Search

Objective: To test the hypothesis that intracranial arterial calcification (IAC) is associated with intracranial large artery stenosis (ILAS) and a higher risk of vascular events and mortality. Method: We leveraged data from two cohorts, the New York-Presbyterian Hospital/Columbia University Irving Medical Center Stroke Registry Study (NYP/CUIMC-SRS) and the Northern Manhattan Study (NOMAS) to test our hypotheses. We measured IAC using CT scans of participants in both cohorts and expressed IAC as present (vs not) and in tertiles. For the CUIMC-SRS, demographic, clinical and ILAS status was collected retrospectively. In NOMAS, we used research brain MRI and MRA to define asymptomatic ILAS and covert brain infarcts(CBI). We built models adjusted for demographics and vascular risk factors for cross-sectional and longitudinal analyses. Results: Cross-sectionally, IAC was associated with ILAS in both cohorts (OR 1.78, 95% CI: 1.16-2.73 for ILAS-related stroke in the NYP/CUIMC-SRS and OR 3.07, 95%CI 1.13-8.35 for ILAS-related covert brain infarcts in NOMAS). In a meta-analysis of both cohorts, IAC in the upper (HR 1.25, 95%CI 1.01-1.55) and middle tertile (HR 1.27, 95%CI 1.01-1.59) was associated with higher mortality compared with participants with no IAC. There were no longitudinal associations between IAC and risk of stroke or other vascular events. Conclusion: In these multiethnic populations, IAC is associated with symptomatic and asymptomatic ILAS as well as higher mortality. IAC may be a useful marker of higher mortality, the role of IAC as an imaging marker of risk of stroke is less certain.

Background: Influenza-like illness (ILI) is an acute trigger for stroke, although joint effects of vaccinations and ILI have not yet been explored. Methods: Data for our case-control study was obtained from MarketScan Commercial Claims and Encounters between 2008 and 2014. Patients 18 to 65 years old who experienced a stroke were matched on age and admission date to a control, defined as patients with head trauma or ankle sprain at an inpatient or emergency department visit. Exposures were ILI in the prior 30 days, and any type of vaccination during the year prior. Our outcome was ischemic and intracerebral hemorrhagic strokes identified using International Classification of Diseases, Ninth Revision (ICD-9 ) codes. Logistic regression models estimated adjusted odds ratios (aORs) controlling for preventive care visits, diabetes, valvular heart disease, smoking, alcohol abuse, obesity, and hypertension. Results: We identified and matched 24 103 cases 18 to 44 years old and 141 811 45 to 65 years old. Those aged 18 to 44 years had increased stroke risk 30 days after ILI (aOR, 1.68 [95% CI, 1.51–1.86]) and reduced risk with any vaccination in the year prior (aOR, 0.92 [95% CI, 0.87–0.99]). Joint effects indicate that ILI was associated with increased stroke risk among those with (aOR, 1.41 [95% CI, 1.08–1.85]) and without (aOR, 1.73 [95% CI, 1.55–1.94]) vaccinations in the prior year ( P interaction =0.16). Among those aged 45 to 65 years, adjusted analyses indicate increased stroke risk for those with ILI (aOR, 1.32 [95% CI, 1.26–1.38]), although there was no effect of vaccinations (aOR, 1.00 [95% CI, 0.97–1.02]). Joint effects indicate that ILI was not associated with stroke among those with any vaccination (aOR, 1.07 [95% CI, 0.96–1.18]) but was associated with increased risk among those without vaccinations ([aOR, 1.39 [95% CI, 1.32–1.47]; P interaction Conclusions: ILI was associated with increased stroke risk in the young and middle-aged, while vaccinations of any type were associated with decreased risk among the young. Joint effects of ILI and vaccinations indicate vaccinations can reduce the effect of ILI on stroke.

Background: Cervical artery dissection (CeAD) is a leading cause of stroke in young adults. Incidence estimates may be limited by under- or overdiagnosis. Objective: We aimed to investigate if CeAD diagnosis would be higher in urban centers compared to rural regions of New York State (NYS). Methods: For this ecological study, administrative codes were used to identify CeAD discharges in the NYS Statewide Planning and Research Cooperative System (SPARCS) from 2009 to 2014. Rural Urban Commuting Area (RUCA) codes were taken from the US Department of Agriculture and included the classifications metropolitan, micropolitan, small town, and rural. Negative binomial models were used to calculate effect estimates and 95% confidence limits (eβ; 95% CL) for the association between RUCA classification and the number of dissections per ZIP code. Models were further adjusted by population. Results: Population information was obtained from the US Census Bureau on 1,797 NYS ZIP codes (70.7% of NYS ZIP codes), 826 of which had at least 1 CeAD-related discharge from 2009 to 2014. Nonrural ZIP codes were more likely to report more CeAD cases relative to rural areas even after adjusting for population (metropolitan effect = eβ 5.00; 95% CI: 3.75–6.66; micropolitan effect 3.02; 95% CI: 2.16–4.23; small town effect 2.34; 95% CI: 1.58–3.47). Conclusions: CeAD diagnosis correlates with population density as defined by rural-urban status. Our results could be due to underdiagnosis in rural areas or overdiagnosis with increasing urbanicity.

Long-term exposure to air pollution has been associated with changes in levels of several metabolites measured in the peripheral blood. However, most work has been conducted in ethnically homogenous populations. We studied the relationship between the plasma metabolome and long-term exposure to three air pollutants: particulate matter (PM) less than 2.5 µm in aero diameter (PM2.5), PM less than 10 µm in aero diameter (PM10) and nitrogen dioxide (NO2) among 107 participants of the Washington Heights and Inwood Community Aging Project (WHICAP) in New York City. Plasma metabolomic profiles were generated using untargeted liquid chromatography coupled with high-resolution mass spectrometry. We estimated the association between each metabolic feature and predicted annual mean exposure to the air pollutants using three approaches: 1. A metabolome wide association study (MWAS) framework; 2. Feature selection using elastic net regression; and 3. A multivariate approach using partial least squares discriminant analysis. Additionally, we identified the pathways enriched by metabolic features associated with exposure through pathway analysis. The samples were collected from 1995 – 2015 and included non-Hispanic white, Caribbean Hispanic, and non-Hispanic Black older adults. Through the MWAS, we found 79 features associated with exposure to PM2.5(false discovery rate at 5%) but none associated with PM10or NO2. Pathway analysis revealed that PM2.5exposure was associated with altered amino acid metabolism, energy production, and oxidative stress response. Six features were found to be associated with PM2.5exposure through all three approaches, annotated as: cysteinylglycine disulfide, a diglyceride, and a dicarboxylic acid. Additionally, we found that the relationship between several features and PM2.5exposure was modified by diet and metabolic diseases. These signals, identified in a neighborhood-representative older population, could help understand the mechanisms through which PM2.5exposure can lead to altered metabolic outcomes in an older population.HIGHLIGHTSLong-term exposure to PM2.5is associated with altered plasma metabolic features in an aging populationThese associations are modified by a dementia diagnosis, history of diabetes, APOE-ε4 allele, and dietPathways related to energy production, amino acid metabolism, and redox homeostasis are associated with exposure to PM2.5GRAPHICAL ABSTRACT

Despite recent advances in treatment and prevention, stroke remains a leading cause of morbidity and mortality. There is a critical need to identify novel modifiable risk factors for disease, including environmental agents. A body of evidence has accumulated suggesting that elevated levels of ambient air pollutants may not only trigger cerebrovascular events in susceptible people (short-term exposures) but also increase the risk of future events (long-term average exposures). This review assesses the updated evidence for both short and long-term exposure to ambient air pollution as a risk factor for stroke incidence and outcomes. It discusses the potential pathophysiologic mechanisms and makes recommendations to mitigate exposure on a personal and community level. The evidence indicates that reduction in air pollutant concentrations represent a significant population-level opportunity to reduce risk of cerebrovascular disease.

