Design of a Novel Intervention Model to Address Cardiovascular Health Disparities in the Rural Underserved Community of Phillips County Arkansas.

Devastating health-related disparities driven by an entanglement of factors disproportionately impact the underserved, low-wealth, and minority community of Phillips county (PC) in the Arkansas Delta Region (ADR). Cardiovascular disease continues to increase with widespread consequences on the local economy, health care systems, and population. Health care and community-based systems have been unsuccessful in reducing out-of-hospital cardiac death, particularly in the ADR, for many reasons. Herein, we share the strategy behind, planning, and goals of The Arkansas Lincoln Project, a novel neighborhood-based strategy bridging the gap between residents, social resources, and health care services in PC.

Predictors of 30-Day Return Following an Emergency Department Visit for Older Adults.

BACKGROUND Older adults who are discharged following emergency department evaluation are at increased risk for functional decline and health care utilization, and are likely to benefit from close follow-up and additional care services. Understanding factors associated with a return emergency department visit within 30 days among older fee-for-service Medicare beneficiaries discharged to the community may assist in identifying patients at greatest need for interventions.METHOD Predictors from Medicare data and public sources were evaluated in a retrospective data analysis of North and South Carolina residents (2011-2012) aged ≥ 65 years using Cox regression proportion hazards ratios (HR) and 95% confidence intervals (CI) for time-to-30-day return events.RESULTS 30-day return rates varied markedly among the 167 emergency department facilities studied (18%-39%). Predictors of 30-day return included: age (85+ versus 65-74; HR, 1.24; 95% CI, 1.22-1.27); male sex (HR, 1.11; 95% CI, 1.14-1.10); non-white race (HR, 1.07; 95% CI, 1.05-1.09); Medicaid eligibility (HR, 1.20; 95% CI, 1.18-1.22); Charlson Score (3+ vs. 0; HR, 1.33; 95% CI, 1.30-1.36); and prior emergency department encounter (3+ vs. 0; HR, 2.35; 95% CI 2.30-2.41).LIMITATIONS This study was limited to Medicare beneficiaries in North Carolina and South Carolina, 2011-2012. Administrative claims data are limited to information required for financial reimbursement. Because we limited our study to older fee-for-service patients, our findings may not be generalizable to managed care patients and other age groups. Patients transferred to another emergency department or facility were not included in the analysis.CONCLUSION Factors predicting 30-day return to the emergency department or hospitalization suggest the potential for care transition improvement efforts to better meet patient needs, thereby potentially improving post-emergency department outcomes.

Utilization of acute care among patients with ESRD discharged home from skilled nursing facilities.

BACKGROUND AND OBJECTIVES: Older adults with ESRD often receive care in skilled nursing facilities (SNFs) after an acute hospitalization; however, little is known about acute care use after SNF discharge to home. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This study used Medicare claims for North and South Carolina to identify patients with ESRD who were discharged home from a SNF between January 1, 2010 and August 31, 2011. Nursing Home Compare data were used to ascertain SNF characteristics. The primary outcome was time from SNF discharge to first acute care use (hospitalization or emergency department visit) within 30 days. Cox proportional hazards models were used to identify patient and facility characteristics associated with the outcome. RESULTS: Among 1223 patients with ESRD discharged home from a SNF after an acute hospitalization, 531 (43%) had at least one rehospitalization or emergency department visit within 30 days. The median time to first acute care use was 37 days. Characteristics associated with a shorter time to acute care use were black race (hazard ratio [HR], 1.25; 95% confidence interval [95% CI], 1.04 to 1.51), dual Medicare-Medicaid coverage (HR, 1.24; 95% CI, 1.03 to 1.50), higher Charlson comorbidity score (HR, 1.07; 95% CI, 1.01 to 1.12), number of hospitalizations during the 90 days before SNF admission (HR, 1.12; 95% CI, 1.03 to 1.22), and index hospital discharge diagnoses of cellulitis, abscess, and/or skin ulcer (HR, 2.59; 95% CI, 1.36 to 4.45). Home health use after SNF discharge was associated with a lower rate of acute care use (HR, 0.72; 95% CI, 0.59 to 0.87). There were no statistically significant associations between SNF characteristics and time to first acute care use. CONCLUSIONS: Almost one in every two older adults with ESRD discharged home after a post-acute SNF stay used acute care services within 30 days of discharge. Strategies to reduce acute care utilization in these patients are needed.

