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Suchy-Dicey AM, Vo TT, Oziel K, Buchwald DS, Nelson LA, Verney SP, French BF. Psychometric reliability, validity, and generalizability of 3MSE scores among American Indian adults: the Strong Heart Study. J Int Neuropsychol Soc 2024; 30:454-463. [PMID: 38263740 DOI: 10.1017/s1355617723011438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
OBJECTIVE Modified Mini-Mental State Examination (3MSE) is often used to screen for dementia, but little is known about psychometric validity in American Indians. METHODS We recruited 818 American Indians aged 65-95 for 3MSE examinations in 2010-2013; 403 returned for a repeat examination in 2017-2019. Analyses included standard psychometrics inferences for interpretation, generalizability, and extrapolation: factor analysis; internal consistency-reliability; test-retest score stability; multiple indicator multiple cause structural equation models. RESULTS This cohort was mean age 73, majority female, mean 12 years education, and majority bilingual. The 4-factor and 2nd-order models fit best, with subfactors for orientation and visuo-construction (OVC), language and executive functioning (LEF), psychomotor and working memory (PMWM), verbal and episodic memory (VEM). Factor structure was supported for both research and clinical interpretation, and factor loadings were moderate to high. Scores were generally consistent over mean 7 years. Younger participants performed better in overall scores, but not in individual factors. Males performed better on OVC and LEF, females better on PMWM. Those with more education performed better on LEF and worse on OVC; the converse was true for bilinguals. All differences were significant, but small. CONCLUSION These findings support use of 3MSE for individual interpretation in clinic and research among American Indians, with moderate consistency, stability, reliability over time. Observed extrapolations across age, sex, education, and bilingual groups suggest some important contextual differences may exist.
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Affiliation(s)
- Astrid M Suchy-Dicey
- Huntington Medical Research Institutes, Pasadena, CA, USA
- Washington State University, Elson S Floyd College of Medicine, Seattle, WA, USA
| | - Thao T Vo
- Washington State University, College of Education, Pullman, WA, USA
| | - Kyra Oziel
- Washington State University, Elson S Floyd College of Medicine, Seattle, WA, USA
| | - Dedra S Buchwald
- Washington State University, Elson S Floyd College of Medicine, Seattle, WA, USA
| | - Lonnie A Nelson
- Washington State University, College of Nursing, Spokane, WA, USA
| | | | - Brian F French
- Washington State University, College of Education, Pullman, WA, USA
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Suchy-Dicey A, Su Y, Buchwald DS, Manson SM, Reiman EM. Volume atrophy in medial temporal cortex and verbal memory scores in American Indians: Data from the Strong Heart Study. Alzheimers Dement 2023; 19:2298-2306. [PMID: 36453775 PMCID: PMC10232670 DOI: 10.1002/alz.12889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 10/06/2022] [Accepted: 10/25/2022] [Indexed: 12/03/2022]
Abstract
INTRODUCTION Distinguishing Alzheimer's disease (AD) patient subgroups may optimize positive clinical outcomes. Cortical atrophy is correlated with memory deficits, but these associations are understudied in American Indians. METHODS We collected imaging and cognition data in the Strong Heart Study (SHS), a cohort of 11 tribes across three regions. We processed 1.5T MRI using FreeSurfer and iterative principal component analysis. Linear mixed models estimated volumetric associations with diabetes. RESULTS Over mean 7 years follow-up (N = 818 age 65-89 years), overall volume loss was 0.5% per year. Significant losses associated with diabetes were especially strong in the right hemisphere. Annualized hippocampal, parahippocampal, entorhinal atrophy were worse for men, older age, diabetes, hypertension, stroke; and associated with both encoding and retrieval memory losses. DISCUSSION Our findings suggest that diabetes is an important risk factor in American Indians for cortical atrophy and memory loss. Future research should examine opportunities for primary prevention in this underserved population.
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Affiliation(s)
- Astrid Suchy-Dicey
- Elson S Floyd College of Medicine, Washington State University, Spokane, Washington, USA
| | - Yi Su
- Banner Alzheimer's Institute, Phoenix, Arizona, USA
| | - Dedra S Buchwald
- Elson S Floyd College of Medicine, Washington State University, Spokane, Washington, USA
| | - Spero M Manson
- Colorado School of Public Health, University of Colorado Anschutz, Aurora, Colorado, USA
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Mascarenhas Fonseca L, Sage Chaytor N, Olufadi Y, Buchwald D, Galvin JE, Schmitter-Edgecombe M, Suchy-Dicey A. Intraindividual Cognitive Variability and Magnetic Resonance Imaging in Aging American Indians: Data from the Strong Heart Study. J Alzheimers Dis 2023; 91:1395-1407. [PMID: 36641671 PMCID: PMC9974814 DOI: 10.3233/jad-220825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND American Indians have high prevalence of risk factors for Alzheimer's disease and related dementias (ADRD) compared to the general population, yet dementia onset and frequency in this population are understudied. Intraindividual cognitive variability (IICV), a measure of variability in neuropsychological test performance within a person at a single timepoint, may be a novel, noninvasive biomarker of neurodegeneration and early dementia. OBJECTIVE To characterize the cross-sectional associations between IICV and hippocampal, total brain volume, and white matter disease measured by magnetic resonance imaging (MRI) among older American Indians. METHODS IICV measures for memory, executive function, and processing speed, and multidomain cognition were calculated for 746 American Indians (aged 64-95) who underwent MRI. Regression models were used to examine the associations of IICV score with hippocampal volume, total brain volume, and graded white matter disease, adjusting for age, sex, education, body mass index, intracranial volume, diabetes, stroke, hypertension, hypercholesterolemia, alcohol use, and smoking. RESULTS Higher memory IICV measure was associated with lower hippocampal volume (Beta = -0.076; 95% CI -0.499, -0.023; p = 0.031). After adjustment for Bonferroni or IICV mean scores in the same tests, the associations were no longer significant. No IICV measures were associated with white matter disease or total brain volume. CONCLUSION These findings suggest that the IICV measures used in this research cannot be robustly associated with cross-sectional neuroimaging features; nonetheless, the results encourage future studies investigating the associations between IICV and other brain regions, as well as its utility in the prediction of neurodegeneration and dementia in American Indians.
