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Mild traumatic brain injury (mTBI) and occupational blast exposure in military Service Members may lead to impaired brain waste clearance which increases neurological disease risk. Perivascular spaces (PVS) are a key part of the glymphatic system which supports brain waste clearance, preferentially during sleep. Visible PVS on clinical magnetic resonance imaging have been previously observed in patients with neurodegenerative diseases and animal neurotrauma models. The purpose of this study was to determine associations between PVS morphological characteristics, military career stage, and mTBI history in Special Operations Forces (SOF) Soldiers. Participants underwent T2-weighed neuroimaging to capture three-dimensional whole brain volumes. Segmentation was performed using a previously validated, multi-scale deep convolutional encoder-decoder neural network. Only PVS clusters within the white matter mask were quantified for analyses. Due to non-normal PVS metric distribution, non-parametric Mann-Whitney U tests were used to determine group differences in PVS outcomes. In total, 223 healthy SOF combat Soldiers (age = 33.1 ± 4.3yrs) were included, 217 reported career stage. Soldiers with mTBI history had greater PVS number (z = 2.51, P = 0.013) and PVS volume (z = 2.42, P = 0.016). In-career SOF combat Soldiers had greater PVS number (z = 2.56, P = 0.01) and PVS volume (z = 2.28, P = 0.02) compared to a baseline cohort. Mild TBI history is associated with increased PVS burden in SOF combat Soldiers that are clinically recovered from mTBI. This may indicate ongoing physiological changes that could lead to impaired waste clearance via the glymphatic system. Future studies should determine if PVS number and volume are meaningful neurobiological outcomes for neurodegenerative disease risk and if clinical interventions such as improving sleep can reduce PVS burden., (© 2024. The Author(s) under exclusive licence to Biomedical Engineering Society.)

Objective: We characterized the receipt of diabetes specialty care and management services among older adults with diabetes., Research Design and Methods: Using a 20% random sample of fee-for-service Medicare beneficiaries aged ≥65 years, we analyzed cohorts of type 1 diabetes (T1D) or type 2 diabetes (T2D) with history of severe hypoglycemia (HoH), and all other T2D annually from 2015 to 2019. Outcomes were receipt of office-based endocrinology care, diabetes education, outpatient diabetes health services, excluding those provided in primary care, and any of the aforementioned services., Results: In the T1D cohort, receipt of endocrinology care and any service increased from 25.9% and 29.2% in 2015 to 32.7% and 37.4% in 2019, respectively. In the T2D with HoH cohort, receipt of endocrinology care and any service was 13.9% and 16.4% in 2015, with minimal increases. Age, race/ethnicity, residential setting, and income were associated with receiving care., Conclusions: These findings suggest that many older adults may not receive specialty diabetes care and underscore health disparities., (© 2024 by the American Diabetes Association.)

Objective: The objective was to estimate the rural-urban differences in the receipt of prepregnancy, prenatal, and postpartum services., Methods: The authors conducted a cross-sectional data analysis using data from the Pregnancy Risk Assessment and Monitoring System from 2016 to 2018 to analyze rural-urban differences in the receipt of medical visits and care content delivery during the prepregnancy year, as well as the prenatal and postpartum periods among birthing people in the US, using survey-weighted multivariable logistic regression models., Results: Rural-dwelling birthing people were significantly less likely to attend a medical visit in the prepregnancy year or postpartum period, even when controlled for sociodemographic and clinical characteristics. Compared to their urban counterparts, they were also less likely to receive comprehensive screening and counseling in the prepregnancy and postpartum maternity phases., Conclusion: Efforts to ameliorate rural-urban differences in maternal care access and quality should explicitly adopt multilevel, systemic approaches to policy and program implementation and evaluation. Policymakers and practitioners should consider telehealth as a potential complementary tool to minimize gaps in quality of care which disproportionately impact rural-dwelling birthing people., Competing Interests: Conflicts of InterestNone declared

Background: Acute myocardial infarction (AMI) complicated by tachyarrhythmias or high-grade atrioventricular block (HAVB) may lead to increased mortality., Purpose: To evaluate the sex differences in patients with AMI complicated by tachyarrhythmias and HAVB and their associated outcomes., Materials and Methods: We analyzed the incidence rates of arrhythmias following AMI from the Acute Coronary Syndrome Israeli Survey database from 2000 to 2018. We assessed the differences in arrhythmias incidence and the associated mortality risk between men and women., Results: This cohort of 14,280 consecutive patients included 3,159 (22.1%) women and 11,121 (77.9%) men. Women were less likely to experience early ventricular tachyarrhythmia (VTA), (1.6% vs. 2.3%, p  = 0.034), but had similar rates of late VTA (2.3% vs. 2.2%, p  = 0.62). Women were more likely to experience atrial fibrillation (AF) (8.6% vs. 5.0%, p  < 0.001) and HAVB (3.7% vs. 2.3%, p  < 0.001). The risk of early VTAs was similar in men and women [adjusted Odds Ratio (aOR) = 0.76, p  = 0.09], but women had a higher risk of AF (aOR = 1.27, p  = 0.004) and HAVB (aOR = 1.30, p  = 0.03). Early [adjusted hazard ratio (aHR) = 2.84, p  < 0.001] and late VTA (aHR =- 4.59, p  < 0.001), AF (aHR = 1.52, p  < 0.001) and HAVB (aHR = 2.83, p  < 0.001) were associated with increased 30-day mortality. Only late VTA (aHR = 2.14, p  < 0.001) and AF (aHR = 1.44, p  = 0.002) remained significant in the post 30 days period., Conclusions: During AMI women experienced more AF and HAVB but fewer early VTAs than men. Early and late VTAs, AF, and HAVB were associated with increased 30-day mortality. Only late VTA and AF were associated with increased post-30-day mortality., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Alnsasra, Tsaban, Weinstein, Nasasra, Ovdat, Beigel, Orvin and Haim.)

