Racial Disparities in Cardiovascular and Cerebrovascular Adverse Events in Patients with Non-Hodgkin Lymphoma: A Nationwide Analysis

Background and Objectives: Non-Hodgkin lymphoma (NHL) has the sixth-highest malignancy-related mortality in the United States (US). However, inequalities exist in access to advanced care in specific patient populations. We aim to study the racial disparities in major adverse cardiovascular and cerebrovascular events (MACCEs) in NHL patients. Materials and Methods: Using ICD-10 codes, patients with NHL were identified from the US National Inpatient Sample 2016-2019 database. Baseline characteristics, comorbidities, and MACCE outcomes were studied, and results were stratified based on the patient's race. Results: Of the 777,740 patients with a diagnosis of NHL, 74.22% (577,215) were White, 9.15% (71,180) were Black, 9.39% (73,000) were Hispanic, 3.33% (25,935) were Asian/Pacific Islander, 0.36% (2855) were Native American, and 3.54% (27,555) belonged to other races. When compared to White patients, all-cause mortality (ACM) was significantly higher in Black patients (aOR 1.27, 95% CI 1.17-1.38, p < 0.001) and in Asian/Pacific Islander patients (aOR 1.27, 95% CI 1.12-1.45, p < 0.001). Sudden cardiac death was found to have a higher aOR in all racial sub-groups as compared to White patients; however, it was statistically significant in Black patients only (aOR 1.81, 95% CI 1.52-2.16, p < 0.001). Atrial fibrillation (AF) risk was significantly lower in patients who were Black, Hispanic, and of other races compared to White patients. Acute myocardial infarction (AMI) was noted to have a statistically significantly lower aOR in Black patients (0.70, 95% CI 0.60-0.81, p < 0.001), Hispanic patients (0.69, 95% CI 0.59-0.80, p < 0.001), and patients of other races (0.57, 95% CI 0.43-0.75, p < 0.001) as compared to White patients. Conclusions: Racial disparities are found in MACCEs among NHL patients, which is likely multifactorial, highlighting the need for healthcare strategies stratified by race to mitigate the increased risk of MACCEs. Further research involving possible epigenomic influences and social determinants of health contributing to poorer outcomes in Black and Asian/Pacific Islander patients with NHL is imperative.

Relationship Between Central Artery Stiffness, Brain Arterial Dilation, and White Matter Hyperintensities in Older Adults: The ARIC Study-Brief Report

[Figure: see text].

Birth hospital and racial and ethnic differences in severe maternal morbidity in the state of California

BACKGROUND

Birth hospital has recently emerged as a potential key contributor to disparities in severe maternal morbidity, but investigations on its contribution to racial and ethnic differences remain limited.

OBJECTIVE

We leveraged statewide data from California to examine whether birth hospital explained racial and ethnic differences in severe maternal morbidity.

STUDY DESIGN

This cohort study used data on all births at ≥20 weeks gestation in California (2007-2012). Severe maternal morbidity during birth hospitalization was measured using the Centers for Disease Control and Prevention index of having at least 1 of the 21 diagnoses and procedures (eg, eclampsia, blood transfusion, hysterectomy). Mixed-effects logistic regression models (ie, women nested within hospitals) were used to compare racial and ethnic differences in severe maternal morbidity before and after adjustment for maternal sociodemographic and pregnancy-related factors, comorbidities, and hospital characteristics. We also estimated the risk-standardized severe maternal morbidity rates for each hospital (N=245) and the percentage reduction in severe maternal morbidity if each group of racially and ethnically minoritized women gave birth at the same distribution of hospitals as non-Hispanic white women.

RESULTS

Of the 3,020,525 women who gave birth, 39,192 (1.3%) had severe maternal morbidity (2.1% Black; 1.3% US-born Hispanic; 1.3% foreign-born Hispanic; 1.3% Asian and Pacific Islander; 1.1% white; 1.6% American Indian and Alaska Native, and Mixed-race referred to as Other). Risk-standardized rates of severe maternal morbidity ranged from 0.3 to 4.0 per 100 births across hospitals. After adjusting for covariates, the odds of severe maternal morbidity were greater among nonwhite women than white women in a given hospital (Black: odds ratio, 1.25; 95% confidence interval, 1.19-1.31); US-born Hispanic: odds ratio, 1.25; 95% confidence interval, 1.20-1.29; foreign-born Hispanic: odds ratio, 1.17; 95% confidence interval, 1.11-1.24; Asian and Pacific Islander: odds ratio, 1.26; 95% confidence interval, 1.21-1.32; Other: odds ratio, 1.31; 95% confidence interval, 1.15-1.50). Among the studied hospital factors, only teaching status was associated with severe maternal morbidity in fully adjusted models. Although 33% of white women delivered in hospitals with the highest tertile of severe maternal morbidity rates compared with 53% of Black women, birth hospital only accounted for 7.8% of the differences in severe maternal morbidity comparing Black and white women and accounted for 16.1% to 24.2% of the differences for all other racial and ethnic groups.

CONCLUSION

In California, excess odds of severe maternal morbidity among racially and ethnically minoritized women were not fully explained by birth hospital. Structural causes of racial and ethnic disparities in severe maternal morbidity may vary by region, which warrants further examination to inform effective policies.

Adverse Trends in Premature Cardiometabolic Mortality in the United States, 1999 to 2018

Background Life expectancy in the United States has recently declined, in part attributable to premature cardiometabolic mortality. We characterized national trends in premature cardiometabolic mortality, overall, and by race-sex groups. Methods and Results Using death certificates from the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research, we quantified premature deaths (<65 years of age) from heart disease, cerebrovascular disease, and diabetes mellitus from 1999 to 2018. We calculated age-adjusted mortality rates (AAMRs) and years of potential life lost (YPLL) from each cardiometabolic cause occurring at <65 years of age. We used Joinpoint regression to identify an inflection point in overall cardiometabolic AAMR trends. Average annual percent change in AAMRs and YPLL was quantified before and after the identified inflection point. From 1999 to 2018, annual premature deaths from heart disease (117 880 to 128 832), cerebrovascular disease (18 765 to 20 565), and diabetes mellitus (16 553 to 24 758) as an underlying cause of death increased. By 2018, 19.7% of all heart disease deaths, 13.9% of all cerebrovascular disease deaths, and 29.1% of all diabetes mellitus deaths were premature. AAMRs and YPLL from heart disease and cerebrovascular disease declined until the inflection point identified in 2011, then remained unchanged through 2018. Conversely, AAMRs and YPLL from diabetes mellitus did not change through 2011, then increased through 2018. Black men and women had higher AAMRs and greater YPLL for each cardiometabolic cause compared with White men and women, respectively. Conclusions Over one-fifth of cardiometabolic deaths occurred at <65 years of age. Recent stagnation in cardiometabolic AAMRs and YPLL are compounded by persistent racial disparities.

