the direction and magnitude of the associations between these four key factors with stroke prevalence across the states. Conclusions When used in a principled variable selection framework, high-performance machine learning can identify key factors of neighborhood-level prevalence of stroke from wide-ranging information in a data-driven way. The Bayesian multilevel modeling approach provides a detailed view of the impact of key factors across the states. The identified major factors and their effect mechanisms can potentially aid policy makers in developing area-based stroke prevention strategies.

Introduction: Incidence of cognitive impairment is higher for residents of the Stroke Belt (SB) compared to those living outside it, but the importance of timing of SB residence is unclear. Methods: Participants were aged 45+ yrs, and enrolled in 2003-2007 in REGARDS. Cognition was assessed annually, by telephone, using the Six-Item Screener (SIS) in 11,488 black or white stroke-free participants currently living in the SB, and 8,949 currently living outside of the SB. Incident cognitive impairment was defined as SIS score of < 4 at last assessment among participants with initial SIS >4. Exposures were defined as SB residence all years, some years, or no years of childhood (ages 0-18) and early adulthood (ages 19-30). Demographic adjusted logistic regression models were stratified by SB residence at enrollment, and were used to estimate the demographic-adjusted odds of incident cognitive impairment. Results: Among those currently residing in the SB, childhood residence outside the SB for some (OR = 0.82; 95% CI: 0.68 - 0.99) or all (OR = 0.76; 95% CI: 0.65 - 0.90) of the time predicted lower odds of incident cognitive impairment. Similarly, early adulthood residence outside the SB for some (OR = 0.86; 95% CI: 0.74 - 0.98) or all (OR = 0.70; 95% CI: 0.58 - 0.84) of the time predicted lower incident cognitive impairment. Conversely, for those currently living outside the SB, the risk of incident cognitive impairment was higher for those who had spent their entire early adulthood in the SB (OR = 1.51; 95% CI: 1.01 - 2.57), with non-significant increased risk for childhood exposure or some early adulthood exposure to the SB (table). Conclusions: These findings suggest that early residence in the SB during childhood or early adulthood increases the risk of cognitive impairment regardless of place of residence in later adulthood. Further research is needed to determine the characteristics of early SB life that are linked to later adult cognitive impairment.

This project used a retrospective case series design to investigate factors associated with stroke in a rural area in Appalachian Kentucky. The south-eastern region of the U.S. is often referred to as the ‘stroke belt,’ and includes the Appalachian region of the state of Kentucky. Data were collected from medical records of patients from a neurology practice and regional hospital with a diagnosis of stroke from March 2012 through November 2015. Data were collected without personal identifiers and included demographic characteristics, stroke type, treatments received, and referrals for additional care including rehabilitation. Data from a total of 84 stroke cases diagnosed between March 2012 and November 2015 were included. Of the 84 cases, 46 (54.8%) were female and all but one was Caucasian. The distribution by race is consistent with the population of the region. The stroke cases ranged in age from 41 to 92 (M=66.3) and the age at stroke diagnosis ranged from 40 to 90 (M=65.7). Fourteen (16.7%) had evidence of a previous stroke at diagnosis. For smokers, the mean age at diagnosis was 62.7 for smokers while for non-smokers it was 67.5. The study reported smoking rates that were nearly three-times the national average, and the smokers in this study were found to have stroke onset approximately five-years earlier than non-smokers. The results from this case series support the need for further investigation on stroke prevalence and factors contributing to continued risk for stroke in Appalachia.