Comparative effectiveness of follow-up imaging approaches in pancreatic cancer.

AIM: Although PET imaging is sometimes used in follow-up of pancreatic cancer, evidence regarding comparative effectiveness of PET and older imaging modalities is limited. PATIENTS & METHODS: Linked cancer registry and Medicare claims data were analyzed to examine patterns of imaging and effects on treatment patterns and survival among newly diagnosed pancreatic cancer patients from 2003 to 2007. RESULTS: 12% of patients received PET during follow-up. In a time-varying exposure model, computed tomography/MRI was associated with lower mortality risk relative to PET in surgical patients (HR: 0.66; 95% CI: 0.52-0.83). In a subset analysis, type of follow-up imaging before 180 days was not associated with mortality after 180 days (computed tomography/MRI vs PET; hazard ratio: 0.98; 95% CI: 0.84-1.16). CONCLUSION: Follow-up PET is uncommon among Medicare beneficiaries with pancreatic cancer, and is generally used late in the disease course. This pattern of PET use was not associated with decreased mortality risk compared with conventional imaging.

A satisfaction survey of current medicines used for migraine therapy in China: is Chinese patent medicine effective compared with Western medicine for the acute treatment of migraine?

OBJECTIVE: To investigate the patient satisfaction with medications commonly used for migraine therapy in patients seen in headache clinic in China with emphasis on the evaluation of Chinese patent medicine (CPM) in relieving acute migraine attack. METHODS: Patients admitted at headache clinics in the neurological departments of four hospitals during April to October 2011 were enrolled in the investigation. The questionnaire was designed based on the validation of a diagnostic questionnaire for a population-based survey in China in 2009. RESULTS: Among 219 eligible patients, 58% had used CPM at the acute attack of migraine while the guideline-recommended treatments were seldom used. However, patients using CPMs were less satisfied than those using Western Medicines (WMs) in either single medication groups or mixed medication groups (P < 0.05). CONCLUSION: Fifty-eight percent of the eligible respondents in Guangdong and Guangxi Province had used CPM at the acute attack of migraine, but based on our data, the effect of CPM on treating migraine attack was poor with low satisfaction compared with WMs. However, many factors may bias or explain our findings. This suggests the need for accelerated research in understanding patient choice, treatment availability, and use of medications.

Restarting the cycle: incidence and predictors of first acute care use after nursing home discharge.

OBJECTIVES: To describe the time to first acute care use (e.g., emergency department (ED) use without hospitalization or rehospitalization) for older adults discharged to home after receiving postacute care in skilled nursing facilities (SNFs); to identify predictors of first acute care use. DESIGN: Retrospective cohort study using administrative claims data. SETTING: SNFs providing postacute care for patients in North and South Carolina (N = 1,474). PARTICIPANTS: A cohort of Medicare beneficiaries aged 65 and older (N = 55,980) who were hospitalized and then transferred to a SNF for postacute care and subsequently discharged home (January 1, 2010, to August 31, 2011). MEASUREMENTS: Medicare institutional claims data (Parts A and B) and Medicare enrollment data were used; facility-level variables were obtained from CMS Nursing Home Compare. Survival from SNF discharge to first acute care use was explored. Cox proportional hazards regression models were used to describe individual-, home care-, and nursing facility-level predictors. RESULTS: After discharge from SNF to home, 22.1% of older adults had an episode of acute care use within 30 days, including 7.2% with an ED visit without hospitalization and 14.8% with a rehospitalization; 37.5% of older adults had their first acute care use within 90 days. Male sex, dual eligibility status, higher Charlson comorbidity score, certain primary diagnoses at index hospitalization (neoplasms and respiratory disease), and care in SNFs with for-profit ownership or fewer licensed practical nurses hours per patient-day were associated with greater likelihood of acute care use. CONCLUSION: Medicare beneficiaries have a high use of acute care services after discharge from SNFs, and several factors associated with acute care use are potentially modifiable. Findings suggest the need for interventions to support beneficiaries as they transition from SNFs to home.