Systemic racism leads to racial/ethnic residential segregation, which can result in health inequities. We examined if the associations between residential segregation and later-life cognition and dementia differed based on segregation measure and by participant race/ethnicity. Tests of memory (n = 4616), language (n = 4333), visuospatial abilities (n = 4557), and incident dementia (n = 4556) were analyzed in older residents of Northern Manhattan, New York (mean age: 75.7 years). Segregation was measured at the block group-level using three indices: dissimilarity, isolation, and interaction. We fit multilevel linear or Cox proportional hazards models and included a race/ethnicity × segregation term to test for differential associations, adjusting for socioeconomic and health factors. Living in block groups with higher proportions of minoritized people was associated with −0.05 SD lower language scores. Living in block groups with higher potential contact between racial/ethnic groups was associated with 0.06–0.1 SD higher language scores. The findings were less pronounced for other cognitive domains and for incident dementia. Non-Hispanic Black adults were most likely to experience negative effects of neighborhood segregation on cognition (language and memory) and dementia. All indices partly capture downstream effects of structural racism (i.e., unequal distributions of wealth/resources) on cognition. Therefore, desegregation and equitable access to resources have the potential to improve later-life cognitive health.

BACKGROUND AND AIM: Age-related cognitive decline is a growing public health issue as increases in life expectancy and the aging of the population are expected to raise the prevalence of cognitive ...

Background and Purpose: Previous studies suggested that quality of care may be lower on weekends than during the week. We hypothesized that, among patients hospitalized for an index ischemic stroke, those admitted on weekends would have a higher risk of 30-day readmission than those admitted on weekdays. Methods: We utilized the 2013 Nationwide Readmission Database, which includes data on US inpatient admissions from the Agency for Healthcare Research and Quality Healthcare Utilization Project. The database includes a nationally representative weighted probability sample of inpatient hospitalizations regardless of insurance status. Patients with primary acute ischemic stroke were identified using previously validated ICD-9-CM diagnosis codes. We conducted a weighted analysis using survey design logistic regression models to estimate crude and adjusted odds ratios (OR) and 95% confidence intervals (95% CI) for the association between weekend admission and 30-day readmission in ischemic stroke patients. Results: Among 319,317 patients admitted for ischemic stroke, 12.1% were readmitted within 30 days. Those with 30-day readmissions had an average of 8 chronic conditions, and all cardiovascular-related comorbidities increased the risk of 30-day readmissions. Ischemic stroke patients admitted on weekends had odds of 30-day readmission similar to patients admitted on weekdays (OR 1.02; 95% CI 0.98–1.06). Weekend admission also did not affect readmission at 7 or 60 days. Conclusions: We found no association between weekend admission and 30-day readmissions, providing indirect evidence of homogeneity in the quality of care delivered during week day and weekend admissions.

Background Influenza may be associated with increased stroke and myocardial infarction (MI) risk. We hypothesized that risk of stroke and MI after influenza-like illness (ILI) would be higher in patients in New York State. We additionally assessed whether this relationship differed across a series of sociodemographic factors. Methods A case-crossover analysis of the 2012–2014 New York Statewide Planning and Research Cooperative System (SPARCS) was used to estimate odds of ischemic stroke and MI after ILI. Each patient’s case window (the time period preceding event) was compared to their control windows (same dates from the previous 2 years) in conditional logistic regression models used to estimate odds ratios and 95% confidence intervals (OR, 95% CI). We varied the case windows from 15 to 365 days preceding event as compared to control windows constructed using the same dates from the previous 2 years. Analyses were stratified by sex, race, and urban-rural status based on residential zip code. Results A total of 33,742 patients were identified as having ischemic stroke and 53,094 had MI. ILI events in the 15 days prior were associated with a 39% increase in odds of ischemic stroke (95% CI 1.09–1.77), increasing to an almost 70% increase in odds when looking at ILI events over the last year (95% CI 1.56, 1.83). In contrast, the effect of ILI hospitalization on MI was strongest in the 15 days prior (OR = 1.24, 95% CI 1.06–1.44). The risk of ischemic stroke after ILI was higher among individuals living in rural areas in the 90 days prior to stroke and among men in the year prior to event. In contrast, the association between ILI and MI varied only across race with whites having significantly higher ILI associated MI. Conclusion This study highlights risk period differences for acute cardiovascular events after ILI, indicating possible differences in mechanism behind the risk of stroke after ILI compared to the risk of MI. High risk populations for stroke after ILI include men and people living in rural areas, while whites are at high risk for MI after ILI. Future studies are needed to identify ways to mitigate these risks.

The magnitude, timing, and etiology of morbidity associated with tropical cyclones remains incompletely quantified. We examined the relative change in cause-specific emergency department (ED) visits among residents of New York City during and after Hurricane Sandy, a tropical cyclone that affected the northeastern United States in October 2012. We used quasi-Poisson constrained distributed lag models to compare the number of ED visits on and after Hurricane Sandy with all other days, 2005–2014, adjusting for temporal trends. Among residents aged ≥65 years, Hurricane Sandy was associated with a higher rate of ED visits due to injuries and poisoning (relative risk (RR) = 1.19, 95% confidence interval (CI): 1.10, 1.28), respiratory disease (RR = 1.35, 95% CI: 1.21, 1.49), cardiovascular disease (RR = 1.10, 95% CI: 1.02, 1.19), renal disease (RR = 1.44, 95% CI: 1.22, 1.72), and skin and soft tissue infections (RR = 1.20, 95% CI: 1.03, 1.39) in the first week following the storm. Among adults aged 18–64 years, Hurricane Sandy was associated with a higher rate of ED visits for renal disease (RR = 2.15, 95% CI: 1.79, 2.59). Among those aged 0–17 years, the storm was associated with lower rates of ED visits for up to 3 weeks. These results suggest that tropical cyclones might result in increased health-care utilization due to a wide range of causes, particularly among older adults.

