Stroke is a major cause of death and serious neurological disability in older adults in the United States today. The most effective means available for reducing the burden of stroke involves risk ...factor modification. Given the growing number of older adults at risk for stroke, it is increasingly important to identify health behaviors that can produce significant change. Ongoing longitudinal studies have identified several behavioral factors that have been shown to improve overall health and reduce the risk of stroke, including effective management of hypertension, cessation of cigarette smoking for those who smoke, and maintaining a healthy diet and active physical lifestyle. Because modification of risk factors remains a primary intervention for effective prevention of stroke, community‐based studies that address and institute stroke prevention strategies have the best opportunity to reduce or postpone the devastating effect of stroke.
Previous estimates of the prevalence of silent cerebral infarction (SCI) on MRI in community-based samples have varied between 5.8% and 17.7% depending on age, ethnicity, presence of comorbidities, ...and imaging techniques. We document the prevalence and risk factors associated with SCI at midlife in the community-based Framingham sample.
Our study sample comprised 2040 Framingham Offspring (53% female; mean age, 62+/-9 years) who attended the sixth examination (1996-1998), underwent volumetric brain MRI (1999-2005,) and were free of clinical stroke at MRI. We examined the age- and sex-specific prevalences and the clinical correlates of SCI using multivariable logistic regression models.
At least 1 SCI was present in 10.7% of participants; 84% had a single lesion. SCI was largely located in the basal ganglia (52%), other subcortical (35%) areas, and cortical areas (11%). Prevalent SCI was associated with the Framingham Stroke Risk Profile score (OR, 1.27; 95% CI, 1.10-1.46); stage I hypertension was determined by JNC-7 criteria (OR,1.56; CI,1.15-2.11), an elevated plasma homocysteine in the highest quartile (OR, 2.23; CI, 1.42-3.51), atrial fibrillation (OR, 2.16; CI, 1.07-4.40), carotid stenosis >25% (OR, 1.62; 1.13-2.34), and increased carotid intimal-medial thickness above the lowest quintile (OR, 1.65; CI, 1.22-2.24).
The prevalence and distribution of SCI in the Framingham Offspring are comparable to previous estimates. Risk factors previously associated with clinical stroke were also found to be associated with midlife SCI. Our results support current guidelines emphasizing early detection and treatment of stroke risk factors.
Stroke is emerging as a major public health problem for women, as it is for men. Controversy persists regarding gender differences in stroke incidence, severity, and poststroke disability.
...Participants in the Framingham Original (n=5119; 2829 women) and Offspring (n=4957, 2565 women) cohorts who were 45 years and stroke-free were followed to first incident stroke. Gender-specific outcome measures were adjusted for the Framingham Stroke Risk Profile components.
We observed 1136 incident strokes (638 in women) over 56 years of follow-up. Women were significantly (P<0.001) older (75.1 versus 71.1 years for men) at their first-ever stroke, had a higher stroke incidence above 85 years of age, lower at all other ages, and a higher lifetime risk of stroke at all ages. There was no significant difference in stroke subtype, stroke severity, and case fatality rates between genders. Women were significantly (P<0.01) more disabled before stroke and in the acute phase of stroke in dressing (59% versus 37%), grooming (57% versus 34%), and transfer from bed to chair (59% versus 35%). At 3 to 6 months poststroke women were more disabled, more likely to be single, and 3.5 times more likely to be institutionalized (P<0.01).
These results from the Framingham Heart Study (FHS) support the existence of gender-differences in stroke incidence, lifetime risk (LTR) of stroke, age at first stroke, poststroke disability, and institutionalization rates. Prestroke disability and sociodemographic factors may contribute to the high rate of institutionalization and poorer outcome observed in women.
BACKGROUND:Age-adjusted stroke incidence has decreased over the past 50 years, likely as a result of changes in the prevalence and impact of various stroke risk factors. An updated version of the ...Framingham Stroke Risk Profile (FSRP) might better predict current risks in the FHS (Framingham Heart Study) and other cohorts. We compared the accuracy of the standard (old) and of a revised (new) version of the FSRP in predicting the risk of all-stroke and ischemic stroke and validated this new FSRP in 2 external cohorts, the 3C (3 Cities) and REGARDS (Reasons for Geographic and Racial Differences in Stroke) studies.
METHODS:We computed the old FSRP as originally described and a new model that used the most recent epoch-specific risk factor prevalence and hazard ratios for individuals ≥55 years of age and for the subsample ≥65 years of age (to match the age range in REGARDS and 3C studies, respectively) and compared the efficacy of these models in predicting 5- and 10-year stroke risks.
