The effect of insulin on bone mineral density among women with type 2 diabetes: a SWAN Pharmacoepidemiology study.

This was a longitudinal study examining the effects of insulin use on bone mineral density loss. Insulin use was found to be associated with greater bone mineral density loss at the femoral neck among women with diabetes mellitus. INTRODUCTION: Women with diabetes mellitus (DM) have higher bone mineral density (BMD) and experience slower BMD loss but have an increased risk of fracture. The data regarding the effect of insulin treatment on BMD remains conflicted. We examined the impact of insulin initiation on BMD. METHODS: We investigated the annual changes in BMD associated with the new use of insulin among women with DM in the Study of Women's Health Across the Nation (SWAN). Propensity score (PS) matching, which is a statistical method that helps balance the baseline characteristics of women who did and did not initiate insulin, was used. Covariates with a potential impact on bone health were included in all models. Mixed model regression was used to test the change in BMD between the two groups. Median follow-up time was 5.4 years. RESULTS: The cohort consisted of 110 women, mean age, 53.6 years; 49% white and 51% black. Women using insulin (n = 55) were similar on most relevant characteristics to the 55 not using insulin. Median diabetes duration for the user group was 10 vs. 5.0 years for the non-user group. There was a greater loss of BMD at the femoral neck among insulin users (- 1.1%) vs non-users (- 0.77%) (p = 0.04). There were no differences in BMD loss at the spine - 0.30% vs - 0.32% (p = 0.85) or at the total hip - 0.31% vs - 0.25 (p = 0.71), respectively. CONCLUSIONS: Women with T2DM who initiated insulin experienced a more rapid BMD loss at the femoral neck as compared to women who did use insulin.

The failing Fontan: what's NEXT...?

The Fontan procedure represents the final stage of the transition to single ventricle physiology. Conversion of very complex congenital heart anatomy, such as hypoplastic left heart syndrome, double-outlet right ventricle or double-inlet left ventricle, to a single ventricle has grown in popularity as morbidity and mortality have improved. As these patients grow, survivors are at risk for impaired ventricular dysfunction, plastic bronchitis, protein-losing enteropathy and late failure. Late failing Fontan patients represent a particularly vexing scenario for clinicians, as the only durable treatment option is cardiac transplantation. However, in the short-term, some of these patients require support beyond medical management, with mechanical circulatory support via extracorporeal life support or a ventricular assist device. We report the successful bridge of an adolescent female post-Fontan conversion with late severe cardiac failure. The patient was initially resuscitated with extracorporeal life support, transitioned to a single Berlin Heart EXCOR® ventricular assist device and, subsequently, underwent successful cardiac transplantation.

Sickle cell disease and complex congenital cardiac surgery: a case report and review of the pathophysiology and perioperative management.

Sickle cell anemia and thalassemia are hemoglobinopathies rarely encountered in the United States. Compounded with congenital heart disease, patients with sickle cell disease (SCD) requiring cardiopulmonary bypass and open-heart surgery represent the proverbial "needle in the haystack". As such, there is some trepidation on the part of clinicians when these patients present for complex cardiac surgery. SCD is an autosomal, recessive condition that results from a single nucleotide polymorphism in the ß-globin gene. Hemoglobin SS molecules (HgbSS) with this point mutation can polymerize under the right conditions, stiffening the erythrocyte membrane and distorting the cellular structure to the characteristic sickle shape. This shape change alters cellular transit through the microvasculature. As a result, circumstances such as hypoxia, hypothermia, acidosis or diminished blood flow can lead to aggregation, vascular occlusion and thrombosis. Chronically, SCD can give rise to multiorgan damage secondary to hemolysis and vascular obstruction. This review and case study details an 11-year-old African-American male with known SCD who presented to the cardiothoracic surgical service with congenital heart disease consisting of an anomalous, intramural right coronary artery arising from the left coronary sinus for surgical consultation and subsequent surgical correction. This case report will include a review of the pathophysiology and current literature regarding preoperative, intraoperative and postoperative management of SCD patients.

The relationship between psychosocial status, acculturation and country of origin in mid-life Hispanic women: data from the Study of Women's Health Across the Nation (SWAN).