In the United States, stroke incidence and related mortality have declined in the past half century.1,2 This drop is largely because of better recognition and control of modifiable cardiovascular disease risk factors.3,4 There remain significant racial disparities however, and studies and surveillance programs consistently show higher rates of stroke and stroke-related mortality in native born blacks when compared with non-Hispanic whites (NHW).5–9 Nowhere is this racial disparity more evident than in the stroke belt, an area in the Southeastern United States with disproportionately high rates of stroke.10–12 Although a higher prevalence of cardiovascular disease risk factors, specifically hypertension, diabetes mellitus, obesity, and cigarette smoking, account for much of the excess stroke risk, it remains unclear why these cardiovascular comorbidities, and other lifestyle-related risk factors, cluster in this region of the United States, particularly in blacks.13–15 Multiple explanations have been proposed, but the medical community has yet to offer a fully satisfactory explanation for what is driving stroke mortality in the ≈700 hot spot counties of the stroke belt.16 A clue is that these counties also have higher proportions of black residents and unemployment, as well as lower educational status, median income, and healthcare use.16 While often ignored in the medical literature, a history of slavery, and ongoing social segregation, racial discrimination, and economic inequality, provide a historical precedent for the phenotype of poor cardiovascular health observed in several predominantly black communities. Although many reports depict the racial disparities and skew in stroke risk factors in this region of the United States, a PubMed search using the words slavery, slave, stroke, stroke belt, and cardiovascular disease returned no relevant articles. Our goal is to review the historical evidence and test the strength of association …

Background Social inequities affecting minority populations after Hurricane Katrina led to an expansion of environmental justice literature. In August 2017, Hurricane Harvey rainfall was estimated as a 3000- to 20,000-year flood event, further affecting minority populations with disproportionate stroke prevalence. The Stomp Out Stroke initiative leveraged multimedia engagement, creating a patient-centered cerebrovascular health intervention. Objective This study aims to address social inequities in cerebrovascular health through the identification of race- or ethnicity-specific health needs and the provision of in-person stroke prevention screening during two community events (May 2018 and May 2019). Methods Stomp Out Stroke recruitment took place through internet-based channels (websites and social networking). Exclusively through web registration, Stomp Out Stroke participants (aged >18 years) detailed sociodemographic characteristics, family history of stroke, and stroke survivorship. Participant health interests were compared by race or ethnicity using Kruskal-Wallis or chi-square test at an α=.05. A Bonferroni-corrected P value of .0083 was used for multiple comparisons. Results Stomp Out Stroke registrants (N=1401) were 70% (973/1390) female (median age 45 years) and largely self-identified as members of minority groups: 32.05% (449/1401) Hispanic, 25.62% (359/1401) African American, 13.63% (191/1401) Asian compared with 23.63% (331/1401) non-Hispanic White. Stroke survivors comprised 11.55% (155/1401) of our population. A total of 124 stroke caregivers participated. Approximately 36.81% (493/1339) of participants had a family history of stroke. African American participants were most likely to have Medicare or Medicaid insurance (84/341, 24.6%), whereas Hispanic participants were most likely to be uninsured (127/435, 29.2%). Hispanic participants were more likely than non-Hispanic White participants to obtain health screenings (282/449, 62.8% vs 175/331, 52.9%; P=.03). Asian (105/191, 54.9%) and African American (201/359, 55.9%) participants were more likely to request stroke education than non-Hispanic White (138/331, 41.6%) or Hispanic participants (193/449, 42.9%). African American participants were more likely to seek overall health education than non-Hispanic White participants (166/359, 46.2% vs 108/331, 32.6%; P=.002). Non-Hispanic White participants (48/331, 14.5%) were less likely to speak to health care providers than African American (91/359, 25.3%) or Asian participants (54/191, 28.3%). During the 2018 and 2019 events, 2774 health screenings were completed across 12 hours, averaging four health screenings per minute. These included blood pressure (1031/2774, 37.16%), stroke risk assessment (496/2774, 17.88%), bone density (426/2774, 15.35%), carotid ultrasound (380/2774, 13.69%), BMI (182/2774, 6.56%), serum lipids (157/2774, 5.65%), and hemoglobin A1c (102/2774, 3.67%). Twenty multimedia placements using the Stomp Out Stroke webpage, social media, #stompoutstroke, television, iQ radio, and web-based news reached approximately 849,731 people in the Houston area. Conclusions Using a combination of internet-based recruitment, registration, and in-person assessments, Stomp Out Stroke identified race- or ethnicity-specific health care needs and provided appropriate screenings to minority populations at increased risk of urban flooding and stroke. This protocol can be replicated in Southern US Stroke Belt cities with similar flood risks.