A randomized, one-year clinical trial comparing the efficacy of topiramate, flunarizine, and a combination of flunarizine and topiramate in migraine prophylaxis.

OBJECTIVES: The objective of this study was to observe the efficacy, safety, and side effects of a combination of flunarizine plus topiramate compared with either flunarizine and or toparamate alone for migraine prophylaxis. METHODS: Out of 150 patients with migraine recruited into the study and randomly assigned to one of three conditions, 126 completed the trial in their group: flunarizine (39), topiramate (44), and flunarizine plus topiramate (43). Patient information was assessed at enrollment and at follow-up visits at the end of months 1-3, 6, 9, and 12. The primary measure of efficacy reduction in mean monthly migraine frequency of at least 50% as compared with baseline. Secondary efficacy parameters included reduction in mean monthly migraine days and severity of headache. Side effects were compared in the three groups by recording adverse reactions and weight changes. RESULTS: The proportion whose monthly headache frequency decreased more than 50% was 66.7% (26/39) in the flunarizine group, 72.7% (32/44) in the topiramate group and 76.7% (33/43) in the combination group, respectively (P=0.593). The mean monthly days and severity of headache in the three groups also declined and was more significant in the flunarizine plus topiramate group than in the flunarizine group and the topiramate group (P<0.05). In the flunarizine group, the average weight change was 0.6kg. Topiramate was associated with a mean weight loss was of -0.9kg in the topiramate group and -0.2kg in the flunarizine plus topiramate group. CONCLUSION: Flunarizine, topiramate, and the combination of flunarizine with topiramate are all effective and have good tolerability in migraine prophylaxis. Adding topiramate to flunarizine may reduce the latter's impact on body weight.

Impact of distance to a urologist on early diagnosis of prostate cancer among black and white patients.

PURPOSE: We examined whether an increased distance to a urologist is associated with a delayed diagnosis of prostate cancer among black and white patients, as manifested by higher risk disease at diagnosis. MATERIALS AND METHODS: North Carolina Central Cancer Registry data were linked to Medicare claims for patients with incident prostate cancer diagnosed in 2004 to 2005. Straight-line distances were calculated from the patient home to the nearest urologist. Race stratified multivariate ordinal logistic regression was used to examine the association between distance to a urologist and prostate cancer risk group (low, intermediate, high or very high/metastasis) at diagnosis for black and white patients while accounting for age, comorbidity, marital status and diagnosis year. An overall model was then used to examine the distance × race interaction effect. RESULTS: Included in analysis were 1,720 white and 531 black men. In the overall cohort the high risk cancer rate increased monotonically with distance to a urologist, including 40% for 0 to 10, 45% for 11 to 20 and 57% for greater than 20 miles. Correspondingly the low risk cancer rate decreased with longer distance. On race stratified multivariate analysis longer distance was associated with higher risk prostate cancer for white and black patients (p = 0.04 and <0.01, respectively) but the effect was larger in the latter group. The distance × race interaction term was significant in the overall model (p = 0.03). CONCLUSIONS: Longer distance to a urologist may disproportionally impact black patients. Decreasing modifiable barriers to health care access, such as distance to care, may decrease racial disparities in prostate cancer.

Relation of ventricular premature complexes to heart failure (from the Atherosclerosis Risk In Communities [ARIC] Study).