RESULTS:The new FSRP was a better predictor of current stroke risks in all 3 samples than the old FSRP (calibration χ of new/old FSRPin men64.0/12.1, 59.4/30.6, and 20.7/12.5; in women42.5/4.1, 115.4/90.3, and 9.8/6.5 in FHS, REGARDS, and 3C, respectively). In the REGARDS, the new FSRP was a better predictor among whites compared with blacks.
CONCLUSIONS:A more contemporaneous, new FSRP better predicts current risks in 3 large community samples and could serve as the basis for examining geographic and racial differences in stroke risk and the incremental diagnostic utility of novel stroke risk factors.
Conflicting research findings regarding the ability of tension or anxiety to predict incident coronary heart disease (CHD) have created uncertainty in the literature. In addition, there are no ...prospective studies relating these characteristics to the development of atrial fibrillation (AF).
From 1984 to 1987, 3682 participants (mean age 48.5 +/- 10.1 year; 52% women) of the Framingham Offspring Study were examined and followed for 10 years for the incidence of CHD, AF, and total mortality. Measures of tension, anxiety, and risk factors for CHD and AF were collected at the baseline examination.
After adjusting for age, systolic blood pressure, body mass index, current cigarette smoking, diabetes, and total cholesterol/high-density cholesterol in Cox proportional hazards models, increased tension was predictive of 10-year incidence of definite CHD (relative risk (RR) = 1.25 relative to a one SD difference; 95% confidence interval (CI), 1.05-1.49) and total mortality (RR = 1.23; 95% CI, 1.06-1.42) in men. After adjusting for AF risk factors, tension also predicted AF in men (RR = 1.24; 95% CI, 1.04-1.48). Anxiety in men (RR = 1.22; 95% CI, 1.08-1.38), and in women (RR = 1.27; 95% CI, 1.05-1.55) was significantly related to total mortality.
Tension was observed to be an independent risk factor for incident CHD, AF, and mortality in men. Anxiety was a risk factor for total mortality in men and women. Our findings suggest that further research into the pathophysiology of the excess morbidity and mortality observed with tension and anxiety is merited.
The magnitude of disability among elderly stroke survivors is substantial. There have been few community-based estimates of the contribution gender and older age make to stroke-related disability and ...outcome. Using the original Framingham Study cohort, we documented gender-specific neurological deficits and disability differences in stroke survivors at six months post-stroke. Logistic regression analyses were performed to estimate odds ratios, comparing men and women, and adjusting for age, and age and stroke subtype. Age and gender-matched controls were then compared to distinguish stroke-related disability from disability associated with general aging. Results showed that almost half (43%) of all elderly stroke survivors in the cohort had moderate to severe neurological deficits. In the crude analyses, women were more dependent in ADLs (33.9% vs 15.6%), less likely to walk unassisted (40.3% vs 17.8%), and living in nursing homes (34.9 % vs 13.3%). After adjusting for age and stroke subtype, it was older age that accounted for the severity of disability. When compared to age and gender-matched controls, stroke cases were significantly more disabled in all domains studied. In this elderly cohort, more women experienced initial strokes and were more disabled at 6 months post-stroke than men. However, older age at stroke onset, not gender or stroke subtype, was associated with greater disability. Health care providers need to understand that strokes occur later in life for women and that because of age, women are at greater risk for disability and institutionalization.
Prone positioning has been used as an intervention to improve oxygenation in critically ill patients with acute respiratory distress syndrome. During the COVID-19 pandemic, resources were even more ...limited given a surge in acute respiratory distress syndrome patients, which outstripped intensive care unit (ICU) capacity at many institutions.
The purpose of this article is to describe the development and implementation of a proning team during the surge in ICU patients with COVID-19 and to measure the impact of the program through surveys of staff involved.
A proning protocol and educational plan was developed. A proning team of redeployed staff was created. A survey of ICU registered nurses and proning team members was used to evaluate the benefits and challenges of the proning team.
The proning team was successful in safely performing more than 300 proning and supinating maneuvers for critically ill patients. There is overwhelming support within the institution for a proning team for future COVID-19 surges.
The development and implementation of the proning team happened quickly to assist with the surge of patients and off-load work from ICU registered nurses. Despite the success of the proning team, more clearly defined roles and expectations, as well as additional education, are needed to further enhance teamwork and workflow.
Creation of the proning team was a creative use of resources that helped manage the large and medically complex patient population. This work may serve as a guide to other health care institutions.