Purpose: Stay-at-home orders and additional fears of the COVID-19 pandemic led to a decrease in the presentation of patients with stroke symptoms in emergency departments across some regions in the U.S. but without a similar decline in mechanical thrombectomy (MT) (1). However, a significant decrease of MT cases was observed in other countries such as France (2). It is unknown if the same phenomenon was observed across the entire U.S. The purpose of this study was to review the volumes of code stroke activation, emergent large vessel occlusion (ELVO) activation, and MT cases in a Stroke Belt region during statewide stay-at-home measures to determine if the percentage of ELVO and MT cases to all code stroke activations were equally affected. Materials and Methods: We retrospectively reviewed hospital data for code stroke activations, code stroke activations for large vessel occlusion (LVO), and MT cases for the 53-day stay-at-home ordinance in North Carolina (March 30 to May 22, 2020). This data set was compared to the two preceding (Dec 14, 2019 to March 29, 2020) and two following (May 23, 2020, to September 5, 2020) 53-day time periods. Results: Code stroke activation volumes during the preceding two 53-day periods leading up to the stay-at-home ordinance were 857 and 785 but significantly decreased to 632 during the statewide stay-at-home orders (P < 0.01);this was a 23% reduction in volume compared to the mean of the two prior periods. All activations then rebounded to baseline levels (890, 886) in the two time periods after lifting stay-at-home orders. Similar decreases were noted for ELVOs and MTs during the stay-at-home time period as there was no significant change in the percentage of ELVO activations per all stroke activations (9.6%, P = 0.50) and cases that ultimately underwent thrombectomy (5.7%, P = 0.80) when compared to both the mean of the prior two 53-day time periods (8.4%, 5.3%, respectively) and the subsequent two respective time periods (9.0%, 4.8%, respectively). Conclusions: In our large catch-basin metropolitan region within the Southeast stroke belt, there was an overall and similar percentage decline in all code stroke activations, ELVO activations, and MT cases during the implementation of statewide mandatory stay-at-home orders. The data suggests that patients were either deferring care during stay-at-home orders despite the severity of symptoms, or there was an actual decline in stroke incidence across all severities in our region during this time period.

BackgroundM2 occlusions may result in poor outcomes and potentially benefit from endovascular therapy. Data on the rate of M2 strokes is lacking.MethodologyPatients with acute ischemic stroke discharged over a period of 3 years from a tertiary level hospital in the ‘stroke belt’ were evaluated for M2 occlusions on baseline vascular imaging. Regional and national incidence was calculated from discharge and multicounty data.ResultsThere were 2739 ICD-9 based AIS discharges. M2 occlusions in 116 (4%, 95% CI 3.5% to 5%) patients constituted the second most common occlusion site. The median National Institute of Health Stroke Scale (NIHSS) score was 12 (IQR 5–18). Good outcomes were observed in 43% (95% CI 34% to 53%), poor outcomes in 57% (95% CI 47% to 66%), and death occurred in 27% (95% CI 19% to 37%) of patients. Receiver operating characteristics curves showed the NIHSS to be predictive of outcomes (area under the curve 0.829, 95% CI 0.745 to 0.913, p3 for NIHSS score ≥9 versus 30 (±34)cm3 for NIHSS score ConclusionM2 occlusions can present with serious neurological deficits and cause significant morbidity and mortality. Patients with M2 occlusions and higher baseline deficits (NIHSS score ≥9) may benefit from endovascular therapy, thus potentially expanding the category of acute ischemic strokes amenable to intervention.