Analogous to rapid ventricular pacing, frequent ventricular premature complexes (VPCs) can predispose over time to cardiomyopathy and subsequent heart failure (HF). We examined the association of frequent VPCs with HF incidence in a population-based cohort, free of HF and coronary heart disease at baseline. At study baseline (1987 to 1989), ≥1 VPC on a 2-minute rhythm electrocardiographic strip was seen in 5.5% (739 of 13,486) of the middle-age (45 to 64 years old at baseline) white and black, men and women of the Atherosclerosis Risk In Communities cohort. Incident HF was defined as the first appearance of International Classification of Diseases code 428.x in the hospital discharge record or death certificate through 2005. During an average follow-up of 15.6 years, incident HF was seen in 10% the participants (19.4% of those with VPCs vs 9.4% of those without). The age-, race-, and gender-adjusted hazard ratio of HF for VPCs was 1.89 (95% confidence interval 1.59 to 2.24). After multivariable adjustment for potential confounders, the hazard ratio of HF for those with any VPC versus no VPC was 1.63 (95% confidence interval 1.36 to 1.96). After additional adjustment for incident coronary heart disease as a time-varying covariate, the hazard ratio was 1.71 (95% confidence interval 1.42 to 2.08). Those with a greater frequency of VPCs or complex VPCs had similar rates of HF compared to those with a single VPC and all had rates greater than those with no VPC. In conclusion, in this large population-based cohort, the presence of VPCs was associated with incident HF, independent of incident coronary heart disease.

The Million Hearts initiative: applying the ABCS of healthy hearts in North Carolina.

Cardiovascular disease (CVD) is the leading cause of death in the United States. The goal of the national Million Hearts initiative is to prevent 1 million heart attacks and strokes by 2017 by promoting evidence-based preventive care and treatments for CVD. North Carolina has ongoing services and investments that will contribute to the success of this initiative.

National prevalence and risk factors for food allergy and relationship to asthma: results from the National Health and Nutrition Examination Survey 2005-2006.

BACKGROUND: The national prevalence and patterns of food allergy (FA) in the United States are not well understood. OBJECTIVE: We developed nationally representative estimates of the prevalence of and demographic risk factors for FA and investigated associations of FA with asthma, hay fever, and eczema. METHODS: A total of 8203 participants in the National Health and Nutrition Examination Survey 2005-2006 had food-specific serum IgE measured to peanut, cow's milk, egg white, and shrimp. Food-specific IgE and age-based criteria were used to define likely FA (LFA), possible FA, and unlikely FA and to develop estimates of clinical FA. Self-reported data were used to evaluate demographic risk factors and associations with asthma and related conditions. RESULTS: In the United States, the estimated prevalence of clinical FA was 2.5% (peanut, 1.3%; milk, 0.4%; egg, 0.2%; shrimp, 1.0%; not mutually exclusive). Risk of possible FA/LFA was increased in non-Hispanic blacks (odds ratio, 3.06; 95% CI, 2.14-4.36), males (1.87; 1.32-2.66), and children (2.04; 1.42-2.93). Study participants with doctor-diagnosed asthma (vs no asthma) exhibited increased risk of all measures of food sensitization. Moreover, in those with LFA, the adjusted odds ratio for current asthma (3.8; 1.5-10.7) and an emergency department visit for asthma in the past year (6.9; 2.4-19.7) were both notably increased. CONCLUSION: Population-based serologic data on 4 foods indicate an estimated 2.5% of the US population has FA, and increased risk was found for black subjects, male subjects, and children. In addition, FA could be an under-recognized risk factor for problematic asthma.

Neurosteroids and self-reported pain in veterans who served in the U.S. Military after September 11, 2001.

OBJECTIVE: Nearly half of Operation Enduring Freedom/Operation Iraqi Freedom veterans experience continued pain post-deployment. Several investigations report analgesic effects of allopregnanolone and other neurosteroids in animal models, but few data are currently available focusing on neurosteroids in clinical populations. Allopregnanolone positively modulates GABA(A) receptors and demonstrates pronounced analgesic and anxiolytic effects in rodents, yet studies examining the relationship between pain and allopregnanolone in humans are limited. We thus hypothesized that endogenous allopregnanolone and other neurosteroid levels may be negatively correlated with self-reported pain symptoms in humans. DESIGN: We determined serum neurosteroid levels by gas chromatography/mass spectrometry (allopregnanolone, pregnenolone) or radioimmunoassay (dehydroepiandrosterone [DHEA], progesterone, DHEA sulfate [DHEAS]) in 90 male veterans who served in the U.S. military after September 11, 2001. Self-reported pain symptoms were assessed in four areas (low back pain, chest pain, muscle soreness, headache). Stepwise linear regression analyses were conducted to investigate the relationship between pain assessments and neurosteroids, with the inclusion of smoking, alcohol use, age, and history of traumatic brain injury as covariates. SETTING: Durham VA Medical Center. RESULTS: Allopregnanolone levels were inversely associated with low back pain (P=0.044) and chest pain (P=0.013), and DHEA levels were inversely associated with muscle soreness (P=0.024). DHEAS levels were positively associated with chest pain (P=0.001). Additionally, there was a positive association between traumatic brain injury and muscle soreness (P=0.002). CONCLUSIONS: Neurosteroids may be relevant to the pathophysiology of self-reported pain symptoms in this veteran cohort, and could represent future pharmacological targets for pain disorders.