Baseline Obesity Increases 25-Year Risk of Mortality due to Cerebrovascular Disease: Role of Race

Background: Although obesity may have a role as a risk factor for cerebrovascular mortality, less is known about how demographic and social groups differ in this regard. Aims: This study had two aims: first to investigate the predictive role of baseline obesity on long-term risk of mortality due to cerebrovascular disease, and second, to test racial variation in this effect. Methods: the Americans’ Changing Lives Study (ACL) 1986–2011 is a state of the art 25-year longitudinal cohort study. ACL followed a nationally representative sample of Blacks (n = 1156) and Whites (n = 2205) for up to 25 years. Baseline obesity was the main predictor of interest, time to cerebrovascular death was the main outcome of interest. Demographic characteristics, socioeconomic status (educational attainment and household income), health behaviors (exercise and smoking), and health (hypertension and depressive symptoms) at baseline were covariates. Cox proportional hazards models were used to test additive and multiplicative effects of obesity and race on the outcome. Results: From the total 3,361 individuals, 177 people died due to cerebrovascular causes (Whites and Blacks). In the pooled sample, baseline obesity did not predict cerebrovascular mortality (hazard ratio (HR) = 0.86, 0.49–1.51), independent of demographic, socioeconomic, health behaviors, and health factors at baseline. Race also interacted with baseline obesity on outcome (HR = 3.17, 1.09–9.21), suggesting a stronger predictive role of baseline obesity on cerebrovascular deaths for Black people compared to White individuals. According to the models that were run specific to each race, obesity predicted risk of cerebrovascular mortality for Blacks (HR = 2.51, 1.43–4.39) but not Whites (HR = 0.69, 0.31–1.53). Conclusions: Baseline obesity better predicts long-term risk of cerebrovascular death in Black individuals compared to White people. More research should explore factors that explain why racial differences exist in the effects of obesity on cerebrovascular outcome. Findings also have implications for personalized medicine.

Low frequency of cervicocranial artery involvement in Japanese with renal artery fibromuscular dysplasia compared with that of Caucasians

BACKGROUND

Fibromuscular dysplasia (FMD), which usually affects the renal artery, also affects the carotid, vertebral, and intracranial arteries. Previous studies have shown a high prevalence of concomitant renal artery and cervicocranial lesions in FMD patients. However, the analyzed subjects were mostly Caucasians in Western countries.

METHOD

We performed a retrospective analysis to examine the prevalence of cervicocranial vascular lesions in Japanese FMD patients with renal artery involvement at a single institution. The presence of cervicocranial lesions was evaluated by Doppler echography and magnetic resonance angiography. We compared this prevalence with that reported in the literature.

RESULT

Thirty-one Japanese FMD patients with renal artery lesions were studied. The mean age was 30 ± 12 years, 71% were women, and 16% were smokers; all patients were Asians and had hypertension. Multifocal, tubular, and unifocal types of renal lesions were found in 52, 35, and 13% of patients, respectively. Bilateral renal lesions were found in 13% of patients. None of the patients had a cervical vascular lesion associated with FMD. Only two patients (8%) had a lesion in the intracranial artery, of which one was a known case of moyamoya disease.

CONCLUSION

These findings suggest that cervical artery involvement and intracranial artery involvement are not common in renal FMD patients in Japan, which is in contrast to the data reported for Caucasian patients in Western countries. Ethnic differences could influence the occurrence of cervicocranial lesions. A study with a larger sample size should be performed to validate these findings.

Lower body functioning and correlates among older American Indians: The Cerebrovascular Disease and Its Consequences in American Indians Study

BACKGROUND

More than six million American Indians live in the United States, and an estimated 1.6 million will be aged ≥65 years old by 2050 tripling in numbers since 2012. Physical functioning and related factors in this population are poorly understood. Our study aimed to assess lower body functioning and identify the prevalence and correlates of "good" functioning in a multi-tribe, community-based sample of older American Indians.

METHODS

Assessments used the Short Physical Performance Battery (SPPB). "Good" lower body functioning was defined as a total SPPB score of ≥10. Potential correlates included demographic characteristics, study site, anthropometrics, cognitive functioning, depressive symptomatology, grip strength, hypertension, diabetes mellitus, heart disease, prior stroke, smoking, alcohol use, and over-the-counter medication use for arthritis or pain. Data were collected between 2010 and 2013 by the Cerebrovascular Disease and Its Consequences in American Indians Study from community-dwelling adults aged ≥60 years (n = 818).

RESULTS

The sample's mean age was 73 ± 5.9 years. After adjustment for age and study site, average SPPB scores were 7.0 (95% CI, 6.8, 7.3) in women and 7.8 (95% CI, 7.5, 8.2) in men. Only 25% of the sample were classified with "good" lower body functioning. When treating lower body functioning as a continuous measure and adjusting for age, gender, and study site, the correlates of better functioning that we identified were younger age, male gender, married status, higher levels of education, higher annual household income, Southern Plains study site, lower waist-hip ratio, better cognitive functioning, stronger grip strength, lower levels of depressive symptomatology, alcohol consumption, and the absence of hypertension, diabetes mellitus, and heart disease. In our fully adjusted models, correlates of "good" lower body functioning were younger age, higher annual household income, better cognitive functioning, stronger grip, and the absence of diabetes mellitus and heart disease.

CONCLUSIONS

These results suggest that "good" lower body functioning is uncommon in this population, whereas its correlates are similar to those found in studies of other older adult populations. Future efforts should include the development or cultural tailoring of interventions to improve lower body functioning in older American Indians.

Relationship of Hyperglycaemia, Hypoglycaemia, and Glucose Variability to Atherosclerotic Disease in Type 2 Diabetes

OBJECTIVE

Type 2 diabetes mellitus (T2DM) is known to be associated with increased cardiovascular risk. The aim of this study was therefore to investigate the independent effects of hyperglycaemia, hypoglycaemia, and glucose variability on microvascular and macrovascular disease in T2DM.

METHODS

Subjects with T2DM of <10 years duration and on stable antiglycaemic treatment underwent carotid intima-media thickness (CIMT), ankle-brachial index (ABI), albumin-creatinine ratio (ACR), and HbA_1c measurement, as well as 72-hour continuous glucose monitoring. Macrovascular disease was defined as one or more of the following: history of ischaemic heart disease (IHD), cerebrovascular accident (CVA), ABI < 0.9, or abnormal CIMT.

RESULTS

The study population comprised 121 subjects with T2DM (89 males : 32 females). The mean age was 62.6 years, and the mean DM duration was 3.7 years. Macrovascular disease was present in 71 patients (58.7%). In multivariate logistic regression analysis, body surface area (BSA) (OR 18.88 (95% CI 2.20-156.69), p = 0.006) and duration of blood glucose (BG) < 3.9 mmol/L (OR 1.12 (95% CI 1.014-1.228), p = 0.024) were independent predictors of macrovascular disease. BSA (OR 12.6 (95% CI 1.70-93.54), p = 0.013) and duration of BG < 3.9 mmol/L (OR 1.09 (95% CI 1.003-1.187), p = 0.041) were independent predictors of abnormal CIMT. Area under the curve for BG > 7.8 mmol/L (β = 15.83, p = 0.005) was the sole independent predictor of albuminuria in generalised linear regression.

CONCLUSIONS

This study demonstrates that hypoglycaemia is associated with the occurrence of atherosclerotic disease while hyperglycaemia is associated with microvascular disease in a Caucasian population with T2DM of recent duration.

Association of stroke risk biomarkers with stroke symptoms: the Reasons for Geographic and Racial Differences in Stroke cohort

Essentials Stroke symptom history predicts future stroke and may indicate prior unrecognized stroke. We studied associations of stroke symptoms with stroke risk biomarkers. Several stroke risk biomarkers were independently associated with stroke symptom history. Findings support a hypothesis that stroke symptoms may represent unrecognized stroke.