ImportanceBlack individuals are more likely than white individuals to develop dementia. Whether higher blood pressure (BP) levels in black individuals explain differences between black and white individuals in dementia risk is uncertain.ObjectiveTo determine whether cumulative BP levels explain racial differences in cognitive decline.Design, Setting, and ParticipantsIndividual participant data from 5 cohorts (January 1971 to December 2017) were pooled from the Atherosclerosis Risk in Communities Study, Coronary Artery Risk Development in Young Adults Study, Cardiovascular Health Study, Framingham Offspring Study, and Northern Manhattan Study. Outcomes were standardized as t scores (mean [SD], 50 [10]); a 1-point difference represented a 0.1-SD difference in cognition. The median (interquartile range) follow-up was 12.4 (5.9-21.0) years. Analysis began September 2018.Main Outcomes and MeasuresThe primary outcome was change in global cognition, and secondary outcomes were change in memory and executive function.ExposuresRace (black vs white).ResultsAmong 34 349 participants, 19 378 individuals who were free of stroke and dementia and had longitudinal BP, cognitive, and covariate data were included in the analysis. The mean (SD) age at first cognitive assessment was 59.8 (10.4) years and ranged from 5 to 95 years. Of 19 378 individuals, 10 724 (55.3%) were female and 15 526 (80.1%) were white. Compared with white individuals, black individuals had significantly faster declines in global cognition (−0.03 points per year faster [95% CI, −0.05 to −0.01]; P = .004) and memory (−0.08 points per year faster [95% CI, −0.11 to −0.06]; P P P P P P = .56) and memory (−0.06 points per year [95% CI, −0.08 to −0.03]; P P Conclusions and RelevanceThese results suggest that black individuals’ higher cumulative BP levels may contribute to racial differences in later-life cognitive decline.

Introduction Non-traumatic Cervical Artery Dissection (CeAD) is a leading cause of ischemic stroke in the young. Influenza-like illnesses (ILI) trigger ischemic strokes. We hypothesized that influenza and ILI are associated with CeAD. Methods In a case-crossover study within the New York State (NYS) Department of Health Statewide Planning and Research Cooperative System (2006–2014), we used ICD-9 codes to exclude major trauma and to define CeAD, influenza, and the Centers for Disease Control defined ILI. We estimated the association of ILI and influenza with CeAD by comparing their prevalence in intervals immediately prior (0–30,0–90,0–180, and 0–365 days) to CeAD (case period) to their prevalence exactly one and two years earlier (control periods). Conditional logistic regression models generated odds ratios and 95% confidence intervals (OR, 95% CI). Models were adjusted for NYS estimates of influenza prevalence rates. Results Our sample included 3,610 cases of CeAD (mean age 52±16 years, 54.7% male, 6.2% Hispanic, 9.9% Black, 68.7% White). During case periods, 7.3% had one or more ILI. ILI was more likely within 90 days of CeAD compared to the same time interval one and two years before (0–15 days: adjusted OR 1.88, 95%CI 1.20–2.94; 0-30 days: adjusted OR 1.74, 95%CI 1.22–2.46; 0–90 days: adjusted OR 1.35, 95%CI 1.00–1.81). Influenza trended with CeAD (adjusted OR 1.86, 95%CI 0.37–9.24), but these results were not statistically significant, due to limited instances of confirmed influenza. Conclusions ILI may increase risk of CeAD for 15 days, and possibly up to three months.

Objectives: To test the hypothesis that brain arterial diameters are associated with cognitive performance, particularly in arteries supplying domain-specific territories. Methods: Stroke-free participants in the Northern Manhattan Study were invited to have a brain MRI from 2003–2008. The luminal diameters of 13 intracranial arterial segments were obtained using time-of-flight magnetic resonance angiogram (MRA), and then averaged and normalized into a global score and region-specific arterial diameters. Z-Scores for executive function, semantic memory, episodic memory and processing speed were obtained at MRI and during follow-up. Adjusted generalized additive models were used to assess for associations. Results: Among the 1034 participants with neurocognitive testing and brain MRI, there were non-linear relationships between left anterior (ACA) and middle cerebral artery (MCA) diameter and semantic memory Z-scores (χ2=10.00; DF=3; p=.019), and left posterior cerebral artery (PCA) and posterior communicating artery (Pcomm) mean diameter and episodic memory Z-scores (χ2=9.88; DF=3; p=.020). Among the 745 participants who returned for 2nd neuropsychological testing, on average 5.0±0.4 years after their MRI, semantic memory change was associated non-linearly with the left PCA/Pcomm mean diameter (χ2=13.09; DF=3; p=.004) and with the right MCA/ACA mean diameter (χ2=8.43; DF=3; p=.03). In both cross-sectional and longitudinal analyses, participants with the larger brain arterial diameters had more consistently lower Z-scores and greater decline than the rest of the participants. Conclusions: Brain arterial diameters may have downstream effects in brain function presenting as poorer cognition. Identifying the mechanisms and the directionality of such interactions may increase the understanding of the vascular contribution to cognitive impairment and dementia. (JINS, 2018, 24, 335–346)

Background: All states have enacted legislation addressing the management of sports-related concussions (SRCs) in adolescent athletes. The effect of these laws on health care utilization is uncertain. Hypothesis/Purpose: The purpose was to evaluate the effects of New York’s 2011 Concussion Management and Awareness Act (“Lystedt Law”) on emergency department (ED) concussion health care visits (EDCHVs) and brain imaging utilization. It was hypothesized that New York concussion legislation would have a significant temporal effect on EDCHVs. Study Design: Descriptive epidemiology study. Methods: Using the New York State Department of Health Statewide Planning and Research Cooperative System (SPARCS) database, trends in EDCHVs from 2005 to 2015 were identified among 12- to 18-year-old patients, comprising 5,740,403 total ED visits. Results: Overall, 208,024 EDCHVs, including 54,669 for an SRC, occurred during the study period. EDCHVs increased from 13,664 (2.74% of all ED visits) in 2005 to a peak of 21,374 (4.26%) in 2013, with greatest relative increases from 2008 to 2013. SRCs followed a similar trend: 3213 (0.64%) in 2005 to a peak of 6197 (1.24%) in 2013. Brain imaging utilization decreased by 5.3% for EDCHVs and 15.4% for SRCs (all comparisons year-by-year and for trends; P < .001). Conclusion: The period of greatest increases in EDCHVs and decreases in brain imaging utilization for SRCs preceded New York concussion legislation by several years, suggesting a minimal direct effect on emergency care–seeking behavior for concussions. Instead, increased public awareness of SRCs and imaging guidelines may have driven EDCHV trends and imaging practices.