Allopregnanolone levels are reduced in temporal cortex in patients with Alzheimer's disease compared to cognitively intact control subjects.

The neurosteroid allopregnanolone has pronounced neuroprotective actions, increases myelination, and enhances neurogenesis. Evidence suggests that allopregnanolone dysregulation may play a role in the pathophysiology of Alzheimer's disease (AD) and other neurodegenerative disorders. Our prior data demonstrate that allopregnanolone is reduced in prefrontal cortex in male patients with AD compared to male cognitively intact control subjects, and inversely correlated with neuropathological disease stage (Braak and Braak). We therefore determined if allopregnanolone levels are also reduced in AD patients compared to control subjects in temporal cortex, utilizing a larger set of samples from both male and female patients. In addition, we investigated if neurosteroids are altered in subjects who are APOE4 allele carriers. Allopregnanolone, dehydroepiandrosterone (DHEA), and pregnenolone levels were determined in temporal cortex postmortem samples by gas chromatography/mass spectrometry, preceded by high performance liquid chromatography (40 subjects with AD/41 cognitively intact control subjects). Allopregnanolone levels are reduced in temporal cortex in patients with AD (median 2.68 ng/g, n=40) compared to control subjects (median 5.64 ng/g, n=41), Mann-Whitney p=0.0002, and inversely correlated with Braak and Braak neuropathological disease stage (Spearman r=-0.38, p=0.0004). DHEA and pregnenolone are increased in patients with AD compared to control subjects. Patients carrying an APOE4 allele demonstrate reduced allopregnanolone levels in temporal cortex (Mann-Whitney p=0.04). In summary, our findings indicate that neurosteroids are altered in temporal cortex in patients with AD and related to neuropathological disease stage. In addition, the APOE4 allele is associated with reduced allopregnanolone levels. Neurosteroids may be relevant to the neurobiology and therapeutics of AD.

Premature ventricular complexes and the risk of incident stroke: the Atherosclerosis Risk In Communities (ARIC) Study.

BACKGROUND AND PURPOSE: Premature ventricular complexes (PVCs) on a 2-minute electrocardiogram are a common, largely asymptomatic finding associated with increased risk of coronary heart disease and death. They may reflect atherosclerosis or other pathogenic pathways that predispose to arrhythmias and stroke. METHODS: We conducted a prospective evaluation of the Atherosclerosis Risk In Communities Study cohort (n=14,783) of middle-aged men and women to assess whether the presence of PVCs at study baseline (1987 to 1989) influenced the risk of incident stroke through December 31, 2004. RESULTS: PVCs were seen in 6.1% of the participants at baseline, and 729 (4.9%) had incident stroke. The unadjusted cumulative proportion of incident stroke in individuals with any PVC was 6.6% compared with 4.1% in those without PVC. The unadjusted hazard ratio of incident stroke in individuals with any PVC compared with those without any PVCs was 1.71 (95% CI, 1.33 to 2.20). Among individuals without hypertension and diabetes at baseline, PVCs were independently associated with incident stroke (hazard ratio: 1.72; 95% CI: 1.14 to 2.59). Among those with either diabetes or hypertension, the presence of any PVCs did not increase the risk of stroke. The association was stronger for noncarotid embolic stroke than for thrombotic stroke and its magnitude increased with higher frequency of PVCs. CONCLUSIONS: Frequent PVCs are associated with risk of incident stroke in participants free of hypertension and diabetes. This suggests that PVCs may contribute to atrioventricular remodeling or may be a risk marker for incident stroke, particularly embolic stroke.