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Affiliation(s)
- Luciana Mascarenhas Fonseca
- Elson S Floyd College of Medicine, Washington State University, United States
- Programa Terceira Idade (PROTER, Old Age Research Group), Department and Institute of Psychiatry, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Naomi Sage Chaytor
- Elson S Floyd College of Medicine, Washington State University, United States
| | - Yunusa Olufadi
- Elson S Floyd College of Medicine, Washington State University, United States
| | - Dedra Buchwald
- Elson S Floyd College of Medicine, Washington State University, United States
- Institute for Research and Education to Advance Community Health, Washington State University, United States
| | - James E. Galvin
- Comprehensive Center for Brain Health, Department of Neurology, University of Miami Miller School of Medicine, United States
| | | | - Astrid Suchy-Dicey
- Elson S Floyd College of Medicine, Washington State University, United States
- Institute for Research and Education to Advance Community Health, Washington State University, United States
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Suchy-Dicey AM, Oziel K, Sawyer C, Olufadi Y, Ali T, Fretts AM, Umans JG, Shibata DK, Longstreth WT, Rhoads K, Buchwald DS, Grabowski TJ. Educational and Clinical Associations With Longitudinal Cognitive Function and Brain Imaging in American Indians: The Strong Heart Study. Neurology 2022; 99:e2637-e2647. [PMID: 36289000 PMCID: PMC9757873 DOI: 10.1212/wnl.0000000000201261] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 08/01/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Little is known about incidence of vascular and Alzheimer dementias in American Indians. METHODS We conducted a large, heterogeneous, population-based, longitudinal cohort study of brain aging in community-dwelling American Indians aged 64-95 years from 11 tribes across 3 states, with neurologic examinations, 1.5T MRI, and extensive cognitive testing. Visit 1 in 2010-2013 (n = 817) and visit 2 in 2017-2019 (n = 403) included all willing, surviving participants. Standardized cognitive tests at both visits included Modified Mini-Mental Status Examination (MMSE), Wechsler Adult Intelligence Scale digit symbol coding (WAIS), Controlled Oral Word Association (COWA), and California Verbal Learning Test short form (CVLT). Test materials added at follow-up included Wide Range Achievement (reading) Test (WRAT) and National Alzheimer Coordinating Center Uniform Data Set cognitive battery (v3 form C2), including Montreal Cognitive Assessment (MoCA). MRI neuroradiologists coded infarcts, hemorrhages, white matter hyperintensities, sulcal atrophy, and ventricle enlargement. RESULTS The mean time between examinations was 6.7 years (SD 1.1, range 3.8-9.1 years). Years of formal education had modest correlation with WRAT reading score (r = 0.45). Prevalence and incidence (respectively) of infarcts were 32% and 12.8/1,000 person-years (PYs) hemorrhages 6% and 4.4/1000 PY worsening sulci 74% and 19.0/1000 PY worsening ventricle 79% and 30.1/1000 PY worsening leukoaraiosis 44% and 26.1/1000 PY. Linear losses per year in cognitive scores were 0.6% MMSE, 1.2% WAIS, 0.6% COWA, and 2.2% CVLT. The mean MoCA scores were 18.9 (SD 4.3). DISCUSSION These are the first data on longitudinal cognitive and imaging changes in American Indians and first reports of Alzheimer disease-related features. The mean scores in MoCA were similar or lower than standard cutoffs used to diagnose dementia in other racial/ethnic groups, suggesting that standardized cognitive tests may not perform well in this population. Test validation, adaptation, and score adjustment are warranted. Years of education were a poor proxy for premorbid function, suggesting novel methods for cognitive score contextualization is also needed in this population. Evaluation of selective survival suggests attrition from death, and frailty should be accounted for in causal analyses. Overall, these data represent a unique opportunity to examine neurology topics of critical importance to an understudied population.
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Affiliation(s)
- Astrid M Suchy-Dicey
- From the Elson S. Floyd College of Medicine (A.M.S.-D., K.O., C.S., Y.O., D.S.B.), Washington State University, Spokane; Oklahoma University Health Sciences Center (T.A.), Oklahoma City; Epidemiology (A.M.F., M.D.J.), School of Public Health, University of Washington, Seattle; MedStar Health Research Institute (J.G.U.), Washington, DC; Neuroradiology (D.K.S.) and Neurology (M.D.J., K.R., T.J.G.), School of Medicine, University of Washington, Seattle.
| | - Kyra Oziel
- From the Elson S. Floyd College of Medicine (A.M.S.-D., K.O., C.S., Y.O., D.S.B.), Washington State University, Spokane; Oklahoma University Health Sciences Center (T.A.), Oklahoma City; Epidemiology (A.M.F., M.D.J.), School of Public Health, University of Washington, Seattle; MedStar Health Research Institute (J.G.U.), Washington, DC; Neuroradiology (D.K.S.) and Neurology (M.D.J., K.R., T.J.G.), School of Medicine, University of Washington, Seattle
| | - Charles Sawyer
- From the Elson S. Floyd College of Medicine (A.M.S.-D., K.O., C.S., Y.O., D.S.B.), Washington State University, Spokane; Oklahoma University Health Sciences Center (T.A.), Oklahoma City; Epidemiology (A.M.F., M.D.J.), School of Public Health, University of Washington, Seattle; MedStar Health Research Institute (J.G.U.), Washington, DC; Neuroradiology (D.K.S.) and Neurology (M.D.J., K.R., T.J.G.), School of Medicine, University of Washington, Seattle
| | - Yunusa Olufadi
