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Chung JW, Bang OY, Ahn K, Park SS, Park TH, Kim JG, Ko Y, Lee S, Lee KB, Lee J, Kang K, Park JM, Cho YJ, Hong KS, Nah HW, Kim DH, Cha JK, Ryu WS, Kim DE, Kim JT, Choi JC, Oh MS, Yu KH, Lee BC, Lee JS, Lee J, Park HK, Kim BJ, Han MK, Bae HJ. Air Pollution Is Associated With Ischemic Stroke via Cardiogenic Embolism. Stroke 2016; 48:17-23. [PMID: 27899751 DOI: 10.1161/strokeaha.116.015428] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 10/26/2016] [Accepted: 11/08/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE The aim of the study was to assessed the impact of short-term exposure to air pollution on ischemic stroke subtype, while focusing on stroke caused via cardioembolism. METHODS From a nationwide, multicenter, prospective, stroke registry database, 13 535 patients with acute ischemic stroke hospitalized to 12 participating centers were enrolled in this study. Data on the hourly concentrations of particulate matter <10 μm, nitrogen dioxide (NO2), sulfur dioxide (SO2), ozone (O3), and carbon monoxide (CO) were collected from 181 nationwide air pollution surveillance stations. The average values of these air pollutants over the 7 days before stroke onset from nearest air quality monitoring station in each patient were used to determine association with stroke subtype. The primary outcome was stroke subtype, including large artery atherosclerosis, small-vessel occlusion, cardioembolism, and stroke of other or undetermined cause. RESULTS Particulate matter <10 μm and SO2 concentrations were independently associated with an increased risk of cardioembolic stroke, as compared with large artery atherosclerosis and noncardioembolic stroke. In stratified analyses, the proportion of cases of cardioembolic stroke was positively correlated with the particulate matter <10 μm, NO2, and SO2 quintiles. Moreover, seasonal and geographic factors were related to an increased proportion of cardioembolic stroke, which may be attributed to the high levels of air pollution. CONCLUSIONS Our findings suggest that the short-term exposure to air pollutants is associated with cardioembolic stroke, and greater care should be taken for those susceptible to cerebral embolism during peak pollution periods. Public and environmental health policies to reduce air pollution could help slow down global increasing trends of cardioembolic stroke.
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Affiliation(s)
- Jong-Won Chung
- From the Department of Neurology (J.-W.C., O.Y.B.), Department of Pediatrics, Environmental Health Center for Atopic Diseases (K.A.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea (S.-S.P., T.H.P.); Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Republic of Korea (J.G.K., Y.K., S.L.); Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea (K.B.L.); Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea (Jun Lee); Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea (K.K., J.-M.P.); Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea (Y.-J.C., K.-S.H.); Department of Neurology, Dong-A University Hospital, Pusan, Republic of Korea (H.-W.N., D.-H.K., J.-K.C.); Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea (W.-S.R., D.-E.K.); Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K.); Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea (J.C.C.); Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.); Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea (J.S.L.); Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Juneyoung Lee); and Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.)
| | - Oh Young Bang
- From the Department of Neurology (J.-W.C., O.Y.B.), Department of Pediatrics, Environmental Health Center for Atopic Diseases (K.A.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea (S.-S.P., T.H.P.); Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Republic of Korea (J.G.K., Y.K., S.L.); Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea (K.B.L.); Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea (Jun Lee); Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea (K.K., J.-M.P.); Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea (Y.-J.C., K.-S.H.); Department of Neurology, Dong-A University Hospital, Pusan, Republic of Korea (H.-W.N., D.-H.K., J.-K.C.); Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea (W.-S.R., D.-E.K.); Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K.); Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea (J.C.C.); Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.); Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea (J.S.L.); Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Juneyoung Lee); and Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.).
| | - Kangmo Ahn
- From the Department of Neurology (J.-W.C., O.Y.B.), Department of Pediatrics, Environmental Health Center for Atopic Diseases (K.A.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea (S.-S.P., T.H.P.); Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Republic of Korea (J.G.K., Y.K., S.L.); Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea (K.B.L.); Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea (Jun Lee); Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea (K.K., J.-M.P.); Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea (Y.-J.C., K.-S.H.); Department of Neurology, Dong-A University Hospital, Pusan, Republic of Korea (H.-W.N., D.-H.K., J.-K.C.); Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea (W.-S.R., D.-E.K.); Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K.); Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea (J.C.C.); Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.); Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea (J.S.L.); Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Juneyoung Lee); and Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.)
