A Cohort Study of Anticholinergic Medication Burden and Incident Dementia and Stroke in Older Adults

BackgroundAnticholinergic medications may increase risk of dementia and stroke, but prospective studies in healthy older people are lacking.ObjectiveCompare risk of incident dementia and stroke by anticholinergic burden among initially healthy older people.DesignProspective cohort study.SettingPrimary care (Australia and USA).Participants19,114 community-dwelling participants recruited for the ASPREE trial, aged 70+ years (65+ if US minorities) without major cardiovascular disease, dementia diagnosis, or Modified Mini-Mental State Examination score below 78/100.MeasurementsBaseline anticholinergic exposure was calculated using the Anticholinergic Cognitive Burden (ACB) score. Dementia was adjudicated using Diagnostic and Statistical Manual of Mental Disorders volume IV criteria, and stroke using the World Health Organization definition.ResultsAt baseline, 15,000 participants (79%) had an ACB score of zero, 2930 (15%) a score of 1–2, and 1184 (6%) a score of ≥ 3 (indicating higher burden). After a median follow-up of 4.7 years and adjusting for baseline covariates, a baseline ACB score of ≥ 3 was associated with increased risk of ischemic stroke (adjusted HR 1.58, 95% CI 1.06, 2.35), or dementia (adjusted HR 1.36, 95% CI 1.01, 1.82), especially of mixed etiology (adjusted HR 1.53, 95% CI 1.06, 2.21). Results were similar for those exposed to moderate/highly anticholinergic medications.LimitationsResidual confounding and reverse causality are possible. Assessment of dose or duration was not possible.ConclusionsHigh anticholinergic burden in initially healthy older people was associated with increased risk of incident dementia and ischemic stroke. A vascular effect may underlie this association. These findings highlight the importance of minimizing anticholinergic exposure in healthy older people.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-020-06550-2.KEY WORDS: anticholinergic burden, dementia, stroke, potentially inappropriate medication     

Ultrasound velocity criteria for carotid in-stent restenosis.

OBJECTIVE: To examine duplex ultrasound (US) criteria for carotid in-stent restenosis (ISR). BACKGROUND: Carotid artery stent (CAS) placement is an alternative to surgery for the treatment of carotid stenosis in high surgical risk patients. US is the primary method used to follow carotid stent patency. This study investigates US velocity measurements in carotid ISR. METHODS: Two hundred sixty consecutive patients with CAS placement from June 2000 to June 2004 were followed with serial US. ISR was determined by using the standard US velocity criteria for nonstented carotid artery using peak systolic velocity (PSV), end-diastolic velocity (EDV), and internal carotid artery to common carotid velocity ratio (ICA/CCA ratio). Patients suspected of having carotid ISR > or =50% by US, underwent invasive angiography with stenosis graded by NASCET criteria. Results were compared to patients with nonstented carotid artery stenosis using Two-tailed Student's t-test. RESULTS: PSV and ICA/CCA ratio increased to a greater degree in ISR. In 50-69% stenotic arteries, the mean ICA/CCA ratio was 2.76 +/- 0.7 in the ISR group compared to 2.04 +/- 0.3 in the nonstented carotid group (P < 0.05). In > or =70% stenotic arteries, there were increases in PSV (520 +/- 93 vs. 362 +/- 60, P < 0.05) and ICA/CCA ratio (7.58 +/- 2 vs. 4.51 +/- 1.3, P < 0.05) in ISR versus nonstented carotid arteries, respectively. CONCLUSION: PSV and ICA/CCA ratio in ISR increased to a greater extent for angiographic stenosis > or =50%. PSV 240 cm/sec and ICA/CCA ratio 2.45 are optimal thresholds for > or =50% ISR, and PSV 450 cm/sec and ICA/CCA ratio 4.3 are optimal thresholds for > or =70% ISR.     