The disparities in stroke mortality between blacks and whites, as well as the increased stroke mortality in the "stroke belt" have long been noted. The reasons for these disparities have yet to be fully explained. The association between trace element status and cardiovascular diseases, including stroke, has been suggested as a possible contributor to the disparities in stroke mortality but has not been fully explored. The purpose of this study is to investigate distributions of four trace elements (arsenic, mercury, magnesium, and selenium) in the environment in relation to stroke risk. The study population (N=27,770) is drawn from the Reasons for Geographic and Racial Disparities in Stroke (REGARDS) cohort. Environmental distribution of each trace element was determined using data from the United States Geological Survey (USGS) and was categorized in quartiles. A proportional hazards model, adjusted for demographic data and stroke risk factors, was used to examine the association of interest. The results showed that higher selenium levels in the environment were associated with increased stroke risk, and the hazard ratio for the 4th quartile compared to the 1st quartile was 1.33 (95% CI: 1.09, 1.62). However, there was no statistically significant relationship between environmental arsenic, mercury or magnesium and the risk of stroke. Because of dietary and non-dietary exposure as well as bioavailability, further research using biomarkers is warranted to examine the association between these trace elements and the risk of stroke.

Introduction: Delays in recognizing stroke during pre-hospital emergency medical system (EMS) care may affect triage and transport time to an appropriate stroke ready hospital and may preclude patients from receiving time dependent treatment. All EMS transports in a large urban area in the stroke belt were evaluated for transport destinations, triage and transport time and stroke recognition following distribution ofan educational training video to local EMS services. Hypothesis: Following video training, local paramedics will improve stroke recognition and shorten triage and transport time to appropriate stroke centers of care. Methods: A training module (

Background: Telestroke improves care to geographically isolated populations. The “Stroke Belt”, defined by stroke mortality and hospitalization data, persists across large rural parts of southern U.S. Using CDC data, we evaluated the impact of 10 variables on stroke outcome within Virginia by county (VA). We hypothesize that economic factors in addition to poor access to a PSC, result in worse stroke outcomes . By introducing better-targeted low cost telestroke services , AIS burden could be reduced. Methods: Data from the 2015 CDC Stroke & Heart Atlas, and FCC, on broadband access, proximity to PSC, PCP supply, socio-demographics (income/unemployment/rural-population/lack of HS education) and HTN death, were analyzed for the outcome metrics: hospitalizations and mortality. Using 3 analytic approaches we developed a “Community Need Index” by ranking and categorizing each of 10 independent variables to identify counties with the most deleterious series of inputs, then ranked and mapped the results. Using the Kruskal-Wallis test we determined the relationship between the independent and dependent variables to identify predictors of negative outcomes. Using ArcGIS we layered 30min drive times to the nearest PSC over the map of VA stroke M&M. Results: SC VA had the greatest burden of stroke disease and lack of resources, exceeding the long recognized Appalachian region as the most disadvantaged region within the VA Stroke Belt. The strongest predictors of stroke M&M were low income, unemployment, lack of HS education, and deaths from HTN (p=0.00). Broadband availability and PCP ratio, had lower or no correlation (respectively). Approx. 20% of the VA pop. (1.5mil) reside &gt 30min from a PSC, with a high proportion in SC Va. Conclusions: Poverty, low employment/income, and minimal education are strongly correlated with poorer stroke outcomes. We present a novel objective state-wide mapping model for stroke M&M which includes critical economic/educational factors to better guide state & federal healthcare & economic investments within the state. Low cost telestroke services could be provided by all major U.S. state hospitals to ameliorate these gaps, particularly as FCC broadband services are expanding in rural U.S. regions.

Background: The stroke belt has a higher stroke mortality rate compared to other regions of the United States with Alabama recording about 3,000 deaths yearly. The University of Alabama at Birmingham (UAB) is the only comprehensive stroke center (CSC) in Alabama equipped to manage the most complex stroke patients. Objective: The purpose of this study was to determine the characteristics and prognosis of patients transferred to a comprehensive stroke center in the stroke belt. Methods: Data was abstracted from the electronic health records of patients admitted to the stroke service between 2016 and 2018. We assessed differences between transfer and non-transfer patients in terms of demographics, stroke severity, insurance, administration of alteplase (t-PA) and thrombectomy (IA). We also evaluated the relationship between the Alabama state stroke designation of the originating hospital including non-stroke centers (level 0), acute stroke ready hospitals, ASRH (level 3), primary stroke centers, PSC (level 2) and direct admissions to UAB (level 1) and characteristics and prognosis of patients. Results: 1107 patients were assessed for the study with 402(36%) being transfers. Race, NIHSS,TPA and IA use, discharge disposition were associated with the level of stroke center, as shown in the table. Level 2 centers transferred patients with more severe strokes, and a higher proportion of TPA and IA use. Non-transfer patients had the best outcome with Home as their primary discharge location compared to patients transferred from level 2 stroke centers. Conclusion: About 36% of our stroke discharge volume is a result of patients transferred to UAB from outside hospitals. We conclude that Level 2 stroke centers are appropriately transferring patients with more severe stroke to CSCs compared to transfers from non-stroke centers and acute stroke ready hospitals. Some of the patients transferred to a CSC from non-stroke centers and ASRHs could be managed at PSCs.