SUMMARY

Background History of stroke symptoms in the absence of prior diagnosed stroke or transient ischemic attack (TIA) is associated with future stroke risk, as are biomarkers of inflammation, cardiac function and hemostasis. Objective To better elucidate the pathobiology of stroke symptoms, we studied associations of these biomarkers with history of stroke symptoms. Methods The Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort enrolled 30 239 black and white Americans age 45 years and older in 2003-7. In cross-sectional analyses in a random sample of 960 participants without prior stroke or TIA, levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP), fibrinogen, factor VIII (FVIII), factor XI (FXI), C-reactive protein (CRP) and D-dimer were studied in relation to self-reported history of six sudden onset stroke symptoms. Results There were 190 participants with at least one stroke symptom and 770 without. Adjusting for age, race, sex and stroke risk factors, NT-proBNP, FXI, CRP and D-dimer in the top vs. bottom quartile were associated with prevalent stroke symptoms with odds ratios 2.69 (95% confidence interval [CI], 1.45-4.98), 1.65 (95% CI, 1.00-2.73), 2.21 (95% CI, 1.32-3.71) and 2.14 (95% CI, 1.22-3.75), respectively. Conclusions Strong associations of stroke risk biomarkers with stroke symptoms in persons without a clinical history of cerebrovascular disease support a hypothesis that some of these stroke symptoms represent unrecognized cerebrovascular disease. Future work is needed to determine whether these biomarkers identify persons with stroke symptoms who have a particularly high stroke risk.

[Epidemiological survey of cerebrovascular disease among population in Inner Mongolia autonomous region]

OBJECTIVE

To understand the epidemiological characteristics of cerebrovascular disease among population in Inner Mongolia.

METHODS

From September 2013 to January 2014, a total of 19 315 local residents in all age groups were selected through cluster random sampling, and face to face questionnaire survey was conducted among them, than health examination was provided for them.

RESULTS

The overall prevalence of cerebrovascular diseases among the population in all age group was 1 812.06/100 000 (2 008.86/100 000 in males and 1 613.24/100 000 in females). The prevalence of cerebrovascular diseases increased with age, and the prevalence was higher in males than in females, in rural population than in urban population and in people with lower educational level than in people with higher educational level. The annual incidence stroke was 392.54/100 000, the difference in the incidence between males and females had no statistical significance (χ(2)=0.380, P=0.846). The incidence of stroke was higher in rural population than in urban population, the difference was statistically significant (χ(2)=13.029, P=0.000). The incidence of stroke increased with age (χ(2)=410.130, P=0.000). The annual mortality of stroke was 149.67/100 000 and the case fatality rate was 15.14%. Compared with the elderly, the prevalence of cerebral hemorrhage and cerebral infarction were higher in young people.

CONCLUSION

The prevalence, incidence, mortality and recurrence rate of cerebrovascular disease were high in the population in Inner Mongolia, ischemic stroke was the major form of cerebrovascular disease.

Socioeconomic characteristics of patients undergoing ambulatory diagnostic cerebral angiography in four US States

AIMS

Several groups have demonstrated the safety of ambulatory cerebral angiography, with no patients experiencing complications related to early discharge. Although this practice appears to be safe, the socioeconomic characteristics factoring in the selection of the patients have not been investigated.

METHODS

We performed a retrospective cohort study involving 45,226 patients undergoing outpatient and 159,046 undergoing inpatient cerebral angiography, who were registered in the State Ambulatory Surgery Databases (SASD) and State Inpatient Databases (SID) respectively for 4 US States (New York, California, Florida, North Carolina).

RESULTS

In a multivariate analysis of diagnostic cerebral angiography, Caucasian race (OR 1.36, 95% CI, 1.31, 1.42) and male gender (OR 1.36, 95% CI, 1.31, 1.41), were significantly associated with outpatient procedures. Higher Charlson Comorbidity Index (CCI) (OR 0.60, 95% CI, 0.54, 0.67), high income (OR 0.70, 95% CI, 0.67, 0.73), high volume hospitals (OR 0.69, 95% CI, 0.66, 0.73), and coverage by Medicare/Medicaid (OR 0.96, 95% CI, 0.92, 0.99) were associated with a decreased chance of outpatient procedures. Institutional charges were significantly less for outpatient cerebral angiography. The median charge for inpatient diagnostic cerebral angiography was $26,968 as compared to $16,151 in the outpatient setting (P < 0.0001, Student's t-test).

CONCLUSION

Access to ambulatory diagnostic cerebral angiography appears to be more common for patients with private insurance and less comorbidities, in the setting of lower volume hospitals. Further investigation is needed in the direction of mapping these disparities in resource utilization.

[Mortality of old-aged (60 years and older) population in Yakutia subject to data of prospective cohort seven-year study]

Level of total mortality and mortality from cardiovascular diseases was defined subsequent to the results of carried out novel prospective study of cohort of old-age population of the Republic. Subject to seven-year cohort study high indexes of mortality from all reasons (42,7%) and from cardiovascular diseases (28,4%) were registered for the population of Yakutia aged 60 years and older. Circulatory diseases comprise 68% of all died; ischemic heart diseases (59%) and cerebrovascular diseases (22%) are the main reasons among the cardiovascular pathology. In the studied cohort there were found no ethnic and gender differences in mortality levels. Total mortality and mortality from cardiovascular pathology, relative risk of fatal issue development increase statistically significant with the age. The growth rate of total and cardiovascular mortality are practically identical in both ethnic groups.

Adult asthma and risk of coronary heart disease, cerebrovascular disease, and heart failure: a prospective study of 2 matched cohorts

Asthma has been associated with increased cardiovascular disease (CVD) risk. The authors ascertained the association of asthma with CVD and the roles that sex, concurrent allergy, and asthma medications may play in this association. They assembled a cohort of 203,595 Northern California adults with asthma and a parallel asthma-free referent cohort (matched 1:1 on age, sex, and race/ethnicity); both cohorts were followed for incident nonfatal or fatal CVD and all-cause mortality from January 1, 1996, through December 31, 2008. Each cohort was 66% female and 47% white. After adjustment for age, sex, race/ethnicity, cardiac risk factors, and comorbid allergy, asthma was associated with a 1.40-fold (95% confidence interval (CI): 1.35, 1.45) increased hazard of coronary heart disease, a 1.20-fold (95% CI: 1.15, 1.25) hazard of cerebrovascular disease, a 2.14-fold (95% CI: 2.06, 2.22) hazard of heart failure, and a 3.28-fold (95% CI: 3.15, 3.41) hazard of all-cause mortality. Stronger associations were noted among women. Comorbid allergy predicted CVD but did not synergistically increase the CVD risk associated with asthma. Only asthma patients using asthma medications (particularly those on oral corticosteroids alone or in combination) were at enhanced risk of CVD. In conclusion, asthma was prospectively associated with increased risk of major CVD. Modifying effects were noted for sex and asthma medication use but not for comorbid allergy.

Methotrexate reduces the occurrence of cerebrovascular events among Taiwanese psoriatic patients: a nationwide population-based study

Psoriasis is a chronic inflammatory disease. The aim of this study was to evaluate the effects of methotrexate and retinoid on risks for developing cerebrovascular disease among psoriatic patients. A population-based nested case-control study was conducted using the Taiwanese National Health Insurance database. Cox proportional hazards models were adopted. The hazard ratio (HR) of newly developed cerebrovascular disease was 1.28 (95% confidence interval (CI) = 1.162-1.413; p < 0.0001) for psoriatic vs. non-psoriatic subjects. In terms of the effects of methotrexate or retinoid on the occurrence of cerebrovascular disease, a significant protection effect (HR = 0.50; 95% CI = 0.27-0.92; p = 0.0264) was found for patients with methotrexate prescription. Retinoid prescription showed no protective effect. Further analyses revealed that a low cumulative methotrexate dose is associated with significant protective effect (HR = 0.53; 95% CI = 0.28-1.00; p = 0.0486) while a high cumulative dose was not (HR 0.80; 95% CI = 0.11-5.68; p = 0.8214). These results suggest that psoriatic patients receiving low-dose methotrexate treatment may have reduced risk for developing cerebrovascular disease. Further prospective study should be performed to validate the vasculoprotective effect of this treatment strategy.