| | - Sang-Soon Park
- From the Department of Neurology (J.-W.C., O.Y.B.), Department of Pediatrics, Environmental Health Center for Atopic Diseases (K.A.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea (S.-S.P., T.H.P.); Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Republic of Korea (J.G.K., Y.K., S.L.); Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea (K.B.L.); Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea (Jun Lee); Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea (K.K., J.-M.P.); Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea (Y.-J.C., K.-S.H.); Department of Neurology, Dong-A University Hospital, Pusan, Republic of Korea (H.-W.N., D.-H.K., J.-K.C.); Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea (W.-S.R., D.-E.K.); Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K.); Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea (J.C.C.); Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.); Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea (J.S.L.); Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Juneyoung Lee); and Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.)
| | - Tai Hwan Park
- From the Department of Neurology (J.-W.C., O.Y.B.), Department of Pediatrics, Environmental Health Center for Atopic Diseases (K.A.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea (S.-S.P., T.H.P.); Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Republic of Korea (J.G.K., Y.K., S.L.); Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea (K.B.L.); Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea (Jun Lee); Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea (K.K., J.-M.P.); Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea (Y.-J.C., K.-S.H.); Department of Neurology, Dong-A University Hospital, Pusan, Republic of Korea (H.-W.N., D.-H.K., J.-K.C.); Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea (W.-S.R., D.-E.K.); Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K.); Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea (J.C.C.); Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.); Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea (J.S.L.); Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Juneyoung Lee); and Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.)
| | - Jae Guk Kim
- From the Department of Neurology (J.-W.C., O.Y.B.), Department of Pediatrics, Environmental Health Center for Atopic Diseases (K.A.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea (S.-S.P., T.H.P.); Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Republic of Korea (J.G.K., Y.K., S.L.); Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea (K.B.L.); Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea (Jun Lee); Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea (K.K., J.-M.P.); Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea (Y.-J.C., K.-S.H.); Department of Neurology, Dong-A University Hospital, Pusan, Republic of Korea (H.-W.N., D.-H.K., J.-K.C.); Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea (W.-S.R., D.-E.K.); Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K.); Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea (J.C.C.); Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.); Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea (J.S.L.); Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Juneyoung Lee); and Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.)
| | - Youngchai Ko
- From the Department of Neurology (J.-W.C., O.Y.B.), Department of Pediatrics, Environmental Health Center for Atopic Diseases (K.A.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea (S.-S.P., T.H.P.); Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Republic of Korea (J.G.K., Y.K., S.L.); Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea (K.B.L.); Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea (Jun Lee); Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea (K.K., J.-M.P.); Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea (Y.-J.C., K.-S.H.); Department of Neurology, Dong-A University Hospital, Pusan, Republic of Korea (H.-W.N., D.-H.K., J.-K.C.); Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea (W.-S.R., D.-E.K.); Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K.); Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea (J.C.C.); Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.); Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea (J.S.L.); Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Juneyoung Lee); and Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.)
| | - SooJoo Lee
- From the Department of Neurology (J.-W.C., O.Y.B.), Department of Pediatrics, Environmental Health Center for Atopic Diseases (K.A.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea (S.-S.P., T.H.P.); Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Republic of Korea (J.G.K., Y.K., S.L.); Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea (K.B.L.); Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea (Jun Lee); Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea (K.K., J.-M.P.); Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea (Y.-J.C., K.-S.H.); Department of Neurology, Dong-A University Hospital, Pusan, Republic of Korea (H.-W.N., D.-H.K., J.-K.C.); Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea (W.-S.R., D.-E.K.); Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K.); Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea (J.C.C.); Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.); Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea (J.S.L.); Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Juneyoung Lee); and Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.)
| | - Kyung Bok Lee
- From the Department of Neurology (J.-W.C., O.Y.B.), Department of Pediatrics, Environmental Health Center for Atopic Diseases (K.A.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea (S.-S.P., T.H.P.); Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Republic of Korea (J.G.K., Y.K., S.L.); Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea (K.B.L.); Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea (Jun Lee); Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea (K.K., J.-M.P.); Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea (Y.-J.C., K.-S.H.); Department of Neurology, Dong-A University Hospital, Pusan, Republic of Korea (H.-W.N., D.-H.K., J.-K.C.); Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea (W.-S.R., D.-E.K.); Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K.); Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea (J.C.C.); Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.); Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea (J.S.L.); Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Juneyoung Lee); and Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.)