After the collaborative is over: what sustains quality improvement initiatives in primary care practices?

BACKGROUND: Multisite quality improvement (QI) initiatives, often known as collaboratives, involving primary care practices such as community health centers, academic practices, and managed care groups have been reported. Yet relatively little is known about the sustainability of these QI initiatives after the initial project, and frequently its funding, has ended. A series of practice characteristics that constitute critical elements for QI sustainability activities, as described in a Sustainability Pyramid Model, were proposed. METHODS: Approximately five months after the cessation of formalized activities of the final collaborative, 25 in-person interviews were conducted in 13 primary care practices that had participated in the three North Carolina Chronic Disease Management collaboratives, which initially involved 33 practices. Clinical outcomes were not considered. FINDINGS: Twelve of the 13 practices stated that the collaborative work resulted in improvement in one or more process and/or outcome clinical measures and those improvements have been continued. Five of the 13 practices reported that sustaining improvements had been a challenge since the collaboratives ended. Content analysis of the interviews indicated that the practices variously cited the practice characteristics, as included in the Sustainability Pyramid Model: regular meetings to study practice population data, leadership commitment, availability of infrastructure/staff support, pursuit of additional funding, publicity, and strategic partnerships. DISCUSSION: Although the improvement activities initiated during the collaborative were sustained, the process of developing and implementing new QI activities appeared to be more challenging for almost half of the practices. The practices that could accomplish this ongoing new QI process had "institutionalized" their QI strategies--a finding with important implications for sustainability.

Novel relationship of serum cholesterol with asthma and wheeze in the United States.

BACKGROUND: Cholesterol exerts complex effects on inflammation. There has been little investigation of whether serum cholesterol is associated with asthma, an inflammatory airways disease with great public health impact. OBJECTIVE: To determine relationships between levels of 3 serum cholesterol measures (total cholesterol [TC], high-density lipoprotein cholesterol [HDL-C], and non-HDL-C) and asthma/wheeze in a sample representative of the US population. METHODS: Cross-sectional study of 7005 participants age >or=6 years from the 2005 to 2006 National Health and Nutrition Examination Survey. RESULTS: Serum TC and non-HDL-C were lower in patients with current asthma than in subjects without current asthma in the overall population (TC, 188.5 vs 192.2 mg/dL; non-HDL-C, 133.9 vs 137.7 mg/dL; P < .05 for both), whereas HDL-C was not different. Adjusted odds ratios (ORs) from multivariate logistic regression per 1-SD increase of TC and non-HDL-C for current asthma were 0.92 (95% CI, 0.86-0.98) and 0.91 (95% CI, 0.85-0.98), respectively. On racial/ethnic stratification, these relationships reflect marked reductions unique to Mexican Americans (MAs; TC, 171.4 vs 189.3 mg/dL; P < .001; OR, 0.62; 95% CI, 0.48-0.80; non-HDL-C, 119.8 vs 137.9 mg/dL; P < .001; OR, 0.62; 95% CI, 0.48-0.79). Among MAs, the adjusted OR for wheeze requiring medical attention was 0.57 (95% CI, 0.43-0.75) for TC and 0.53 (95% CI, 0.33-0.85) for non-HDL-C. Relationships between cholesterol and asthma/wheeze were independent of body mass index and serum C-reactive protein, and similar between atopic and nonatopic participants. CONCLUSION: Serum TC and non-HDL-C are inversely related to asthma in the US population, chiefly reflecting a relationship among MAs.

Comparative effectiveness of beta-blockers in elderly patients with heart failure.