[Bioelectric activity of the brain in patients of elderly and senile age with a cerebrovascular pathology]

According to this work, bioelectric activity of a brain of 345 patients with a cerebrovascular pathology was studied; among them 139 patients with ischemic strokes (IS) in carotid pools, 206 sick with chronic ischemia of a brain (CIB), 91 patients with discircular encephalopathy of the 1st stage (DE-1), 115 patients with DE of the 2nd stage (DE-2). All observation has been subdivided into two categories: the basic, including 4 basic groups of supervision, and control. Criteria of division of the basic category observation into groups were the region of residing and a nationality. At EEG analysis of patients with IS dominating slow-wave activity is registered in all cases. At patients with CIB changes of bioelectric activity of the expressed degree had a diffusive character.

Screening for asymptomatic cardiovascular disease in Arab patients with diabetes

AIM

Diabetes mellitus is a major risk factor for atherosclerosis and accordingly increased morbidity and mortality. This study aimed at screening high risk diabetic patients for atherosclerosis in different arterial territories.

METHODS

All high risk asymptomatic patients attending the diabetic clinic, King Fahd Hospital of the University, Saudi Arabia were invited to be screened for peripheral arterial disease (PAD), extra-cranial cerebrovascular disease (CVD) and coronary artery disease (CAD) over one year. All participants underwent measurement of ankle brachial pressure index, carotid Duplex scan and exercise electrocardiography (ECG). All patients underwent evaluation of conventional risk factors for atherosclerosis

RESULTS

One hundred and sixty nine patients were invited to be screened. Of these 138 (82%) completed all the screening tests. The mean age was 53.5±7.18 years. Seventy-five (55%) had evidence of subclinical atherosclerosis. In the atherosclerotic group, 24 patients had PAD, 47 had CVD and 30 had CAD. There were significant differences between the atherosclerotic and non-atherosclerotic groups with regard to most risk factors. In age, sex adjusted, the risk of developing atherosclerosis was significantly increased with all risk factors. Dyslipidemia had the highest association (OR 9.7, 95% CI 8.1-10.2)

CONCLUSION

Participation and diagnostic yield of screening for atherosclerosis had satisfactory validity and reliability. Routine screening in high-risk diabetic patients can serve as an effective tool for diagnosis of sub clinical cardiovascular disease and provide strategies to optimize risk reduction.

Health care utilization data in Tennessee: inpatient discharges, 2005

Data on the utilization of healthcare services are useful for assessing the health status of the general population and the delivery of hospital services in a state that is facing major health and healthcare challenges. They can assist health planning and health system reform efforts by allowing comparisons to other states and to national averages, by identifying patient groups with unusually high utilization rates, by tracking trends in utilization over time, and by demonstrating the effects of various healthcare reforms. This report summarizes hospital inpatient discharge data for patients treated in Tennessee's non-federal, short-stay hospitals in 2005. The analysis focuses on the hospital utilization patterns of leading acute and chronic conditions for racial and gender groups.

Mortality risk in older inner-city African Americans

OBJECTIVES

To investigate mortality risks in a sample of poor, inner-city-dwelling, older African Americans.

DESIGN

Prospective cohort study.

SETTING

St. Louis, Missouri.

PARTICIPANTS

Six hundred twenty-two African Americans aged 68 to 102 at the time of their 1992 to 1994 baseline interviews.

MEASUREMENTS

Risk factors previously identified in the literature were examined for seven categories: demographic, socioeconomic, psychosocial, biomedical, disability and physical function, perceived health, and health services utilization. Vital status was ascertained through 2002.

RESULTS

Three hundred eighty-six subjects (62.1%) were deceased and 236 were alive (mortality higher than in matched controls). Significant risks for mortality were older age, male sex, annual income less than $10,000, cancer, cerebrovascular disease, dependencies in lower-body function, and number of physician visits in the 12 months before baseline.

CONCLUSION

In addition to improving the risk factors for stroke and malignant disease in this population, studies focused on improving lower-body functioning may be warranted as a part of efforts aimed at enhancing longevity in older African-American adults.

Agreement of self-reported comorbid conditions with medical and physician reports varied by disease among end-stage renal disease patients

OBJECTIVE

To compare self-report of eight diseases with review of medical records and physician reports.

STUDY DESIGN AND SETTING

In a cohort of 965 incident end-stage renal disease (ESRD) patients (Choices for Healthy Outcomes in Caring for End-stage renal disease study), data on existing medical conditions were obtained from medical record abstraction, physician report (CMS Form 2728), and self-report in a baseline questionnaire. We evaluated agreement with kappa statistics (k) and sensitivity of self-report. Regression models were used to examine characteristics associated with agreement.

RESULTS

The results showed excellent or substantial agreement between self-report and the medical record for diabetes (k=0.93) and coronary artery intervention (k=0.79), and poor agreement for chronic obstructive pulmonary disease (k=0.20). Physician-reported prevalence for all diseases was equal or lower than that by self-report. Male patients were more likely to inaccurately report hypertension. Compared to white patients, African American patients were more likely to inaccurately report cardiovascular diseases.

CONCLUSION

In ESRD patients, self-report agreement with the medical record varies with the specific disease. Awareness of diseases of the cardiovascular system appears to be low. African American and male ESRD patients are at risk of low awareness of disease and educational interventions are needed in this high-risk population.

Cerebrovascular disease among patients from the Indian subcontinent

In this study, the authors document the characteristics of South Asian (SA) cerebrovascular patients. A retrospective medical record review comparing SA (n = 99) and European-American (n = 106) patients was performed. SA patients were younger and had a greater prevalence of diabetes, but lower prevalences of hyperlipidemia and tobacco use. SA patients experienced a 75% lower risk of cardiogenic infarctions, but a threefold increased risk of intracranial atherothrombosis. Risk factor modifications and secondary prevention strategies may differ for SA patients.

A561C polymorphism of E-selectin is associated with ischemic cerebrovascular disease in the Japanese population without diabetes mellitus and hypercholesterolemia

E-selectin, which is a member of the selectin superfamily of adhesion molecules, contributes to the leukocyte-endothelial cell attachments and is involved in the pathogenesis of thrombovascular diseases as a consequence. We investigated the A561C mutation in the E-selectin gene in 235 Japanese patients with ischemic cerebrovascular disease (CVD) and 301 age- and sex-matched healthy controls. Excluding the subjects with diabetes mellitus and hypercholesterolemia, the AC genotype frequencies of patients with ischemic CVD were higher than those of controls: 12.7% vs. 5.8% (P=0.04). Our results show that E-selectin gene polymorphisms represent an increased risk for ischemic CVD in the Japanese population without diabetes mellitus and hypercholesterolemia.

