Long-Term Trends in Secondhand Smoke Exposure in High-Rise Housing Serving Low-Income Residents in New York City: Three-Year Evaluation of a Federal Smoking Ban in Public Housing, 2018-2021.

INTRODUCTION: In July 2018, the U.S. Department of Housing and Urban Development passed a rule requiring public housing authorities to implement smoke-free housing (SFH) policies. We measured secondhand smoke (SHS) exposure immediately before, and repeatedly up to 36 months post-SFH policy implementation in a purposeful sample of 21 New York City (NYC) high-rise buildings (>15 floors): 10 NYC Housing Authority (NYCHA) buildings subject to the policy and 11 privately managed buildings in which most residents received housing vouchers (herein "Section 8"). AIMS AND METHODS: We invited participants from nonsmoking households (NYCHA n = 157, Section-8 n = 118) to enroll in a longitudinal air monitoring study, measuring (1) nicotine concentration with passive, bisulfate-coated filters, and (2) particulate matter (PM2.5) with low-cost particle sensors. We also measured nicotine concentrations and counted cigarette butts in common areas (n = 91 stairwells and hallways). We repeated air monitoring sessions in households and common areas every 6 months, totaling six post-policy sessions. RESULTS: After 3 years, we observed larger declines in nicotine concentration in NYCHA hallways than in Section-8, [difference-in-difference (DID) = -1.92 µg/m3 (95% CI -2.98, -0.87), p = .001]. In stairwells, nicotine concentration declines were larger in NYCHA buildings, but the differences were not statistically significant [DID= -1.10 µg/m3 (95% CI -2.40, 0.18), p = .089]. In households, there was no differential change in nicotine concentration (p = .093) or in PM2.5 levels (p = .385). CONCLUSIONS: Nicotine concentration reductions in NYCHA common areas over 3 years may be attributable to the SFH policy, reflecting its gradual implementation over this time. IMPLICATIONS: Continued air monitoring over multiple years has demonstrated that SHS exposure may be declining more rapidly in NYCHA common areas as a result of SFH policy adherence. This may have positive implications for improved health outcomes among those living in public housing, but additional tracking of air quality and studies of health outcomes are needed. Ongoing efforts by NYCHA to integrate the SFH policy into wider healthier-homes initiatives may increase policy compliance.

A functional MRI study of three motor tasks in the evaluation of stroke recovery.

Functional brain imaging studies have provided insights into the processes related to motor recovery after stroke. The comparative value of different motor activation tasks for probing these processes has received limited study. We hypothesized that different hand motor tasks would activate the brain differently in controls, and that this would affect control-patient comparisons. Functional magnetic resonance imaging (MRI) was used to evaluate nine control subjects and seven patients with good recovery after a left hemisphere hemiparetic stroke. The volume of activated brain in bilateral sensorimotor cortex and four other motor regions was compared during each of three tasks performed by the right hand: index-finger tapping, four-finger tapping, and squeezing. In control subjects, activation in left sensorimotor cortex was found to be significantly larger during squeezing as compared with index-finger tapping. When comparing control subjects with stroke patients, patients showed a larger volume of activation in right sensorimotor cortex during index-finger tapping but not with four-finger tapping or squeezing. In addition, patients also showed a trend toward larger activation volume than controls within left supplementary motor area during index-finger tapping but not during the other tasks. Motion artifact was more common with squeezing than with the tapping tasks. The choice of hand motor tasks used during brain mapping can influence findings in control subjects as well as the differences identified between controls and stroke patients. The results may be useful for future studies of motor recovery after stroke.

Quantitative assessment of mirror movements after stroke.

