Blood Pressure and Cognitive Decline Over 8 Years in Middle-Aged and Older Black and White Americans

Although the association between high blood pressure (BP), particularly in midlife, and late-life dementia is known, less is known about variations by race and sex. In a prospective national study of 22 164 blacks and whites ≥45 years without baseline cognitive impairment or stroke from the REGARDS cohort study (Reasons for Geographic and Racial Differences in Stroke), enrolled 2003 to 2007 and followed through September 2015, we measured changes in cognition associated with baseline systolic and diastolic BP (SBP and DBP), as well as pulse pressure (PP) and mean arterial pressure, and we tested whether age, race, and sex modified the effects. Outcomes were global cognition (Six-Item Screener; primary outcome), new learning (Word List Learning), verbal memory (Word List Delayed Recall), and executive function (Animal Fluency Test). Median follow-up was 8.1 years. Significantly faster declines in global cognition were associated with higher SBP, lower DBP, and higher PP with increasing age ( P<0.001 for age×SBP×follow-up-time, age×DBP×follow-up-time, and age×PP×follow-up-time interaction). Declines in global cognition were not associated with mean arterial pressure after adjusting for PP. Blacks, compared with whites, had faster declines in global cognition associated with SBP ( P=0.02) and mean arterial pressure ( P=0.04). Men, compared with women, had faster declines in new learning associated with SBP ( P=0.04). BP was not associated with decline of verbal memory and executive function, after controlling for the effect of age on cognitive trajectories. Significantly faster declines in global cognition over 8 years were associated with higher SBP, lower DBP, and higher PP with increasing age. SBP-related cognitive declines were greater in blacks and men

Implementing just climate adaptation policy: An analysis of recognition, framing, and advocacy coalitions in Boston, U.S.A.

Cities face intersectional challenges implementing climate adaptation policy. This research contributes to scholarship dedicated to understanding how policy implementation affects socially vulnerable groups, with the overarching goal of promoting justice and equity in climate policy implementation. We apply a novel framework that integrates social justice theory and the advocacy coalition framework to incrementally assess just climate adaptation in Boston, Massachusetts in the United States. Boston made an ambitious commitment to address equity as part of its climate planning and implementation efforts. In this paper, we evaluate the first implementation stage over the period 2016–2019 during which Boston developed coastal resilience plans for three neighborhoods. Despite Boston\u27s commitment to equity, we find injustice was nevertheless reproduced through representation and coalition dynamics, the framing of problems and solutions, and a failure to recognize the priorities and lived experiences of city residents. The assessment framework presented can be adapted to evaluate how other climate adaptation initiatives advance social justice and highlights the need for incremental evaluation over short time periods to inform ongoing implementation efforts

Refractory Hypertension: Determination of Prevalence, Risk Factors and Comorbidities in a Large, Population-Based Cohort

Refractory hypertension is an extreme phenotype of antihypertensive treatment failure. Participants in the REasons for Geographic And Racial Differences in Stroke (REGARDS) Study, a large (n=30 239), population-based cohort were evaluated to determine the prevalence of refractory hypertension and associated cardiovascular risk factors and comorbidities. Refractory hypertension was defined as uncontrolled blood pressure (systolic/diastolic, ≥140/90 mm Hg) on ≥5 antihypertensive drug classes. Participants with resistant hypertension (systolic/diastolic, ≥140/90 mm Hg on ≥3 or <140/90 mm Hg on ≥4 antihypertensive classes) and all participants treated for hypertension served as comparator groups. Of 14 809 REGARDS participants receiving antihypertensive treatment, 78 (0.5%) had refractory hypertension. The prevalence of refractory hypertension was 3.6% among participants with resistant hypertension (n=2144) and 41.7% among participants on ≥5 antihypertensive drug classes. Among all participants with hypertension, black race, male sex, living in the stroke belt or buckle, higher body mass index, lower heart rate, reduced estimated glomerular filtration rate, albuminuria, diabetes mellitus, and history of stroke and coronary heart disease were associated with refractory hypertension. Compared with resistant hypertension, prevalence ratios for refractory hypertension were increased for blacks (3.00; 95% confidence interval, 1.68–5.37) and those with albuminuria (2.22; 95% confidence interval, 1.40–3.52) and diabetes mellitus (2.09; 95% confidence interval, 1.32–3.31). The median 10-year Framingham risk for coronary heart disease and stroke was higher among participants with refractory hypertension when compared with those with either comparator group. These data indicate that although resistant hypertension is relatively common among treated patients with hypertension, true antihypertensive treatment failure is rare

Apparent treatment-resistant hypertension and risk for stroke, coronary heart disease, and all-cause mortality