- From the Elson S. Floyd College of Medicine (A.M.S.-D., K.O., C.S., Y.O., D.S.B.), Washington State University, Spokane; Oklahoma University Health Sciences Center (T.A.), Oklahoma City; Epidemiology (A.M.F., M.D.J.), School of Public Health, University of Washington, Seattle; MedStar Health Research Institute (J.G.U.), Washington, DC; Neuroradiology (D.K.S.) and Neurology (M.D.J., K.R., T.J.G.), School of Medicine, University of Washington, Seattle
| | - Tauqeer Ali
- From the Elson S. Floyd College of Medicine (A.M.S.-D., K.O., C.S., Y.O., D.S.B.), Washington State University, Spokane; Oklahoma University Health Sciences Center (T.A.), Oklahoma City; Epidemiology (A.M.F., M.D.J.), School of Public Health, University of Washington, Seattle; MedStar Health Research Institute (J.G.U.), Washington, DC; Neuroradiology (D.K.S.) and Neurology (M.D.J., K.R., T.J.G.), School of Medicine, University of Washington, Seattle
| | - Amanda M Fretts
- From the Elson S. Floyd College of Medicine (A.M.S.-D., K.O., C.S., Y.O., D.S.B.), Washington State University, Spokane; Oklahoma University Health Sciences Center (T.A.), Oklahoma City; Epidemiology (A.M.F., M.D.J.), School of Public Health, University of Washington, Seattle; MedStar Health Research Institute (J.G.U.), Washington, DC; Neuroradiology (D.K.S.) and Neurology (M.D.J., K.R., T.J.G.), School of Medicine, University of Washington, Seattle
| | - Jason G Umans
- From the Elson S. Floyd College of Medicine (A.M.S.-D., K.O., C.S., Y.O., D.S.B.), Washington State University, Spokane; Oklahoma University Health Sciences Center (T.A.), Oklahoma City; Epidemiology (A.M.F., M.D.J.), School of Public Health, University of Washington, Seattle; MedStar Health Research Institute (J.G.U.), Washington, DC; Neuroradiology (D.K.S.) and Neurology (M.D.J., K.R., T.J.G.), School of Medicine, University of Washington, Seattle
| | - Dean K Shibata
- From the Elson S. Floyd College of Medicine (A.M.S.-D., K.O., C.S., Y.O., D.S.B.), Washington State University, Spokane; Oklahoma University Health Sciences Center (T.A.), Oklahoma City; Epidemiology (A.M.F., M.D.J.), School of Public Health, University of Washington, Seattle; MedStar Health Research Institute (J.G.U.), Washington, DC; Neuroradiology (D.K.S.) and Neurology (M.D.J., K.R., T.J.G.), School of Medicine, University of Washington, Seattle
| | - W T Longstreth
- From the Elson S. Floyd College of Medicine (A.M.S.-D., K.O., C.S., Y.O., D.S.B.), Washington State University, Spokane; Oklahoma University Health Sciences Center (T.A.), Oklahoma City; Epidemiology (A.M.F., M.D.J.), School of Public Health, University of Washington, Seattle; MedStar Health Research Institute (J.G.U.), Washington, DC; Neuroradiology (D.K.S.) and Neurology (M.D.J., K.R., T.J.G.), School of Medicine, University of Washington, Seattle
| | - Kristoffer Rhoads
- From the Elson S. Floyd College of Medicine (A.M.S.-D., K.O., C.S., Y.O., D.S.B.), Washington State University, Spokane; Oklahoma University Health Sciences Center (T.A.), Oklahoma City; Epidemiology (A.M.F., M.D.J.), School of Public Health, University of Washington, Seattle; MedStar Health Research Institute (J.G.U.), Washington, DC; Neuroradiology (D.K.S.) and Neurology (M.D.J., K.R., T.J.G.), School of Medicine, University of Washington, Seattle
| | - Dedra S Buchwald
- From the Elson S. Floyd College of Medicine (A.M.S.-D., K.O., C.S., Y.O., D.S.B.), Washington State University, Spokane; Oklahoma University Health Sciences Center (T.A.), Oklahoma City; Epidemiology (A.M.F., M.D.J.), School of Public Health, University of Washington, Seattle; MedStar Health Research Institute (J.G.U.), Washington, DC; Neuroradiology (D.K.S.) and Neurology (M.D.J., K.R., T.J.G.), School of Medicine, University of Washington, Seattle
| | - Thomas J Grabowski
- From the Elson S. Floyd College of Medicine (A.M.S.-D., K.O., C.S., Y.O., D.S.B.), Washington State University, Spokane; Oklahoma University Health Sciences Center (T.A.), Oklahoma City; Epidemiology (A.M.F., M.D.J.), School of Public Health, University of Washington, Seattle; MedStar Health Research Institute (J.G.U.), Washington, DC; Neuroradiology (D.K.S.) and Neurology (M.D.J., K.R., T.J.G.), School of Medicine, University of Washington, Seattle
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Suchy-Dicey A, Howard B, Longstreth WT, Reiman EM, Buchwald D. APOE genotype, hippocampus, and cognitive markers of Alzheimer's disease in American Indians: Data from the Strong Heart Study. Alzheimers Dement 2022; 18:2518-2526. [PMID: 35142437 PMCID: PMC9363523 DOI: 10.1002/alz.12573] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 11/01/2021] [Accepted: 12/10/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND The apolipoprotein E (APOE) ε4 allele confers higher risk of neurodegeneration and Alzheimer's disease (AD), but differs by race/ethnicity. We examined this association in American Indians. METHODS The Strong Heart Study is a population-based cohort of American Indians who were 64 to 95 years of age in 2010 to 2013. APOE ε4 status, brain imaging, and neuropsychological testing was collected in N = 811 individuals. Summary statistics, graphics, and generalized linear regressions-adjusted for sociodemographics, clinical features, and intracranial volume with bootstrap variance estimator-compared APOE ε4 carriers with non-carriers. RESULTS APOE ε4 carriers comprised 22% of the population (0.7% homozygotes). Participants were mean 73 years, 67% female, and 54% had some college education. The majority were obese (>50%), hypertensive (>80%), and diabetic (>50%). Neither imaging findings nor multidomain cognitive testing showed any substantive differences between APOE ε4 carriers and non-carriers. CONCLUSION We found no evidence of neurodegenerative risk from APOE ε4 in American Indians. Additional studies are needed to examine potential protective features.