Background: Randomized trials of continuous glucose monitoring (CGM) often estimate treatment effects using standard intent-to-treat (ITT) analyses. We explored how adjusting for CGM-measured wear time could complement existing analyses by estimating the effect of receiving and using CGM 100% of the time. Methods: We analyzed data from two 6-month CGM trials spanning diverse ages, the Wireless Innovation for Seniors with Diabetes Mellitus (WISDM) and CGM Intervention in Teens and Young Adults with Type 1 Diabetes (CITY) Studies. To adjust the ITT estimates for CGM use, as measured by wear time, we used an instrumental variable (IV) approach with the treatment assignment as an instrument. Outcomes included (1) time in range ([TIR] 70-180 mg/dL), time below range ([TBR] ≤70 mg/dL), and time above range ([TAR] ≥250 mg/dL). We estimated outcomes based on CGM use in the last 28 days of the trial and the full trial. Findings: In the WISDM study, the wear time rates over the 28-day window and full trial period were 93.1% (standard deviation [SD]: 20.4) and 94.5% (SD: 11.9), respectively. In the CITY study, the wear time rates over the 28-day window and full trial period were 82.2% (SD: 26.5) and 83.1% (SD: 21.5), respectively. IV-based estimates for the effect of CGM on TIR, TBR, and TAR suggested greater improvements in glycemic management than the ITT counterparts. The magnitude of the differences was proportional to the level of wear time observed in the trials. Interpretation: In trials of CGM use, the effect of variable wear time is non-negligible. By providing adherence-adjusted estimates, the IV approach may have additional utility for individual clinical decision-making.

Background: Dapagliflozin and empagliflozin have shown clinical benefits in patients with heart failure (HF). Their comparative monetary value remains undetermined, and we therefore sought to compare the cost-per-outcome implications of utilizing dapagliflozin versus empagliflozin to prevent cardiovascular death (CVD) in patients with HF across the spectrum of ejection fraction., Methods: We estimated the cost needed to treat (CNT) to prevent one CVD with either dapagliflozin or empagliflozin. CNT was estimated by multiplying the annualized number needed to treat (aNNT) by the annual cost of therapy. The aNNTs were calculated based on data from the DAPA-HF and DELIVER trials for dapagliflozin, and the EMPEROR-Reduced and EMPEROR-Preserved trials for empagliflozin. Drug costs were calculated as 75% of the 2022 US National Average Drug Acquisition Cost., Results: The aNNT to prevent one event of CVD was 110 (95% confidence interval [CI] 58-∞) for dapagliflozin in a pooled analysis of DAPA-HF and DELIVER versus 204 (95% CI 71-∞) for empagliflozin in a pooled analysis of the EMPEROR-Reduced and EMPEROR-Preserved trials. The annual costs of therapy were $4807 and $4992, respectively. The corresponding CNTs were $528,770 (95% CI $278,806-∞) for dapagliflozin and $1,018,368 (95% CI $354,432-∞) for empagliflozin. This remained consistent in Europe, using the price estimates in Germany, with CNT (€77,490 for dapagliflozin and €143,708 for empagliflozin)., Conclusion: In incorporating data from all four outcomes trials of sodium-glucose cotransporter 2 inhibitors, dapagliflozin provides better monetary value for preventing CVD events in patients with HF across the spectrum of ejection fraction., (© 2023. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Left ventricular assist devices (LVADs) have been increasingly used in patients with advanced heart failure, either as a destination therapy or as a bridge to heart transplant. Continuous flow (CF) LVADs have revolutionized advanced heart failure treatment. However, significant vascular pathology and complications have been linked to their use. While the newer CF-LVAD generations have led to a reduction in some vascular complications such as stroke, no major improvement was noticed in the rate of other vascular complications such as gastrointestinal bleeding. This review attempts to provide a comprehensive summary of the effects of CF-LVAD on vasculature, including pathophysiology, clinical implications, and future directions.

Food insecurity is associated with poor clinical outcomes among adults with diabetes, but associations with nonclinical outcomes, such as missed work, have not been well characterized. Our objective was to assess the associations between food insecurity, health-related missed workdays, and overnight hospitalizations. We pooled National Health Interview Survey data from the period 2011-18 to analyze food insecurity among 13,116 US adults ages 18-65 who had diabetes. Experiencing food insecurity, compared with being food secure, was associated with increased odds of reporting any health-related missed workdays, more than twice the rate of health-related missed workdays, and increased odds of overnight hospitalization within the prior twelve months. There was no significant association between food insecurity and the number of nights spent hospitalized. These findings underscore the broad impacts of food insecurity on health and wellness for working-age adults with diabetes. When weighing the costs and benefits of proposed interventions to address food insecurity, policy makers should consider potential benefits related to productivity in addition to implications for health care use.

Aims: Multidisciplinary team (MDT) management in heart failure (HF) is recommended to reduce mortality and HF hospitalization. We investigated whether an MDT in a community-based HF unit (HFU) impacted patients' healthcare utilization (HCU) and costs., Methods and Results: A retrospective cohort study was conducted among HF patients who visited at least once in a regional community-based HFU, established for ambulatory specialist care for New York Heart Association Functional Classes III and IV, between January 2012 and August 2019. HCU data were obtained from the health maintenance organization's claims data for 12 months before and after first HFU visit. Multivariable generalized estimating equation models were specified for the annual average change in total healthcare utilization and hospitalization costs. Our cohort consisted of 962 patients, of whom 843 (87.6%) completed at least 12 months of follow-up (Group A) and 119 (12.4%) died within 12 months following their first visit (Group B). Both groups were comparable regarding sex, socio-economic status, Charlson Comorbidity Index, ischaemic heart disease, and/or carotid artery disease. Those who died within 12 months were older and had more hypertension, diabetes, chronic renal disease, and malignancy. There was a significant reduction in the total average annual HCU costs of the entire study population 12 months after the first HFU visit [$12 675 (±17 210) after vs. $13 188 (±15 011) before, P = 0.014]. This was driven by a reduction in costs among patients who completed 12 months of follow-up [$11 955 (±17 352) after vs. $13 112 (±15 268) before, P < 0.001], whereas an increase in these costs was observed among patients who died during follow-up [$17 774 (±15 292) after vs. $13 728 (±13 093) before, P = 0.015]. These opposite trends stem mainly from a decrease [$3540 (±8991) after vs. $4941 (±6806) before, P < 0.001] vs. increase [$10 932 (±11 660) after vs. $6733 (±7215) before, P = 0.002] in hospitalization costs of these groups, respectively. The multivariable models revealed that patients who died within 12 months following the first visit to the HFU demonstrated a significant increase of 57% in hospitalization costs following their first visit [relative risk (RR) = 1.57, 95% confidence interval (CI): 1.20-2.05, P = 0.001], whereas there was a decrease of 34% in the hospitalization costs of patients who completed 12 months of follow-up after their first visit (RR = 0.66, 95% CI: 0.54-0.81, P < 0.001). The entire cohort demonstrated 27% decrease in hospitalization costs following their first HFU visit (RR = 0.73, 95% CI: 0.62-0.87, P < 0.001)., Conclusions: Intensification of therapy by a dedicated MDT significantly reduced healthcare utilization and costs, predominantly due to a decrease in hospitalizations., (© 2021 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Is it possible to reduce crime without exacerbating adversarial relationships between police and citizens? Community policing is a celebrated reform with that aim, which is now adopted on six continents. However, the evidence base is limited, studying reform components in isolation in a limited set of countries, and remaining largely silent on citizen-police trust. We designed six field experiments with Global South police agencies to study locally designed models of community policing using coordinated measures of crime and the attitudes and behaviors of citizens and police. In a preregistered meta-analysis, we found that these interventions led to mixed implementation, largely failed to improve citizen-police relations, and did not reduce crime. Societies may need to implement structural changes first for incremental police reforms such as community policing to succeed.