Cerebrovascular risk factors, activity limitations, and depressed mood in African American older adults

This study investigated the association between cerebrovascular risk factors (CVRFs), physical activity limitations, and depressed mood. The 12-item Short-Form Health Survey (SF-12) was administered to 1,034 urban African American older adults. A chi-square analysis demonstrated that the prevalence of depressed mood among those with high CVRF burden (13.4%) was significantly higher than among those with low vascular burden (7.6%). Physical activity limitations also predicted depressed mood, but this relationship did not mediate the relationship between cerebrovascular burden and depression. These findings highlight the relationships among cerebrovascular burden, physical activity limitations, and depressed mood among African American older adults.

Mental illness and principal physical diagnoses among Asian American and Pacific Islander users of emergency services

The stigma of mental illness is one of the factors that prevents Asian Americans/Pacific Islanders (APIs) from seeking formal mental health services. A somatic complaint is more acceptable in expressing psychiatric/emotional distress. Admission diagnoses in API emergency service users with secondary psychiatric diagnoses were identified from the 2001 National Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (HCUP). The sample consisted of 10,623 adult APIs. The study examined the differences in the six leading principal physical admission diagnoses between API emergency service users with psychiatric diagnoses and those without psychiatric diagnoses. Several of the study findings create concern (e.g., the higher percentage of APIs with psychiatric diagnosis who were discharged against medical advice, the high percentage admitted with medication intoxication). Further study is needed to provide guidance for clinical practice.

Effect of atrial septal aneurysm on risk of cerebrovascular events in Japanese patients

BACKGROUND

The aim of the present study was to determine whether atrial septal aneurysm (ASA) detected by transthoracic echocardiography (TTE) is an independent risk factor of cerebrovascular events for Japanese people.

METHODS

A control study was conducted with 178 patients with ASA (follow-up rate, 96.7%; median follow-up period, 5.6 years) and 176 control patients (follow-up rate, 97.8%; median follow-up period, 5.4 years), selected from 42,528 consecutive patients who underwent TTE in the Omiya Medical Center, Jichi Medical School, from April 1991 to March 2001. Data were collected by structured review of patient charts and a subsequent telephone survey. Long-term cerebrovascular risk factors were evaluated by logistic regression analysis.

RESULTS

A previous episode of cerebral infarction had occurred in nine ASA patients (5.1%) and 11 control patients (6.3%). During the follow-up period, new cerebral infarction occurred in 12 ASA patients (6.7%) and six control patients (3.4%). Only atrial fibrillation was found to be an independent risk factor of new cerebral infarction (OR, 5.06; 95% CI, 1.32-19.46; P=0.04).

CONCLUSIONS

ASA is not an independent risk factor of cerebrovascular events for Japanese patients. Thus, aggressive strategies such as anticoagulation are not essential for ASA patients without embolic episodes.

From 1960s Evans County Georgia to present-day Jackson, Mississippi: an exploration of the evolution of cardiovascular disease in African Americans

Cardiovascular disease (CVD) is the No. 1 cause of mortality in the United States and it disproportionately affects African Americans. However, there are earlier reports that African Americans had significantly less CVD than whites. This racial discrepancy in CVD rates was noticed primarily for coronary heart disease (CHD). This issue was examined in the Evans County (Georgia) Cardiovascular Disease Study conducted in the 1960s. It showed that African American men had significantly lower rates of CHD than white men. Over the last couple of decades, the rates of CVD have been declining. However, the rate of decline of CVD in African Americans has not been equal to that seen in whites, such that African Americans now have a disproportionate share of CVD in the United States. In the 1990s, the Jackson Heart Study was designed to explore the reasons for the current racial discrepancy. This articles reviews the findings of the Evans County Study and explores various hypotheses for why CVD in African Americans has evolved from a disease from which African Americans may have been "protected" to one in which they shoulder a disproportionate burden.

Differences between Hispanics and non-Hispanic Whites in use of hospital procedures for cerebrovascular disease

OBJECTIVE

This study examined disparities in the use of in-hospital diagnostic and therapeutic procedures for Hispanics with cerebrovascular disease compared to their non-Hispanic White counterparts.

DESIGN

This is a cross-sectional study using 1996 hospital administrative data.

METHODS

Hispanics and non-Hispanic Whites with diagnosis codes indicating occlusion or stenosis of precerebral arteries or transient cerebral ischemia were included, with a total of 18,674 New York patients (5.1% Hispanic) and 22,624 California patients (11.1% Hispanic). Adjusted odds ratios compared Hispanics with non-Hispanic Whites for six diagnostic and therapeutic procedures for cerebrovascular disease, controlling for patient and hospital characteristics.

RESULTS

Hispanics had higher rates of non-invasive diagnostic procedures (head CT scan, head/neck diagnostic ultrasound, echocardiogram, and head MRI). The odds of invasive diagnostic testing (cerebral arteriogram) and therapeutic procedures (carotid endarterectomy) were lower for Hispanics. Most findings remained unchanged in logistic regression models with patient and hospital characteristics. Adding a measure of the concentration of Hispanic patients by hospital eliminated or reduced observed differences between Hispanics and Whites.

CONCLUSIONS

Controlling for each hospital's experience with Hispanic patients eliminated or reduced the magnitude of the disparities in procedure use, suggesting that the concentration of Hispanic patients in a hospital is associated with different patterns of procedure use.

Increased risk of heart disease and stroke among foreign-born females residing in the United States

BACKGROUND

Although the number of foreign-born people residing in the United States is at its highest point in 80 years, a mortality analysis of the foreign born has not been conducted since 1989. This article provides an update of mortality rates among the foreign born in the United States and, in particular, examines mortality rates from heart disease among foreign-born females.

METHODS

We calculated mortality rates for U.S.-born and foreign-born people for all causes-ischemic heart disease, stroke, neoplastic disease, hypertensive diseases, diabetes, accidents, infectious disease, and chronic obstructive pulmonary disease-for 1997. Death data were obtained from the 1997 Multiple Cause of Death data file, and population data were obtained from the 1997 Current Population Survey.

RESULTS

While all-cause, age-adjusted mortality rates for foreign-born people are significantly lower than for native-born people, deaths due to ischemic heart disease and stroke are significantly higher among foreign-born females than native-born females (161.63 and 58.24 deaths, respectively, per 100,000 foreign-born females vs 122.01 and 49.39 deaths per 100,000 native-born females).

CONCLUSIONS

Foreign-born females appear to be at greater risk of death from ischemic heart disease and stroke than native-born females. Future research efforts are needed to determine which foreign-born groups are most at risk for heart disease and stroke so that targeted prevention efforts can be initiated.

Risk factors for cardiovascular and cerebrovascular death among African Americans and Hispanics in Los Angeles, California

OBJECTIVE

To describe the risk factors associated with cardiovascular mortality in the African American (AA) and Hispanic populations in Los Angeles County in an effort to define causes for the excess mortality seen in AAs.

METHODS

This was a longitudinal analysis of all-cause, cardiovascular, and cerebrovascular mortality in a large, prospective multiethnic cohort of individuals aged 45-74 years. Death rates between AA and Hispanic men and women during the six-year period from 1993 to 1998 due to hypertension, cardiomyopathy, acute myocardial infarction (AMI), ischemic heart disease, and stroke were compared.

RESULTS

There were 1,157 deaths due to cardiovascular disease (CVD) or cerebrovascular disease among the 71,798 eligible members of the cohort included in these analyses. Age-adjusted mortality rates were two to five times higher in AAs as compared with Hispanics (e.g., 373.15 in AAs for hypertensive disease vs 50.37 in Hispanics). A history of hypertension was the most common significant risk factor for CVD; other risk factors significantly associated with CVD mortality included cigarette smoking and a past history of diabetes and stroke. Adjusting for these factors did not remove the significance of AA ethnicity as a risk factor for CVD mortality in either subjects reporting or subjects not reporting hypertension at baseline.