Factors that affect human hemopoiesis are produced by T-cell growth factor dependent and independent cultured T-cell leukemia-lymphoma cells

Some laboratory results and clinical situations suggest that human T cells may be important in the regulation of growth of hematopoietic cells. Since the discovery of T-cell growth factor (TCGF), systems are now available for the long-term specific in vitro propagation of mature normal or neoplastic human T cells, providing an opportunity to study the influence of T cells on hematopoiesis. Recently, 24 cell lines from patients with cutaneous T-cell lymphoma (CTCL) and T-cell acute lymphoblastic leukemia (T-ALL) were grown with TCGF and then assessed for release of humoral factors that affect hematopoiesis. Conditioned media (CM) from these cell lines were tested for erythroid burst- promoting activity (BPA) and granulocyte colony-stimulating activity (CSA). BPA was detected in CM from 3/6 cultures of T-ALL patients and 4/6 CTCL cultures. CSA was found in the CM from 6/8 cultures of T-ALL patients, 7/12 CTCL cultures, and 3/4 CTCL cell lines that become independent of exogenous TCGF for growth. The CSA from several of the neoplastic T-cell cultures stimulated high levels of eosinophil colonies, a possible source of the eosinophilia seen in these patients. The ability of continuously proliferating human T lymphocytes, which retain functional specificity and responsiveness to normal humoral regulation, to produce factors that directly or indirectly stimulate myeloid and erythroid colony formation lends further credence to the role of T lymphocytes in regulating hematopoiesis.     

Lower Leg Anterior and Lateral Intracompartmental Pressure Changes Before and After Classic Versus Skate Nordic Rollerskiing

Context

Chronic exertional compartment syndrome (CECS) is a debilitating condition resulting in loss of function and a decrease in athletic performance. Cases of CECS are increasing among Nordic skiers; therefore, analysis of intracompartmental pressures (ICPs) before and after Nordic skiing is warranted.

Objective

To determine if lower leg anterior and lateral ICPs and subjective lower leg pain levels increased after a 20-minute Nordic rollerskiing time trial and to examine if differences existed between postexercise ICPs for the 2 Nordic rollerskiing techniques, classic and skate.

Design

Crossover study.

Setting

Outdoor paved loop.

Patients or Other Participants

Seven healthy Division I Nordic skiers (3 men, 4 women; age = 22.71 ± 1.38 y, height = 175.36 ± 6.33 cm, mass = 70.71 ± 6.58 kg).

Intervention(s)

Participants completed two 20-minute rollerskiing time trials using the classic and skate technique in random order. The time trials were completed 7 days apart. Anterior and lateral ICPs and lower leg pain scores were obtained at baseline and at minutes 1 and 5 after rollerskiing.

Main Outcome Measure(s)

Anterior and lateral ICPs (mm Hg) were measured using a Stryker Quic STIC handheld monitor. Subjective measures of lower leg pain were recorded using the 11-point Numeric Rating Scale.

Results

Increases in both anterior (P = .000) and lateral compartment (P = .002) ICPs were observed, regardless of rollerskiing technique used. Subjective lower leg pain increased after the classic technique for the men from baseline to 1 minute postexercise and after the skate technique for the women. Significant 3-way interactions (technique × time × sex) were observed for the anterior (P = .002) and lateral (P = .009) compartment ICPs and lower leg pain (P = .005).

Conclusions

Postexercise anterior and lateral ICPs increased compared with preexercise ICPs after both classic and skate rollerskiing techniques. Lower leg pain is a primary symptom of CECS. The subjective lower leg pain 11-point Numeric Rating Scale results indicate that increases in lower leg ICPs sustained during Nordic rollerskiing may increase discomfort during activity. Our results therefore suggest that Nordic rollerskiing contributes to increases in ICPs, which may lead to the development of CECS.Key Words: chronic exertional compartment syndrome, compartment syndrome, anterior compartment, lower leg pain Nordic skiing

Key Points

• The exact cause of chronic exertional compartment syndrome is currently unknown.
• The diagnosis of chronic exertional compartment syndrome is increasing within the competitive Nordic skiing population.
• Increases in anterior and lateral intracompartmental pressures were observed after a 20-minute time trial using either the classic or skating Nordic rollerskiing technique.