METHOD: To test the hypothesis that psychosocial symptomatology differs by country of origin and acculturation among Hispanic women, we examined 419 women, aged 42-52 years at baseline, enrolled in the New Jersey site of the Study of Women's Health Across the Nation (SWAN). Women were categorized into six groups: Central (CA, n = 29) or South American (SA, n = 106), Puerto Rican (PR, n = 56), Dominican (D, n = 42), Cuban (Cu, n = 44) and non-Hispanic Caucasian (NHC, n = 142). Acculturation, depressive symptoms, hostility/cynicism, mistreatment/discrimination, sleep quality, social support, and perceived stress were assessed at baseline. Physical functioning, trait anxiety and anger were assessed at the fourth annual follow-up. Comparisons between Hispanic and non-Hispanic Caucasians used χ², t test or non-parametric alternatives; ANOVA or Kruskal-Wallis testing examined differences among the five Hispanic sub-groups. Multivariable regression models used PR women as the reference group. RESULTS: Hispanic women were overall less educated, less acculturated (p < 0.001 for both) and reported more depressive symptoms, cynicism, perceived stress, and less mistreatment/discrimination than NHCs. Along with D women, PR women reported worse sleep than Cu women (p < 0.01) and more trait anxiety than SA and Cu women (p < 0.01). Yet, PR women were most acculturated (21.4% highly acculturated vs. CA (0.0%), D (4.8%), SA (4.8%) and Cu (2.3%) women; p < 0.001). In regression models, PR women reported depressive symptoms more frequently than D, Cu, or SA women, and reported trait anxiety more frequently than Cu or SA women. Greater acculturation was associated with more favorable psychosocial status, but PR ethnicity was negatively related to psychosocial status. CONCLUSION: Psychosocial symptomatology among Hispanic women differs by country of origin and the relatively adverse profile of Puerto Rican women is not explained by acculturation.

Menopausal symptoms within a Hispanic cohort: SWAN, the Study of Women's Health Across the Nation.

INTRODUCTION: Since the designation of people as Hispanic involves the amalgamation of a number of different cultures and languages, we sought to test the hypothesis that menopausal symptoms would differ among Hispanic women, based upon country of origin and degree of acculturation. METHODS: A total of 419 women, aged 42-52 years at baseline, were categorized as: Central American (CA, n = 29) or South American (SA, n = 106), Puerto Rican (PR, n = 56), Dominican (D, n = 42), Cuban (Cu, n = 44) and non-Hispanic Caucasian (n = 142). We assessed vasomotor symptoms, vaginal dryness and trouble in sleeping. Hispanics and non-Hispanic Caucasians were compared using the chi(2) test, t test or non-parametric alternatives; ANOVA or Kruskal-Wallis testing examined differences among the five Hispanic sub-groups. Multivariable regression models used PR women as the reference group. RESULTS: Hispanic women were overall less educated, less acculturated (p < 0.001 for both) than non-Hispanic Caucasians and more of them reported vasomotor symptoms (34.1-72.4% vs. 38.3% among non-Hispanic Caucasians; p = 0.0293) and vaginal dryness (17.9-58.6% vs. 21.1% among non-Hispanic Caucasians, p = 0.0287). Among Hispanics, more CA women reported vasomotor symptoms than D, Cu, SA, or PR women (72.4% vs. 45.2%, 34.1%, 50.9%, and 51.8%, respectively). More CA (58.6%) and D women (38.1%) reported vaginal dryness than PR (17.9%), Cu (25.0%) and SA (31.4%) women. More PR and D women reported trouble in sleeping (66.1 and 64.3%, respectively) compared to CA (51.7%), Cu (36.4%), and SA (45.3%) women. CONCLUSION: Symptoms associated with menopause among Hispanic women differed by country of origin but not acculturation. Central American women appear to be at greatest risk for both vasomotor symptoms and vaginal dryness.

Cognitive activities delay onset of memory decline in persons who develop dementia.