Background: Clinical and geospatial differences in acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH) patients within stroke belt region mobile stroke units (MSU) have not been described. We sought to understand presentation differences in the Mid-South. Methods: Consecutive MSU patients were analyzed for demographic, call, and clinical characteristics. Cases were geocoded, spatially joined to zip code shapefile with raw counts normalized to population; incidence rates were calculated and symbolized by mathematical natural breaks. Results: 292 AIS and 29 ICHs were transported in 52 weeks; age was similar (ICH 63 + 15 vs. AIS 64 + 15), cases were mostly female (ICH 64%; AIS 60%), with African Americans (AA) significantly more likely to have AIS (74%) compared to ICH (64%; p=0.023). Median ICH NIHSS was significantly higher (median 9.5, IQR 5.5-17) then AIS NIHSS (median 5, IQR 2-9; p+ 37mmHg vs. AIS 159 + 35mmHg; p+ 21mmHg vs. AIS 91 + 21mmHg; p=0.003). ICH patients were significantly more likely to be treated within the first 60 minutes of symptom onset (p Conclusions: Mid-South ICH MSU patients have surprisingly different demographics than National data, and were most commonly female, but less likely to be of AA. A discreet geospatial ICH pattern was identified for high ICH risk.

Aims A recently described phenomenon is that of myocardial infarction (MI) events that meet criteria for MI, but that have very low peak troponin elevations, so-called ‘microsize MI’. These events are very common and associated with increased risk of all-cause mortality. Our aim is to compare risk factors for microsize MI vs. usual MI events. Methods and results Among 24 470 participants of the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort free of coronary heart disease at baseline, heart-related hospitalizations were expert adjudicated for MI using published guidelines. Myocardial infarctions were classified as microsize MI (peak troponin Conclusion The similarities in risk profiles suggest a possible common aetiology and should encourage clinicians to both treat reversible risk factors for microsize MI and to initiate secondary prevention strategies following these events until this emerging clinical entity is better understood. Future studies should further assess the clinical outcomes of these two entities and their effect on future management.

Background and Purpose— The stroke belt is described as an 8-state region with high stroke mortality across the southeastern United States. Using spatial statistics, we identified clusters of high stroke mortality (hot spots) and adjacent areas of low stroke mortality (cool spots) for US counties and evaluated for regional differences in county-level risk factors. Methods— A cross-sectional study of stroke mortality was conducted using Multiple Cause of Death data (Centers for Disease Control and Prevention) to compute age-adjusted adult stroke mortality rates for US counties. Local indicators of spatial association statistics were used for hot-spot mapping. County-level variables were compared between hot and cool spots. Results— Between 2008 and 2010, there were 393 121 stroke-related deaths. Median age-adjusted adult stroke mortality was 61.7 per 100 000 persons (interquartile range=51.4–74.7). We identified 705 hot-spot counties (22.4%) and 234 cool-spot counties (7.5%); 44.5% of hot-spot counties were located outside of the stroke belt. Hot spots had greater proportions of black residents, higher rates of unemployment, chronic disease, and healthcare utilization, and lower median income and educational attainment. Conclusions— Clusters of high stroke mortality exist beyond the 8-state stroke belt, and variation exists within the stroke belt. Reconsideration of the stroke belt definition and increased attention to local determinants of health underlying small area regional variability could inform targeted healthcare interventions.