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Affiliation(s)
- Astrid Suchy-Dicey
- Washington State University Elson S Floyd College of Medicine, Seattle, Washington, USA
| | - Barbara Howard
- MedStar Health Research Institute, Phoenix, Arizona, USA
| | - W T Longstreth
- University of Washington Neurology and Epidemiology Departments, Seattle, Washington, USA
| | | | - Dedra Buchwald
- Washington State University Elson S Floyd College of Medicine, Seattle, Washington, USA
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Demographic reporting across a decade of neuroimaging: a systematic review. Brain Imaging Behav 2022; 16:2785-2796. [DOI: 10.1007/s11682-022-00724-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2022] [Indexed: 11/25/2022]
Abstract
Abstract
Diversity of participants in biomedical research with respect to race, ethnicity, and biological sex is crucial, particularly given differences in disease prevalence, recovery, and survival rates between demographic groups. The objective of this systematic review was to report on the demographics of neuroimaging studies using magnetic resonance imaging (MRI). The Web of Science database was used and data collection was performed between June 2021 to November 2021; all articles were reviewed independently by at least two researchers. Articles utilizing MR data acquired in the United States, with n ≥ 10 human subjects, and published between 2010–2020 were included. Non-primary research articles and those published in journals that did not meet a quality control check were excluded. Of the 408 studies meeting inclusion criteria, approximately 77% report sex, 10% report race, and 4% report ethnicity. Demographic reporting also varied as function of disease studied, participant age range, funding, and publisher. We anticipate quantitative data on the extent, or lack, of reporting will be necessary to ensure inclusion of diverse populations in biomedical research.
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Suchy-Dicey A, Muller C, Shibata D, Howard BV, Cole SA, Longstreth WT, Devereux RB, Buchwald D. Comparing Vascular Brain Injury and Stroke by Cranial Magnetic Resonance Imaging, Physician-Adjudication, and Self-Report: Data from the Strong Heart Study. Neuroepidemiology 2021; 55:398-406. [PMID: 34428763 PMCID: PMC8448943 DOI: 10.1159/000517804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 06/10/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Epidemiologic studies often use self-report as proxy for clinical history. However, whether self-report correctly identifies prevalence in minority populations with health disparities and poor health-care access is unknown. Furthermore, overlap of clinical vascular events with covert vascular brain injury (VBI), detected by imaging, is largely unexamined. METHODS The Strong Heart Study recruited American Indians from 3 regions, with surveillance and adjudication of stroke events from 1989 to 2013. In 2010-2013, all 817 survivors, aged 65-95 years, underwent brain imaging, neurological history interview, and cognitive testing. VBI was defined as imaged infarct or hemorrhage. RESULTS Adjudicated stroke was prevalent in 4% of participants and separately collected, self-reported stroke in 8%. Imaging-defined VBI was detected in 51% and not associated with any stroke event in 47%. Compared with adjudication, self-report had 76% sensitivity and 95% specificity. Participants with adjudicated or self-reported stroke had the poorest performance on cognitive testing; those with imaging-only (covert) VBI had intermediate performance. CONCLUSION In this community-based cohort, self-report for prior stroke had good performance metrics. A majority of participants with VBI did not have overt, clinically recognized events but did have neurological or cognitive symptoms. Data collection methodology for studies in a resource-limited setting must balance practical limitations in costs, accuracy, feasibility, and research goals.
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Affiliation(s)
- Astrid Suchy-Dicey
- Elson S. Floyd College of Medicine, Washington State University, Spokane, Washington, USA
- Initiative for Research and Education to Advance Community Health, Washington State University, Seattle, Washington, USA
| | - Clemma Muller
- Elson S. Floyd College of Medicine, Washington State University, Spokane, Washington, USA
- Initiative for Research and Education to Advance Community Health, Washington State University, Seattle, Washington, USA
| | - Dean Shibata
- Department of Radiology, University of Washington, Seattle, Washington, USA
| | | | - Shelley A Cole
- Texas Biomedical Research Institute, San Antonio, Texas, USA
| | - W T Longstreth
- Department of Neurology, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | | | - Dedra Buchwald
- Elson S. Floyd College of Medicine, Washington State University, Spokane, Washington, USA
- Initiative for Research and Education to Advance Community Health, Washington State University, Seattle, Washington, USA
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Manson SM, Buchwald DS. Aging and Health of American Indians and Alaska Natives: Contributions from the Native Investigator Development Program. J Aging Health 2021; 33:3S-9S. [PMID: 34167345 PMCID: PMC8627114 DOI: 10.1177/08982643211014399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: To describe recent advances in our knowledge regarding the health and illness of older American Indians and Alaska Natives, and factors underlying why this special population lives 5.5 years less than the 78.5 years of U.S. all races. Methods: The articles in this supplemental issue, authored by participants in a National Institutes of Health-sponsored early research career development program, examine high priority health concerns that contribute to the increased risk of Native elders for chronic disease and resulting impairment that compromise their life expectancy. Results: Important insights into the roles that racial discrimination, food security, hypertension, alcohol consumption, memory problems, and military service play in the health and well-being of older American Indians and Alaska Natives. Discussion: Early career faculty development programs focused on increasing the diversity of the scientific workforce not only promote greater racial and ethnic minority representation in the field of aging, but can simultaneously add to the knowledge base regarding the health status and function of often ignored, vulnerable older members of communities that suffer significant health disparities.
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Affiliation(s)
- Spero M. Manson
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Dedra S. Buchwald
- Institute for Research and Education to Advance Community Health, Washington State University, Seattle, WA, USA
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Lewis JP, Suchy-Dicey AM, Noonan C, Jernigan VBB, Umans JG, Domoto-Reilly K, Buchwald DS, Manson S. Associations of Binge Drinking With Vascular Brain Injury and Atrophy in Older American Indians: The Strong Heart Study. J Aging Health 2021; 33:51S-59S. [PMID: 34167344 PMCID: PMC8845484 DOI: 10.1177/08982643211013696] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: American Indians (AIs) generally consume less alcohol than the US general population; however, the prevalence of alcohol use disorder is higher. This is the first large cohort study to examine binge drinking as a risk factor for vascular brain injury (VBI). Methods: We used linear and Poisson regression to examine the association of self-reported binge drinking with VBI, measured via magnetic resonance imaging (MRI), in 817 older AIs who participated in the Strong Heart and Cerebrovascular Disease and Its Consequences in American Indians studies. Results: Any binge drinking at multiple time-points was associated with increased sulcal (β = 0.360, 95% CI [0.079, 0.641]) and ventricle dilatation (β = 0.512, 95% CI [0.174, 0.850]) compared to no binge drinking. Discussion: These observed associations are consistent with previous findings. Identifying how binge drinking may contribute to VBI in older AIs may suggest modifiable health behaviors for neurological risk reduction and disease prevention.