Apparent treatment-resistant hypertension (aTRH) is defined as uncontrolled hypertension despite the use of three or more antihypertensive medication classes or controlled hypertension while treated with four or more antihypertensive medication classes. We evaluated the association of aTRH with incident stroke, coronary heart disease (CHD), and all-cause mortality. Participants from the population-based REasons for Geographic And Racial Differences in Stroke (REGARDS) Study treated for hypertension with aTRH (n = 2043) and without aTRH (n = 12,479) were included. aTRH was further categorized as controlled aTRH (≥4 medication classes and controlled hypertension) and uncontrolled aTRH (≥3 medication classes and uncontrolled hypertension). Over a median of 5.9, 4.4, and 6.0 years of follow-up, the multivariable adjusted hazard ratio for stroke, CHD, and all-cause mortality associated with aTRH versus no aTRH was 1.25 (0.94–1.65), 1.69 (1.27–2.24), and 1.29 (1.14–1.46), respectively. Compared with controlled aTRH, uncontrolled aTRH was associated with CHD (hazard ratio, 2.33; 95% confidence interval, 1.21–4.48), but not stroke or mortality. Comparing controlled aTRH with no aTRH, risk of stroke, CHD, and all-cause mortality was not elevated. aTRH was associated with an increased risk for coronary heart disease and all-cause mortality

The species diversity&nbsp;×&nbsp;fire severity relationship is hump-shaped in semiarid yellow pine and mixed conifer forests

The combination of direct human influences and the effects of climate change are resulting in altered ecological disturbance regimes, and this is especially the case for wildfires. Many regions that historically experienced low–moderate severity fire regimes are seeing increased area burned at high severity as a result of interactions between high fuel loads and climate warming with a number of negative ecological effects. While ecosystem impacts of altered fire regimes have been examined in the literature, little is known of the effects of changing fire regimes on forest understory plant diversity even though understory taxa comprise the vast majority of forest plant species and play vital roles in overall ecosystem function. We examined understory plant diversity across gradients of wildfire severity in eight large wildfires in yellow pine and mixed conifer temperate forests of the Sierra Nevada, California, USA. We found a generally unimodal hump-shaped relationship between local (alpha) plant diversity and fire severity. High-severity burning resulted in lower local diversity as well as some homogenization of the flora at the regional scale. Fire severity class, post-fire litter cover, and annual precipitation were the best predictors of understory species diversity. Our research suggests that increases in fire severity in systems historically characterized by low and moderate severity fire may lead to plant diversity losses. These findings indicate that global patterns of increasing fire size and severity may have important implications for biodiversity

The contributions of unhealthy lifestyle factors to apparent resistant hypertension: findings from the Reasons for Geographic And Racial Differences in Stroke (REGARDS) study

Objectives: Unhealthy lifestyle factors may contribute to apparent treatment resistant hypertension (aTRH). We examined associations of unhealthy lifestyle factors with aTRH in individuals taking antihypertensive medications from three or more classes. Methods: Participants (n = 2602) taking three or more antihypertensive medication classes were identified from the population-based REasons for Geographic And Racial Differences in Stroke (REGARDS) study. aTRH was defined as having SBP/DBP at least 140/90 mmHg despite the use of three or more antihypertensive medication classes or the use of four or more classes to achieve blood pressure control. Lifestyle factors included obesity, physical inactivity, current smoking, heavy alcohol consumption, a low Dietary Approaches to Stop Hypertension (DASH) diet score and high sodium-to-potassium (Na/K) intake. Results: Among participants taking three or more antihypertensive medication classes, 1293 (49.7%) participants had aTRH. The prevalence of unhealthy lifestyle factors in participants with and without aTRH was 55.2 and 51.7%, respectively, for obesity, 42.2 and 40.5% for physical inactivity, 11.3 and 11.5% for current smoking, 3.1 and 4.0% for heavy alcohol consumption, 23.1 and 21.5% for low-DASH diet score, and 25.4 and 24.4% for high Na/K intake. After adjustment for age, sex, race, and geographic region of residence, none of the unhealthy lifestyle factors were associated with aTRH. The associations between each unhealthy lifestyle factor and aTRH remained nonsignificant after additional adjustment for education, income, depressive symptoms, total calorie intake, and comorbidities. Conclusions: Unhealthy lifestyle factors did not have independent associations with aTRH among individuals taking three or more antihypertensive medication classes

Rethinking the patient: using Burden of Treatment Theory to understand the changing dynamics of illness