| | - Jun Lee
- From the Department of Neurology (J.-W.C., O.Y.B.), Department of Pediatrics, Environmental Health Center for Atopic Diseases (K.A.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea (S.-S.P., T.H.P.); Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Republic of Korea (J.G.K., Y.K., S.L.); Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea (K.B.L.); Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea (Jun Lee); Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea (K.K., J.-M.P.); Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea (Y.-J.C., K.-S.H.); Department of Neurology, Dong-A University Hospital, Pusan, Republic of Korea (H.-W.N., D.-H.K., J.-K.C.); Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea (W.-S.R., D.-E.K.); Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K.); Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea (J.C.C.); Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.); Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea (J.S.L.); Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Juneyoung Lee); and Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.)
| | - Kyusik Kang
- From the Department of Neurology (J.-W.C., O.Y.B.), Department of Pediatrics, Environmental Health Center for Atopic Diseases (K.A.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea (S.-S.P., T.H.P.); Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Republic of Korea (J.G.K., Y.K., S.L.); Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea (K.B.L.); Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea (Jun Lee); Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea (K.K., J.-M.P.); Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea (Y.-J.C., K.-S.H.); Department of Neurology, Dong-A University Hospital, Pusan, Republic of Korea (H.-W.N., D.-H.K., J.-K.C.); Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea (W.-S.R., D.-E.K.); Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K.); Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea (J.C.C.); Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.); Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea (J.S.L.); Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Juneyoung Lee); and Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.)
| | - Jong-Moo Park
- From the Department of Neurology (J.-W.C., O.Y.B.), Department of Pediatrics, Environmental Health Center for Atopic Diseases (K.A.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea (S.-S.P., T.H.P.); Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Republic of Korea (J.G.K., Y.K., S.L.); Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea (K.B.L.); Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea (Jun Lee); Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea (K.K., J.-M.P.); Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea (Y.-J.C., K.-S.H.); Department of Neurology, Dong-A University Hospital, Pusan, Republic of Korea (H.-W.N., D.-H.K., J.-K.C.); Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea (W.-S.R., D.-E.K.); Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K.); Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea (J.C.C.); Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.); Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea (J.S.L.); Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Juneyoung Lee); and Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.)
| | - Yong-Jin Cho
- From the Department of Neurology (J.-W.C., O.Y.B.), Department of Pediatrics, Environmental Health Center for Atopic Diseases (K.A.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea (S.-S.P., T.H.P.); Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Republic of Korea (J.G.K., Y.K., S.L.); Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea (K.B.L.); Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea (Jun Lee); Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea (K.K., J.-M.P.); Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea (Y.-J.C., K.-S.H.); Department of Neurology, Dong-A University Hospital, Pusan, Republic of Korea (H.-W.N., D.-H.K., J.-K.C.); Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea (W.-S.R., D.-E.K.); Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K.); Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea (J.C.C.); Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.); Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea (J.S.L.); Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Juneyoung Lee); and Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.)
| | - Keun-Sik Hong
- From the Department of Neurology (J.-W.C., O.Y.B.), Department of Pediatrics, Environmental Health Center for Atopic Diseases (K.A.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea (S.-S.P., T.H.P.); Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Republic of Korea (J.G.K., Y.K., S.L.); Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea (K.B.L.); Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea (Jun Lee); Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea (K.K., J.-M.P.); Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea (Y.-J.C., K.-S.H.); Department of Neurology, Dong-A University Hospital, Pusan, Republic of Korea (H.-W.N., D.-H.K., J.-K.C.); Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea (W.-S.R., D.-E.K.); Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K.); Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea (J.C.C.); Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.); Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea (J.S.L.); Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Juneyoung Lee); and Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.)
| | - Hyun-Wook Nah
- From the Department of Neurology (J.-W.C., O.Y.B.), Department of Pediatrics, Environmental Health Center for Atopic Diseases (K.A.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea (S.-S.P., T.H.P.); Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Republic of Korea (J.G.K., Y.K., S.L.); Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea (K.B.L.); Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea (Jun Lee); Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea (K.K., J.-M.P.); Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea (Y.-J.C., K.-S.H.); Department of Neurology, Dong-A University Hospital, Pusan, Republic of Korea (H.-W.N., D.-H.K., J.-K.C.); Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea (W.-S.R., D.-E.K.); Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K.); Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea (J.C.C.); Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.); Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea (J.S.L.); Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Juneyoung Lee); and Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.)
| | - Dae-Hyun Kim
- From the Department of Neurology (J.-W.C., O.Y.B.), Department of Pediatrics, Environmental Health Center for Atopic Diseases (K.A.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea (S.-S.P., T.H.P.); Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Republic of Korea (J.G.K., Y.K., S.L.); Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea (K.B.L.); Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea (Jun Lee); Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea (K.K., J.-M.P.); Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea (Y.-J.C., K.-S.H.); Department of Neurology, Dong-A University Hospital, Pusan, Republic of Korea (H.-W.N., D.-H.K., J.-K.C.); Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea (W.-S.R., D.-E.K.); Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K.); Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea (J.C.C.); Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.); Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea (J.S.L.); Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Juneyoung Lee); and Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.)