Introduction: Gait speed is associated with multiple adverse outcomes of aging. We hypothesized that physical inactivity would be prospectively inversely associated with gait speed independently of white matter hyperintensity volume and silent brain infarcts on MRI. Methods: Participants in the Northern Manhattan Study MRI sub-study had physical activity assessed when they were enrolled into the study. A mean of 5 years after the MRI, participants had gait speed measured via a timed 5-meter walk test. Physical inactivity was defined as reporting no leisure-time physical activity. Multi-variable logistic and quantile regression was performed to examine the associations between physical inactivity and future gait speed adjusted for confounders. Results: Among 711 participants with MRI and gait speed measures (62% women, 71% Hispanic, mean age 74.1 ± 8.4), the mean gait speed was 1.02 ± 0.26 m/s. Physical inactivity was associated with a greater odds of gait speed in the lowest quartile (p = 0.005). Conclusions: Physical inactivity is associated with slower gait speed independently of osteoarthritis, grip strength, and subclinical ischemic brain injury. Modifying sedentary behavior poses a target for interventions aimed at reducing decline in mobility.

Background Mobile stroke units ( MSU s) reduce time to intravenous thrombolysis in acute ischemic stroke. Whether this advantage exists in densely populated urban areas with many proximate hospitals is unclear. Methods and Results We evaluated patients from the METRONOME (Metropolitan New York Mobile Stroke) registry with suspected acute ischemic stroke who were transported by a bi‐institutional MSU operating in Manhattan, New York, from October 2016 to September 2017. The comparison group included patients transported to our hospitals via conventional ambulance for acute ischemic stroke during the same hours of MSU operation (Monday to Friday, 9 am to 5 pm) . Our exposure was MSU care, and our primary outcome was dispatch‐to‐thrombolysis time. We estimated mean differences in the primary outcome between both groups, adjusting for clinical, demographic, and geographic factors, including numbers of nearby designated stroke centers and population density. We identified 66 patients treated or transported by MSU and 19 patients transported by conventional ambulance. Patients receiving MSU care had significantly shorter dispatch‐to‐thrombolysis time than patients receiving conventional care (mean: 61.2 versus 91.6 minutes; P =0.001). Compared with patients receiving conventional care, patients receiving MSU care were significantly more likely to be picked up closer to a higher mean number of designated stroke centers in a 2.0‐mile radius (4.8 versus 2.7, P =0.002). In multivariable analysis, MSU care was associated with a mean decrease in dispatch‐to‐thrombolysis time of 29.7 minutes (95% CI , 6.9–52.5) compared with conventional care. Conclusions In a densely populated urban area with a high number of intermediary stroke centers, MSU care was associated with substantially quicker time to thrombolysis compared with conventional ambulance care.

Objectives We aimed to determine the relation between childhood adversities and prior involvement with Child Protective Services (CPS) history among children presenting for evaluation at a Child Advocacy Center. Study design The study evaluated children presenting to a Child Advocacy Center (CAC) from 2009 to 2014. A five-item child adversity measure, based on mother’s report, was characterized into a scale of none, one, or two or more adversities. Caseworkers at the CAC assessed whether families had a prior history of involvement with CPS. Results Among the 727 children included in the analyses, 43% had a prior history of involvement with CPS. Twenty-six percent of the children experienced one childhood adversity while 29% experienced two or more. In regression analyses adjusting for socio-demographics, experiencing one (Prevalence Ratio (PR) 1.25 95%CI 1.0–1.5) or two or more adversities (PR1.67 95%CI 1.4, 2.0) was associated with higher prevalence of CPS history compared to those who reported none. Conclusions Childhood adversities are associated with prior contact with CPS, suggesting there are missed opportunities to provide services to high-risk families. CACs may be in a unique position to advocate for families and prevent further victimization of children.

Background: High blood pressure (BP), particularly in mid-life, increases the risk for late-life cognitive impairment and dementia (CID). The extent to which Blacks’ and Hispanics’ worse BP control starting in young adulthood contributes to their greater risk of CID compared to Whites is uncertain. Objective: To describe a pooled, multi-ethnic cohort created to determine the associations between BP levels over the life course and CID risk in Blacks, Hispanics, and Whites. Methods: We pooled individual-level data from 35,473 adults (22.6% Blacks, 8.1% Hispanics, 67.3% Whites, 2% Other) with baseline age ≥18 and cognitive assessments across 6 longitudinal cohorts in the United States from 1971 to 2016: Atherosclerosis Risk in Communities Study (ARIC), Coronary Artery Risk Development in Young Adults Study (CARDIA), Cardiovascular Health Study (CHS), Framingham Offspring Study (FOS), Multi-Ethnic Study of Atherosclerosis (MESA), and Northern Manhattan Study (NOMAS). We harmonized cognitive tests across studies into 3 factors representing global cognitive performance, executive function, and memory using statistically appropriate confirmatory factor analysis. Mean (SD) follow up was 17.1 (10.9) years. Results: The mean (SD) baseline age was 54.3 (16.4) years and 19554 (55.1%) participants were female (Table). There were 3193 (9.0%) first incident strokes (2651 ischemic, 348 hemorrhagic, and 117 other or undetermined type) and 15147 (42.7%) deaths. The Table presents mean BPs at the first and last visits by cohort and the pooled sample. From the initial to the last assessment, mean global cognition decreased over time (p Conclusion: This will be the first comprehensive, large investigation of the association of BP levels from young adulthood to late-life and CID risk in Blacks, Hispanics, and Whites.

Background: Mobile stroke units (MSUs) reduce time to thrombolytic treatment in acute ischemic stroke. It is unclear whether this time advantage persists in densely-populated urban areas with many readily-accessible hospitals. Methods: We collected clinical data, treatment times, numbers of nearby designated stroke centers (DSC), and distances traveled from suspected stroke patients transported by a single-institution MSU operating in Manhattan, New York from October 2016-September 2017. For comparison, we collected information on patients transported to our institution via conventional ambulance for acute stroke during the same hours of MSU operation (Monday-Friday, 9AM-5PM). Our exposure was MSU care, and our coprimary outcomes were dispatch-to-scene arrival and scene arrival-to-thrombolysis times. We estimated mean differences in each primary outcome between both groups, adjusting for clinical, demographic, and geographic factors. Results: We identified 66 patients transported by MSU, of whom 29 (44%) were treated with IV thrombolysis, and 19 patients transported by conventional ambulance, of whom 9 (48%) were treated with IV thrombolysis. Patients treated in the MSU traveled longer to accepting hospitals and were picked up closer to a greater number of DSCs in a 1 mile radius than non-MSU patients (Table). Despite longer median dispatch-to-ambulance arrival and ambulance arrival-to-hospital arrival times than non-MSU patients, MSU patients had shorter mean dispatch-to-thrombolysis and ambulance arrival-to-thrombolysis times. In multivariable analysis, MSU care was associated with a mean increase in dispatch-to-ambulance arrival time of 6.5 minutes (95% CI, 2.3-10.6) that was offset by a mean decrease in ambulance arrival-to-thrombolysis time of 42.2 minutes (95% CI, 31.1-53.4). Conclusions: In a densely populated urban area, MSU care was associated with substantially quicker time-to-thrombolysis when compared to conventional care.