To determine if marriage and marital strain are related to the 10-year coronary heart disease (CHD) incidence or total mortality. Research has demonstrated associations between marital strain and ...prognosis of heart disease, but little research has addressed the association between specific aspects of marital strain and incident CHD.
From 1984 to 1987, 3682 participants (mean age 48.5 +/- 10.1 (standard deviation) years; 52% women) of the Framingham Offspring Study were examined; measures of marital status, marital strain, and risk factors for CHD were collected at the baseline examination. The present study describes the 10-year follow-up for incident CHD and total mortality.
After adjusting for age, systolic blood pressure, body mass index, cigarette smoking, diabetes, and total cholesterol/high density cholesterol, the married men compared with unmarried men were almost half as likely to die during follow-up (hazard ratio (HR) = 0.54; 95% confidence interval (CI): 0.34-0.83). Women who "self-silenced" during conflict with their spouse, compared with women who did not, had four times the risk of dying (HR = 4.01; 95% CI: 1.75-9.20). Men with wives who were upset by work were 2.7 times more likely to develop CHD (HR = 2.71; 95% CI: 1.22-6.03). Marital happiness, satisfaction, and disagreements were not related to the development of CHD or death in men or women.
Our study suggests that marital communication, conflict, and strain are associated with adverse health outcomes. Further research into the influence of marital stress on health is merited.
BackgroundPrior studies have shown variation in the intensity of end-of-life care in intensive care units (ICUs) among patients of different races. ObjectiveWe sought to identify variation in the ...levels of care at the end of life in the ICU and to assess for any association with race and ethnicity. DesignAn observational, retrospective cohort study. SettingsA tertiary care center in Boston, MA. ParticipantsAll critically ill patients admitted to medical and surgical ICUs between June 2019 and December 2020. ExposureSelf-identified race and ethnicity. Main Outcome and MeasureThe primary outcome was death. Secondary outcomes included "code status," markers of intensity of care, consultation by the Palliative care service, and consultation by the Ethics service. ResultsA total of 9083 ICU patient encounters were analyzed. One thousand two hundred fifty-nine patients (14%) died in the ICU; the mean age of patients was 64 years (standard deviation 16.8), and 44% of patients were women. A large number of decedents (22.7%) did not have their race identified. These patients had a high rate of interventions at death. Code status varied by race, with more White patients designated as "Comfort Measures Only" (CMO) (74%) whereas more Black patients were designated as "Do Not Resuscitate/Do Not Intubate (DNR/DNI) and DNR/ok to intubate" (12.1% and 15.7%) at the end of life; after adjustment for age and severity of illness, there were no statistical differences by race for the use of the CMO code status. Use of dialysis at the end of life varied by self-identified race. Specifically, Black and Unknown patients were more likely to receive renal replacement therapy, even after adjustment for age and severity of illness (24% and 20%, p = 0.003). ConclusionsOur data describe a gap in identification of race and ethnicity, as well as differences at the end of life in the ICU, especially with respect to code status and certain markers of intensity.
Abstract Background Compared with those with health insurance, the uninsured receive less care for chronic conditions, such as hypertension and diabetes, and experience higher mortality. Methods We ...investigated the relations of health insurance status to the prevalence, treatment, and control of major cardiovascular disease risk factors—hypertension and elevated low-density lipoprotein (LDL) cholesterol—among Framingham Heart Study (FHS) participants in gender-specific, age-adjusted analyses. Participants who attended the seventh Offspring cohort examination cycle (1998-2001) or the first Third Generation cohort examination cycle (2002-2005) were studied. Results Among 6098 participants, 3.8% were uninsured at the time of the FHS clinic examination and ages ranged from 19 to 64 years. The prevalence of hypertension and elevated LDL cholesterol was similar for the insured and uninsured; however, the proportion of those who obtained treatment and achieved control of these risk factors was lower among the uninsured. Uninsured men and women were less likely to be treated for hypertension with odds ratios for treatment of 0.19 (95% confidence interval CI, 0.07-0.56) for men and 0.31 (95% CI, 0.12-0.79) for women. Among men, the uninsured were less likely to receive treatment or achieve control of elevated LDL cholesterol than the insured, with odds ratios of 0.12 (95% CI, 0.04-0.38) for treatment and 0.17 (95% CI, 0.05-0.56) for control. Conclusion The treatment and control of hypertension and hypercholesterolemia are lower among uninsured adults. Increasing the proportion of insured individuals may be a means to improve the treatment and control of cardiovascular disease risk factors and to reduce health disparities.
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