| | - Jae-Kwan Cha
- From the Department of Neurology (J.-W.C., O.Y.B.), Department of Pediatrics, Environmental Health Center for Atopic Diseases (K.A.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea (S.-S.P., T.H.P.); Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Republic of Korea (J.G.K., Y.K., S.L.); Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea (K.B.L.); Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea (Jun Lee); Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea (K.K., J.-M.P.); Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea (Y.-J.C., K.-S.H.); Department of Neurology, Dong-A University Hospital, Pusan, Republic of Korea (H.-W.N., D.-H.K., J.-K.C.); Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea (W.-S.R., D.-E.K.); Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K.); Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea (J.C.C.); Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.); Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea (J.S.L.); Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Juneyoung Lee); and Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.)
| | - Wi-Sun Ryu
- From the Department of Neurology (J.-W.C., O.Y.B.), Department of Pediatrics, Environmental Health Center for Atopic Diseases (K.A.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea (S.-S.P., T.H.P.); Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Republic of Korea (J.G.K., Y.K., S.L.); Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea (K.B.L.); Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea (Jun Lee); Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea (K.K., J.-M.P.); Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea (Y.-J.C., K.-S.H.); Department of Neurology, Dong-A University Hospital, Pusan, Republic of Korea (H.-W.N., D.-H.K., J.-K.C.); Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea (W.-S.R., D.-E.K.); Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K.); Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea (J.C.C.); Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.); Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea (J.S.L.); Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Juneyoung Lee); and Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.)
| | - Dong-Eog Kim
- From the Department of Neurology (J.-W.C., O.Y.B.), Department of Pediatrics, Environmental Health Center for Atopic Diseases (K.A.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea (S.-S.P., T.H.P.); Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Republic of Korea (J.G.K., Y.K., S.L.); Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea (K.B.L.); Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea (Jun Lee); Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea (K.K., J.-M.P.); Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea (Y.-J.C., K.-S.H.); Department of Neurology, Dong-A University Hospital, Pusan, Republic of Korea (H.-W.N., D.-H.K., J.-K.C.); Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea (W.-S.R., D.-E.K.); Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K.); Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea (J.C.C.); Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.); Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea (J.S.L.); Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Juneyoung Lee); and Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.)
| | - Joon-Tae Kim
- From the Department of Neurology (J.-W.C., O.Y.B.), Department of Pediatrics, Environmental Health Center for Atopic Diseases (K.A.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea (S.-S.P., T.H.P.); Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Republic of Korea (J.G.K., Y.K., S.L.); Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea (K.B.L.); Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea (Jun Lee); Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea (K.K., J.-M.P.); Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea (Y.-J.C., K.-S.H.); Department of Neurology, Dong-A University Hospital, Pusan, Republic of Korea (H.-W.N., D.-H.K., J.-K.C.); Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea (W.-S.R., D.-E.K.); Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K.); Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea (J.C.C.); Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.); Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea (J.S.L.); Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Juneyoung Lee); and Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.)
| | - Jay Chol Choi
- From the Department of Neurology (J.-W.C., O.Y.B.), Department of Pediatrics, Environmental Health Center for Atopic Diseases (K.A.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea (S.-S.P., T.H.P.); Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Republic of Korea (J.G.K., Y.K., S.L.); Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea (K.B.L.); Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea (Jun Lee); Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea (K.K., J.-M.P.); Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea (Y.-J.C., K.-S.H.); Department of Neurology, Dong-A University Hospital, Pusan, Republic of Korea (H.-W.N., D.-H.K., J.-K.C.); Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea (W.-S.R., D.-E.K.); Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K.); Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea (J.C.C.); Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.); Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea (J.S.L.); Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Juneyoung Lee); and Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.)
| | - Mi-Sun Oh
- From the Department of Neurology (J.-W.C., O.Y.B.), Department of Pediatrics, Environmental Health Center for Atopic Diseases (K.A.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea (S.-S.P., T.H.P.); Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Republic of Korea (J.G.K., Y.K., S.L.); Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea (K.B.L.); Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea (Jun Lee); Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea (K.K., J.-M.P.); Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea (Y.-J.C., K.-S.H.); Department of Neurology, Dong-A University Hospital, Pusan, Republic of Korea (H.-W.N., D.-H.K., J.-K.C.); Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea (W.-S.R., D.-E.K.); Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K.); Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea (J.C.C.); Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.); Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea (J.S.L.); Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Juneyoung Lee); and Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.)