BACKGROUND AND PURPOSE: Mirror movements (MM) are involuntary synchronous movements of one limb during voluntary unilateral movements of the opposite limb. We measured MM in stroke and control subjects and evaluated whether MM after stroke are related to motor function. METHODS: Twenty-three patients and 16 control subjects were studied. A computerized dynamometer was used during two squeezing tasks to measure intended movements from the active hand as well as MM from the opposite hand. Motor deficits were measured with the arm motor component of the Fugl-Meyer scale. RESULTS: During paretic hand squeezing, MM in the unaffected hand were detected in 70% (repetitive squeeze) to 78% (sustained squeeze) of stroke patients. For both tasks, this was significantly (P < 0.05) greater than the incidence of MM in the paretic hand or in either hand of control subjects (17% to 44%), except when compared with the incidence of MM in the dominant hand of control subjects (56%; P = 0.17). The incidence of MM in the paretic hand was not significantly different from that seen in either hand of control subjects. Patients with MM in the unaffected hand had significantly greater motor deficit than patients without MM. Patients with MM in the paretic hand had significantly better motor function than patients without MM. CONCLUSIONS: Simultaneously recording motor performances of both hands provides precise information to characterize MM. MM in the unaffected hand and in the paretic hand are associated with different degrees of motor deficit after stroke. Evaluation of MM may be useful for studying mechanisms of stroke recovery.

Recovery following lateral medullary infarction.

Lateral medullary infarction (LMI) has a well-defined clinical syndrome and vascular pathology. The functional outcome and degree of disability of patients with LMI, however, have not been as well investigated. We followed 18 consecutive patients with LMI during inpatient stroke rehabilitation. Thirteen patients were followed after discharge from the hospital over a mean time of 1 year. The degree of disability on admission and discharge from the hospital, and at follow-up was assessed using the motor component of the Functional Independence Measurement (FIM-motor). All patients were discharged home. During inpatient rehabilitation, the functional performance of all patients improved substantially from FIM-motor 50.9 +/- 13.0 (mean +/- SD) on admission to 76.9 +/- 10.5 at discharge. Patients with lower FIM-motor scores on admission had more functional improvement from admission to discharge than those with higher FIM-motor scores on admission. Patients with disease of the posterior inferior cerebellar artery showed significantly less functional improvement than patients with disease of the vertebral artery or no identified vascular pathology in the posterior circulation. In the follow-up group, the FIM-motor scores further improved to 84.6 +/- 8.4, indicating nearly full functional independence. Eighty-five percent were totally independent with ambulation. Five of seven previously working patients returned to work. Patients with LMI have few functional deficits after completion of inpatient rehabilitation, continue to improve functionally after discharge, and often resume their previous activities.

A functional MRI study of subjects recovered from hemiparetic stroke.

BACKGROUND AND PURPOSE: Stroke recovery mechanisms remain incompletely understood, particularly for subjects with cortical stroke, in whom limited data are available. We used functional magnetic resonance imaging to compare brain activations in normal controls and subjects who recovered from hemiparetic stroke. METHODS: Functional magnetic resonance imaging was performed in ten stroke subjects with good recovery, five with deep, and five with cortical infarcts. Brain activation was achieved by index finger-tapping. Statistical parametric activation maps were obtained using a t test and a threshold of P < .001. In five bilateral motor regions, the volume of activated brain for each stroke subject was compared with the distribution of activation volumes among nine controls. RESULTS: Control subjects activated several motor regions. During recovered hand finger-tapping, stroke subjects activated the same regions as controls, often in a larger brain volume. In the unaffected hemisphere, sensorimotor cortex activation was increased in six of nine stroke subjects compared with controls. Cerebellar hemisphere contralateral and premotor cortex ipsilateral to this region, as well as supplementary motor areas, also had increased activation. In the stroke hemisphere, activation exceeding controls was uncommon, except that three of five cortical strokes showed peri-infarct activation foci. During unaffected hand finger-tapping, increased activation by stroke subjects compared with controls was uncommon; however, decreased activation was seen in unaffected sensorimotor cortex, suggesting that this region's responsiveness increased to the ipsilateral hand and decreased to contralateral hand movements. Use of a different threshold for defining activation (P < .01) did not change the overall findings (kappa = .75). CONCLUSIONS: Recovered finger-tapping by stroke subjects activated the same motor regions as controls but to a larger extent, particularly in the unaffected hemisphere. Increased reliance on these motor areas may represent an important component of motor recovery. Functional magnetic resonance imaging studies of subjects who recovered from stroke provide evidence for several processes that may be related to restoration of neurologic function.