CONCLUSIONS

The evidence for both higher relative severity and higher incidence of hypertensive disease among AAs, and the consistency of the effect across gender, suggests that a major determinant of risk may be a gene environment interaction.

Serum cholesteryl ester transfer protein concentrations in healthy Chinese subjects and cardio-cerebrovascular disease patients

Serum cholesteryl ester transfer protein (CETP) concentration was measured in 1128 healthy Chinese subjects using a "sandwich" enzyme immunoassay and was 1.84 +/- 1.55 mg/l (mean +/- S.D.). The frequency distribution of CETP in healthy subjects was markedly skewed towards low concentrations. The CETP concentration in females was significantly higher than that in males (2.40 +/- 1.65 mg/l vs. 1.49 +/- 1.37 mg/l, P < 0.001). There was a weak inverse correlation between the CETP concentration and age (r = -0.19, P < 0.001). The CETP concentrations were significantly higher in 117 myocardial infarction (MI) survivors and 110 stroke patients than that in 335 healthy, age-matched males (1.98 +/- 1.68 173 +/- 1.45, and 1.40 +/- 1.37 mg/l respectively, P < 0.01), while no relation was found between CETP concentration and lipids concentration in MI, stroke and healthy group.

Prevalence of methylenetetrahydrofolate reductase C677T and its association with arterial and venous thrombosis in the Chinese population

Moderate hyperhomocysteinaemia (MHH) is associated with arterial and venous thrombosis. A main genetic defect related to MHH is a C to T substitution at nucleotide 677 of the 5,10-methylenetetrahydrofolate reductase (MTHFR) gene. A prothrombin 20210A mutation was recently identified as a risk factor for arterial and venous thrombosis. However, studies on the prevalence of mutant MTHFR C677T and prothrombin G20210A and their association with thrombosis were controversial and seldom reported in the Chinese population. We investigated the prevalence of MTHFR C677T and prothrombin G20210A genotypes by polymerase chain reaction (PCR) followed by restriction enzyme digestion in 420 Chinese subjects: 53 with deep venous thrombosis (DVT); 145 with cerebrovascular disease [115 cerebral infarction, 30 cerebral haemorrhage (CH)]; 100 with coronary artery disease (CAD); and 122 control subjects. The prevalence of the mutated MTHFR 677TT genotype and the 677T allele in normal controls was 12.3% and 30.7% respectively, similar to that in Caucasians and Japanese. The mutant 677T homozygotes and alleles were more frequent in patients with DVT than in controls (18.9% vs. 12.3%, 0.01 < P < 0. 025; 48.1% vs. 30.7%, P < 0.005). The relative risk of DVT among the carriers of 677TT and 677T were significantly increased [odds ratios: 3.4, 95% confidence interval (CI) 1.3-9.5, and 3.6, 95% CI 1. 7-7.7, respectively). The mutant MTHFR heterozygous 677C/T carriers were increased in patients with cerebral infarction compared with controls (53.9% vs. 36.9%, 0.01 < P < 0.025). Relative risk of cerebral infarction was 0.96 (95% CI 0.4-2.3) for 677TT homozygotes and 1.99 (95% CI 1.2-3.4) for 677C/T heterozygotes. However, the distribution of the MTHFR TT genotype was less frequent in patients with CAD with coronary artery stenosis of > 50% than in controls (2. 8% vs. 12.3%, 0.025 < P < 0.05). Relative risk of CAD was not increased among the carriers of 677TT and 677T (odds ratios: 0.2, 95% CI 0-1.1, and 0.97, 95% CI 0.5-1.8, respectively). There were no differences in the distribution of the MTHFR genotypes among CH, CAD with coronary artery stenosis of < 50% and controls. The prothrombin 20210A mutation was not found in any patients or controls. These results demonstrated that MTHFR 677T was associated with DVT and cerebral infarction but was less associated with CAD in the Chinese population.

Race/ethnicity and location of stroke mortality: implications for population-based studies

BACKGROUND AND PURPOSE

Stroke community surveillance projects often focus on hospital data rates. We hypothesized that not including strokes which occurred in nursing homes or at home would differentially affect race/ethnic stroke rates.

METHODS

Texas vital statistics data were studied to compare age-specific (45 to 59, 60 to 74, and >/=75 years) location of stroke death for African Americans (AAs), Hispanic Americans (HAs), and non-Hispanic whites (NHWs). Rate ratios are reported with 95% CIs; NHW is used as the referent group.

RESULTS

During 1991 to 1996, there were 52 996 stroke deaths in Texas for individuals aged 45 years and older. HAs in the oldest age group (>/=75 years) were 33% more likely than NHWs to die in the hospital, and HAs aged 45 to 59 and 60 to 74 years were 4% and 10%, respectively, more likely to die in the hospital. AAs aged >/=75 years were 19% more likely to die in the hospital. HAs aged 60 to 74 years were 35% less likely to die in a nursing home, whereas HAs aged >/=75 years were 43% less likely than NHWs to die in a nursing home. AAs aged >/=75 were 33% less likely to die in a nursing home. Death at home was 19% more likely in HAs aged 60 to 74 years. Significant gender differences are also reported.

CONCLUSIONS

Using hospital data alone would overestimate stroke mortality in the HA and AA groups. Stroke community surveillance projects should account for ethnic and gender differences in location of death to avoid bias in race/ethnic and gender comparisons.

Stroke mortality in blacks. Disturbing trends

BACKGROUND

Despite long-term declines in US stroke mortality rates, declines have slowed in the past decade and targets for blacks for the years 2000 and 2010 seem attainable only by extraordinary measures, if at all. This review focuses attention on key aspects of this problem. Data from the US National Center for Health Statistics and reports of population-based studies of stroke mortality published since 1987 retrieved by computerized literature searches were reviewed.

SUMMARY OF REVIEW

The third leading cause of death in black women and the sixth in black men in the United States in 1996, stroke accounted for 10 509 deaths in women and 7972 in men among blacks: 7.92% and 5.33%, respectively, of the total deaths. Age-adjusted death rates per 100 000 were black women, 39.2; white women, 22.9; black men, 50.9; and white men, 26.3. Available data indicate that compared with US whites, US blacks have greater mortality rates for every stroke subtype, with the likely exception of cerebral infarction due to extracranial carotid artery occlusion. These differences will persist into the 21st century. The number of stroke deaths in blacks increased by >8% between 1992 and 1996.

CONCLUSIONS

Increased research on stroke in blacks is needed to develop more effective strategies for primary and secondary prevention of stroke to reduce the high burden of premature mortality and morbidity. Renewed efforts to prevent and control stroke risk factors (in particular elevated blood pressure, diabetes, and smoking) are needed among US blacks.