&lt;b&gt;Background&lt;/b&gt; In this article we outline Burden of Treatment Theory, a new model of the relationship between sick people, their social networks, and healthcare services. Health services face the challenge of growing populations with long-term and life-limiting conditions, they have responded to this by delegating to sick people and their networks routine work aimed at managing symptoms, and at retarding - and sometimes preventing - disease progression. This is the new proactive work of patient-hood for which patients are increasingly accountable: founded on ideas about self-care, self-empowerment, and self-actualization, and on new technologies and treatment modalities which can be shifted from the clinic into the community. These place new demands on sick people, which they may experience as burdens of treatment.&lt;p&gt;&lt;/p&gt; &lt;b&gt;Discussion&lt;/b&gt; As the burdens accumulate some patients are overwhelmed, and the consequences are likely to be poor healthcare outcomes for individual patients, increasing strain on caregivers, and rising demand and costs of healthcare services. In the face of these challenges we need to better understand the resources that patients draw upon as they respond to the demands of both burdens of illness and burdens of treatment, and the ways that resources interact with healthcare utilization.&lt;p&gt;&lt;/p&gt; &lt;b&gt;Summary&lt;/b&gt; Burden of Treatment Theory is oriented to understanding how capacity for action interacts with the work that stems from healthcare. Burden of Treatment Theory is a structural model that focuses on the work that patients and their networks do. It thus helps us understand variations in healthcare utilization and adherence in different healthcare settings and clinical contexts

Blood Pressure Control in Diabetes: Temporal progress yet persistent racial disparities: national results from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study

OBJECTIVE Despite widespread dissemination of target values, achieving a blood pressure of <130/80 mmHg is challenging for many individuals with diabetes. The purpose of the present study was to examine temporal trends in blood pressure control in hypertensive individuals with diabetes as well as the potential for race, sex, and geographic disparities. RESEARCH DESIGN AND METHODS We analyzed baseline data from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study, a national, population-based, longitudinal cohort study of 30,228 adults (58% European American and 42% African American), examining the causes of excess stroke mortality in the southeastern U.S. We calculated mean blood pressure and blood pressure control rates (proportion with blood pressure <130/80 mmHg) for 5,217 hypertensive diabetic participants by year of enrollment (2003–2007) using multivariable logistic regression models. RESULTS Only 43 and 30% of European American and African American diabetic hypertensive participants, respectively, demonstrated a target blood pressure of <130/80 mmHg (P < 0.001). However, a temporal trend of improved control was evident; the odds of having a blood pressure <130/80 mmHg among diabetic hypertensive participants of both races enrolled in 2007 (as compared with those enrolled in 2003) were ∼50% greater (P < 0.001) in multivariate models. CONCLUSIONS These data suggest temporal improvements in blood pressure control in diabetes that may reflect broad dissemination of tighter blood pressure control targets and improving medication access. However, control rates remain low, and significant racial disparities persist among African Americans that may contribute to an increased risk for premature cardiovascular disease

Type of mRNA COVID-19 vaccine and immunomodulatory treatment influence humoral immunogenicity in patients with inflammatory rheumatic diseases

Patients with inflammatory rheumatic diseases (IRD) are at increased risk for worse COVID-19 outcomes. Identifying whether mRNA vaccines differ in immunogenicity and examining the effects of immunomodulatory treatments may support COVID-19 vaccination strategies. We aimed to conduct a long-term, model-based comparison of the humoral immunogenicity following BNT162b2 and mRNA-1273 vaccination in a cohort of IRD patients. Patients from the Swiss IRD cohort (SCQM), who assented to mRNA COVID-19 vaccination were recruited between 3/2021-9/2021. Blood samples at baseline, 4, 12, and 24 weeks post second vaccine dose were tested for anti-SARS-CoV-2 spike IgG (anti-S1). We examined differences in antibody levels depending on the vaccine and treatment at baseline while adjusting for age, disease, and past SARS-CoV-2 infection. 565 IRD patients provided eligible samples. Among monotherapies, rituximab, abatacept, JAKi, and TNFi had the highest odds of reduced anti-S1 responses compared to no medication. Patients on specific combination therapies showed significantly lower antibody responses than those on monotherapy. Irrespective of the disease, treatment, and past SARS-CoV-2 infection, the odds of higher antibody levels at 4, 12, and 24 weeks post second vaccine dose were, respectively, 3.4, 3.8, and 3.8 times higher with mRNA-1273 versus BNT162b2 (p < 0.0001). With every year of age, the odds ratio of higher peak humoral immunogenicity following mRNA-1273 versus BNT162b2 increased by 5% (p < 0.001), indicating a particular benefit for elderly patients. Our results suggest that in IRD patients, two-dose vaccination with mRNA-1273 versus BNT162b2 results in higher anti-S1 levels, even more so in elderly patients