Background: Prediction of readmission and death after hospitalization for heart failure (HF) is an unmet need., Aim: We evaluated the ability of clinical parameters, NT-proBNP level and noninvasive lung impedance (LI), to predict time to readmission (TTR) and time to death (TTD)., Methods and Results: The present study is a post hoc analysis of the IMPEDANCE-HF extended trial comprising 290 patients with LVEF ≤45% and New York Heart Association functional class II-IV, randomized 1:1 to LI-guided or conventional therapy. Of all patients, 206 were admitted 766 times for HF during a follow-up of 57 ± 39 months. The normal LI (NLI), representing the "dry" lung status, was calculated for each patient at study entry. The current degree of pulmonary congestion (PC) compared with its dry status was represented by ΔLIR = ([measured LI/NLI] - 1) × 100%. Twenty-six parameters recorded during HF admission were used to predict TTR and TTD. To determine the parameter which mainly impacted TTR and TTD, variables were standardized, and effect size (ES) was calculated. Multivariate analysis by the Andersen-Gill model demonstrated that ΔLIRadmission (ES = 0.72), ΔLIRdischarge (ES = -3.14), group assignment (ES = 0.2), maximal troponin during HF admission (ES = 0.19), LVEF related to admission (ES = -0.22) and arterial hypertension (ES = 0.12) are independent predictors of TTR (p < 0.01, χ2 = 1,206). Analysis of ES showed that residual PC assessed by ∆LIRdischarge was the most prominent predictor of TTR. One percent improvement in predischarge PC, assessed by ∆LIRdischarge, was associated with a likelihood of TTR increase by 14% (hazard ratio [HR] 1.14, 95% confidence interval [CI] 1.13-1.15, p < 0.01) and TTD increase by 8% (HR 1.08, 95% CI 1.07-1.09, p < 0.01)., Conclusion: The degree of predischarge PC assessed by ∆LIR is the most dominant predictor of TTR and TTD., (© 2020 S. Karger AG, Basel.)

Background and Aim: Revascularization guidelines support routine Heart Team (HT) discussion of appropriate patients. The effect of HT on decision making and clinical outcomes has not been explored. The aim of our study is to investigate the impact of the HT on the mode and delay to revascularization., Methods: We compared data from a prospective cohort of consecutive patients with multivessel coronary artery disease (CAD) referred for HT discussion between 2016 and 2017 (HT group) with a historic control group of patients matched according to clinical and angiographic characteristics treated between 2005 and 2015 (No HT group)., Results: There were 93 patients in each group. The HT group and the No HT groups had a similar rate of ACS as well as cardiovascular risk factors and significant left ventricular (LV) dysfunction. No difference was observed in the mean Society of Thoracic Surgery score (2.5 ± 3 vs 3 ± 3; P = .32) and the mean SYNTAX score was low and similar in both groups (21 ± 6 vs 19 ± 6; P = .59). The treatment recommendations changed greatly, with 63% of patients being referred for coronary artery bypass grafting (CABG) after HT discussion but only 23% in the No HT group (P < .01). HT discussion led to a significant delay to PCI (8 ± 5 vs 1.8 ± 4 days; P = .02), while surgical revascularization times were not affected., Conclusion: HT discussion in patients with multivessel CAD was associated with an increased referral to CABG but led to a significant delay in revascularization by angioplasty. The impact of these findings on patient satisfaction and outcome should be further investigated., (© 2020 Wiley Periodicals LLC.)

Acute coronary syndrome is a precipitant of acute heart failure in a substantial proportion of cases, and the presence of both conditions is associated with a higher risk of short-term mortality compared to acute coronary syndrome alone. The diagnosis of acute coronary syndrome in the setting of acute heart failure can be challenging. Patients may present with atypical or absent chest pain, electrocardiograms can be confounded by pre-existing abnormalities, and cardiac biomarkers are frequently elevated in patients with chronic or acute heart failure, independently of acute coronary syndrome. It is important to distinguish transient or limited myocardial injury from primary myocardial infarction due to vascular events in patients presenting with acute heart failure. This paper outlines various clinical scenarios to help differentiate between these conditions and aims to provide clinicians with tools to aid in the recognition of acute coronary syndrome as a cause of acute heart failure. Interpretation of electrocardiogram and biomarker findings, and imaging techniques that may be helpful in the diagnostic work-up are described. Guidelines recommend an immediate invasive strategy for patients with acute heart failure and acute coronary syndrome, regardless of electrocardiographic or biomarker findings. Pharmacological management of patients with acute coronary syndrome and acute heart failure should follow guidelines for each of these syndromes, with priority given to time-sensitive therapies for both. Studies conducted specifically in patients with the combination of acute coronary syndrome and acute heart failure are needed to better define the management of these patients., (© 2020 European Society of Cardiology.)