Chronic exertional compartment syndrome (CECS) is a debilitating condition resulting in loss of function and a decrease in athletic performance. In general, a compartment syndrome occurs when the circulation and function of tissues within a closed space are compromised by increased pressure within that space.¹ An increase in tissue pressure within an enclosed space can threaten perfusion and tissue viability. In the case of CECS, this increase in tissue pressure within the confined space is reversible and will decrease after exercise ceases.² Common symptoms of CECS in the lower leg include burning, aching, paresthesia, weakness, and an inability to dorsiflex the foot. These symptoms are detrimental to performance and, if left untreated, have the potential to end an athlete''s career. Chronic exertional compartment syndrome has been reported among runners, cyclists, and military personnel.³ Recently, increasing anecdotal evidence of CECS among competitive Nordic skiers has been shown; however, no researchers have examined the relationship between Nordic skiing and intracompartmental pressures (ICPs).Rollerskiing is a typical dry-land method of Nordic ski training and may be performed using either the classic or the skate technique. Rollerskis are shortened Nordic skis with 1 wheel at each end designed to be used on smooth indoor or outdoor surfaces. Classic rollerskiing uses the same kick-and-glide motion as on snow. Classic rollerskis have wider wheels than skate rollerskis. A ratchet mechanism on 1 wheel only rolls forward, providing unidirectional travel and limiting negative gain. Skate rollerskiing uses the same lateral leg push as on snow. Skate rollerskis have narrower wheels, similar to in-line skates, and both wheels roll freely in either direction. For both techniques, boots and bindings are the same as those used for Nordic skiing on the snow.Anecdotally, some athletes complain that they experience more lower leg pain during classic rollerskiing than classic snow skiing, which could be attributed to the weight of the ski (approximately 2.5 kg per pair of classic rollerskis compared with approximately 1.18 kg per pair of classic snow skis). More recent anecdotal evidence has suggested that any increased pressure observed during the classic rollerskiing technique may be attributed to the quality of the rollerski wheels and the skier''s effort needed to maintain forward tracking and control of the ski while in motion. This suggestion is similar to anecdotal reports of increased lower leg pain while skate skiing in icy conditions, when one must sustain muscular contractions in the lower leg and foot to maintain control of the ski.It is unknown whether Nordic skiing causes chronic increases in anterior and lateral ICPs, which may contribute to the development of CECS. Combined with a thorough history and clinical examination, ICP testing is the gold standard used to diagnose CECS.⁴ In this study, if anterior and lateral ICPs increased during Nordic rollerskiing, the findings could point to Nordic rollerskiing as a possible contributor in the development of CECS. Coaches, athletes, and health care personnel may then seek modified skiing techniques and equipment to avoid increased ICPs during Nordic rollerskiing.The purpose of our study was to determine if ICPs of the anterior and lateral lower leg compartments increased among collegiate Nordic skiers after a 20-minute rollerskiing time trial. We also aimed to determine whether postexercise ICPs differed for the classic rollerskiing technique versus the skate rollerskiing technique. We hypothesized that the ICPs of both the anterior and lateral lower leg compartments would increase among collegiate Nordic skiers after the 20-minute time trial. We also hypothesized that postexercise anterior and lateral ICPs would be higher after the skate rollerskiing technique than the classic rollerskiing technique. Significant results will allow physicians, athletic trainers, coaches, and athletes to better understand CECS and the Nordic skiing population, which may lead to modified training methods or injury-prevention practices for both symptomatic and asymptomatic skiers.     

Sun protective behaviors at an outdoor entertainment event in Australia

An observational study was conducted to examine the use of sun protective hats, clothing, and sunglasses of people attending an outdoor entertainment event in an area of high‐to‐extreme ultraviolet radiation in New South Wales, Australia. Armidale is unique, as it is a highly‐elevated area, almost 1000 m above sea level, and temperatures are often mild with very high‐to‐extreme levels of ultraviolet radiation. Four trained data collectors observed attendees as they entered the event, and recorded their use of sun protective hats, clothing, and sunglasses. While more than half of the attendees wore sun protective hats, only 14% wore sun protective clothing. Broad‐brimmed hats were considered sun protective, while sun protective clothing was defined by shirts with at least three‐quarter‐length sleeves. Females were more likely to wear both a sun protective hat and clothing than males, and children were less protected than adults. Legislative changes are required to ensure that organizers of outdoor events have a legal responsibility to provide a safe environment for attendees, including strategies to help reduce ultraviolet radiation exposure.     

Demands of Multiple Behavior Change in Type 2 Diabetes Risk Reduction

The purpose of this study was to explore individual experiences of participation in multiple activities recommended for type 2 diabetes risk reduction. Twelve individuals at risk for type 2 diabetes described their experiences regarding risk-reduction activities. A grounded theory method guided data collection and analysis. Data analysis revealed facilitators and inhibitors associated with participation in recommended multiple behavior change for type 2 diabetes risk reduction. Our findings emphasize social and personal factors that increase or decrease the likelihood of adherence to prevention recommendations. Findings suggest that health care providers provide structured yet individualized recommendations to support multiple behavior change efforts.