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Affiliation(s)
- Jordan P. Lewis
- University of Alaska Anchorage, WWAMI School of Medical Education, College of Health
| | - Astrid M Suchy-Dicey
- Institute for Research and Education to Advance Community Health, Washington State University,Elson S Floyd College of Medicine, Washington State University
| | - Carolyn Noonan
- Institute for Research and Education to Advance Community Health, Washington State University,Elson S Floyd College of Medicine, Washington State University
| | | | - Jason G. Umans
- MedStar Health Research Institute, Hyattsville, MD; Georgetown-Howard Universities Center for Clinical and Translational Science, Washington, DC
| | | | - Dedra S Buchwald
- Institute for Research and Education to Advance Community Health, Washington State University,Elson S Floyd College of Medicine, Washington State University
| | - Spero Manson
- Centers for American Indian and Alaska Native Health, University of Colorado Anschutz Medical Campus
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Suchy-Dicey A, Noonan C, Burduli E, Mateen FJ, Longstreth W, Buchwald D, Navas-Acien A. Urinary Arsenic and Cadmium Associations with Findings from Cranial MRI in American Indians: Data from the Strong Heart Study. ENVIRONMENTAL HEALTH PERSPECTIVES 2020; 128:127009. [PMID: 33332184 PMCID: PMC7745762 DOI: 10.1289/ehp6930] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 11/13/2020] [Accepted: 11/20/2020] [Indexed: 05/28/2023]
Abstract
BACKGROUND Arsenic and cadmium are known cardiovascular toxicants that pose disproportionate risk to rural communities where environmental exposures are high. American Indians have high vascular risk, which may be attributable in part to these exposures. OBJECTIVE We examined urine metal concentrations in association with magnetic resonance imaging findings of vascular brain injury or cerebral atrophy in adult American Indians. METHODS We measured arsenic and cadmium in American Indian participants from the Strong Heart Study (1989-1991) and evaluated these associations with later (2010-2013) measures of infarct, hemorrhage, white matter hyperintensity (WMH) grade, brain and hippocampal volume, and sulcal and ventricle atrophy using nested multivariate regression analyses. RESULTS Among participants with available data (N=687), the median urine arsenic:creatinine ratio was 7.54μg/g [interquartile range (IQR): 4.90-11.93] and the cadmium:creatinine ratio was 0.96μg/g (IQR: 0.61-1.51). Median time between metal measurement and brain imaging was 21 y (range: 18-25 y). Statistical models detected significant associations between arsenic and higher burden of WMH [grade increase=0.014 (95% CI: 0.000, 0.028) per 10% increase in arsenic]; and between cadmium and presence of lacunar infarcts [relative risk (RR)=1.024 (95% CI: 1.004, 1.045) per 10% increase in cadmium]. DISCUSSION This population-based cohort of American Indian elders had measured values of urine arsenic and cadmium several times higher than previous population- and clinic-based studies in the United States and Mexico, and comparable values with European industrial workers. Our findings of associations for arsenic and cadmium exposures with vascular brain injury are consistent with established literature. Environmental toxicant accumulation is modifiable; public health policy may benefit from focusing on reductions in environmental metals. https://doi.org/10.1289/EHP6930.
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Affiliation(s)
- Astrid Suchy-Dicey
- Elson S. Floyd College of Medicine, Washington State University (WSU), Spokane, Washington, USA
- Institute for Research and Education to Advance Community Health, WSU, Seattle, Washington, USA
| | - Carolyn Noonan
- Elson S. Floyd College of Medicine, Washington State University (WSU), Spokane, Washington, USA
- Institute for Research and Education to Advance Community Health, WSU, Seattle, Washington, USA
| | | | - Farrah J. Mateen
- Department of Neurology, Massachusetts General Hospital; Harvard Medical School, Boston, Massachusetts, USA
| | - W.T. Longstreth
- Department of Epidemiology, School of Public Heath, University of Washington (UW), Seattle, Washington, USA
- Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Dedra Buchwald
- Elson S. Floyd College of Medicine, Washington State University (WSU), Spokane, Washington, USA
- Institute for Research and Education to Advance Community Health, WSU, Seattle, Washington, USA
| | - Ana Navas-Acien
- Department of Environmental Health Sciences, Mailman School of Public Heath, Columbia University, New York, New York, USA
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11
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Cognitive Correlates of MRI-defined Cerebral Vascular Injury and Atrophy in Elderly American Indians: The Strong Heart Study. J Int Neuropsychol Soc 2020; 26:263-275. [PMID: 31791442 PMCID: PMC7083690 DOI: 10.1017/s1355617719001073] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE American Indians experience substantial health disparities relative to the US population, including vascular brain aging. Poorer cognitive test performance has been associated with cranial magnetic resonance imaging findings in aging community populations, but no study has investigated these associations in elderly American Indians. METHODS We examined 786 American Indians aged 64 years and older from the Cerebrovascular Disease and its Consequences in American Indians study (2010-2013). Cranial magnetic resonance images were scored for cortical and subcortical infarcts, hemorrhages, severity of white matter disease, sulcal widening, ventricle enlargement, and volumetric estimates for white matter hyperintensities (WMHs), hippocampus, and brain. Participants completed demographic, medical history, and neuropsychological assessments including testing for general cognitive functioning, verbal learning and memory, processing speed, phonemic fluency, and executive function. RESULTS Processing speed was independently associated with the presence of any infarcts, white matter disease, and hippocampal and brain volumes, independent of socioeconomic, language, education, and clinical factors. Other significant associations included general cognitive functioning with hippocampal volume. Nonsignificant, marginal associations included general cognition with WMH and brain volume; verbal memory with hippocampal volume; verbal fluency and executive function with brain volume; and processing speed with ventricle enlargement. CONCLUSIONS Brain-cognition associations found in this study of elderly American Indians are similar to those found in other racial/ethnic populations, with processing speed comprising an especially strong correlate of cerebrovascular disease. These findings may assist future efforts to define opportunities for disease prevention, to conduct research on diagnostic and normative standards, and to guide clinical evaluation of this underserved and overburdened population.