Background and Purpose: Non-traumatic Cervical Artery Dissection (CeAD) is a leading cause of ischemic stroke in patients 15 to 45 years old. Influenza-like illnesses (ILI) have been found to trigger ischemic stroke, but ILI has not been investigated in relation to CeAD. We hypothesized that ILI and influenza would be associated with CeAD. Methods: We used a case-crossover design among patients > 18 years old at time of first non-traumatic CeAD within the New York State (NYS) Department of Health Statewide Planning and Research Cooperative System (2006-2014). We used ICD-9 codes to define CeAD (443.21, 443.24) excluding individuals with major trauma (integer values 800-804 and 850-854), confirmed influenza (480, 487.0, 487.1, 487.8), and a broader influenza definition endorsed by the CDC for ILI surveillance. We compared ILI and influenza in sequential, mutually exclusive intervals preceding CeAD (0-15, 16-30, 31-90, 91-180, and 181-365 days prior to CeAD: case period) and overlapping intervals (0-30, 0-90, 0-180, and 0-365 days prior to CeAD: alternate case period) to ILI and influenza exactly one and two years earlier (control periods). Conditional logistic regression models were used to calculate odds ratios and 95% confidence intervals (OR, 95% CI) before and after adjusting for annual NYS population estimates of influenza prevalence rate. Results: Our final sample included 3,861 cases of CeAD (mean age 52±16 and 55.5% of male). We found 1,736 instances of ILI and 113 of influenza during the 3 years preceding CeAD. Patients were more likely to have ILI within 30 days of CeAD compared to the same time one and two years before (0-15 days: adjusted OR 1.53, 95% CI 1.02 - 2.30; 0-30 days: adjusted OR 1.60, 95% CI 1.14 - 2.23). ILI during later overlapping or sequential intervals was not associated with CeAD in adjusted models. Influenza was associated with CeAD between 31 and 90 days after CeAD, but this effect was no longer significant after adjusting for prevalence rate of influenza, perhaps due the small number of patients with confirmed influenza. Conclusions: ILI may increase risk of CeAD for up to one month. Further research on mechanisms by which ILI and influenza may trigger dissection are warranted.

Background and Purpose: Influenza may be associated with stroke risk. We hypothesized that risk of ischemic stroke is increased after influenza-like illness (ILI), and that these effects are even greater for those in an urban environment, of Black race, and male sex. Methods: A case-crossover analysis of the 2012-2014 inpatient and outpatient New York Statewide Planning and Research Cooperative System (SPARCS) was used to estimate the odds of hospitalization for ischemic stroke after hospitalization for ILI. Each patient’s case window (the time period preceding stroke) was compared to their control windows (constructed using the same dates from the previous two years) in conditional logistic regression models used to estimate odds ratios and 95% confidence intervals (OR, 95% CI). We varied the case windows from 15 to 365 days. Analyses were stratified by urban and rural status based on residential zip code, sex, and race. Results: A total of 30,912 patients were identified as having an ischemic stroke in 2014 and included in the study (49% male, 20% Black, 84% urban, mean age 71.9 [SD 14.7] years). ILI in the 15 days before a stroke was associated with an overall increase in odds of stroke (OR=1.39, 95% CI 1.09-1.77), and this association remained over time (Table). There was no significant interaction between ILI and urbanicity (p=0.29), sex (p=0.81), or race (p=0.85). Conclusion: ILI was associated with stroke risk, but there was no evidence of race, sex or location differences in the relationship between ILI and stroke.

Increasing air pollution in low- and middle-income countries (LMICs) may be contributing to worsening respiratory health, yet to date most relevant studies have been conducted in industrialized nations. Particularly, there are few studies for India, the world’s second most populated country, and on this country’s poorest populations, who may be at the highest risk. We investigated the influence of long-term nitrogen dioxide (NO2) exposure at residential location on lung function decline over a 5-year period in a cohort of low-income adults in Mysore, Karnataka, India. In 2012–2014 and in 2017–2018, we conducted standardized interviews and performed in-home field spirometry before and after bronchodilation. We estimated annual average NO2 in 2017 based on interpolation of seasonal air pollution sampling and used linear mixed effects models with a person-specific random effect to estimate NO2 versus lung function cross-sectionally at baseline and longitudinally, adjusting for potential confounders (age at baseline, sex, smoking status, and long-term seasonality). Among healthy participants (with no COPD or asthma based on lung function tests), NO2 levels were associated with a decline in lung function pre- and post-bronchodilation (−21.7 ml [95% CI: −42.1, −1.3] for FEV1 and −22.2 ml [95% CI: −46.8, 2.3] for FVC pre-bronchodilation, −25.2 ml [95% CI: −48.4, −4.1] for FEV1 and −26.6 ml [95% CI: −51.1, −2.2] for FVC post-bronchodilation) per interquartile range (10 ppb) increase in NO2. Longitudinal impacts of air pollution on lung function were not statistically significant. Results suggest that air pollution exposure is associated with worse lung function among apparently healthy individuals among urban poor communities in India. Future studies should further characterize time-varying air pollution exposures and collect further longitudinal health data in these understudied communities.

Previous studies of exercise have focused on measuring physical activity in totality using summary statistics such as metabolic equivalent score for total intensity or total energy count. We aimed to examine the multidimensionality of leisure-time physical activity (LTPA) and to identify the specific LTPA components that were associated with cardiovascular mortality in the elderly. The Northern Manhattan Study (NOMAS) is a multiethnic prospective cohort of elderly stroke-free individuals consisting of a total of 3298 participants recruited between 1993 and 2001, with a median follow-up of 17 years. Physical activity questionnaire data were available in 3293 NOMAS participants, who were categorized into subgroups with similar exercise patterns by model-based cluster analysis. Three subgroup-defining LTPA features were identified and were considered as primary exposures in Cox proportional hazard models: frequency of activity, number of activity types (variety), and energy-to-duration ratio (EDR). We considered cardiovascular mortality and non-cardiovascular mortality as outcomes in Cox cause-specific proportional hazard models, and all-cause mortality as outcome in Cox models. A high activity frequency was associated with reduced cardiovascular mortality (hazard ratio, HR = 0.93, P = 0.03), but demonstrated no effect on non-cardiovascular death. A high EDR was associated with increased risk of cardiovascular death (HR = 1.30, P = 0.01). A high number of activity types was beneficial in reducing all-cause mortality (HR = 0.87, P = 0.01). Exercise frequency was protective against cardiovascular mortality, and a high variety of activity was protective against all-cause mortality. The performance of frequent and varied non-intense exercise in an elderly population such as ours is achievable and can reduce the risk of death.