Cardiogenic shock (CS) is a complex multifactorial clinical syndrome with extremely high mortality, developing as a continuum, and progressing from the initial insult (underlying cause) to the subsequent occurrence of organ failure and death. There is a large spectrum of CS presentations resulting from the interaction between an acute cardiac insult and a patient's underlying cardiac and overall medical condition. Phenotyping patients with CS may have clinical impact on management because classification would support initiation of appropriate therapies. CS management should consider appropriate organization of the health care services, and therapies must be given to the appropriately selected patients, in a timely manner, whilst avoiding iatrogenic harm. Although several consensus-driven algorithms have been proposed, CS management remains challenging and substantial investments in research and development have not yielded proof of efficacy and safety for most of the therapies tested, and outcome in this condition remains poor. Future studies should consider the identification of the new pathophysiological targets, and high-quality translational research should facilitate incorporation of more targeted interventions in clinical research protocols, aimed to improve individual patient outcomes. Designing outcome clinical trials in CS remains particularly challenging in this critical and very costly scenario in cardiology, but information from these trials is imperiously needed to better inform the guidelines and clinical practice. The goal of this review is to summarize the current knowledge concerning the definition, epidemiology, underlying causes, pathophysiology and management of CS based on important lessons from clinical trials and registries, with a focus on improving in-hospital management., (© 2020 European Society of Cardiology.)

Background: Self-care is important in chronic diseases such as heart failure. The cultural background of health care providers might influence their view on self-care behaviour and education they provide. The aim of this study was to describe health care providers' perceptions of the role of culture in self-care and how those perceptions shape their experiences and their practices., Methods: A qualitative study was performed in Israel, a country with a culturally diverse population. Data were collected using semi-structured interviews with 12 healthcare providers from different cultural backgrounds. Interviews were recorded and transcribed verbatim and analysed using content analysis., Results: Healthcare providers experienced cultural background influenced their patients' self-care behaviour. Perceived culture-specific barriers to self-care such as dietary traditions interfering with the recommended diet, willingness to undertake self-care and beliefs conflicting with medical treatment were identified. Healthcare providers described that they adapted patient education and care based on the cultural background of the patients. Shared cultural background, awareness and knowledge of differences were described as positively influencing self-care education, while cultural differences could complicate this process., Conclusions: Cultural-specific barriers for self-care were perceived by health care providers and they identified that their own cultural background shapes their experiences and their practices.

Introduction: There is no consensus regarding the natural history of rheumatic mitral stenosis (MS) among adults presenting with nonsevere disease. This study aims to describe the progression of stenosis among adult rheumatic MS patients, to identify predictive factors for progression, and to assess the incidence of complications., Methods: A retrospective cohort analysis was performed among patients with rheumatic MS treated at a single center. Eighty-five patients were included with mild to moderate MS, ≥30 years old on initial echocardiography. Demographics, medical history, echocardiographic reports over at least 10 years, and related complications were obtained from a computerized database., Results: Over a period of 13.1 ± 2.38 years, 75 patients (88%) had no significant progression in stenosis severity. The final echocardiographic assessment demonstrated 2 groups with a significant difference between them regarding the mitral valve area (1.58 ± 0.44 vs. 1.1 ± 0.26 cm2, p = 0.001) and mean valvular pressure gradient (6.27 ± 2.52 vs. 8.5 ± 2.69 mm Hg, p = 0.01). Patients with indolent MS (group A) were compared to patients with progressive disease (group B), and a higher percent of Bedouin patients were found in group B (OR 8.036, p = 0.015). No significant differences were found in other parameters. Complications including atrial fibrillation, cerebral ischemic events, and impaired right ventricle function, although frequent, were not statistically different between the groups., Conclusions: An indolent natural progression of rheumatic MS was observed in our study. Despite this finding, it still has potentially deleterious effects. Bedouin patients have a higher risk for progressive disease., (© 2020 S. Karger AG, Basel.)

Background: The most common cause of pulmonary hypertension (PH) in developed countries is left heart disease (LHD, group 2 PH). The development of PH in heart failure (HF) patients is indicative of worse outcomes., Objective: The aim of this study was to evaluate the long term outcomes of HF patients with PH in a national long-term registry., Methods: Study included 9 cardiology centers across Israel between 01/2013-01/2015, with a 12-month clinical follow-up and 24-month mortality follow-up. Patients were age ≥18 years old with HF and pre-inclusion PH due to left heart disease determined by echocardiography [estimated systolic pulmonary arterial pressure (SPAP) ≥ 50 mmHg]. Patients were categorized into 3 groups: HF with reduced (HFrEF < 40%), mid-range (HFmrEF 40-49%), and preserved (HFpEF ≥ 50%) ejection fraction., Results: The registry included 372 patients, with high prevalence of cardiovascular risk factors. Median HF duration was 4 years and 65% were in severe HF New York Heart Association (NYHA) classification ≥3. Mean systolic pulmonary artery pressure (SPAP) was 62 ± 11 mmHg. During 2-years of follow-up, 54 patients (15%) died. Univariable predictors of mortality included NYHA grade 3-4, chronic renal failure, and SPAP ≥ 65 mmHg. Severe PH was associated with mortality in HFpEF, but not HFmrEF or HFrEF, and remained significant after multivariable adjustment with an adjusted hazard ratio of 2.99, (95%CI 1.29-6.91, p = 0.010)., Conclusions: The combination of HFpEF with severe PH was independently associated with increased mortality. Currently, HFpEF patients are included with group 2 PH patients. Defining HFpEF with severe PH as a sub-class may be more appropriate, as these patients are at increased risk and deserve special consideration., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: Physical activity is an essential part of managing heart failure. However, adherence to activity recommendations is low, especially in female patients. The aim of this study was to investigate the perceptions of healthcare providers regarding sex differences in physical activity, motivation, barriers, and whether adaptations in care based on sex might be meaningful., Methods: This is a qualitative study; data were collected in semi-structured interviews with healthcare providers. The data were analysed using qualitative content analysis., Results: The major overarching theme was that healthcare providers feel that "Men and women are equal, but different". This theme was explained in terms of 7 sub-themes with associated categories, as follows: "Men and women prefer and perform different physical activity regardless of health status", "Male and female heart failure patients have different motivations for, and barriers to, being active", "Factors related to differences in physical activity and physical capacity between male and female heart failure patients", "Heart failure has more impact on physical activity and physical capacity than patient's sex", and "Tailoring activity advice for heart failure patients based on sex.", Discussion: Healthcare providers had clear opinions regarding the existence of sex differences that might affect patients' care. Several differences were identified in male and female heart failure patients in terms of physical activity. There seems to be a conflict between fear of discriminating and the value of personalizing care.

