Studies of long-term cognitive change should account for the potential effects of education on the outcome, since some studies have demonstrated an association of education with dementia risk. Evaluating cognitive change is more ideal than evaluating cognitive performance at a single time point, because it should be less susceptible to confounding. In this analysis of 14,020 persons from a US cohort study, the Atherosclerosis Risk in Communities (ARIC) Study, we measured change in performance on 3 cognitive tests over a 20-year period, from ages 48-67 years (1990-1992) through ages 70-89 years (2011-2013). Generalized estimating equations were used to evaluate the association between education and cognitive change in unweighted adjusted models, in models incorporating inverse probability of attrition weighting, and in models using cognitive scores imputed from the Telephone Interview for Cognitive Status for participants not examined in person. Education did not have a strong relationship with change in cognitive test performance, although the rate of decline was somewhat slower among persons with lower levels of education. Methods used to account for selective dropout only marginally changed these observed associations. Future studies of risk factors for cognitive impairment should focus on cognitive change, when possible, to allow for reduction of confounding by social or cultural factors.

Background and Purpose Individuals with stroke-like symptoms are recommended to receive rapid diagnostic evaluation. Emergency medical services (EMS) transport, compared to private modes, and hospital notification prior to arrival may reduce delays in evaluation. This study estimated associations between hospital arrival modes (EMS or private; with or without EMS pre-notification) and times for completion and interpretation of initial brain imaging in presumed stroke patients. Methods Among suspected stroke patients identified and enrolled by the North Carolina Stroke Care Collaborative (NCSCC) registry in 2008-2009, we analyzed data on arrival modes, meeting recommended targets for brain imaging completion and interpretation times (<25 minutes and <45 minutes since hospital arrival, respectively), and patient- and hospital-level characteristics. We used modified Poisson regression to estimate adjusted risk ratios (RR) and 95% confidence intervals (CI). Results Of 13,894 eligible patients, 21% had their brain imaging completed and 23% had their brain imaging interpreted by a physician within target times. Arrival by EMS (versus private transport) was associated with both brain imaging completed within 25 minutes of arrival [EMS with pre-notification: RR=3.0, 95% CI=2.1-4.1; EMS without pre-notification: RR=1.9, 95% CI=1.6-2.3] and brain imaging interpreted within 45 minutes [EMS with pre-notification: RR=2.7, 95% CI=2.3-3.3; EMS without pre-notification: RR=1.7, 95% CI=1.4-2.1]. Conclusions Presumed stroke patients arriving to the hospital by EMS were more likely to receive brain imaging and have it interpreted by a physician in a timely manner than those arriving by private transport. Moreover, EMS arrivals with hospital pre-notification experienced the most rapid evaluation.

Repeatability was acceptable for all PWV measures in a multicenter, population-based study of older adults and supports its use in epidemiologic studies. Quantifying PWV measurement variation is critical for applications to risk assessment and stratification and eventual translation to clinical practice.

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Key Points Question What is the association of COVID-19 vaccine efficacy and coverage scenarios with and without nonpharmaceutical interventions (NPIs) with SARS-CoV-2 infections, hospitalizations, and deaths? Findings A decision analytical model of North Carolina found that removing NPIs while vaccines were distributed resulted in substantial increases in infections, hospitalizations, and deaths. Furthermore, as NPIs were removed, higher vaccination coverage with less efficacious vaccines contributed to a larger reduction in risk of infection compared with more efficacious vaccines at lower coverage. Meaning These findings highlight the need for high COVID-19 vaccine coverage and continued adherence to NPIs before safely resuming many prepandemic activities.

higher levels of social support were moderately associated with greater multi-dimensional cognitive function at mid-life, but mid-life social support was not associated with temporal change in global cognitive function over 20 years into late life. Prospective studies with time-dependent measures of social support and cognition are needed to better understand the role of social engagement in ageing-related cognitive functioning.

IntroductionThe goal of this trial is to determine whether implementation of a user-centred clinical decision support (CDS) system can increase adoption of initiation of buprenorphine (BUP) into the routine emergency care of individuals with opioid use disorder (OUD).MethodsA pragmatic cluster randomised trial is planned to be carried out in 20 emergency departments (EDs) across five healthcare systems over 18 months. The intervention consists of a user-centred CDS integrated into ED clinician electronic workflow and available for guidance to: (1) determine whether patients presenting to the ED meet criteria for OUD, (2) assess withdrawal symptoms and (3) ascertain and motivate patient willingness to initiate treatment. The CDS guides the ED clinician to initiate BUP and facilitate follow-up. The primary outcome is the rate of BUP initiated in the ED. Secondary outcomes are: (1) rates of receiving a referral, (2) fidelity with the CDS and (3) rates of clinicians providing any ED-initiated BUP, referral for ongoing treatment and receiving Drug Addiction Act of 2000 training. Primary and secondary outcomes will be analysed using generalised linear mixed models, with fixed effects for intervention status (CDS vs usual care), prespecified site and patient characteristics, and random effects for study site.Ethics and disseminationThe protocol has been approved by the Western Institutional Review Board. No identifiable private information will be collected from patients. A waiver of informed consent was obtained for the collection of data for clinician prescribing and other activities. As a minimal risk implementation study of established best practices, an Independent Study Monitor will be utilised in place of a Data Safety Monitoring Board. Results will be reported in ClinicalTrials.gov and published in open-access, peer-reviewed journals, presented at national meetings and shared with the clinicians at participating sites via a broadcast email notification of publications.Trial registration number NCT03658642; Pre-results.

OBJECTIVES To evaluate whether education level is associated with change in cognitive performance. DESIGN Prospective cohort study. SETTING The Atherosclerosis Risk in Communities (ARIC) Study, a community-based cohort. PARTICIPANTS Nine thousand two hundred sixty-eight ARIC participants who underwent cognitive evaluation at least twice over a 15-year period. MEASUREMENTS Education was evaluated as a predictor of change in word recall, the Digit Symbol Substitution Test (DSST), and word fluency. A random-effects linear regression model, and a time by educational level interaction was used. RESULTS Educational level was highly associated with cognitive performance. The effect on performance of a less than high school education (vs more than high school) was equivalent to the effect of as much as 22 years of cognitive aging, but educational level was not associated with change in cognitive performance in whites or blacks, with the exception of the DSST for whites, in whom those with lower levels of education had less decline in scores. CONCLUSION Educational level was not associated with change in cognitive performance, although the higher baseline cognitive performance of individuals with more education might explain lower rates of dementia in more-educated individuals, because more decline would have to take place between baseline higher performance and time at which dementia was diagnosed in more-educated individuals.