BACKGROUND: Persons destined to develop dementia experience an accelerated rate of decline in cognitive ability, particularly in memory. Early life education and participation in cognitively stimulating leisure activities later in life are 2 factors thought to reflect cognitive reserve, which may delay the onset of the memory decline in the preclinical stages of dementia. METHODS: We followed 488 initially cognitively intact community residing individuals with epidemiologic, clinical, and cognitive assessments every 12 to 18 months in the Bronx Aging Study. We assessed the influence of self-reported participation in cognitively stimulating leisure activities on the onset of accelerated memory decline as measured by the Buschke Selective Reminding Test in 101 individuals who developed incident dementia using a change point model. RESULTS: Each additional self-reported day of cognitive activity at baseline delayed the onset of accelerated memory decline by 0.18 years. Higher baseline levels of cognitive activity were associated with more rapid memory decline after that onset. Inclusion of education did not significantly add to the fit of the model beyond the effect of cognitive activities. CONCLUSIONS: Our findings show that late life cognitive activities influence cognitive reserve independently of education. The effect of early life education on cognitive reserve may be mediated by cognitive activity later in life. Alternatively, early life education may be a determinant of cognitive reserve, and individuals with more education may choose to participate in cognitive activities without influencing reserve. Future studies should examine the efficacy of increasing participation in cognitive activities to prevent or delay dementia.

Hippocampal neurochemistry, neuromorphometry, and verbal memory in nondemented older adults.

BACKGROUND: Characterization of the behavioral correlates of neuromorphometry and neurochemistry in older adults has important implications for an improved understanding of the aging process. The objective of this study was to test the hypothesis that a measure of hippocampal neuronal metabolism was associated with verbal memory in nondemented older adults after controlling for hippocampal volume. METHODS: 4-T MRI, proton magnetic resonance spectroscopy ((1)H MRS), and neuropsychological assessment were conducted in 48 older adults (23 women; mean age 81 years). Average hippocampal N-acetyl aspartate/creatine ratios (NAA/Cr) and hippocampal volumes were obtained. Neuropsychological evaluation included tests of verbal memory (Buschke and Grober Free and Cued Selective Reminding Test-Immediate Recall [FCSRT-IR], Wechsler Memory Scale-Revised Logical Memory subtest) and attention and executive function (Trail Making Test Parts A and B). RESULTS: Linear regression analysis indicated that after adjusting for age, hippocampal NAA/Cr was a significant predictor of FCSRT-IR performance (beta = 0.38, p = 0.01, R (2) = 0.21). Hippocampal volume was also a significant predictor of FCSRT-IR performance after adjusting for age and midsagittal area (beta = 0.47, p = 0.01, R (2) = 0.24). In a combined model, hippocampal NAA/Cr (beta = 0.33, p = 0.03) and volume (beta = 0.35, p = 0.03) were independent predictors of FCSRT-IR performance, accounting for 30% of the variance in memory. CONCLUSIONS: These findings indicate that nondemented older adults with smaller hippocampal volumes and lower levels of hippocampal N-acetyl aspartate/creatine ratio metabolites perform more poorly on a test of verbal memory. The integrity of both the structure and metabolism of the hippocampus may underlie verbal memory function in nondemented elderly.

Education delays accelerated decline on a memory test in persons who develop dementia.

OBJECTIVE: To test the cognitive reserve hypothesis by examining the effect of education on memory decline during the preclinical course of dementia. BACKGROUND: Low education is a well known risk factor for Alzheimer disease (AD). Persons destined to develop AD experience an accelerated rate of decline in cognitive ability, particularly in memory. The cognitive reserve hypothesis predicts that persons with greater education begin to experience acceleration in cognitive decline closer to the time of diagnosis than persons with lower reserve, but that their rate of decline is more rapid after the time of acceleration due to increased disease burden. METHODS: We studied the influence of education on rates of memory decline as measured by the Buschke Selective Reminding Test in 117 participants with incident dementia in the Bronx Aging Study. Subjects had detailed cognitive assessments at entry and at annual follow-up visits. We estimated the time at which the rate of decline begins to accelerate (the change point), and the pre- and post-acceleration rates of decline, from the longitudinal data using a change point model. RESULTS: Each additional year of formal education delayed the time of accelerated decline on the Buschke Selective Reminding Test by 0.21 years. Post-acceleration, the rate of memory decline was increased by 0.10 points per year for each year of additional formal education. CONCLUSIONS: As predicted by the cognitive reserve hypothesis, higher education delays the onset of accelerated cognitive decline; once it begins it is more rapid in persons with more education.

High risk neurological gait syndrome and vascular dementia.