| | - Kyung-Ho Yu
- From the Department of Neurology (J.-W.C., O.Y.B.), Department of Pediatrics, Environmental Health Center for Atopic Diseases (K.A.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea (S.-S.P., T.H.P.); Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Republic of Korea (J.G.K., Y.K., S.L.); Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea (K.B.L.); Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea (Jun Lee); Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea (K.K., J.-M.P.); Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea (Y.-J.C., K.-S.H.); Department of Neurology, Dong-A University Hospital, Pusan, Republic of Korea (H.-W.N., D.-H.K., J.-K.C.); Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea (W.-S.R., D.-E.K.); Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K.); Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea (J.C.C.); Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.); Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea (J.S.L.); Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Juneyoung Lee); and Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.)
| | - Byung-Chul Lee
- From the Department of Neurology (J.-W.C., O.Y.B.), Department of Pediatrics, Environmental Health Center for Atopic Diseases (K.A.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea (S.-S.P., T.H.P.); Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Republic of Korea (J.G.K., Y.K., S.L.); Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea (K.B.L.); Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea (Jun Lee); Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea (K.K., J.-M.P.); Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea (Y.-J.C., K.-S.H.); Department of Neurology, Dong-A University Hospital, Pusan, Republic of Korea (H.-W.N., D.-H.K., J.-K.C.); Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea (W.-S.R., D.-E.K.); Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K.); Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea (J.C.C.); Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.); Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea (J.S.L.); Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Juneyoung Lee); and Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.)
| | - Ji Sung Lee
- From the Department of Neurology (J.-W.C., O.Y.B.), Department of Pediatrics, Environmental Health Center for Atopic Diseases (K.A.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea (S.-S.P., T.H.P.); Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Republic of Korea (J.G.K., Y.K., S.L.); Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea (K.B.L.); Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea (Jun Lee); Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea (K.K., J.-M.P.); Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea (Y.-J.C., K.-S.H.); Department of Neurology, Dong-A University Hospital, Pusan, Republic of Korea (H.-W.N., D.-H.K., J.-K.C.); Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea (W.-S.R., D.-E.K.); Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K.); Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea (J.C.C.); Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.); Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea (J.S.L.); Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Juneyoung Lee); and Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.)
| | - Juneyoung Lee
- From the Department of Neurology (J.-W.C., O.Y.B.), Department of Pediatrics, Environmental Health Center for Atopic Diseases (K.A.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea (S.-S.P., T.H.P.); Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Republic of Korea (J.G.K., Y.K., S.L.); Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea (K.B.L.); Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea (Jun Lee); Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea (K.K., J.-M.P.); Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea (Y.-J.C., K.-S.H.); Department of Neurology, Dong-A University Hospital, Pusan, Republic of Korea (H.-W.N., D.-H.K., J.-K.C.); Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea (W.-S.R., D.-E.K.); Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K.); Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea (J.C.C.); Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.); Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea (J.S.L.); Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Juneyoung Lee); and Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.)
| | - Hong-Kyun Park
- From the Department of Neurology (J.-W.C., O.Y.B.), Department of Pediatrics, Environmental Health Center for Atopic Diseases (K.A.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea (S.-S.P., T.H.P.); Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Republic of Korea (J.G.K., Y.K., S.L.); Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea (K.B.L.); Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea (Jun Lee); Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea (K.K., J.-M.P.); Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea (Y.-J.C., K.-S.H.); Department of Neurology, Dong-A University Hospital, Pusan, Republic of Korea (H.-W.N., D.-H.K., J.-K.C.); Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea (W.-S.R., D.-E.K.); Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K.); Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea (J.C.C.); Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.); Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea (J.S.L.); Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Juneyoung Lee); and Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.)
| | - Beom Joon Kim
- From the Department of Neurology (J.-W.C., O.Y.B.), Department of Pediatrics, Environmental Health Center for Atopic Diseases (K.A.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea (S.-S.P., T.H.P.); Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Republic of Korea (J.G.K., Y.K., S.L.); Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea (K.B.L.); Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea (Jun Lee); Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea (K.K., J.-M.P.); Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea (Y.-J.C., K.-S.H.); Department of Neurology, Dong-A University Hospital, Pusan, Republic of Korea (H.-W.N., D.-H.K., J.-K.C.); Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea (W.-S.R., D.-E.K.); Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K.); Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea (J.C.C.); Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.); Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea (J.S.L.); Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Juneyoung Lee); and Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.)