Impact of nativity and race on "Stroke Belt" mortality

The southeastern region of the United States has been recognized for 6 decades as an area of excess cerebrovascular mortality rates. While the reasons for the disease variation remain an enigma, South Carolina has consistently been the forerunner of the "Stroke Belt." To determine the effects of nativity (birthplace) on stroke mortality rates in South Carolina, proportional mortality ratios (PMRs) were calculated for stroke deaths in South Carolina during 1980-1996 according to birthplace and stratified by gender, race, age, and educational status. The analyses revealed a graded risk of stroke by birthplace, with the highest PMRs (95% CI) among individuals born in South Carolina (104.8 [103.4 to 106.3]), intermediate PMRs in those born in the Southeast other than South Carolina (92.5 [90.2 to 94.9]), and lowest PMRs for those born outside the Southeast (77.4 [74.9 to 80.1]). The lower stroke PMRs for individuals born outside the Southeast were more striking in blacks (51.8 [45.2 to 59.3]) than in whites (84.9 [82.0 to 88.0]) and for men (73.3 [69.5 to 77.3]) than women (83.5 [79.9 to 87.3]). The findings, particularly in blacks, were not explainable by gender, differences in age, and/or markers of educational and socioeconomic status. These findings suggest that nativity is a significant risk marker for the geographic variation in stroke mortality. Moreover, the regional disparities for nativity and subsequent stroke mortality appear to be greater in blacks than in whites and for men than for women. An understanding of factors linking birthplace to risk for cerebrovascular mortality could facilitate efforts directed at stroke prevention.

Ethnic differences in incidence of stroke: prospective study with stroke register

OBJECTIVE

To identify ethnic differences in the incidence of first ever stroke.

DESIGN

A prospective community stroke register (1995-6) with multiple notification sources. Pathological classification of stroke in all cases was based on brain imaging or necropsy data. Rates were standardised to European and world populations and adjusted for age, sex, and social class in multivariate analysis.

SETTING

A multi-ethnic population of 234 533 in south London, of whom 21% are black.

RESULTS

612 strokes were registered. The crude annual incidence rate was 1.3 strokes per 1000 population per year (95% confidence interval 1.20 to 1.41) and 1.25 per 1000 population per year (1.15 to 1.35) age adjusted to the standard European population. Incidence rates adjusted for age and sex were significantly higher in black compared with white people (P<0.0001), with an incidence rate ratio of 2.21 (1.77 to 2.76). In multivariable analysis increasing age (P<0.0001), male sex (P<0.003), black ethnic group (P<0.0001), and lower social class (P<0.0001) in people aged 35-64 were independently associated with an increased incidence of stroke.

CONCLUSIONS

Incidence rates of stroke are higher in the black population; this is not explained by confounders such as social class, age, and sex. Ethnic differences in genetic, physiological, and behavioural risk factors for stroke require further elucidation to aid development of effective strategies for stroke prevention in multi-ethnic communities.

Racial bias in federal nutrition policy, Part II: Weak guidelines take a disproportionate toll

Many diet-related chronic diseases take a disproportionate toll among members of racial minorities. Research shows the prevalence of diabetes, hypertension, cancer, and heart disease is higher among various ethnic groups compared with whites. The Guidelines and the Food Guide Pyramid, however, promote the use of multiple servings of meats and dairy products each day and do not encourage replacing these foods with vegetables, legumes, fruits, and grains. The Dietary Guidelines for Americans encourage a 30% caloric reduction in fat intake and make no provision for further reductions for those who wish to minimize health risks. Abundant evidence has shown that regular exercise combined with diets lower in fat and richer in plant products than is encouraged by the Dietary Guidelines for Americans are associated with reduced risk of these chronic conditions. While ineffective Dietary Guidelines potentially put all Americans at unnecessary risk, this is particularly true for those groups hardest hit by chronic disease.

Stroke incidence and survival among middle-aged adults: 9-year follow-up of the Atherosclerosis Risk in Communities (ARIC) cohort

BACKGROUND AND PURPOSE

Although stroke mortality rates in the United States are well documented, assessment of incidence rates and case fatality are less well studied.

METHODS

A cohort of 15 792 men and women aged 45 to 64 years from a population sample of households in 4 US communities was followed from 1987 to 1995, an average of 7. 2 years. Incident strokes were identified through annual phone contacts and hospital record searching and were then validated.

RESULTS

Of the 267 incident definite or probable strokes, 83% (n=221) were categorized as ischemic strokes, 10% (n=27) were intracerebral hemorrhages, and 7% (n=19) were subarachnoid hemorrhages. The age-adjusted incidence rate (per 1000 person-years) of total strokes was highest among black men (4.44), followed by black women (3.10), white men (1.78), and white women (1.24). The black versus white age-adjusted rate ratio (RR) for ischemic stroke was 2.41 (95% CI, 1.85 to 3.15), which was attenuated to 1.38 (95% CI, 1.01 to 1.89) after adjustment for baseline hypertension, diabetes, education level, smoking status, and prevalent coronary heart disease. There was a tendency for the adjusted case fatality rates to be higher among blacks and men, although none of the case fatality comparisons across sex or race was statistically significant.

CONCLUSIONS

After accounting for established baseline risk factors, blacks still had a 38% greater risk of incident ischemic stroke compared with whites. Identification of new individual and community-level risk factors accounting for the elevated incidence of stroke requires further investigation and incorporation into intervention planning.

Urinary sodium and potassium profile of blacks and whites in relation to education in two different geographic urban areas. TOMHS Research Group. Treatment of Mild Hypertension Study

The high Na/low K environment of modern society is related to the genesis of hypertension and stroke. There is prior evidence of racial, geographical, and social class differences in Na and K intake and blood pressure. Baseline data from the Treatment of Mild Hypertension Study (TOMHS) was used to assess urinary Na and K excretion profiles by race, clinic geographic area, and education. Participants were adult black and white hypertensive patients from the Birmingham, Alabama, and Chicago, Illinois, area. Level of education was categorized as: less than college graduate and college graduate or more. Two overnight urine samples were collected and analyzed for Na and K at entry from 154 blacks and 281 whites. The urinary Na:K ratio was significantly higher in both blacks (5.1 v 3.8, P < .001) and whites (4.1 v 3.4, P < .005) in Birmingham compared with Chicago. This was primarily due to the lower excretion of urinary K in blacks (12.8 v 16.9 mmol/8 h, P < .01) and whites (14.0 v 16.5 mmol/8 h, P < .01). The highest urinary Na:K ratio was observed in blacks in Birmingham with lower education level; urinary Na excretion was high in blacks with a lower education level in both cities. No such differences were seen in whites. Although TOMHS was not population-based, these findings suggest the possibility that potassium intake among persons with stage 1 hypertension is related to geographic area in both blacks and whites, and sodium intake is inversely related to education level in blacks.

Stroke in Hispanic veterans: a descriptive study

BACKGROUND

Differences in risk factor prevalence and distribution of atherosclerotic cerebrovascular disease have been reported among different racial-ethnic groups. Identification of stroke syndromes and risk factors specific to the Puerto Rican male population should lead to more effective diagnosis, treatment, and prevention programs.

METHODS

We prospectively and consecutively evaluated 118 Hispanic male veterans admitted to our Stroke Unit from June 1994 to September 1995.

RESULTS

Ninety patients (76%) had an ischemic infarct, 26 (22%) had a transient ischemic attack, and 2 (2%) had an intracerebral and/or subarachnoid hemorrhage. Hypertension was the most common risk factor. Echocardiographic studies were done in 64% of the patients, and the most common findings were concentric left ventricular hypertrophy and diastolic dysfunction. Cerebral angiography was done in 40 cases, and findings were abnormal in 32 (80%).

CONCLUSIONS

We believe this is the largest descriptive study of Hispanic male veterans with stroke syndromes. It provides baseline data to serve as a comparison group for future research.