We defined a 'high-risk neurological gait' (HRNG) syndrome based on presence of any one of hemiparetic, frontal, and unsteady gaits, and examined its validity to predict vascular dementia (VD) over 3 and 5 years in 399 nondemented older adults, age 75 and over. Cox analysis was used to estimate hazard ratios (HR) for VD adjusted for potential confounders. At baseline, 54 subjects had HRNG. 14 subjects developed VD over 3 years and 25 by 5 years. HRNG predicted risk of VD within the first three (HR 3.3, 95% CI 1.8-5.9) and five years (HR 2.7, 95% CI 1.7-4.2). Including executive dysfunction (Digit symbol scores <16) improved validity; subjects with HRNG and executive dysfunction (HR 12.5, 95% CI 5.5-28.4) or either (HR 5.9, 95% CI 3.6-9.7) had higher risk of VD over five years. Diagnosing HRNG is a clinically relevant approach to identifying older adults at high risk of VD over short intervals.

A genotype of exceptional longevity is associated with preservation of cognitive function.

OBJECTIVE: To test whether cholesterol ester transfer protein (CETP) genotype (VV homozygosity for I405V) is associated with preservation of cognitive function in addition to its association with exceptional longevity. METHODS: We studied Ashkenazi Jews with exceptional longevity (n = 158; age 99.2 +/- 0.3 years) for the associations of CETP VV genotype and lipoprotein phenotype, using the Mini-Mental State Examination (MMSE). To confirm the role of CETP in a younger cohort, we studied subjects from the Einstein Aging Study (EAS) for associations between CETP VV and cognitive impairment. RESULTS: Subjects with MMSE > 25 were twice as likely to have the CETP VV genotype (29% vs 14%, p = 0.02), and those with the VV genotype were more likely (61% vs 30%, p = 0.02) to have MMSE > 25. Subjects with the VV genotype had lower levels of CETP (1.73 +/- 0.11 vs 2.12 +/- 0.10 mug/mL, p = 0.01), higher high-density lipoprotein (HDL) levels (p = 0.02), and larger lipoprotein particles (p = 0.03). In the EAS cohort, an approximately fivefold increase in the VV genotype (21% vs 4%, p = 0.02), higher HDL levels, and larger lipoprotein particle sizes were associated with less dementia and improved memory. CONCLUSIONS: Using two independent cohorts, we implicate the longevity CETP gene as a modulator of age-related cognitive function. A specific CETP genotype is associated with lower CETP levels and a favorable lipoprotein profile. It has not been determined whether modulation of this gene prevents age-related decline or AD.

Incidence of epilepsy in a racially diverse, community-dwelling, elderly cohort: results from the Einstein aging study.

OBJECTIVE: To determine age-specific incidence and cumulative incidence of epilepsy in a well-defined cohort of elderly people, and to examine how rates of epilepsy are modified by sex, race, stroke, dementia, head injury, and depression. METHODS: The authors examined data from a reconstructed cohort based on 1919 community-dwelling volunteers, followed as part of a large ongoing prospective aging study. RESULTS: Age-specific incidence was 10.6 (per 100,000 person-years) between ages 45 and 59, 25.8 between ages 60 and 74, and 101.1 between ages 75 and 89. Cumulative incidence was 0.15% from age 45 to age 60, 0.38% to age 70, 1.01% to age 80, and 1.47% to age 90. In addition, the difference in cumulative incidence among African-American subjects approached statistical significance (57.6/100,000 person-years versus 26.1 in Caucasian, p=0.10), and the difference in incidence among subjects reporting a history of stroke was significantly elevated (p=0.029). Incidence of epilepsy was not statistically elevated among males, those with dementia, or individuals reporting a history of head injury or treatment for depression. Among "healthy" subjects without history of stroke, head injury, or dementia, we observed a cumulative risk of epilepsy with onset after age 60 of only 1.1%. CONCLUSIONS: The incidence of epilepsy was low in this relatively healthy cohort of elderly people, especially among subjects without known risk factors. In this study we identified African-American race as a risk factor in the elderly for epilepsy independent of stroke.

Leisure activities and the risk of amnestic mild cognitive impairment in the elderly.