Contrary to commonly held views, children do not recover better than adults after a stroke.1 The lifelong individual, family, and societal burden of stroke is likely to be greater than in adults because infants and children surviving stroke face many more years living with disability. The key difference between children and adults is that childhood stroke (occurring during the perinatal period and beyond) results primarily in a changed ability to achieve, rather than lose, functional independence. The extent and severity of deficits across motor, sensory, cognitive, social, and behavioral domains may not be apparent in the short-term after stroke, particularly in newborns and preschool children, who typically grow into their deficits.2,3 The World Health Organization’s International Classification of Functioning (ICF), Disability, and Health can be applied to childhood stroke to describe its impact across health domains, including impairment in body structures and functions, activity limitations and participation restrictions at individual, institutional and social levels. This review will focus on childhood stroke, defined as stroke from 1 month to 18 years of age, and where possible use the ICF framework to describe outcome after arterial ischemic stroke (AIS) and hemorrhagic stroke (HS). ### Mortality After Childhood Stroke Stroke is among the top 10 causes of death in the pediatric population. The reported mortality for AIS ranges from 7% to 28%1,4 and from 6% to 54% for HS.5 In the US study reporting stroke mortality during a 10-year period from 1979 to 1998, 4881 deaths could be attributed to childhood stroke, giving average annual mortality rates of 0.09 per 100 000 person-years for AIS 0.14 for intracerebral hemorrhage and 0.11 for subarachnoid hemorrhage.6 Risk of death was higher in infants, males, blacks, and children living in the South-Eastern Stroke belt States.6,7 Declining mortality rates have …

Background Diabetes prevalence and incidence vary by neighborhood socioeconomic environment (NSEE) and geographic region in the United States. Identifying modifiable community factors driving type 2 diabetes disparities is essential to inform policy interventions that reduce the risk of type 2 diabetes. Objective This paper aims to describe the Diabetes Location, Environmental Attributes, and Disparities (LEAD) Network, a group funded by the Centers for Disease Control and Prevention to apply harmonized epidemiologic approaches across unique and geographically expansive data to identify community factors that contribute to type 2 diabetes risk. Methods The Diabetes LEAD Network is a collaboration of 3 study sites and a data coordinating center (Drexel University). The Geisinger and Johns Hopkins University study population includes 578,485 individuals receiving primary care at Geisinger, a health system serving a population representative of 37 counties in Pennsylvania. The New York University School of Medicine study population is a baseline cohort of 6,082,146 veterans who do not have diabetes and are receiving primary care through Veterans Affairs from every US county. The University of Alabama at Birmingham study population includes 11,199 participants who did not have diabetes at baseline from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, a cohort study with oversampling of participants from the Stroke Belt region. Results The Network has established a shared set of aims: evaluate mediation of the association of the NSEE with type 2 diabetes onset, evaluate effect modification of the association of NSEE with type 2 diabetes onset, assess the differential item functioning of community measures by geographic region and community type, and evaluate the impact of the spatial scale used to measure community factors. The Network has developed standardized approaches for measurement. Conclusions The Network will provide insight into the community factors driving geographical disparities in type 2 diabetes risk and disseminate findings to stakeholders, providing guidance on policies to ameliorate geographic disparities in type 2 diabetes in the United States. International Registered Report Identifier (IRRID) DERR1-10.2196/21377

Background Dietary patterns represent a broad picture of food and nutrient consumption and may be more predictive of health outcomes than individual foods and nutrients. Objective We investigated the relations among race, gender, family structure, parental socioeconomic status (SES), dietary patterns, and cardiovascular disease (CVD) profiles among adolescents in the southeastern region of the United States. Methods A total of 743 adolescents from a cross-sectional study were divided into 4 dietary pattern groups by K-means cluster analysis. Multinomial logistic regression was performed to determine the relations among the parental SES, family structures, and dietary patterns of the adolescents. Associations between dietary patterns and CVD profiles were analyzed by multiple linear regression. Results Four dietary patterns were derived: “healthy” (17%), “snacks and sweets” (26%), “processed meat” (20%), and “sugar-sweetened beverage (SSB) and fried food” (37%). Whites and females were more likely to have a “healthy” dietary pattern (Ps