Computerized measurement of motor performance after stroke.

BACKGROUND AND PURPOSE: Stroke scales usually convert motor status to a score along an ordinal scale and do not provide a permanent recording of motor performance. Computerized methods sensitive to small changes in neurological status may be of value for studying and measuring stroke recovery. METHODS: We developed a computerized dynamometer and tested 23 stroke subjects and 12 elderly control subjects on three motor tasks: sustained squeezing, repetitive squeezing, and index finger tapping. For each subject, scores on the Fugl-Meyer and National Institutes of Health stroke scales were also obtained. RESULTS: Sustained squeezing by the paretic hand of stroke subjects was weaker (9.2 kg) than the unaffected hand (20.2 kg; P < .0005), as well as control dominant (23.1 kg; P < .0005) and nondominant (19.9 kg; P < .005) hands. Paretic index finger tapping was slower (2.5 Hz) than the unaffected hand (4.2 Hz; P < .01), as well as control dominant (4.7 Hz; P < .0005) and nondominant (4.9 Hz; P < .0005) hands. Many features of dynamometer data correlated significantly with stroke subjects' Fugl-Meyer scores, including sustained squeeze maximum force (rho = .91) and integral of force over 5 seconds (rho = .91); repetitive squeeze mean force (rho = .92) and mean frequency (rho = .73); and index finger tap mean frequency (rho = .83). Correlation of these motor parameters with National Institutes of Health stroke scale score was weaker in all cases, a consequence of the scoring of nonmotor deficits on this scale. Dynamometer measurements showed excellent interrater (r = .99) and intrarater (r = .97) reliability. CONCLUSIONS: The degree of motor deficit quantitated with the dynamometer is strongly associated with the extent of neurological abnormality measured with the use of two standardized stroke scales. The computerized dynamometer rapidly measures motor function along a continuous, linear scale and produces a permanent recording of hand motor performance accessible for subsequent analyses.

Autoantibodies in patients with silicone implants.

We assessed the prevalence of autoantibodies in women with silicone implants and controls. Five hundred consecutive patients with silicone implants, 25 age-matched normal women, 25 women with silicone implants and no rheumatic symptoms, and 100 women with fibromyalgia were tested. Immunofluorescence antinuclear antibodies (ANA) were performed using HEp-2 cells. Subtype autoantibodies were performed by enzyme-linked immunoassay and Western blot. ANA tests were positive in 30% of patients with silicone implants and rheumatic symptoms, 8% of age-matched normal women, 28% of women with silicone implants without clinical symptoms, and 25% of women with fibromyalgia and no silicone implants. The predominant ANA pattern was speckled (55%). ANA subtype testing was positive in 4.8% of patients and none of the controls. We conclude that a larger proportion of women with silicone implants have autoantibodies compared to age-matched asymptomatic women suggesting immune activation in women with silicone implants.

Plasmapheresis in fulminant acute disseminated encephalomyelitis.

We describe two patients with fulminant acute disseminated encephalomyelitis (ADEM) treated with plasmapheresis after they failed to improve on steroids. Both patients improved concomitant with the plasma exchange. These are the first reported cases of fulminant ADEM with extensive white matter abnormalities on imaging studies treated with a regimen of plasmapheresis and steroids. Plasmapheresis may be beneficial in this disorder.

Measurement of regional pulmonary blood flow with PET.