BACKGROUND: Whether beta-blockers (BBs) other than carvedilol, metoprolol succinate, and bisoprolol fumarate (evidence-based beta-blockers [EBBBs]) improve survival in patients with heart failure (HF) is unknown. We compared the effectiveness of EBBBs vs non-EBBBs on survival. METHODS: Our study population included North Carolina residents at least 65 years old who were eligible for Medicare and Medicaid with pharmacy benefits and had had at least 1 hospitalization for HF during the period 2001 through 2004. Primary outcome was survival from 30 days to 1 year. Secondary outcomes included number and days of rehospitalizations for HF and number of outpatient visits. Cohorts were defined by BB class (EBBBs, non-EBBBs, or no BBs) in first 30 days after discharge from index hospitalization for HF. Outcomes were analyzed using inverse probability-weighted (IPW) estimators with propensity score adjustment. RESULTS: Of 11,959 patients, 40% were nonwhite, 79% were female, and 26% were at least 85 years old. Fifty-nine percent received no BB, 23% received EBBBs, and 18% received non-EBBBs. One-year adjusted mortality rates were 28.3% (no BBs), 22.8% (non-EBBBs), and 24.2% (EBBBs). The IPW-adjusted comparisons of 1-year mortality outcomes for either non-EBBBs or EBBBs compared with no BBs were statistically significant (P = .002 for both), but there was no statistical difference between the 2 BB groups (P = .43). The IPW-adjusted mean numbers of rehospitalizations for HF were 0.33 (no BBs), 0.29 (non-EBBBs), and 0.41 (EBBBs), with statistically more rehospitalizations in patients receiving EBBBs compared with no BBs (P = .002) and with non-EBBBs (P < .001). CONCLUSION: In this elderly population, the comparative effectiveness of EBBBs vs non-EBBBs was similar for 1-year survival, whereas the rehospitalization rate was higher for patients receiving EBBBs.

Cerebrospinal fluid dehydroepiandrosterone levels are correlated with brain dehydroepiandrosterone levels, elevated in Alzheimer's disease, and related to neuropathological disease stage.

OBJECTIVE: It is currently unknown whether cerebrospinal fluid (CSF) neurosteroid levels are related to brain neurosteroid levels in humans. CSF and brain dehydroepiandrosterone (DHEA) levels are elevated in patients with Alzheimer's disease (AD), but it is unclear whether CSF DHEA levels are correlated with brain DHEA levels within the same subject cohort. We therefore determined DHEA and pregnenolone levels in AD patients (n = 25) and cognitively intact control subjects (n = 16) in both CSF and temporal cortex. DESIGN: DHEA and pregnenolone levels were determined by gas chromatography/mass spectrometry preceded by HPLC. Frozen CSF and temporal cortex specimens were provided by the Alzheimer's Disease Research Center at Duke University Medical Center. Data were analyzed by Mann-Whitney U test statistic and Spearman correlational analyses. RESULTS: CSF DHEA levels are positively correlated with temporal cortex DHEA levels (r = 0.59, P < 0.0001) and neuropathological disease stage (Braak and Braak) (r = 0.42, P = 0.007). CSF pregnenolone levels are also positively correlated with temporal cortex pregnenolone levels (r = 0.57, P < 0.0001) and tend to be correlated with neuropathological disease stage (Braak) (r = 0.30, P = 0.06). CSF DHEA levels are elevated (P = 0.032), and pregnenolone levels tend to be elevated (P = 0.10) in patients with AD, compared with cognitively intact control subjects. CONCLUSIONS: These findings indicate that CSF DHEA and pregnenolone levels are correlated with temporal cortex brain levels of these neurosteroids and that CSF DHEA is elevated in AD and related to neuropathological disease stage. Neurosteroids may thus be relevant to the pathophysiology of AD.

Percutaneous Coronary Intervention or Coronary Artery Bypass Grafting: Intervention in Older Persons with Acute Coronary Syndrome-Part I.

This is Part I of a two-part article on treatment of acute coronary syndrome in the older population. Part I analyzes the differential utilization of invasive therapies with respect to age and heart disease. Part II (to be published in the next issue of Clinical Geriatrics) will summarize information from the literature on acute coronary syndrome outcomes from invasive treatments (percutaneous coronary interventions or coronary artery bypass grafting) among older persons.