Aims: Readmissions for heart failure (HF) are a major burden. We aimed to assess whether the extent of improvement in pulmonary fluid content (ΔPC) during HF hospitalization evaluated by lung impedance (LI), or indirectly by other clinical and laboratory parameters, predicts readmissions., Methods and Results: The present study is based on pre-defined secondary analysis of the IMPEDANCE-HF extended trial comprising 266 HF patients at New York Heart Association Class II-IV and left ventricular ejection fraction ≤ 35% randomized to LI-guided or conventional therapy during long-term follow-up. Lung impedance-guided patients were followed for 58 ± 36 months and the control patients for 46 ± 34 months (P < 0.01) accounting for 253 and 478 HF hospitalizations, respectively (P < 0.01). Lung impedance, N-terminal pro-brain natriuretic peptide, weight, radiological score, New York Heart Association class, lung rales, leg oedema, or jugular venous pressure were measured at admission and discharge on each hospitalization in both groups with the difference defined as ΔPC. Average LI-assessed ΔPC was 12.1% vs. 9.2%, and time to HF readmission was 659 vs. 306 days in the LI-guided and control groups, respectively (P < 0.01). Lung impedance-based ΔPC predicted 30 and 90 day HF readmission better than ΔPC assessed by the other variables (P < 0.01). The readmission rate for HF was lower if ΔPC > median compared with ΔPC ≤ median for all parameters evaluated in both study groups with the most pronounced difference predicted by LI (P < 0.01). Net reclassification improvement analysis showed that adding LI to the traditional clinical and laboratory parameters improved the predictive power significantly., Conclusions: The extent of ΔPC improvement, primarily the LI based, during HF-hospitalization, and study group allocation strongly predicted readmission and event-free survival time., (© 2018 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of the European Society of Cardiology.)

The United States operates the world's largest refugee resettlement program. However, there is almost no systematic evidence on whether refugees successfully integrate into American society over the long run. We address this gap by drawing on linked administrative data to directly measure a long-term integration outcome: naturalization rates. Assessing the full population of refugees resettled between 2000 and 2010, we find that refugees naturalize at high rates: 66% achieved citizenship by 2015. This rate is substantially higher than among other immigrants who became eligible for citizenship during the same period. We also find significant heterogeneity in naturalization rates. Consistent with the literature on immigration more generally, sociodemographic characteristics condition the likelihood of naturalization. Women, refugees with longer residency, and those with higher education levels are more likely to obtain citizenship. National origins also matter. While refugees from Iran, Iraq, and Somalia naturalize at higher rates, those from Burma, Ukraine, Vietnam, and Liberia naturalize at lower rates. We also find naturalization success is significantly shaped by the initial resettlement location. Placing refugees in areas that are urban, have lower rates of unemployment, and have a larger share of conationals increases the likelihood of acquiring citizenship. These findings suggest pathways to promote refugee integration by targeting interventions and by optimizing the geographic placement of refugees., Competing Interests: The authors declare no conflict of interest.

This paper provides a practical clinical application of guideline recommendations relating to the inpatient monitoring of patients with acute heart failure, through the evaluation of various clinical, biomarker, imaging, invasive and non-invasive approaches. Comprehensive inpatient monitoring is crucial to the optimal management of acute heart failure patients. The European Society of Cardiology heart failure guidelines provide recommendations for the inpatient monitoring of acute heart failure, but the level of evidence underpinning most recommendations is limited. Many tools are available for the in-hospital monitoring of patients with acute heart failure, and each plays a role at various points throughout the patient's treatment course, including the emergency department, intensive care or coronary care unit, and the general ward. Clinical judgment is the preeminent factor guiding application of inpatient monitoring tools, as the various techniques have different patient population targets. When applied appropriately, these techniques enable decision making. However, there is limited evidence demonstrating that implementation of these tools improves patient outcome. Research priorities are identified to address these gaps in evidence. Future research initiatives should aim to identify the optimal in-hospital monitoring strategies that decrease morbidity and prolong survival in patients with acute heart failure., (© 2018 The Authors. European Journal of Heart Failure © 2018 European Society of Cardiology.)

Objective: We tested whether remote dielectric sensing (ReDS)-directed fluid management reduces readmissions in patients recently hospitalized for heart failure (HF)., Background: Pulmonary congestion is the most common cause of worsening HF leading to hospitalization. Accurate remote monitoring of lung fluid volume may guide optimal treatment and prevent re-hospitalization. ReDS technology is a quantitative non-invasive method for measuring absolute lung fluid volume., Methods: Patients hospitalized for acute decompensated HF were enrolled during their index admission and followed at home for 90days post-discharge. Daily ReDS readings were obtained using a wearable vest, and were used as a guide to optimizing HF therapy, with a goal of maintaining normal lung fluid content. Comparisons of the number of HF hospitalizations during ReDS-guided HF therapy were made, both to the 90days prior to enrollment and to the 90days following discontinuation of ReDS monitoring., Results: Fifty patients were enrolled, discharged, and followed at home for 76.9±26.2days. Patients were 73.8±10.3years old, 40% had LVEF above 40%, and 38% were women. Compared to the pre- and post-ReDS periods, there were 87% and 79% reductions in the rate of HF hospitalizations, respectively, during ReDS-guided HF therapy. The hazard ratio between the ReDS and the pre-ReDS period was 0.07 (95% CI [0.01-0.54] p=0.01), and between the ReDS and the post-ReDS period was 0.11 (95% CI [0.014-0.88] p=0.037)., Conclusions: These findings suggest that ReDS-guided management has the potential to reduce HF readmissions in acute decompensated HF patients recently discharged from the hospital., (Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Recent studies suggest that angiogenic imbalance during pregnancy may lead to acute peripartum cardiomyopathy (PPCM). We propose that angiogenic imbalance and residual cardiac dysfunction may exist even after recovery from PPCM., Methods and Results: Twenty-nine women at least 12 months after presentation with PPCM, who exhibited recovery of left ventricular (LV) ejection fraction (≥50%), were included in the study (mean age 35±6 years, LV ejection fraction 61.0±3.9%). The number of circulating endothelial progenitor cells (EPCs) and plasma levels of proangiogenic vascular endothelial growth factor and of soluble vascular endothelial growth factor receptor Flt1 (sFlt1) were measured. All patients underwent comprehensive cardiac function assessment, including tissue Doppler imaging and 2-dimensional (2D) strain echocardiography. All measurements were compared with healthy controls. Patients with a history of PPCM have significantly higher sFlt1 concentrations (median [25th-75th percentile]; 149.57, [63.14-177.89] versus 20.29, [15.00-53.89] pg/mL, P<0.001) and significantly decreased vascular endothelial growth factor/sFlt1 ratio (P=0.012) compared with controls, with a trend toward lower concentration of circulating CD34 + /KDR + levels. In addition, patients with PPCM had lower early velocities E' septal (9.9±2.1 versus 11.0±1.5 cm/s, P=0.02), with a significantly lower systolic velocity S' septal (7.6±1.2 versus 8.5±1.2 cm/s, P=0.003) by tissue Doppler imaging. Significantly lower LV global longitudinal (-19.1±3.3 versus -22.7±2.2%, P<0.001) and apical circumferential 2D strain (-16.6±4.9 versus -21.2±7.9, P=0.02) were present in patients with PPCM compared with controls., Conclusions: Higher concentration of sFlt1 with concomitant decreased circulating endothelial progenitor cell levels along with inappropriate attenuated vascular endothelial growth factor levels may imply an angiogenic imbalance that exists even after recovery and may thus predispose to PPCM. In addition, tissue Doppler imaging and 2D strain were able to identify residual myocardial injury in post-PPCM women with apparent recovery of LV systolic function. Both angiogenic imbalance and residual myocardial injury may play an important role in the recurrence of LV dysfunction during subsequent pregnancies., (© 2016 American Heart Association, Inc.)