OBJECTIVE: To study the influence of leisure activity participation on risk of development of amnestic mild cognitive impairment (aMCI). METHODS: The authors examined the relationship between baseline level of participation in leisure activities and risk of aMCI in a prospective cohort of 437 community-residing subjects older than 75 years, initially free of dementia or aMCI, using Cox analysis adjusted for age, sex, education, and chronic illnesses. The authors derived Cognitive and Physical Activity Scales based on frequency of participation in individual activities. RESULTS: Over a median follow-up of 5.6 years, 58 subjects had development of aMCI. A one-point increase on the Cognitive (hazard ratio [HR] 0.95, 95% CI 0.91 to 0.99) but not Physical Activities Scale (HR 0.97, 95% CI 0.93 to 1.01) was associated with lower risk of aMCI. Subjects with Cognitive Activity scores in the highest (HR 0.46, 95% CI 0.24 to 0.91) and middle thirds (HR 0.52, 95% CI 0.29 to 0.96) had a lower risk of aMCI compared with subjects in the lowest third. The association persisted even after excluding subjects who converted to dementia within 2 years of meeting criteria for aMCI. CONCLUSIONS: Cognitive activity participation is associated with lower risk of development of amnestic mild cognitive impairment, even after excluding individuals at early stages of dementia.

Dementia incidence may increase more slowly after age 90: results from the Bronx Aging Study.

BACKGROUND: Dementia incidence increases dramatically from age 65 to age 85, with many studies reporting a doubling every 5 years. The incidence beyond age 85 is not established. OBJECTIVE: To estimate the incidence of dementia as a function of age, with a particular focus on persons aged 85 and over. METHODS: The Bronx Aging Study began in 1980 with 488 healthy, nondemented community-dwelling individuals, age 75 to 85. Persons in the study received clinical examinations and cognitive testing approximately every 12 months until death or loss to follow-up. The diagnosis of dementia was made using Diagnostic and Statistical Manual of Mental Disorders-III-R at diagnostic case conferences. Dementia incidence rates were calculated for 5-year age bands using person-time of follow-up as the denominator. RESULTS: The relative incidence rate ratios of dementia for age 80 to 84 vs 75 to 79 was 2.32 (95% CI 1.23 to 4.37), the relative rate for age 85 to 89 vs 80 to 84 was 1.89 (95% CI 1.26 to 2.83), the relative rate for age 90 to 94 vs 85 to 89 was 1.49 (95% CI 0.86 to 2.58), while the relative rate for age 95 to 99 vs 90 to 94 was 1.31 (95% CI 0.38 to 4.46). Similar results were seen for men and women considered separately. Had the rate of increase from age 75 to 89 continued into the 90s, the study would have had 73% power to detect a significant difference between the rates for age 90 to 94 and 85 to 89 given the amount of observed follow-up time. CONCLUSIONS: Whereas dementia incidence continues to increase beyond age 85, the rate of increase appears to slow relative to that of 65- to 85-year-olds. These results suggest that dementia in the oldest old might be related not to the aging process itself but with age-associated risk factors.

A new screening tool for cervical dystonia.

BACKGROUND: Family studies of dystonia may be limited in part by small family size and incomplete ascertainment of dystonia in geographically dispersed families. Further, prevalence estimates of dystonia are believed to be underestimates, as most studies are clinic-based and many individuals do not present to a physician or are misdiagnosed. As a low-cost highly sensitive screening tool is needed to improve case detection for genetic and epidemiologic studies, the authors developed the Beth Israel Dystonia Screen (BIDS), a computer-assisted telephone interview. OBJECTIVE: To evaluate the validity and utility of a computer-assisted telephone interview in screening for cervical dystonia. METHODS: The BIDS was administered and videotaped neurologic examinations performed on 193 individuals from 16 families with cervical and cranial dystonia. With use of a final rating of definite dystonia, as determined by video review of a systematic neurologic evaluation, as the gold standard, the predictive value of a subset of questions from the BIDS was assessed. RESULTS: A positive response to at least two of five screening questions had a sensitivity for cervical dystonia of 100% and a specificity of 92%. With use of a positive response to three or more questions, definite dystonia was determined with 81% sensitivity and 97% specificity. CONCLUSIONS: The Beth Israel Dystonia Screen (BIDS) identifies cervical dystonia with excellent sensitivity and specificity in a family-based sample. The authors recommend the BIDS for family studies, but cross-validation in a population sample is advisable before applying this method to epidemiologic studies.

Sesame allergy in Britain: a questionnaire survey of members of the Anaphylaxis Campaign.