To identify risk factors (RF) for diabetes within a multiethnic cohort and to examine whether race-ethnicity modified their effects.Participants in the Northern Manhattan Study without diabetes at baseline were studied from 1993 to 2014 (n=2430). Weibull regression models with interval censoring data were fit to calculate hazard ratios and 95% confidence intervals for incident diabetes. We tested for interactions between RF and race-ethnicity.During a mean follow-up period of 11years, there were 449 diagnoses of diabetes. Being non-Hispanic black (HR 1.69 95% CI 1.11-2.59) or Hispanic (HR 2.25 95% CI 1.48-3.40) versus non-Hispanic white, and body mass index (BMI; HR 1.34 per SD 95% CI 1.21-1.49) were associated with greater risk of diabetes; high-density lipoprotein cholesterol (HR 0.75 95% CI 0.66-0.86) was protective. There were interactions by race-ethnicity. In stratified models, the effects of BMI, current smoking, and C-reactive protein (CRP) on risk of diabetes differed by race-ethnicity (p for interaction0.05). The effects were greater among non-Hispanic whites than non-Hispanic blacks and Hispanics.Although Hispanics and non-Hispanic blacks had a greater risk of diabetes than whites, there were variations by race-ethnicity in the association of BMI, smoking, and CRP with risk of diabetes. Unique approaches should be considered to reduce diabetes as traditional RF may not be as influential in minority populations.

Background and Purpose— Long-term exposure to ambient air pollution is associated with higher risk of cardiovascular disease and stroke. We hypothesized that long-term exposure to air pollution would be associated with magnetic resonance imaging markers of subclinical cerebrovascular disease. Methods— Participants were 1075 stroke-free individuals aged ≥50 years drawn from the magnetic resonance imaging subcohort of the Northern Manhattan Study who had lived at the same residence for at least 2 years before magnetic resonance imaging. Cross-sectional associations between ambient air pollution and subclinical cerebrovascular disease were analyzed. Results— We found an association between distance to roadway, a proxy for residential exposure to traffic pollution, and white matter hyperintensity volume; however, after adjusting for risk factors, this relationship was no longer present. All other associations between pollutant measures and white matter hyperintensity volume were null. There was no clear association between exposure to air pollutants and subclinical brain infarcts or total cerebral brain volume. Conclusions— We found no evidence that long-term exposure to ambient air pollution is independently associated with subclinical cerebrovascular disease in an urban population-based cohort.

Background and Purpose— Hospitals are increasingly using 30-day readmission (30dRA) to define the quality of care and reimbursement. We hypothesized that common infections occurring during the stroke stay are associated with 30dRA. Methods— We conducted a weighted analysis of the federally managed 2013 National Readmission Database to assess the relationship between infection during a stroke hospitalization and 30dRA among ischemic stroke survivors. Ischemic stroke, common infections (defined as sepsis, pneumonia, and urinary tract infection), and comorbidities were identified using International Classification of Diseases Ninth Revision ( ICD-9 ) diagnosis codes, and intravenous tPA (tissue-type plasminogen activator) or intra-arterial therapy was identified using ICD-9 procedure codes. Survey design logistic regression models were fit to estimate crude and adjusted odds ratios and 95% CI for the association between infections and 30dRA. Results— Among 319 317 ischemic stroke patients, 12.1% were readmitted within 30 days, and 29% had an infection during their index hospitalization. Patients with infection during their stroke admission had a 21% higher odds of being readmitted than patients without any type of infection (adjusted odds ratio, 1.21; 95% CI, 1.16–1.26). The association between infection and unplanned readmission was similar with an increased odds of unplanned readmission (adjusted odds ratio, 1.23; 95% CI, 1.18–1.29). When assessing specific types of infections, only urinary tract infections were associated with 30dRA in adjusted models (odds ratio, 1.10; 95% CI, 1.04–1.16). Conclusions— In a nationally representative cohort, patients who had a common infection during their stroke hospitalization were at increased odds of being readmitted. Patients with infection may benefit from earlier poststroke follow-up or closer monitoring.

ObjectiveTo evaluate the association between long-term exposure to ambient air pollution and cognitive decline in older adults residing in an urban area.MethodsData for this study were obtained from 2 prospective cohorts of residents in the northern Manhattan area of New York City: the Washington Heights–Inwood Community Aging Project (WHICAP) and the Northern Manhattan Study (NOMAS). Participants of both cohorts received in-depth neuropsychological testing at enrollment and during follow-up. In each cohort, we used inverse probability weighted linear mixed models to evaluate the cross-sectional and longitudinal associations between markers of average residential ambient air pollution (nitrogen dioxide [NO2], fine particulate matter [PM2.5], and respirable particulate matter [PM10]) levels in the year prior to enrollment and measures of global and domain-specific cognition, adjusting for sociodemographic factors, temporal trends, and censoring.ResultsAmong 5,330 participants in WHICAP, an increase in NO2 was associated with a 0.22 SD lower global cognitive score at enrollment (95% confidence interval [CI], −0.30, −0.14) and 0.06 SD (95% CI, −0.08, −0.04) more rapid decline in cognitive scores between visits. Results were similar for PM2.5 and PM10 and across functional cognitive domains. We found no evidence of an association between pollution and cognitive function in NOMAS.ConclusionWHICAP participants living in areas with higher levels of ambient air pollutants have lower cognitive scores at enrollment and more rapid rates of cognitive decline over time. In NOMAS, a smaller cohort with fewer repeat measurements, we found no statistically significant associations. These results add to the evidence regarding the adverse effect of air pollution on cognitive aging and brain health.

Background and Purpose— Peripartum strokes during delivery admissions are rare but have high maternal morbidity. Infections have been proposed as a possible stroke trigger. We hypothesized that women who had infections diagnosed at the time of delivery admission would have higher risk of stroke during their delivery hospitalization. Methods— We conducted a case–control study using state inpatient administrative databases for California (2007–2011), Florida (2009–2011), and New York (2009–2011). Women whose admission included a vaginal or cesarean delivery, with a new diagnosis of stroke during the admission, were considered cases and were randomly matched to 3 in-state controls by age/admission year and presence and severity of hypertensive disorders of pregnancy. The primary exposure of interest was infection of any type present on admission. Secondary exposures included race/ethnicity, payer status, delivery method, and known vascular risk factors such as chronic hypertension, diabetes mellitus, smoking, alcohol abuse, hypercoagulable states, coagulopathies, and renal disease. We used multivariable conditional logistic regression to estimate the odds ratios and 95% confidence intervals for the association of infections and known vascular risk factors with stroke risk. Results— A total of 455 cases (mean age, 29.8), of whom 195 (42.9%) had hypertensive disorders of pregnancy, were matched with 1365 controls. Infection of any type present on admission increased the odds of stroke diagnosis during the admission (adjusted odds ratio, 1.74; 95% confidence interval, 1.29–2.35). Risk was higher for genitourinary infections (adjusted odds ratio, 2.56; 95% confidence interval, 1.25–5.24) and sepsis (adjusted odds ratio, 10.4; 95% confidence interval, 2.15–20.0). The association between infection and stroke during delivery admission did not differ by the presence of hypertensive disorders of pregnancy. Conclusions— Infections present on admission increased stroke risk during delivery admissions in women with and without hypertensive disorders of pregnancy. The results were driven by genitourinary infections and sepsis. Infections may be an underrecognized precipitant of peripartum stroke.