UNLABELLED: We have previously reported a method for measuring regional pulmonary blood flow (PBF) in experimental animals using 15O-water and PET. The method requires withdrawing blood from the pulmonary artery during the PET scan, so that the input function can be estimated for the one-compartment model used to analyze the data. The purpose of the present study was to modify and validate this technique for a more general use in humans. METHODS: PBF was measured after injections of 15O-water in 15 normal subjects and in five patients with reduced cardiac output. In ten of the normal subjects, PBF was also measured after the injection of 68Ga-albumin macroaggregates (MAA). In the five other normal subjects and in the cardiomyopathy patients, PBF was measured twice after two separate 15O-water administrations. The input function was estimated from a region of interest (ROI) over the right ventricle (RV), with corrections when necessary, for time delays between RV and lung tissue. RESULTS: The mean value for PBF in the normal subjects was 121 +/- 32 ml/min/100 ml lung, and was 57 +/- 33 ml/min/100 ml lung in the patients with cardiomyopathy. The correlation between PBF measured with 15O-water and PBF measured with 68Ga-MAA was r = 0.96. There was no significant difference in the mean value for PBF or the ventral-dorsal distribution of PBF when sequential measurements were made in the same individual. PBF increased in general in the ventral-dorsal direction in these supine subjects, although PBF was more evenly distributed in the cardiomyopathy patients. CONCLUSION: Measurement of regional PBF with 15O-water and PET appears to be a valid, noninvasive approach for evaluating the pulmonary perfusion pattern of humans.

Exercise Doppler echocardiography identifies abnormal hemodynamics in adults with congenital heart disease.

The hemodynamic factors contributing to reduced exercise capacity in adults with congenital heart disease are not fully defined. We hypothesized that they would demonstrate reduced exercise capacity compared with age-matched control subjects because of abnormal exercise hemodynamics and ventricular performance demonstrable by echocardiography. We retrospectively analyzed the results of all studies in all patients with congenital heart disease (from 1988 to 1993) and found that the peak work load and double product achieved were decreased in comparison with normal values (79 +/- 47 W vs 149 +/- 52 W [p < 0.0001] and 19,210 +/- 6805 vs 25,701 +/- 6440 [p = 0.005], respectively). Seven patients achieved work loads < 40 W associated with an exaggerated exercise pulmonary artery pressure response, decreases in right and/or left ventricular function with exercise, or both. Normal or near-normal exercise tolerance was observed in the following patient groups: (1) repaired tetralogy of Fallot, (2) uncomplicated I-transposition of the great arteries, and (3) Ebstein's anomaly with atrial septal defect. We conclude that exercise echocardiography provides new hemodynamic information for evaluating functional limitations in congenital heart disease.

Quantification of mitral regurgitation by velocity-encoded cine nuclear magnetic resonance imaging.

OBJECTIVES: The feasibility of velocity-encoded cine nuclear magnetic resonance (NMR) imaging to measure regurgitant volume and regurgitant fraction in patients with mitral regurgitation was evaluated. BACKGROUND: Velocity-encoded cine NMR imaging has been reported to provide accurate measurement of the volume of blood flow in the ascending aorta and through the mitral annulus. Therefore, we hypothesized that the difference between mitral inflow and aortic systolic flow provides the regurgitant volume in the setting of mitral regurgitation. METHODS: Using velocity-encoded cine NMR imaging at a magnet field strength of 1.5 T and color Doppler echocardiography, 19 patients with isolated mitral regurgitation and 10 normal subjects were studied. Velocity-encoded cine NMR images were acquired in the short-axis plane of the ascending aorta and from the short-axis plane of the left ventricle at the level of the mitral annulus. Two independent observers measured the ascending aortic flow volume and left ventricular inflow volume to calculate the regurgitant volume as the difference between left ventricular inflow volume and aortic flow volume, and the regurgitant fraction was calculated. Using accepted criteria of color flow Doppler imaging and spectral analysis, the severity of mitral regurgitation was qualitatively graded as mild, moderate or severe and compared with regurgitant volume and regurgitant fraction, as determined by velocity-encoded cine NMR imaging. RESULTS: In normal subjects the regurgitant volume was -6 +/- 345 ml/min (mean +/- SD). In patients with mild, moderate and severe mitral regurgitation, the regurgitant volume was 156 +/- 203, 1,384 +/- 437 and 4,763 +/- 2,449 ml/min, respectively. In normal subjects the regurgitant fraction was 0.7 +/- 6.1%. In patients with mild, moderate and severe mitral regurgitation, the regurgitant fraction was 3.1 +/- 3.4%, 24.5 +/- 8.9% and 48.6 +/- 7.6%, respectively. The regurgitant fraction correlated well with the echocardiographic severity of mitral regurgitation (r = 0.87). Interobserver reproducibilities for regurgitant volume and regurgitant fraction were excellent (r = 0.99, SEE = 238 ml; r = 0.98, SEE = 4.1%, respectively). CONCLUSIONS: These findings suggest that velocity-encoded NMR imaging can be used to estimate regurgitant volume and regurgitant fraction in patients with mitral regurgitation and can discriminate patients with moderate or severe mitral regurgitation from normal subjects and patients with mild regurgitation. It may be useful for monitoring the effect of therapy intended to reduce the severity of mitral regurgitation.