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12
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Shibata D, Suchy-Dicey A, Carty CL, Madhyastha T, Ali T, Best L, Grabowski TJ, Longstreth WT, Buchwald D. Lifestyle Risk Factors and Findings on Brain Magnetic Resonance Imaging of Older Adult American Indians: The Strong Heart Study. Neuroepidemiology 2019; 53:162-168. [PMID: 31163423 DOI: 10.1159/000501181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 12/19/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Clinical stroke is prevalent in American Indians, but the lifestyle risk factors for vascular brain injury have not been well-studied in this population. The purpose of this study was to correlate brain magnetic resonance imaging (MRI) findings with obesity, alcohol use, and smoking behaviors in elderly American Indians from the Strong Heart Study. METHODS Cranial MRI scans (n = 789) were analyzed for dichotomous measures of infarcts, hemorrhages, white matter hyperintensities (WMH), and cerebral atrophy and continuous measures of total brain, WMH, and hippocampal volume. Poisson regression was used to estimate prevalence ratios, and linear regression was used to estimate measures of association for continuous outcomes. Models were adjusted for the risk factors of interest as well as age, sex, study site, income, education, hypertension, diabetes, and low-density lipoprotein cholesterol. RESULTS Smoking was associated with increased hippocampal atrophy (p = 0.002) and increased prevalence of sulcal widening (p < 0.001). Relative to nonsmokers, smokers with more than 25 pack-years of smoking had a 27% (95% CI 7-47%) increased prevalence of high-grade sulci, p = 0.005. Body mass index was inversely associated with prevalence of nonlacunar infarcts and sulcal widening (all p = 0.004). Alcohol use was not significantly associated with any of the measured MRI findings. CONCLUSIONS This study found similar associations between smoking and vascular brain injury among American Indians, as seen in other populations. In particular, these findings support the role of smoking as a key correlate for cerebral atrophy.
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Affiliation(s)
- Dean Shibata
- Department of Radiology, University of Washington, Seattle, Washington, USA,
| | - Astrid Suchy-Dicey
- Partnerships for Native Health, Washington State University, Pullman, Washington, USA
| | - Cara L Carty
- Partnerships for Native Health, Washington State University, Pullman, Washington, USA.,Elson S Floyd College of Medicine, Washington State University, Seattle, Washington, USA
| | - Tara Madhyastha
- Department of Radiology, University of Washington, Seattle, Washington, USA.,Integrated Brain Imaging Center, University of Washington, Seattle, Washington, USA
| | - Tauqeer Ali
- Center for American Indian Health Research, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Lyle Best
- Strong Heart Study-Dakota Center, Eagle Butte, South Dakota, USA
| | - Thomas J Grabowski
- Integrated Brain Imaging Center, University of Washington, Seattle, Washington, USA.,Department of Neurology, University of Washington, Seattle, Washington, USA
| | - W T Longstreth
- Department of Neurology, University of Washington, Seattle, Washington, USA.,Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Dedra Buchwald
- Partnerships for Native Health, Washington State University, Pullman, Washington, USA.,Elson S Floyd College of Medicine, Washington State University, Seattle, Washington, USA
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13
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Suchy-Dicey AM, Muller CJ, Madhyastha TM, Shibata D, Cole SA, Zhao J, Longstreth WT, Buchwald D. Telomere Length and Magnetic Resonance Imaging Findings of Vascular Brain Injury and Central Brain Atrophy: The Strong Heart Study. Am J Epidemiol 2018; 187:1231-1239. [PMID: 29860472 DOI: 10.1093/aje/kwx368] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 12/01/2017] [Indexed: 12/27/2022] Open
Abstract
Telomeres are repeating regions of DNA that cap chromosomes. They shorten over the mammalian life span, especially in the presence of oxidative stress and inflammation. Telomeres may play a direct role in cell senescence, serving as markers of premature vascular aging. Leukocyte telomere length (LTL) may be associated with premature vascular brain injury and cerebral atrophy. However, reports have been inconsistent, especially among minority populations with a heavy burden of illness related to vascular aging. We examined associations between LTL and magnetic resonance imaging in 363 American Indians aged 64-93 years from the Strong Heart Study (1989-1991) and its ancillary study, Cerebrovascular Disease and Its Consequences in American Indians (2010-2013). Our results showed significant associations of LTL with ventricular enlargement and the presence of white matter hyperintensities. Secondary models indicated that renal function may mediate these associations, although small case numbers limited inference. Hypertension and diabetes showed little evidence of effect modification. Results were most extreme among participants who evinced the largest decline in LTL. Although this study was limited to cross-sectional comparisons, it represents (to our knowledge) the first consideration of associations between telomere length and brain aging in American Indians. Findings suggest a relationship between vascular aging by cell senescence and severity of brain disease.
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Affiliation(s)
- Astrid M Suchy-Dicey
- Initiative for Research and Education to Advance Community Health, Elson S. Floyd College of Medicine, Washington State University, Seattle, Washington
| | - Clemma J Muller
- Initiative for Research and Education to Advance Community Health, Elson S. Floyd College of Medicine, Washington State University, Seattle, Washington
| | - Tara M Madhyastha
- Department of Radiology, School of Medicine, University of Washington, Seattle, Washington
| | - Dean Shibata
- Department of Radiology, School of Medicine, University of Washington, Seattle, Washington
| | | | - Jinying Zhao
- Department of Epidemiology, College of Public Health and Health Professions, University of Florida, Gainesville, Florida
| | - W T Longstreth
- Department of Neurology, School of Medicine, University of Washington, Seattle, Washington
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington
| | - Dedra Buchwald
- Initiative for Research and Education to Advance Community Health, Elson S. Floyd College of Medicine, Washington State University, Seattle, Washington
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14
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Haring B, Omidpanah A, Suchy-Dicey AM, Best LG, Verney SP, Shibata DK, Cole SA, Ali T, Howard BV, Buchwald D, Devereux RB. Left Ventricular Mass, Brain Magnetic Resonance Imaging, and Cognitive Performance: Results From the Strong Heart Study. Hypertension 2017; 70:964-971. [PMID: 28893898 DOI: 10.1161/hypertensionaha.117.09807] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 06/15/2017] [Accepted: 08/18/2017] [Indexed: 01/14/2023]
Abstract
Left ventricular mass (LVM) has been shown to serve as a measure of target organ damage resulting from chronic exposure to several risk factors. Data on the association of midlife LVM with later cognitive performance are sparse. We studied 721 adults (mean age 56 years at baseline) enrolled in the Strong Heart Study (SHS, 1993-1995) and the ancillary CDCAI (Cerebrovascular Disease and Its Consequences in American Indians) Study (2010-2013), a study population with high prevalence of cardiovascular disease. LVM was assessed with transthoracic echocardiography at baseline in 1993 to 1995. Cranial magnetic resonance imaging and cognitive testing were undertaken between 2010 and 2013. Generalized estimating equations were used to model associations between LVM and later imaging and cognition outcomes. The mean follow-up period was 17 years. A difference of 25 g in higher LVM was associated with marginally lower hippocampal volume (0.01%; 95% confidence interval, 0.02-0.00; P=0.001) and higher white matter grade (0.10; 95% confidence interval, 0.02-0.18; P=0.014). Functionally, participants with higher LVM tended to have slightly lower scores on the modified mini-mental state examination (0.58; 95% confidence interval, 1.08-0.08; P=0.024). The main results persisted after adjusting for blood pressure levels or vascular disease. The small overall effect sizes are partly explained by survival bias because of the high prevalence of cardiovascular disease in our population. Our findings emphasize the role of cardiovascular health in midlife as a target for the prevention of deleterious cognitive and functional outcomes in later life.