Background: Previous investigations have suggested that lung impedance (LI)-guided treatment reduces hospitalizations for acute heart failure (AHF). A single-blind 2-center trial was performed to evaluate this hypothesis (ClinicalTrials.gov-NCT01315223)., Methods: The study population included 256 patients from 2 medical centers with chronic heart failure and left ventricular ejection fraction ≤35% in New York Heart Association class II-IV, who were admitted for AHF within 12 months before recruitment. Patients were randomized to a control group treated by clinical assessment and a monitored group whose therapy was also assisted by LI, and followed for at least 12 months. Noninvasive LI measurements were performed with a new high-sensitivity device. Patients, blinded to their assignment group, were scheduled for monthly visits in the outpatient clinics. The primary efficacy endpoint was AHF hospitalizations; the secondary endpoints were all-cause hospitalizations and mortality., Results: There were 67 vs 158 AHF hospitalizations during the first year (P < .001) and 211 vs 386 AHF hospitalizations (P < .001) during the entire follow-up among the monitored patients (48 ± 32 months) and control patients (39 ± 26 months, P = .01), respectively. During the follow-up, there were 42 and 59 deaths (hazard ratio 0.52, 95% confidence interval 0.35-0.78, P = .002) with 13 and 31 of them resulting from heart failure (hazard ratio 0.30, 95% confidence interval 0.15-0.58 P < .001) in the monitored and control groups, respectively. The incidence of noncardiovascular death was similar., Conclusion: Our results seem to validate the concept that LI-guided preemptive treatment of chronic heart failure patients reduces hospitalizations for AHF as well as the incidence of heart failure, cardiovascular, and all-cause mortality., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Spasm of the left main coronary artery (LM) is considered to be rare. We investigated the angiographic characteristics of the LM in patients with combined LM and disease involving additional vessels, who underwent coronary artery bypass grafting (CABG) and underwent repeat coronary angiography within 5 years of the CABG, to examine the apparent frequency of spasm of the LM on initial angiography and its possible predictors. A retrospective analysis was performed of patients who underwent coronary angiography in our institute, who were found to have significant LM stenosis and disease involving additional vessels, underwent CABG and repeat coronary angiography within 5 years of the CABG. Data on angiographic characteristics of the LM on the initial angiogram were investigated. Of 84 patients, 17 (20%) were found to have a normal LM on repeat angiography (group A), and 67 (80%) demonstrated significant stenosis (group B). The degree of LM stenosis was milder in the initial angiogram in group A than in group B (64 ± 15% vs 72 ± 14%, p = 0.047). Most patients in group A demonstrated tubular LM stenosis at initial catheterization in comparison to group B (71% vs 18%). Using multivariate analysis, the only predictor for a normal LM at repeat catheterization was found to be tubular stenosis at initial catheterization (odds ratio 123, 95% confidence interval 4.0 to 3696). In conclusion, LM coronary spasm is a common finding, particularly in those with the appearance of tubular stenosis, and it should be excluded even in patients with additional coronary disease in certain instances to prevent unnecessary CABG., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Heart failure (HF) is a progressive disorder associated with impaired quality of life, high morbidity, mortality and frequent hospitalization and affects millions of people from all around the world. Despite further improvements in HF therapy, mortality and morbidity remains to be very high. The life-long treatment, frequent hospitalization, and sophisticated and very expensive device therapies for HF also leads a substantial economic burden on the health care system. Therefore, implementation of evidence-based guideline-recommended therapy is very important to overcome its worse clinical outcomes. However, HF therapy is a long process that has many drawbacks and sometimes HF guidelines cannot answers to every question which rises in everyday clinical practice. In this paper, commonly encountered questions, overlooked points, controversial issues, management strategies in grey zone and problems arising during follow up of a HF patient in real life clinical practice have been addressed in the form of expert opinions based on the available data in the literature.

Coronary atherosclerosis is a progressive disease. We sought to determine whether this fact also applies to patients at an advanced age with normal coronary arteries (NCAs) undergoing repeat catheterization at least 5 years later. Of the 189 patients who were found to have NCAs, 154 (81%) remained with NCAs and 35 (19%) developed obstructive coronary artery disease (OCAD). Development of OCAD was observed at all ages. Isolated risk factors were not associated with the appearance of OCAD, but the combination of diabetes mellitus with age >65 years or with smoking was associated with the appearance of OCAD (P = .04 for both). In conclusion, the finding of angiographically NCAs in elderly individuals does not prevent the later development of OCAD., (© The Author(s) 2014.)