Evaluation of electrocardiographic criteria for right atrial enlargement by quantitative two-dimensional echocardiography.

OBJECTIVES: This study was conducted to evaluate the sensitivity and specificity of traditional electrocardiographic (ECG) criteria for right atrial enlargement and identify improve criteria, using quantitative two-dimensional echocardiography. BACKGROUND: Traditional ECG criteria for right atrial enlargement, such as P pulmonale, have been increasingly criticized as insensitive and nonspecific. Quantitative two-dimensional echo-cardiography has been shown to be a useful method for evaluating atrial size. METHODS: Hospitalized patients with mild, moderate and severe right atrial enlargement were selected from our laboratory's data base and compared with age- and gender-correlated hospitalized control subjects. After exclusions, 100 patients with right atrial enlargement and 25 control patients remained. Planimetric measurement of right atrial volumes was accomplished by two independent observers using the single-plane method of discs algorithm. Electrocardiograms were independently evaluated for current and newly proposed right atrial enlargement criteria. RESULTS: Fifty-two patients (52%) were in sinus rhythm, 41 were in atrial fibrillation, 5 were in atrial flutter, and 2 were in ectopic atrial rhythm. All control subjects were in sinus rhythm. The right atrial volume for the control group was 35.0 +/- 7.4 ml (mean +/- SD), with a narrow, roughly normal distribution. The right atrial volume for the patient group was 147.6 +/- 69.1 ml (median 127.2) in a wide, skewed distribution. The difference of mean values was highly significant (p = 0.0001). Right ventricular enlargement was found to some degree in all patients with right atrial enlargement. The most powerful predictors of right atrial enlargement were a QRS axis > 90 degrees, a P wave height in lead V2 > 1.5 mm and an R/S ratio > 1 in lead V1 in the absence of complete right bundle branch block. The combined sensitivity of these three criteria was 49%, with preservation of 100% specificity. P pulmonale detected only 6% of patients with right atrial enlargement. CONCLUSIONS: Using quantitative two-dimensional echocardiography, we found that most previously reported ECG criteria for right atrial enlargement have low predictive power. The best predictors of right atrial enlargement were a P wave height > 1.5 mm in lead V2 and, as new criteria, a QRS axis > 90 degrees and an R/S ratio > 1 in lead V1 in the absence of complete right bundle branch block. The combined sensitivity of these three criteria was 49%, with preservation of 100% specificity. Further studies are needed to prospectively validate these findings.

The effects of regional pulmonary blood flow on protein flux measurements with PET.

We used PET to evaluate whether changes in regional pulmonary blood flow (PBF) or plasma volume (PV) affect calculations of the pulmonary transcapillary escape rate (PTCER) for 68Ga-labeled transferrin. We reduced PBF in five dogs by inflating a right atrial balloon. Regional PBF decreased 25% to 174 +/- 40 ml/min/100 ml lung without a change in PV or PTCER. In eight other dogs, we decreased PBF and PV via controlled arterial hemorrhage. PBF decreased 45% to 110 +/- 33 ml/min/100 ml lung and PV decreased 22% without a change in PTCER. We also used a series of computer simulations to evaluate the effect of even greater reductions in regional PBF on PTCER calculations. These simulations showed, in support of the experimental data, that if PBF was greater than 40 ml/min/100 ml lung, PTCER could be accurately measured. However, below this level, PV was increasingly under-estimated and PTCER overestimated. The results indicate the sensitivity of the PTCER calculation to errors in the PV measurement, especially in regions of markedly reduced regional PBF.