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Affiliation(s)
- Bernhard Haring
- Department of Medicine I, Comprehensive Heart Failure Center, University of Würzburg, Bavaria, Germany (B.V.H.); Initiative for Research and Education to Advance Community Health, Washington State University, Seattle (A.O., A.M.S.-D.); Missouri Breaks Industries Research Inc, Eagle Butte, SD (L.G.B.); Department of Psychology and Psychology Clinical Neuroscience Center, University of New Mexico, Albuquerque (S.P.V.); Department of Radiology, School of Medicine, University of Washington, Seattle (D.K.S.); Department of Genetics, Texas Biomedical Research Institute, San Antonio (S.A.C.); Department of Biostatistics and Epidemiology, College of Public Health, University of Oklahoma, Health Sciences Center (T.A.); MedStar Health Research Institute, Hyattsville, MD (B.V.H.); Initiative for Research and Education to Advance Community Health, Elson S. Floyd College of Medicine, Washington State University, Seattle (D.B.); and Greenberg Division of Cardiology, Weill Cornell Medicine, New York, NY (R.B.D.).
| | - Adam Omidpanah
- Department of Medicine I, Comprehensive Heart Failure Center, University of Würzburg, Bavaria, Germany (B.V.H.); Initiative for Research and Education to Advance Community Health, Washington State University, Seattle (A.O., A.M.S.-D.); Missouri Breaks Industries Research Inc, Eagle Butte, SD (L.G.B.); Department of Psychology and Psychology Clinical Neuroscience Center, University of New Mexico, Albuquerque (S.P.V.); Department of Radiology, School of Medicine, University of Washington, Seattle (D.K.S.); Department of Genetics, Texas Biomedical Research Institute, San Antonio (S.A.C.); Department of Biostatistics and Epidemiology, College of Public Health, University of Oklahoma, Health Sciences Center (T.A.); MedStar Health Research Institute, Hyattsville, MD (B.V.H.); Initiative for Research and Education to Advance Community Health, Elson S. Floyd College of Medicine, Washington State University, Seattle (D.B.); and Greenberg Division of Cardiology, Weill Cornell Medicine, New York, NY (R.B.D.)
| | - Astrid M Suchy-Dicey
- Department of Medicine I, Comprehensive Heart Failure Center, University of Würzburg, Bavaria, Germany (B.V.H.); Initiative for Research and Education to Advance Community Health, Washington State University, Seattle (A.O., A.M.S.-D.); Missouri Breaks Industries Research Inc, Eagle Butte, SD (L.G.B.); Department of Psychology and Psychology Clinical Neuroscience Center, University of New Mexico, Albuquerque (S.P.V.); Department of Radiology, School of Medicine, University of Washington, Seattle (D.K.S.); Department of Genetics, Texas Biomedical Research Institute, San Antonio (S.A.C.); Department of Biostatistics and Epidemiology, College of Public Health, University of Oklahoma, Health Sciences Center (T.A.); MedStar Health Research Institute, Hyattsville, MD (B.V.H.); Initiative for Research and Education to Advance Community Health, Elson S. Floyd College of Medicine, Washington State University, Seattle (D.B.); and Greenberg Division of Cardiology, Weill Cornell Medicine, New York, NY (R.B.D.)
| | - Lyle G Best
- Department of Medicine I, Comprehensive Heart Failure Center, University of Würzburg, Bavaria, Germany (B.V.H.); Initiative for Research and Education to Advance Community Health, Washington State University, Seattle (A.O., A.M.S.-D.); Missouri Breaks Industries Research Inc, Eagle Butte, SD (L.G.B.); Department of Psychology and Psychology Clinical Neuroscience Center, University of New Mexico, Albuquerque (S.P.V.); Department of Radiology, School of Medicine, University of Washington, Seattle (D.K.S.); Department of Genetics, Texas Biomedical Research Institute, San Antonio (S.A.C.); Department of Biostatistics and Epidemiology, College of Public Health, University of Oklahoma, Health Sciences Center (T.A.); MedStar Health Research Institute, Hyattsville, MD (B.V.H.); Initiative for Research and Education to Advance Community Health, Elson S. Floyd College of Medicine, Washington State University, Seattle (D.B.); and Greenberg Division of Cardiology, Weill Cornell Medicine, New York, NY (R.B.D.)
| | - Steven P Verney
- Department of Medicine I, Comprehensive Heart Failure Center, University of Würzburg, Bavaria, Germany (B.V.H.); Initiative for Research and Education to Advance Community Health, Washington State University, Seattle (A.O., A.M.S.-D.); Missouri Breaks Industries Research Inc, Eagle Butte, SD (L.G.B.); Department of Psychology and Psychology Clinical Neuroscience Center, University of New Mexico, Albuquerque (S.P.V.); Department of Radiology, School of Medicine, University of Washington, Seattle (D.K.S.); Department of Genetics, Texas Biomedical Research Institute, San Antonio (S.A.C.); Department of Biostatistics and Epidemiology, College of Public Health, University of Oklahoma, Health Sciences Center (T.A.); MedStar Health Research Institute, Hyattsville, MD (B.V.H.); Initiative for Research and Education to Advance Community Health, Elson S. Floyd College of Medicine, Washington State University, Seattle (D.B.); and Greenberg Division of Cardiology, Weill Cornell Medicine, New York, NY (R.B.D.)