Background and Purpose— The evidence supporting the deleterious cardiovascular health effects of living near a major roadway is growing, although this association is not universal. In primary analyses, we hypothesized that residential proximity to a major roadway would be associated with incident ischemic stroke and that cardiovascular risk factors would modify that association. Methods— NOMAS (The Northern Manhattan Study) is an ongoing, population-based cohort study designed to measure cardiovascular risk factors, stroke incidence, and other outcomes in a multiethnic urban population. Recruitment occurred from 1993 to 2001 and participants are followed-up annually by telephone. Residential addresses at baseline were geocoded and Euclidean distance to nearest major roadway was estimated and categorized as in prior studies. We used Cox proportional hazard models to calculate hazard ratios and 95% confidence intervals for the association of this distance to incidence of stroke and other outcomes, adjusting for sociodemographic and cardiovascular risk factors, year at baseline, and neighborhood socioeconomic status. We assessed whether these associations varied by age, sex, smoking status, diabetes mellitus, and hypertension. Results— During a median follow-up period of 15 years (n=3287), 11% of participants were diagnosed with ischemic stroke. Participants living 400 m away. This association was more pronounced among noncurrent smokers (hazard ratio, 1.54; 95% confidence interval, 1.05–2.26) and not evident among smokers (hazard ratio, 0.69; 95% confidence interval, 0.23–2.06). There was no clear pattern of association between proximity to major roadways and other cardiovascular events including myocardial infarction, all-cause death, or vascular death. Conclusions— In this urban multiethnic cohort, we found evidence supporting that within-city variation in residential proximity to major roadway is associated with higher risk of ischemic stroke. An individual’s smoking history modified this association, with the association remaining only among participants not currently smokers.

Background and Purpose: Hospitals are increasingly utilizing 30-day readmission as a quality of care metric. We hypothesize that common infections common during the stroke stay are associated with 30-day readmission (30dRA). Methods: We conducted a weighted analysis of the federally managed 2013 National Readmission Database to assess the relationship between infection during a stroke hospitalization and 30dRA among ischemic stroke survivors. Ischemic stroke, common infections (defined as sepsis, pneumonia (PNA), and urinary tract infection (UTI)), and comorbidities were identified using ICD-9 diagnosis codes, and IV-tPA or intra-arterial therapy were identified using ICD-9 procedure codes. Survey design logistic regression models were fit to estimate crude and adjusted odds ratios (OR) and 95% confidence intervals (CI) for the association between infections and 30d-RA. Results: Of the 402042 ischemic stroke patients, 11.2% (n=45247) were readmitted within 30 days, and ~16% (n=7240) had an infection during their index hospitalization. Patients who had a common stroke infection during their stroke admission had a 36% higher odds of being readmitted than patients without any type of infection (OR 1.36, 95%CI 1.30-1.42; Figure 1). The increased odds of readmission remained after adjusting for confounders (OR 1.16, 95%CI 1.11-1.22; Figure 1). Stratifying by age, patients under 65 who had an infection during their stroke admission had an increased adjusted odds of 30d-RA (OR 1.38, 95%CI 1.28-1.49), than those over 65 (OR 1.11, 95%CI 1.06-1.17). The increased odds of readmission remained for those who had sepsis, PNA and a UTI (Figure 1), even after adjusting for covariates of interest. Conclusions: Using a nationally representative cohort we show that patients who have a common infection during their stroke stay are at increased odds of being readmitted. This presents a unique patients population who may benefit from an earlier post-stroke follow-up.

Background and Purpose: Influenza has been identified as a trigger for stroke, and prior work demonstrated a decreased risk of stroke in people vaccinated for influenza. We aimed to identify the relationship between seasonal influenza rates, stroke rates, and the year-to-year variability in influenza vaccination effectiveness (VE). Methods: Using data from 2004-2015 from the New York Department of Health Statewide Planning and Research Cooperative System (SPARCS), we removed any common temporal patterns using cross correlation functions to assess potential correlations between influenza rates and total stroke (ischemic and hemorrhagic) rates, with a sub-analysis investigating ischemic stroke and hemorrhagic stroke rates separately. Time series regression models (autoregressive integrated moving average: ARIMA) and time series forecasting systems were used to assess the interrelationship of influenza rates, stroke rates, and VE. Validated ICD-9 codes were used to identify emergency department and hospital visits for influenza and stroke, and influenza VE data for each year were available publically from the CDC. Results: In the raw data, stroke hospitalizations appeared to increase shortly after increases in influenza. The cross correlation function for all stroke yielded a significant lag of 1 month, suggesting that stroke hospitalizations increased one month after an increase in influenza presentations. Accounting for seasonality and the lag, peaks in influenza rates were significantly related to peaks in stroke hospitalizations (P=0.04). When investigating ischemic and hemorrhagic stroke separately, there appeared to be a similar but non-statistically significant relationship with a 1 month lag of both stroke subtype peaks after influenza peaks (p=0.1195 and p=0.1921, respectively). Time forecasting analysis did not support a relationship between VE and stroke hospitalization rates; however, VE estimates were based on national data presented by the CDC and may differ for New York State specifically, in addition to varying vaccination rates. Conclusion: The seasonality of stroke may be attributed to the seasonality in influenza, though influenza vaccine effectiveness was not associated with the seasonality of stroke.

Background and Purpose: We hypothesized that acute ischemic stroke (AIS) patients with hospital acquired infection (HAI) would have worse outcomes than patients with an infection present on admission (IPOA) or no infection. Methods: We used the 2007-2009 California State Inpatient Database from the Health Care Utilization Project (HCUP). Patients who were over the age of 18 and hospitalized with AIS, defined by previously validated ICD-9 codes, were included. Validated ICD-9 codes for sepsis, pneumonia and urinary tract infections were used to categorize patients as having IPOA (infection diagnosed within 24 hours of admission), HAI (infection during admission), or no infection using federal guidelines. The outcomes of interest were length of hospital stay (LOS), and poor discharge outcome (discharge someplace other than home). Results: A total of 133,678 patients with diagnosis of AIS were identified; 2.6% (N=3436) had HAI, 15.1% (N=20126) had IPOA, and 82.3% (N=110026) had no infection. Mean LOS was longer for patients with HAI compared to IPOA and no infection (18.5 vs. 8.5 vs. 5.1 days: p Conclusion: IPOA and HAI were each associated with increased LOS. Even after accounting for LOS, patients with HAI had poor discharge outcomes and a higher risk of death.

Introduction: White matter hyperintensity volume (WMHV) and subclinical brain infarcts (SBI) are associated with impaired mobility, but less is known about the association of WMHV in specific brain regions. We hypothesized that anterior WMHV would be associated with lower scores on the Short Physical Performance Battery (SPPB), a well-validated mobility scale. Methods: The SPPB was measured a median of 5 years after enrollment into the Northern Manhattan MRI sub study. Volumetric distributions for WMHV in 14 brain regions as a proportion of total cranial volume were determined. Multi-variable linear regression was performed to examine the association of SBI and regional log-WMHV with the SPPB score. Results: Among 668 participants with SPPB measurements (mean 74 ± 9 years, 37% male and 70% Hispanic), the mean SPPB score was 8.2 ± 2.9. Total (beta = –0.3 per SD, p = 0.001), anterior periventricular (beta = –0.4 per SD, p = 0.001), parietal (beta = –0.2 per SD, p = 0.02) and frontal (beta = –0.3 per SD, p = 0.002) WMHVs were associated with SPPB; other WMHV and SBI were not associated with the SPPB. Conclusions: WMHV, especially in the anterior ­cerebral regions, is associated with a lower SPPB. Prevention of subclinical cerebrovascular disease is a potential target to prevent physical decline in the elderly.