Pulmonary vascular permeability in interstitial lung disease. A positron emission tomographic study.

We evaluated pulmonary vascular permeability with positron emission tomography (PET) in 16 patients with interstitial lung disease (ILD) by measuring the pulmonary transcapillary escape rate (PTCER) for transferrin labeled with gallium-68. In patients with active ILD, defined by lung biopsy or clinical criteria, mean PTCER was significantly greater than in normal subjects (118 +/- 46 versus 21 +/- 11 x 10(-4) min-1, respectively, p less than 0.05). Mean PTCER in patients with inactive ILD, in contrast, was not different from that in normal subjects (32 +/- 10 x 10(-4) min-1, p = NS). Thus, these data suggest that PET measurements of PTCER might serve as an index of disease activity in patients with ILD.

Pulmonary vascular permeability after lung transplantation. A positron emission tomographic study.

We evaluated pulmonary vascular permeability in 15 patients after lung transplantation (21 allografts) by measuring the pulmonary transcapillary escape rate (PTCER) for Ga-68-labeled transferrin, using positron emission tomography. Seven recipients (four unilateral, three bilateral lung transplants) were studied within 3 days of transplantation, and each developed hypoxemia and allograft infiltrates consistent with the "reimplantation response." PTCER was higher in subjects studied within 1 day than in those studied at a later time, and fell in seven allografts studied serially. The initial PTCER also correlated (r = 0.77) with length of ischemic (preservation) time, even in the three subjects with bilateral allografts. Eight other recipients (five unilateral, three bilateral transplants) were evaluated for possible organ rejection at least 1 wk after transplantation. PTCER was normal in patients without clinical or histologic evidence of rejection, and it was elevated in recipients with rejection. PTCER fell each time after treatment for rejection with increased immunosuppression in the three patients studied serially. These data suggest that positron emission tomography measurements of PTCER might be a useful way to evaluate both the reimplantation response and organ rejection after lung transplantation.

Effect of smoking on pulmonary vascular permeability. A positron emission tomography study.

Positron emission tomography (PET) can be used to evaluate pulmonary vascular endothelial permeability by measuring the pulmonary transcapillary escape rate (PTCER) for radiolabeled transferrin. Because epithelial permeability, as evaluated by other techniques, is significantly affected by cigarette smoking, we used PET to compare the effects of smoking on extravascular lung density (EVD) and PTCER in seven normal chronic cigarette smokers within 30 min of smoking a cigarette and seven normal nonsmokers. We found no difference in PTCER and EVD between the two groups. We conclude that the interpretation of acute or chronic lung injury studies with PET should not be affected by cigarette smoking in the subject population.

Lisfranc's fracture-dislocation. A review of the literature and case reports.

The authors present an in-depth discussion of Lisfranc's fracture-dislocations, including classifications, mechanisms of injury, radiographic evaluation, and a literature review. Four cases are presented for review. Lisfranc's fracture-dislocation is a rare injury that can lead to prolonged disability if undiagnosed or if there is a delay in treatment.

Physiologic consequences of tracheal intubation.

Many principles that originate in the operating room and in fluid mechanics modeling are relevant to endotracheal intubation in the pulmonary and critical care setting. These factors should be appreciated by pulmonologists and intensivists, as they may contribute to improved safety during the process of airway access. The usual reflex responses to stimulation of oropharyngeal and upper airway receptors include glottic closure, hypertension, tachycardia, and reflex bronchoconstriction. These reflexes can be modified by technical or pharmacologic reduction of sensory receptor stimulation or by parenteral agents, which diminish efferent responses, including anesthetics, vasoactive drugs, and adrenergic blockers. Topical anesthesia and parenteral sedatives may be the preferred agents when overall risk and benefit are considered. Intubation also has consequences related to a reduction in airway caliber, to changes in respiratory mechanics, and to the creation of turbulent airflow in the endotracheal tube.