| | - Dean K Shibata
- Department of Medicine I, Comprehensive Heart Failure Center, University of Würzburg, Bavaria, Germany (B.V.H.); Initiative for Research and Education to Advance Community Health, Washington State University, Seattle (A.O., A.M.S.-D.); Missouri Breaks Industries Research Inc, Eagle Butte, SD (L.G.B.); Department of Psychology and Psychology Clinical Neuroscience Center, University of New Mexico, Albuquerque (S.P.V.); Department of Radiology, School of Medicine, University of Washington, Seattle (D.K.S.); Department of Genetics, Texas Biomedical Research Institute, San Antonio (S.A.C.); Department of Biostatistics and Epidemiology, College of Public Health, University of Oklahoma, Health Sciences Center (T.A.); MedStar Health Research Institute, Hyattsville, MD (B.V.H.); Initiative for Research and Education to Advance Community Health, Elson S. Floyd College of Medicine, Washington State University, Seattle (D.B.); and Greenberg Division of Cardiology, Weill Cornell Medicine, New York, NY (R.B.D.)
| | - Shelley A Cole
- Department of Medicine I, Comprehensive Heart Failure Center, University of Würzburg, Bavaria, Germany (B.V.H.); Initiative for Research and Education to Advance Community Health, Washington State University, Seattle (A.O., A.M.S.-D.); Missouri Breaks Industries Research Inc, Eagle Butte, SD (L.G.B.); Department of Psychology and Psychology Clinical Neuroscience Center, University of New Mexico, Albuquerque (S.P.V.); Department of Radiology, School of Medicine, University of Washington, Seattle (D.K.S.); Department of Genetics, Texas Biomedical Research Institute, San Antonio (S.A.C.); Department of Biostatistics and Epidemiology, College of Public Health, University of Oklahoma, Health Sciences Center (T.A.); MedStar Health Research Institute, Hyattsville, MD (B.V.H.); Initiative for Research and Education to Advance Community Health, Elson S. Floyd College of Medicine, Washington State University, Seattle (D.B.); and Greenberg Division of Cardiology, Weill Cornell Medicine, New York, NY (R.B.D.)
| | - Tauqeer Ali
- Department of Medicine I, Comprehensive Heart Failure Center, University of Würzburg, Bavaria, Germany (B.V.H.); Initiative for Research and Education to Advance Community Health, Washington State University, Seattle (A.O., A.M.S.-D.); Missouri Breaks Industries Research Inc, Eagle Butte, SD (L.G.B.); Department of Psychology and Psychology Clinical Neuroscience Center, University of New Mexico, Albuquerque (S.P.V.); Department of Radiology, School of Medicine, University of Washington, Seattle (D.K.S.); Department of Genetics, Texas Biomedical Research Institute, San Antonio (S.A.C.); Department of Biostatistics and Epidemiology, College of Public Health, University of Oklahoma, Health Sciences Center (T.A.); MedStar Health Research Institute, Hyattsville, MD (B.V.H.); Initiative for Research and Education to Advance Community Health, Elson S. Floyd College of Medicine, Washington State University, Seattle (D.B.); and Greenberg Division of Cardiology, Weill Cornell Medicine, New York, NY (R.B.D.)
| | - Barbara V Howard
- Department of Medicine I, Comprehensive Heart Failure Center, University of Würzburg, Bavaria, Germany (B.V.H.); Initiative for Research and Education to Advance Community Health, Washington State University, Seattle (A.O., A.M.S.-D.); Missouri Breaks Industries Research Inc, Eagle Butte, SD (L.G.B.); Department of Psychology and Psychology Clinical Neuroscience Center, University of New Mexico, Albuquerque (S.P.V.); Department of Radiology, School of Medicine, University of Washington, Seattle (D.K.S.); Department of Genetics, Texas Biomedical Research Institute, San Antonio (S.A.C.); Department of Biostatistics and Epidemiology, College of Public Health, University of Oklahoma, Health Sciences Center (T.A.); MedStar Health Research Institute, Hyattsville, MD (B.V.H.); Initiative for Research and Education to Advance Community Health, Elson S. Floyd College of Medicine, Washington State University, Seattle (D.B.); and Greenberg Division of Cardiology, Weill Cornell Medicine, New York, NY (R.B.D.)
| | - Dedra Buchwald
- Department of Medicine I, Comprehensive Heart Failure Center, University of Würzburg, Bavaria, Germany (B.V.H.); Initiative for Research and Education to Advance Community Health, Washington State University, Seattle (A.O., A.M.S.-D.); Missouri Breaks Industries Research Inc, Eagle Butte, SD (L.G.B.); Department of Psychology and Psychology Clinical Neuroscience Center, University of New Mexico, Albuquerque (S.P.V.); Department of Radiology, School of Medicine, University of Washington, Seattle (D.K.S.); Department of Genetics, Texas Biomedical Research Institute, San Antonio (S.A.C.); Department of Biostatistics and Epidemiology, College of Public Health, University of Oklahoma, Health Sciences Center (T.A.); MedStar Health Research Institute, Hyattsville, MD (B.V.H.); Initiative for Research and Education to Advance Community Health, Elson S. Floyd College of Medicine, Washington State University, Seattle (D.B.); and Greenberg Division of Cardiology, Weill Cornell Medicine, New York, NY (R.B.D.)
| | - Richard B Devereux
- Department of Medicine I, Comprehensive Heart Failure Center, University of Würzburg, Bavaria, Germany (B.V.H.); Initiative for Research and Education to Advance Community Health, Washington State University, Seattle (A.O., A.M.S.-D.); Missouri Breaks Industries Research Inc, Eagle Butte, SD (L.G.B.); Department of Psychology and Psychology Clinical Neuroscience Center, University of New Mexico, Albuquerque (S.P.V.); Department of Radiology, School of Medicine, University of Washington, Seattle (D.K.S.); Department of Genetics, Texas Biomedical Research Institute, San Antonio (S.A.C.); Department of Biostatistics and Epidemiology, College of Public Health, University of Oklahoma, Health Sciences Center (T.A.); MedStar Health Research Institute, Hyattsville, MD (B.V.H.); Initiative for Research and Education to Advance Community Health, Elson S. Floyd College of Medicine, Washington State University, Seattle (D.B.); and Greenberg Division of Cardiology, Weill Cornell Medicine, New York, NY (R.B.D.)
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