Purpose: To determine whether objective visual function, measured by swept-parameter visual evoked potential (sVEP), is preferentially degraded by neutral density filtration (NDF) in normal control and fellow eyes compared to amblyopic eyes, and to determine whether the response to NDF is a function of stimulus type, using grating and vernier stimuli., Methods: Monocular Snellen acuity and both grating and vernier sVEP responses were measured in each eye of 23 children or adolescents with amblyopia and 21 visually and neurologically normal children or adolescents. Acuity and sVEP responses were measured with and without a 2.0 log unit neutral density filter before the viewing eye., Results: Suprathreshold sVEP grating responses were more sensitive than vernier to degradation by amblyopia in the unfiltered state and to NDF-induced preferential degradation of responses from fellow and normal control eyes. For threshold measurements, on the other hand, vernier responses were more sensitive to degradation by amblyopia in the unfiltered state and to NDF-induced preferential depression. Threshold vernier responses of amblyopic eyes were paradoxically enhanced by NDF., Conclusions: Neutral density filtration causes preferential degradation of both threshold and suprathreshold sVEP responses in normal control eyes and fellow eyes of amblyopes, compared to amblyopic eyes. The degradation is stimulus specific and dependent upon whether threshold or suprathreshold responses are measured. Grating responses are more likely to identify suprathreshold abnormalities, while vernier stimuli are more likely to detect threshold abnormalities. These findings may be used to optimize the stimulus parameters and design of future studies utilizing evoked potential techniques in amblyopic subjects., (Copyright 2014 The Association for Research in Vision and Ophthalmology, Inc.)

Background: The left anterior descending artery (LAD) supplies blood to a large part of the myocardium. However, the amount of myocardium supplied varies depending on the length of the LAD and as a result, occlusion of its proximal portion may influence outcome. We investigated the prognosis of patients with anterior wall myocardial infarction as the initial presentation of coronary disease who underwent primary percutaneous coronary intervention (PPCI) in our institution due to isolated proximal LAD occlusion., Methods: We retrospectively analyzed all patients that underwent PPCI in our institution from 2002 to June 2012. The individuals who fulfilled the above criteria constituted the study group. We recorded demographic, clinical, and angiographic data as well as mortality during the study period., Results: Of 2,532 patients undergoing PPCI, 196 had isolated proximal LAD occlusion. In 112 of them (57%), the LAD wrapped around the apex (group A) and in the remaining 84 (43%), the LAD terminated at or before the apex (group B). At univariate analysis, patients in group A were found to be older (P = 0.04). Over the study period, 28% of patients in group A died in comparison to 2.4% in group B (P < 0.01). When differentiating between cardiac and non-cardiac death, both were also significantly higher in group A (P < 0.01). At multivariate analysis, the strongest predictor of death was long LAD versus shorter LAD (HR 9.1, 95% CI 1.1-76, P = 0.04)., Conclusion: Wrap-around LAD is a strong predictor of prognosis in patients with anterior wall MI undergoing PPCI to isolated proximal LAD occlusion. In addition, those with a shorter LAD have an excellent prognosis., (© 2013 Wiley Periodicals, Inc.)

There is much debate on the pathogenesis of ischemic mitral regurgitation (MR), usually related to global or regional left ventricular dysfunction or remodeling secondary to chronic ischemic changes, altering the tethering and closing forces on the mitral apparatus. There is a paucity of literature describing MR in the setting of acute ischemia. We describe a case in which the MR was dynamic and directly related to changes in coronary collateral flow.

The frequency, clinical presentation, and management of severely stenotic isolated nondominant right coronary artery (NDRCA) have not been adequately defined. We sought to do so in a large cohort of patients undergoing coronary angiography. We retrospectively analyzed all patients who underwent coronary angiography in our institute between 1995 and June 2012, looking at those with a severe lesion in the NDRCA, recording demographic, clinical, and angiographic data. Of the 43,327 patients, 35 (0.08%) were found to have a severely stenotic NDRCA as a single-vessel disease. The most common indication for catheterization was acute coronary syndrome (49%). Most of the patients were managed conservatively (66%) and the entire group had a relatively benign course, with no coronary deaths. Severe stenosis of the NDRCA as isolated disease is a very rare entity, and although most commonly presenting with acute coronary syndrome, conservative management was the usual approach.

Background: Primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI) is associated with increased bleeding complications, impacting clinical outcome. Transradial PPCI could decrease the risk of bleeding, but concerns about technical difficulties and longer reperfusion times limit its adoption., Aim and Methods: This was a retrospective comparison of reperfusion times and bleeding complications in a large cohort of STEMI patients treated by PPCI through the transradial (TR; n = 244) or transfemoral approach (TF; n = 364) from January 2005 to December 2009. Endpoints were door-to-balloon time, access-site and non-access site bleeding, as well 1-month and 1-year mortality rates., Results: Patients treated with TR-PPCI were younger than those having TF-PPCI, (57 ± 13 years vs 62 ± 13 years, respectively; P<.01), more frequently males (84% vs 73%, respectively; P<.01), and had less renal failure (9% vs 16%, respectively; P<.01) or hemodynamic compromise, ie, pulmonary edema or cardiogenic shock (1% vs 4%, respectively; P=.01). Angiographic and angioplasty characteristics, including the angiographic success rate, were similar, with the exception of a higher use of aspiration devices in the TR-PPCI group (31% vs 15%, respectively; P<.01). The door-to-balloon time was similar in both groups (76 ± 40 minutes vs 74 ± 41 minutes; P=NS). Significant lower rates of overall bleeding (6% vs 31%; P<.01), access-site bleeding (4% vs 27%; P<.01), non-access site bleeding (1% vs 3%; P=.01) and need for blood transfusion (0% vs 3%; P=.01) were observed in the TR-PPCI group. One-month (3% vs 7%; P<.05) and 1-year mortality rates (4% vs 11%; P<.05) were lower in the TR-PPCI group. Radial PCI was an independent predictor of 1-year mortality., Conclusion: TR-PPCI is feasible in STEMI patients and can be performed efficiently within the time limits recommended. This approach provides advantages in terms of reduction of bleeding that could translate into an improved clinical outcome.