Objective We hypothesized that ILI is associated with risk of incident stroke, and that the risk would be highest closest in time to the event. Methods This case‐crossover analysis utilized data obtained from the California State Inpatient Database of the Healthcare Cost and Utilization Project (HCUP). The outcome of interest was ischemic stroke. Exposure was defined as a visit to the emergency department or hospitalization for influenza‐like illness (ILI) 365, 180, 90, 30, or 15 days before stroke (risk period) or similar time intervals exactly 1 or 2 years before stroke (control period). Conditional logistic regression was used to calculate the odds ratio and 95% confidence interval (OR, 95% CI). Results In 2009, 36,975 hospitalized ischemic strokes met inclusion criteria, and of these strokes, 554 (1.5%) had at least 1 episode of ILI in the 365‐day risk period prior to their stroke. Using non‐overlapping time intervals from ILI to stroke, the odds of ischemic stroke was greatest in the first 15 days post ILI (OR: 2.88, 95% CI: 1.86–4.47). The strength of the relationship decreased as the time from ILI increased, and was no longer significant after 60 days. There was a significant interaction (P = 0.017) with age and ILI; the odds of stroke associated increased 7% with each 10‐year decrease in age (OR per 10‐year age decrease 1.07, 95% CI: 1.03–1.35). Interpretation We found that ILI increases short‐term risk of stroke, particularly in people under the age of 45, and therefore may be considered to act as a trigger for stroke.

Introduction: Age-related decline in gait and balance is a contributor to morbidity in the elderly. Subclinical cerebrovascular disease, seen on magnetic resonance imaging (MRI) as white matter hyperintensities (WMH) and silent brain infarcts (SBI), is associated with impaired mobility. Less is known about the association of WMH in specific brain regions and mobility impairment. We hypothesized that anterior WMH volume would be associated with lower scores on the Short Physical Performance Battery (SPPB), a well-validated mobility scale associated with falls and mortality in the elderly. Methods: Participants in the Northern Manhattan Study MRI cohort had the SPPB measured a median of 5 years after enrollment. The SPPB has three domains with a maximum total score of 12: gait speed, chair stands, standing balance. Volumetric distributions for WMH volume across 14 brain regions (brainstem, cerebellum, and bilateral frontal, occipital, temporal, and parietal lobes, and bilateral anterior and posterior periventricular white matter) were determined separately for each hemisphere by combining bimodal image intensity distribution and atlas based methods. Multi-variable linear regression was performed to examine the association between SBI and total and regional (frontal, parietal, occipital, temporal, anterior, posterior, and brainstem) head size-corrected WMH volumes, with the total SPPB score; models were adjusted for cardiovascular disease risk factors, osteo-arthritis, and grip strength. Results: Among 668 stroke-free participants with the SPPB available, mean age at the time of assessment was 74 ±9 years, 37% were male and 70% Hispanic; the mean SPPB score was 8.2 ± 2.9, interquartile range 7-10. Mean total WMHV was 0.55±0.75cc, mean anterior WMH volume 0.18±0.24cc, and 12% of participants had SBI. In multi-variable models, total WMHV was associated with a lower SPPB (beta = -0.3 per SD of logWMH, p=0.004), while SBI was not (beta= -0.12, p=0.7). For regional WMH volumes, only greater anterior periventricular WMHV was associated with SPPB (beta= -0.29 per SD, p=0.009). Conclusions: White matter hyperintensities, especially in the anterior cerebral regions, are associated with a lower SPPB. Prevention of subclinical cerebrovascular disease is a potential target to prevent physical aging in the elderly.

Background and Purpose: Sepsis has been identified as a risk factor for stroke, however, the underlying mechanisms remain unclear and risk factors that may predispose a patient to an increased stroke risk post-sepsis are unknown. The study aims to identify risk factors associated with post-sepsis stroke and subsets of the population that are most vulnerable to stroke after sepsis. Methods: The 2007 - 2009 California State Inpatient Database from the Health Care Utilization Project (HCUP) was used. Patients who were over the age of 18 and hospitalized with sepsis, defined by ICD-9 codes, were included. Patients who died during their sepsis hospitalization were excluded. The outcome of interest was a primary diagnosis of stroke, including ischemic and hemorrhagic, as defined through ICD-9 codes. Associations between risk factors and stroke were analyzed using multivariable logistic regression. A composite risk score was generated to assess the accuracy of prediction among the post-sepsis population. Results: Of the 114679 patients with diagnosis of sepsis, 0.5% (N=572) had a primary diagnosis of stroke within a year of their sepsis hospitalization. Significant predictors for stroke are listed in Table 1. A score was generated from these risk factors with points assigned based on beta coefficients. The ROC for the score is 0.6840. As the composite score increases, the risk of stroke increases (OR=1.46, 95% CI 1.40-1.53 for each point increase in the score). Post-sepsis patients with a score greater than or equal to 1 (N=35773) have the highest prevalence (prevalence = 31.19%) and are more likely to have a stroke. (OR= 3.18, 95% CI 2.69, 3.76) Conclusion: Independent risk factors for stroke after sepsis include valvular diseases, congestive heart failure, coagulopathy, lymphoma, peripheral vascular diseases, pulmonary circulation disorders, and renal failure.

Introduction Quality improvement collaboratives are a popular model used to address gaps between evidence-based practice and patient care. Little is known about use of such collaboratives in emergency medical services, particularly for improving prehospital stroke care. To determine the feasibility of using this approach to improve prehospital stroke care, we conducted a pilot study of the Emergency Medical Services Stroke Quality Improvement Collaborative. Methods Seventeen Massachusetts emergency medical service agencies participated in the quality improvement collaborative pilot project. We identified 5 prehospital stroke performance measures to assess the quality of prehospital care, guide collaborative activities, and monitor change in performance over time. During learning sessions, participants were trained in quality improvement and performance measurement, analyzed performance measure results, and shared successes and challenges. Focus groups were conducted to understand participants’ experiences with the collaborative. Results Participating emergency medical service agencies collected stroke performance measures on 3,009 stroke patients during the pilot study. Adherence to 4 of 5 performance measures increased significantly over time. Participants acknowledged that the collaborative provided them with an efficient and effective framework for stroke quality improvement and peer-learning opportunities. Conclusion As evidenced in Massachusetts, quality improvement collaboratives can be an effective tool to improve prehospital stroke care. The data collected, improvements made, participation of emergency medical service agencies, and positive experiences within the collaborative support the continued use of this approach.