Total homocyst(e)ine concentration and the likelihood of nonfatal stroke: results from the Third National Health and Nutrition Examination Survey, 1988-1994

BACKGROUND AND PURPOSE

Elevated serum total homocyst(e)ine [H(e)] is an independent risk factor for stroke. Few studies, however, have examined this association in blacks.

METHODS

Data from the Third National Health and Nutrition Examination Survey (n=4534), a nationally representative sample of US adults, were used to examine the relationship between H(e) and a physician diagnosis of stroke (n=185) in both black and white adults. Multivariate-adjusted logistic regression analyses were used to examine this relationship.

RESULTS

Serum vitamin B12 and folate concentrations were significantly lower among participants in the highest H(e) quartile (>/=12.1 micromol/L) than among participants in the lowest quartile (</=7.4 micromol/L). Those in the highest quartile were older, had higher mean cholesterol and blood pressure levels, and were more likely to smoke and to have completed <12 years of education. After adjustment for age, the odds ratio (OR) for stroke was 2.9 (95% confidence interval [CI], 1.4 to 5.7; highest versus lowest quartile). Adjustment for gender, race/ethnicity, education, systolic blood pressure, cholesterol, diabetes mellitus, and smoking reduced the magnitude of the association (OR, 2.3; 95% CI, 1.2 to 4. 6). The association between H(e) and stroke did not differ by race [P=0.265 for race-H(e) interaction term]. The multivariate adjusted OR for the highest quartile versus the lowest was 2.5 (1.1 to 5.5) among whites and 1.4 (0.4 to 4.7) among blacks.

CONCLUSIONS

In this nationally representative sample of US adults, H(e) concentration was independently associated with an increased likelihood of nonfatal stroke. This association was present in both black and white adults.

Alcohol intake, body weight, and mortality in a multiethnic prospective cohort

The purpose of this analysis was to investigate the effects of alcohol intake and body weight on mortality from all causes, cancer, and cerebrovascular and coronary heart disease. A cohort of more than 40,000 persons with Caucasian, Chinese, Filipino, Japanese, and native Hawaiian ethnicity was followed for close to 20 years. We calculated mortality rates using the person-years at risk for each gender and ethnic group as denominators. We used proportional hazards regression models to adjust for confounding variables and to estimate relative risks. Men and women with low alcohol intake (1-7 drinks per week) experienced a 20% reduction in total mortality. At higher levels of alcohol intake, women and Asian men experienced no mortality benefit. The protective effect of alcohol consumption was limited to coronary heart disease mortality. The relation between body mass index and total mortality was J-shaped for all groups. In agreement with previous reports, this study found that persons with moderate alcohol intake appear to have a lower risk of dying than nondrinkers, but the possible protective levels of alcohol for women and Asian men appear to be lower than for Caucasian men.

Differences between Israeli Jews and Arabs in morbidity and mortality rates for diseases potentially associated with dietary risk factors

BACKGROUND

Cancer, ischemic heart disease, cerebrovascular disease and diabetes together comprise almost 70% of the causes of death in Israel. Dietary factors such as total caloric intake, saturated fats, polyunsaturated fatty acids, trace elements, vitamins, certain proteins, and fiber have all been suggested as playing a role in the pathogenesis of these diseases.

AIM

In this study, patterns of mortality and morbidity (where available) for selected diseases were compared between the Jewish and Arab population groups in Israel.

METHODS

Data on cause-specific mortality in Israel between 1973 and 1994 were obtained from the Israel Central Bureau of Statistics. Age-adjusted rates for selected diseases were compared between the Jewish and Arab population groups.

RESULTS

Until 1987, the age-adjusted ischemic heart disease mortality rates in the Arab population were slightly lower than those in the Jewish population. Since 1990, they have been slightly higher. Cerebrovascular disease mortality rates have consistently been higher in the Arab population and the gap has been increasing. Similarly, the mortality rates for diabetes mellitus were slightly higher in the Arab population during the 1970 and 1980s and the gap has increased markedly. On the other hand, age-adjusted mortality rates from colorectal cancer are about three times as high and breast cancer mortality rates about twice as high in the Jewish population. The differences for incidence rates are even greater.

CONCLUSIONS

This study demonstrates the contradictory mortality rates for cardiovascular disease as compared with colon and breast cancer in the Jewish and Arab population. While representative dietary data for the populations are lacking, there is evidence that the dietary patterns of the Jewish and Arab population groups differ in many important aspects. It is possible that this may at least partly explain the contradictory differences in mortality and morbidity. The national nutrition surveys currently being initiated by the Ministry of Health should contribute to a better understanding of this subject.

The geographic variation in stroke incidence in two areas of the southeastern stroke belt: the Anderson and Pee Dee Stroke Study

BACKGROUND AND PURPOSE

South Carolina and the southeastern United States have maintained the highest stroke mortality in the country. The Anderson and Pee Dee Stroke Study is an assessment of cerebrovascular disease incidence in 2 geographically defined communities in the stroke belt.

METHODS

Strokes were identified in the Anderson and Pee Dee areas of South Carolina. All hospitalized and out-of-hospital deaths occurring during 1990 among the residents of these 2 areas were included. Strokes were classified by an independent panel of neurologists using a standard protocol that included specific criteria for stroke and subtypes.

RESULTS

The overall age-adjusted stroke incidence rates (per 100 000 population) were significantly higher in the Pee Dee population (293.1) compared with Anderson (211.2). The geographic differences were more dramatic in the younger age groups of 35 to 64 years. Likewise, incidence rates for blacks were nearly twice the rates for whites. The rates in the Pee Dee were higher than the rates from other studies in the United States and other parts of the world. Although the stroke subtypes did not vary between the 2 regions, race-sex differences were identified.

CONCLUSIONS

High stroke incidence and disease rates persist for all 4 race-sex groups in the Southeast and reflect similar risks as mortality rates. However, geographic variability in stroke rates suggests that the pattern of disease in the region is not so much a "belt" of increased stroke in contiguous areas but rather more a "necklace" of different levels of risk. These results should be useful in the identification of factors associated with this geographic enigma.

Ischemic heart disease and stroke mortality in African-American, Hispanic, and non-Hispanic white men and women, 1985 to 1991

We compare recent trends in ischemic heart disease (IHD) and stroke mortality in California among the 6 major sex-racial or -ethnic groups. Rates of age-specific and -adjusted mortality were calculated for persons aged 35 and older during the years 1985 to 1991. Log-linear regression modeling was performed to estimate the average annual percentage change in mortality. During 1985 through 1991, the mortality for IHD and stroke was generally highest for African Americans, intermediate for non-Hispanic whites, and lowest for Hispanics. Age-adjusted mortality for IHD declined significantly in all sex-racial or -ethnic groups except African-American women, and stroke rates declined significantly in all groups except African-American and Hispanic men. African Americans had excess IHD mortality relative to non-Hispanic whites until late in life, after which mortality of non-Hispanic whites was higher. Similarly, African Americans and Hispanics had excess stroke mortality relative to non-Hispanic whites early in life, whereas stroke mortality in non-Hispanic whites was higher at older ages. The lower IHD and stroke mortality among Hispanics was paradoxical, given the generally adverse risk profile and socioeconomic status observed among Hispanics. An alarmingly high prevalence of self-reported cardiovascular disease risk factors in 1994 to 1996, particularly hypertension, leisure-time sedentary lifestyle, and obesity, is a serious public health concern, with implications for future trends in cardiovascular disease mortality. Of particular concern was the growing disparities in stroke and IHD mortality among younger-aged African Americans relative to Hispanics and non-Hispanic whites.