Coronary embolization is a rare cause of acute myocardial infarction (AMI) and few descriptions are found in the literature. Since atrial fibrillation is a known cause of systemic embolization our aim was to investigate the incidence of globular filling defects suggesting embolization in patients presenting with atrial fibrillation (AF) and ST elevation AMI with single vessel disease. We retrospectively analyzed all patients from our data base between 2002 and 2011 (2,067 patients) presenting with AF, AMI and single vessel disease and compared them to a randomly chosen control group with AMI, single vessel disease and in sinus rhythm. Of the 14 patients meeting the above criteria, 12 had a globular filling defect at the occlusion site (86%), in comparison to only 8 of 30 in the control group (27%) (p < 0.01). The study group patients were older, more frequently female, diabetic, dyslipidemic and hypertensive and had more valvular heart disease, while patients in the control group were more often smokers. Almost all the patients in the study group were either not receiving anticoagulation or inadequately anticoagulated. Atrial fibrillation was found to be the only factor independently associated with a globular filling defect on multivariable analysis (OR 34, 95% CI: 2-72). In conclusion, a globular filling defect is a common finding in patients with AF and single vessel disease presenting with AMI, probably as a result of embolization.

Objectives: Our aim was to investigate whether collateral flow may predict myocardial blush grade (MBG) in acute myocardial infarction patients undergoing primary percutaneous coronary intervention., Background: No-reflow is a well known phenomenon associated with increased morbidity and mortality due to underperfused myocardium; therefore early prediction of no-reflow is of major importance. We have observed that in patients with good collateral filling of the infarct related artery as seen prior to primary angioplasty, the clearance of the contrast medium from the myocardium may be impaired., Methods: We retrospectively analyzed the MBG as observed by collateral filling in 81 patients and correlated it with the final MBG. Patients were divided into two groups-those with collateral MBG 0 or 1 (34) and those with myocardial blush 2 or 3 (47)., Results: Of the 34 patients in the first group 71% remained in the same MBG group after primary percutaneous coronary intervention and the rest improved. Of the 47 individuals with collateral MBG 2 or 3, 87% remained in the same group following primary percutaneous coronary intervention, and the rest deteriorated (P < 0.01 for both groups)., Conclusions: Collaterals may predict MBG in acute myocardial infarction patients undergoing primary percutaneous coronary intervention., (Copyright © 2011 Wiley Periodicals, Inc.)

Aim: We sought to characterize visual motion processing in children with cerebral visual impairment (CVI) due to periventricular white matter damage caused by either hydrocephalus (eight individuals) or periventricular leukomalacia (PVL) associated with prematurity (11 individuals)., Method: Using steady-state visually evoked potentials (ssVEP), we measured cortical activity related to motion processing for two distinct types of visual stimuli: 'local' motion patterns thought to activate mainly primary visual cortex (V1), and 'global' or coherent patterns thought to activate higher cortical visual association areas (V3, V5, etc.). We studied three groups of children: (1) 19 children with CVI (mean age 9y 6mo [SD 3y 8mo]; 9 male; 10 female); (2) 40 neurologically and visually normal comparison children (mean age 9y 6mo [SD 3y 1mo]; 18 male; 22 female); and (3) because strabismus and amblyopia are common in children with CVI, a group of 41 children without neurological problems who had visual deficits due to amblyopia and/or strabismus (mean age 7y 8mo [SD 2y 8mo]; 28 male; 13 female)., Results: We found that the processing of global as opposed to local motion was preferentially impaired in individuals with CVI, especially for slower target velocities (p=0.028)., Interpretation: Motion processing is impaired in children with CVI. ssVEP may provide useful and objective information about the development of higher visual function in children at risk for CVI., (© The Authors. Journal compilation © Mac Keith Press 2011.)

Objectives: Angioplasty of a stenosis at the ostium of a diagonal branch of the left anterior descending artery as an isolated lesion often poses a dilemma due to the risk involved in treating the lesion in comparison to the potential benefit. Therefore, we sought to investigate our experience with this issue., Methods: Between 1995 and 2010, we retrospectively analyzed 39,300 patients who underwent invasive coronary angiography in our institution. Of these, a total of 22 had an isolated diagonal stenosis. The patients were either treated conservatively or underwent angioplasty and were followed for several years. Clinical and angiographic data were compared between the two groups., Results: Thirteen of the patients were treated conservatively and 9 underwent successful PCI. Baseline characteristics did not differ between the groups. The severity of the stenosis was also similar in the two groups, but in the angioplasty group, the diameter of the vessel was significantly larger (P<.01). More patients were recatheterized during the follow-up period in the conservative arm, although this did not reach statistical difference. There was no difference in mortality between the two groups., Conclusions: Initial conservative medical approach is a reasonable approach in treating isolated diagonal ostial stenosis.

Objectives: The infarct-related artery (IRA) in inferior wall myocardial infarction (IMI) may be problematic to identify due to occasional instances in which the right coronary (RCA) and left circumflex (CX) arteries are both occluded. We sought to investigate if impaired collateral myocardial blush (CMBG) identifies the correct IRA., Methods: Between 2002 and 2010, we retrospectively analyzed 1907 patients who underwent primary angioplasty at our institution. Of these, 44 had an IMI together with total occlusion of both the RCA and CX., Results: Thirty of these had good collaterals to both distal vessels. Ten of this group had impaired CMBG, indicating the IRA. In 2 patients, angioplasty was attempted in the wrong artery in retrospect., Conclusions: The correct IRA may be difficult to identify in patients with IMI and occlusion of both RCA and CX arteries. Impaired CMBG is a new tool to aid in this challenge.

CONTEXT. Although neurological toxicity from elemental mercury vapor and organic mercury exposure has been commonly reported in the literature, it is rarely reported from soft tissue injection of elemental mercury. We present a case of neurological dysfunction from subcutaneous injection of elemental mercury. CASE DETAILS. A 35-year-old Latin American man subacutely developed gait ataxia, diplopia, and vomiting 1 year after subcutaneous injection of elemental mercury, a practice common in Afro-Caribbean and Latin-American cultures. Physical examination showed an indurated plaque on his right shoulder at the injection site, left third nerve and bilateral sixth nerve palsies, nystagmus, dysarthria, and gait and limb ataxia. The patient's serum and 24-h urine mercury levels were significantly elevated; he underwent excision of the mercury reservoir and chelation with dimercaptosuccinic acid but experienced only mild improvement after 1 year. DISCUSSION. Neurological sequelae from elemental mercury, specifically cognitive dysfunction, tremor, cortical myoclonus, and peripheral neuropathy, have been reported but cranial neuropathies, ataxia, cerebrospinal fluid pleocytosis, and the presence of anti-Purkinje cell type-Tr antibody have not. Treatment involves removal of any existing mercury reservoir and chelation; however, improvement in neurological dysfunction after treatment has rarely been reported in the literature.