| | - Moon-Ku Han
- From the Department of Neurology (J.-W.C., O.Y.B.), Department of Pediatrics, Environmental Health Center for Atopic Diseases (K.A.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea (S.-S.P., T.H.P.); Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Republic of Korea (J.G.K., Y.K., S.L.); Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea (K.B.L.); Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea (Jun Lee); Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea (K.K., J.-M.P.); Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea (Y.-J.C., K.-S.H.); Department of Neurology, Dong-A University Hospital, Pusan, Republic of Korea (H.-W.N., D.-H.K., J.-K.C.); Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea (W.-S.R., D.-E.K.); Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K.); Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea (J.C.C.); Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.); Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea (J.S.L.); Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Juneyoung Lee); and Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.)
| | - Hee-Joon Bae
- From the Department of Neurology (J.-W.C., O.Y.B.), Department of Pediatrics, Environmental Health Center for Atopic Diseases (K.A.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea (S.-S.P., T.H.P.); Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Republic of Korea (J.G.K., Y.K., S.L.); Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea (K.B.L.); Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea (Jun Lee); Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea (K.K., J.-M.P.); Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea (Y.-J.C., K.-S.H.); Department of Neurology, Dong-A University Hospital, Pusan, Republic of Korea (H.-W.N., D.-H.K., J.-K.C.); Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea (W.-S.R., D.-E.K.); Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K.); Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea (J.C.C.); Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.); Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea (J.S.L.); Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Juneyoung Lee); and Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.).
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Wilker EH, Preis SR, Beiser AS, Wolf PA, Au R, Kloog I, Li W, Schwartz J, Koutrakis P, DeCarli C, Seshadri S, Mittleman MA. Long-term exposure to fine particulate matter, residential proximity to major roads and measures of brain structure. Stroke 2015; 46:1161-6. [PMID: 25908455 DOI: 10.1161/strokeaha.114.008348] [Citation(s) in RCA: 171] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND PURPOSE Long-term exposure to ambient air pollution is associated with cerebrovascular disease and cognitive impairment, but whether it is related to structural changes in the brain is not clear. We examined the associations between residential long-term exposure to ambient air pollution and markers of brain aging using magnetic resonance imaging. METHODS Framingham Offspring Study participants who attended the seventh examination were at least 60 years old and free of dementia and stroke were included. We evaluated associations between exposures (fine particulate matter [PM2.5] and residential proximity to major roadways) and measures of total cerebral brain volume, hippocampal volume, white matter hyperintensity volume (log-transformed and extensive white matter hyperintensity volume for age), and covert brain infarcts. Models were adjusted for age, clinical covariates, indicators of socioeconomic position, and temporal trends. RESULTS A 2-μg/m(3) increase in PM2.5 was associated with -0.32% (95% confidence interval, -0.59 to -0.05) smaller total cerebral brain volume and 1.46 (95% confidence interval, 1.10 to 1.94) higher odds of covert brain infarcts. Living further away from a major roadway was associated with 0.10 (95% confidence interval, 0.01 to 0.19) greater log-transformed white matter hyperintensity volume for an interquartile range difference in distance, but no clear pattern of association was observed for extensive white matter. CONCLUSIONS Exposure to elevated levels of PM2.5 was associated with smaller total cerebral brain volume, a marker of age-associated brain atrophy, and with higher odds of covert brain infarcts. These findings suggest that air pollution is associated with insidious effects on structural brain aging even in dementia- and stroke-free persons.
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Affiliation(s)
- Elissa H Wilker
- From the Cardiovascular Epidemiology Research Unit, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (E.H.W., M.A.M.); Exposure, Epidemiology and Risk Program, Department of Environmental Health (E.H.W., J.S., P.K.) and Department of Epidemiology (W.L., J.S., M.A.M.), Harvard T.H. Chan School of Public Health, Boston, MA; Department of Biostatistics, School of Public Health (S.R.P., A.S.B., R.A.) and Department of Neurology, School of Medicine (A.S.B., P.A.W., S.S.), Boston University, MA; Framingham Heart Study, MA (S.R.P., A.S.B., P.A.W., S.S.); Department of Geography and Environmental Development, Ben-Gurion University of the Negev, Beer Sheva, Israel (I.K.); and Department of Neurology and Center for Neuroscience, University of California, Davis (C.D.).