Sesame is a major allergen in countries where it is a common food. It was noted that an increasing number of members of the UK charity, the anaphylaxis campaign, were reporting allergy to sesame. This study, sought to examine features of sesame allergy among members of the Anaphylaxis Campaign (which supports those at potentially life-threatening risk from allergies) focusing on clinical symptoms and features of the foods implicated. A physician-designed questionnaire was sent by post to 400 members of the Anaphylaxis Campaign who reported avoidance of sesame. Two hundred and eighty replies were received (70%). Twenty-three replies (7%) were excluded and 96 replies (24%) came from subjects who avoided sesame but had never reacted to it. One hundred and fifty people (54%) reported 288 reactions to sesame. 89% of reactive subjects reported other atopic diseases and notably 84% were also nut/peanut allergic. One in six (17%) had suffered potentially life-threatening symptoms, with 65% of severe reactions happening on first known exposure. The age of first reaction ranged from 6 months to 65 yr. The majority of reactions reported (91%) involved foods or dishes which had sesame as a deliberate ingredient, rather than sesame as an accidental contaminant. Respondents represented a well-informed and highly selected group of people at risk from potentially life-threatening allergies. Sesame should be identified clearly as an ingredient and separately from nuts and peanuts when it may be an allergen contaminant. People at potential risk need clear allergy diagnosis and informed guidance to enable them to avoid this key allergen more easily.

Transsexual limb transplants in fiddler crabs and expression of novel sensory capabilities.

We used transsexual limb transplants in fiddler crabs to examine how peripheral sensory structures interact with the central nervous system (CNS) to produce a sexually dimorphic behavior. Female and male chemosensory feeding claws were transplanted onto male hosts in place of nonfeeding, nonchemosensory claws. Successfully transplanted claws retain donor morphologies and contain chemosensory neurons. Neurons in successfully transplanted female feeding claws express the enhanced sensitivity to chemical cues seen in female, but not male, neurons in claws of normal animals. When chemically stimulated, the transplanted claws evoke feeding behavior not observed in normal males, even though the sensory neurons in the transplanted limb project to the host's sexually dimorphic neuropil not known to receive chemosensory input. Behavioral sensitivity is directly related to the sensitivity of peripheral neurons in the transplanted feeding claw. Thus, the interactions between peripheral neurons and their targets may restructure the CNS so that novel sensory capabilities are expressed, and this can produce sexually dimorphic behaviors.

A CUB-serine protease in the olfactory organ of the spiny lobster Panulirus argus.

csp, a gene encoding a protein with high sequence identity to trypsinlike serine protease and CUB domains, was identified from a cDNA library from the olfactory organ (antennular lateral flagellum) of the spiny lobster Panulirus argus. The full-length cDNA sequence of csp is 1801 bp, encoding a protein of 50.25 kD, with three domains: signal peptide, trypsinlike serine protease, and CUB (named for a class of compounds including Complement subcomponents Clr/Cls, Uegf, and Bone morphogenic protein-1). RT-PCR, Northern blots, and immunoblots showed that csp is predominantly expressed in the lateral flagellum and eyestalk. Immunocytochemistry showed that Csp is present in olfactory (aesthetasc) sensilla around auxiliary cells (glia that surround the inner dendrites of olfactory receptor neurons, ORNs) and ORN outer dendrites. We propose that Csp is expressed and secreted by auxiliary cells, associates with ORN cell membranes or extracellular matrix via the CUB domain, and has trypsinlike activity. In the eyestalk, Csp is associated with cells surrounding axons between neuropils of the eyestalk ganglia. Possible functions in the olfactory organ and eyestalk are discussed. To our knowledge, this is the first report from any olfactory system of a gene encoding a protein with serine protease and CUB domains.

Possible effect of DRGs on the classification of stroke: implications for epidemiological surveillance.

BACKGROUND AND PURPOSE: Accurate data on the distribution of stroke subtypes are essential for understanding the forces driving recent morbidity and mortality trends. The introduction of diagnosis-related groups (DRGs) in the 1980s may have affected the distribution of stroke subtypes as defined by International Classification of Diseases, Ninth Revision (ICD-9), discharge diagnosis codes. METHODS: The Pawtucket Heart Health Program cardiovascular surveillance data were used to examine trends in stroke classification for 1980 to 1991 in relation to the introduction of DRGs in 2 communities in Massachusetts and Rhode Island, where DRGs were implemented 2 years apart. Included were all hospital discharges for residents aged 35 to 74 with a primary ICD-9 diagnosis of 431 to 432, 434, or 436 to 437 (N=1386 in Rhode Island, N=1839 in Massachusetts). RESULTS: In each state, concurrently with the introduction of DRGs, the proportion of strokes classified as cerebral occlusion (ICD-9 434.0 to 434.9) increased, and the proportion classified as acute but ill-defined (ICD-9 436.0 to 436.9) decreased. Before DRGs, 30.0% of strokes in Rhode Island and 26.6% in Massachusetts were classified as cerebral occlusion, whereas 51.8% in Rhode Island and 51.7% in Massachusetts were classified as acute ill defined. After DRGs were instituted, the proportions of cerebral occlusion and acute, ill-defined stroke, respectively, were 70.9% and 8.5% in Rhode Island and 74.1% and 7.7% in Massachusetts (chi(2), all P<0.001). The proportions of strokes classified as intracerebral hemorrhage or transient cerebral ischemia remained constant. CONCLUSIONS: The implementation of DRGs may have influenced coding of strokes to the ICD-9. Findings highlight the limitations of hospital discharge data for evaluating stroke subtypes and demonstrate the need for community-based surveillance for monitoring specific trends in stroke.