| | - Sarah R Preis
- From the Cardiovascular Epidemiology Research Unit, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (E.H.W., M.A.M.); Exposure, Epidemiology and Risk Program, Department of Environmental Health (E.H.W., J.S., P.K.) and Department of Epidemiology (W.L., J.S., M.A.M.), Harvard T.H. Chan School of Public Health, Boston, MA; Department of Biostatistics, School of Public Health (S.R.P., A.S.B., R.A.) and Department of Neurology, School of Medicine (A.S.B., P.A.W., S.S.), Boston University, MA; Framingham Heart Study, MA (S.R.P., A.S.B., P.A.W., S.S.); Department of Geography and Environmental Development, Ben-Gurion University of the Negev, Beer Sheva, Israel (I.K.); and Department of Neurology and Center for Neuroscience, University of California, Davis (C.D.)
| | - Alexa S Beiser
- From the Cardiovascular Epidemiology Research Unit, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (E.H.W., M.A.M.); Exposure, Epidemiology and Risk Program, Department of Environmental Health (E.H.W., J.S., P.K.) and Department of Epidemiology (W.L., J.S., M.A.M.), Harvard T.H. Chan School of Public Health, Boston, MA; Department of Biostatistics, School of Public Health (S.R.P., A.S.B., R.A.) and Department of Neurology, School of Medicine (A.S.B., P.A.W., S.S.), Boston University, MA; Framingham Heart Study, MA (S.R.P., A.S.B., P.A.W., S.S.); Department of Geography and Environmental Development, Ben-Gurion University of the Negev, Beer Sheva, Israel (I.K.); and Department of Neurology and Center for Neuroscience, University of California, Davis (C.D.)
| | - Philip A Wolf
- From the Cardiovascular Epidemiology Research Unit, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (E.H.W., M.A.M.); Exposure, Epidemiology and Risk Program, Department of Environmental Health (E.H.W., J.S., P.K.) and Department of Epidemiology (W.L., J.S., M.A.M.), Harvard T.H. Chan School of Public Health, Boston, MA; Department of Biostatistics, School of Public Health (S.R.P., A.S.B., R.A.) and Department of Neurology, School of Medicine (A.S.B., P.A.W., S.S.), Boston University, MA; Framingham Heart Study, MA (S.R.P., A.S.B., P.A.W., S.S.); Department of Geography and Environmental Development, Ben-Gurion University of the Negev, Beer Sheva, Israel (I.K.); and Department of Neurology and Center for Neuroscience, University of California, Davis (C.D.)
| | - Rhoda Au
- From the Cardiovascular Epidemiology Research Unit, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (E.H.W., M.A.M.); Exposure, Epidemiology and Risk Program, Department of Environmental Health (E.H.W., J.S., P.K.) and Department of Epidemiology (W.L., J.S., M.A.M.), Harvard T.H. Chan School of Public Health, Boston, MA; Department of Biostatistics, School of Public Health (S.R.P., A.S.B., R.A.) and Department of Neurology, School of Medicine (A.S.B., P.A.W., S.S.), Boston University, MA; Framingham Heart Study, MA (S.R.P., A.S.B., P.A.W., S.S.); Department of Geography and Environmental Development, Ben-Gurion University of the Negev, Beer Sheva, Israel (I.K.); and Department of Neurology and Center for Neuroscience, University of California, Davis (C.D.)
| | - Itai Kloog
- From the Cardiovascular Epidemiology Research Unit, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (E.H.W., M.A.M.); Exposure, Epidemiology and Risk Program, Department of Environmental Health (E.H.W., J.S., P.K.) and Department of Epidemiology (W.L., J.S., M.A.M.), Harvard T.H. Chan School of Public Health, Boston, MA; Department of Biostatistics, School of Public Health (S.R.P., A.S.B., R.A.) and Department of Neurology, School of Medicine (A.S.B., P.A.W., S.S.), Boston University, MA; Framingham Heart Study, MA (S.R.P., A.S.B., P.A.W., S.S.); Department of Geography and Environmental Development, Ben-Gurion University of the Negev, Beer Sheva, Israel (I.K.); and Department of Neurology and Center for Neuroscience, University of California, Davis (C.D.)
| | - Wenyuan Li
- From the Cardiovascular Epidemiology Research Unit, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (E.H.W., M.A.M.); Exposure, Epidemiology and Risk Program, Department of Environmental Health (E.H.W., J.S., P.K.) and Department of Epidemiology (W.L., J.S., M.A.M.), Harvard T.H. Chan School of Public Health, Boston, MA; Department of Biostatistics, School of Public Health (S.R.P., A.S.B., R.A.) and Department of Neurology, School of Medicine (A.S.B., P.A.W., S.S.), Boston University, MA; Framingham Heart Study, MA (S.R.P., A.S.B., P.A.W., S.S.); Department of Geography and Environmental Development, Ben-Gurion University of the Negev, Beer Sheva, Israel (I.K.); and Department of Neurology and Center for Neuroscience, University of California, Davis (C.D.)