Lower standing systolic blood pressure as a predictor of falls in the elderly: a community-based prospective study.

OBJECTIVES: We investigated prospectively the relationships among falls, physical balance, and standing and supine blood pressure (BP) in elderly persons. BACKGROUND: Falls occur often and adversely affect the activities of daily living in the elderly; however, their relationship to BP has not been clarified thoroughly. METHODS: A total of 266 community-dwelling elderly persons age 65 years or over (123 men and 143 women, mean age of 76 years) were selected from among residents of Coop City, Bronx, New York. Balance was evaluated at baseline using computerized dynamic posturography (DPG). During a one-year follow-up, we collected information on subsequent falls on a monthly basis by postcard and telephone follow-up. RESULTS: One or more falls occurred in 60 subjects (22%) during the one-year follow-up. Women fell more frequently than men (28% vs. 16%, p < 0.03), and fallers were younger than nonfallers. Fallers (n = 60) had lower systolic BP (SBP) levels when compared with nonfallers (n = 206) (128 +/- 17 vs. 137 +/- 22 mm Hg for standing, p < 0.006; 137 +/- 16 vs. 144 +/- 22 mm Hg for lying, p < 0.02), whereas diastolic BP was not related to falls. Falls occurred 2.8 times more often in the lower BP subgroup (<140 mm Hg for standing SBP) than in the higher BP subgroup (> or =140 mm Hg, p < 0.0003), and gender-related differences were observed (p = 0.006): 3.4 times for women (p < 0.0001) versus 1.9 times for men (p = 0.30). Loss of balance, as detected by DPG, did not predict future falls and was also not associated with baseline BP levels. Multiple logistic regression analysis demonstrated that female gender (relative risk [RR] = 2.1, p = 0.02), history of falls (RR = 2.5, p = 0.008) and lower standing SBP level (RR = 0.78 for 10 mm Hg increase, p = 0.005) were independent predictors of falls during one year of follow-up. CONCLUSIONS: Lower standing SBP, even within normotensive ranges, was an independent predictor of falls in the community-dwelling elderly. Elderly women with a history of falls and with lower SBP levels should have more attention paid to the prevention of falls and related accidents.

Morphology and distribution of setae on the antennules of the Caribbean spiny lobster Panulirus argus reveal new types of bimodal chemo-mechanosensilla.

This study describes the morphology and distribution of setae on the lateral and medial flagella of the antennules of the spiny lobster Panulirus argus in an effort to identify antennular chemoreceptors in addition to the well-studied aesthetasc chemosensilla. Setae were examined using light and electron microscopy, and their distribution on flagellar annuli was analyzed. We identified ten setal types based on external morphology: hooded, plumose, short setuled, long simple, medium simple, short simple, aesthetasc, guard, companion, and asymmetric setae, with the last four types being unique to the "tuft" located on the distal half of the lateral flagellum. The three setal types whose ultrastructure was examined--hooded, long simple, and medium simple setae--had characteristics of bimodal (chemo-mechanoreceptive) sensilla. The antennules have four distinct annular types based on their setal complement, as shown by cluster analysis. This basic distribution of non-tuft setal types is similar for both lateral and medial flagella. Annuli in the tuft region have tuft setal types superimposed on a basic organization of non-tuft setal types. These results show that the antennules possess a diverse set of setae, that these setae have a highly ordered arrangement on the antennules, that at least four (and probably many more) of these setal types are chemosensilla, and suggest that most antennular chemosensilla are bimodally sensitive.