| | - Joel Schwartz
- From the Cardiovascular Epidemiology Research Unit, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (E.H.W., M.A.M.); Exposure, Epidemiology and Risk Program, Department of Environmental Health (E.H.W., J.S., P.K.) and Department of Epidemiology (W.L., J.S., M.A.M.), Harvard T.H. Chan School of Public Health, Boston, MA; Department of Biostatistics, School of Public Health (S.R.P., A.S.B., R.A.) and Department of Neurology, School of Medicine (A.S.B., P.A.W., S.S.), Boston University, MA; Framingham Heart Study, MA (S.R.P., A.S.B., P.A.W., S.S.); Department of Geography and Environmental Development, Ben-Gurion University of the Negev, Beer Sheva, Israel (I.K.); and Department of Neurology and Center for Neuroscience, University of California, Davis (C.D.)
| | - Petros Koutrakis
- From the Cardiovascular Epidemiology Research Unit, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (E.H.W., M.A.M.); Exposure, Epidemiology and Risk Program, Department of Environmental Health (E.H.W., J.S., P.K.) and Department of Epidemiology (W.L., J.S., M.A.M.), Harvard T.H. Chan School of Public Health, Boston, MA; Department of Biostatistics, School of Public Health (S.R.P., A.S.B., R.A.) and Department of Neurology, School of Medicine (A.S.B., P.A.W., S.S.), Boston University, MA; Framingham Heart Study, MA (S.R.P., A.S.B., P.A.W., S.S.); Department of Geography and Environmental Development, Ben-Gurion University of the Negev, Beer Sheva, Israel (I.K.); and Department of Neurology and Center for Neuroscience, University of California, Davis (C.D.)
| | - Charles DeCarli
- From the Cardiovascular Epidemiology Research Unit, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (E.H.W., M.A.M.); Exposure, Epidemiology and Risk Program, Department of Environmental Health (E.H.W., J.S., P.K.) and Department of Epidemiology (W.L., J.S., M.A.M.), Harvard T.H. Chan School of Public Health, Boston, MA; Department of Biostatistics, School of Public Health (S.R.P., A.S.B., R.A.) and Department of Neurology, School of Medicine (A.S.B., P.A.W., S.S.), Boston University, MA; Framingham Heart Study, MA (S.R.P., A.S.B., P.A.W., S.S.); Department of Geography and Environmental Development, Ben-Gurion University of the Negev, Beer Sheva, Israel (I.K.); and Department of Neurology and Center for Neuroscience, University of California, Davis (C.D.)
| | - Sudha Seshadri
- From the Cardiovascular Epidemiology Research Unit, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (E.H.W., M.A.M.); Exposure, Epidemiology and Risk Program, Department of Environmental Health (E.H.W., J.S., P.K.) and Department of Epidemiology (W.L., J.S., M.A.M.), Harvard T.H. Chan School of Public Health, Boston, MA; Department of Biostatistics, School of Public Health (S.R.P., A.S.B., R.A.) and Department of Neurology, School of Medicine (A.S.B., P.A.W., S.S.), Boston University, MA; Framingham Heart Study, MA (S.R.P., A.S.B., P.A.W., S.S.); Department of Geography and Environmental Development, Ben-Gurion University of the Negev, Beer Sheva, Israel (I.K.); and Department of Neurology and Center for Neuroscience, University of California, Davis (C.D.)
| | - Murray A Mittleman
- From the Cardiovascular Epidemiology Research Unit, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (E.H.W., M.A.M.); Exposure, Epidemiology and Risk Program, Department of Environmental Health (E.H.W., J.S., P.K.) and Department of Epidemiology (W.L., J.S., M.A.M.), Harvard T.H. Chan School of Public Health, Boston, MA; Department of Biostatistics, School of Public Health (S.R.P., A.S.B., R.A.) and Department of Neurology, School of Medicine (A.S.B., P.A.W., S.S.), Boston University, MA; Framingham Heart Study, MA (S.R.P., A.S.B., P.A.W., S.S.); Department of Geography and Environmental Development, Ben-Gurion University of the Negev, Beer Sheva, Israel (I.K.); and Department of Neurology and Center for Neuroscience, University of California, Davis (C.D.)
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