Objectives: The aim of this study was to determine the prevalence of idiopathic normal-pressure hydrocephalus (iNPH) in elderly persons in a large population-based sample using radiologic and clinical examinations. Methods:We examined representative elderly populations aged 70 years and older that had undergone neuropsychiatric evaluations and CT of the brain between 1986 and 2000 (n 5 1,238). Gait was evaluated by clinical examination and history of walking difficulty. Cognitive function was evaluated with the Mini-Mental State Examination and urinary incontinence by selfreport. iNPH was diagnosed in concordance with the American-European iNPH guidelines. Exclusion criteria were history of meningitis, severe head trauma, and subarachnoid hemorrhage.Results: The prevalence of probable iNPH was 0.2% in those aged 70-79 years (n 5 2) and 5.9%(n 5 24) in those aged 80 years and older, with no difference between men and women. Only 2 of these persons had been treated for iNPH. Hydrocephalic ventricular enlargement, i.e., a CT image consistent with NPH, was found in 56 persons (4.5%). An Evans Index .0.3 was found in 256 (20.7%) and occluded sulci at the high convexity in 67 persons (5.4%). All of these findings were more common in the older age groups. The number of elderly and people with dementia is increasing in most parts of the world.1 It is therefore important to learn more about the prevalence of treatable causes of dementia. Idiopathic normal-pressure hydrocephalus (iNPH) is a treatable neurologic disorder first described by Salomón Hakim in 1965.2 iNPH is characterized by gait and balance impairment, cognitive deterioration, and urinary incontinence, and radiologically by a communicating ventricular enlargement.3 Treatment by diversion of CSF to the peritoneal cavity or heart is successful in reversing symptoms in more than 80% of the patients. 4 iNPH is thus one of the few causes of reversible dementia, but it is still underdiagnosed. 5,6 The prevalence of iNPH in selected populations and in community-based studies on young elderly varies between 0.1% and 2.9%.5,7-10 However, few large population-based studies have investigated the prevalence of iNPH, and most included few persons older than 80 years. Thus, the prevalence still has to be examined in population-based studies including many persons older than 80 years.The aim of this study was to determine the prevalence of iNPH by examining CT images of the brain and clinical signs of iNPH in a large representative elderly population.METHODS Study population. Between 1986 and 2000, studies on representative elderly populations in Gothenburg, Sweden, were conducted using identical examinations (including neuropsychiatric examinations and key informant interviews) at each

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Objective: We examined clinical and imaging findings of suspected idiopathic normal pressure hydrocephalus (iNPH) in relation to vascular risk factors and white matter lesions (WMLs), using a nested case-control design in a representative, population-based sample.Methods: From a population-based sample, 1,235 persons aged 70 years or older were examined with CT of the brain between 1986 and 2000. We identified 55 persons with hydrocephalic ventricular enlargement, i.e., radiologic findings consistent with iNPH. Among these, 26 had clinical signs that fulfilled international guideline criteria for probable iNPH. These cases were labeled suspected iNPH. Each case was matched to 5 controls from the same sample, based on age, sex, and study cohort. Data on risk factors were obtained from clinical examinations and the Swedish Hospital Discharge Register. History of hypertension, diabetes mellitus (DM), smoking, overweight, history of coronary artery disease, stroke/TIA, and WMLs on CT were examined. Risk factors associated with iNPH with a p value ,0.1 in x 2 tests were included in conditional logistic regression models. Idiopathic normal pressure hydrocephalus (iNPH) is probably more common than previously supposed. We have recently reported that 5.9% of persons older than 80 years have this disorder. 1 Treatment with shunt surgery improves symptoms in more than 80% of patients. 2 Despite this, iNPH is underdiagnosed and undertreated.1,3 Furthermore, little is known about the underlying disease mechanisms. It is important to learn more about risk factors for the disease in order to understand pathophysiologic mechanisms and suggest preventive measures. Vascular risk factors, such as hypertension, diabetes, and ischemic heart disease, have previously been associated with iNPH in hospital-based, case-control studies.4-9 Also, cerebral white matter lesions (WMLs), which are associated with small vessel disease and white matter ischemia, 10 are common in iNPH. 11,12 It has therefore been suggested that vascular mechanisms may be related to the development of iNPH. However, previous studies on risk factors have not been population-based. Furthermore, there are no previous epidemiologic investigations regarding WMLs in iNPH.

Excess mortality was found in this nationwide cohort of patients with acromegaly, mainly related to circulatory and malignant diseases. Although still high, mortality significantly declined over time. This could be explained by the more frequent use of pituitary surgery, decreased prevalence of hypopituitarism and the availability of new medical treatment options.

Background:Multiple Northeast U.S. communities have discovered per- and polyfluoroalkyl substances (PFASs) in drinking water aquifers in excess of health-based regulatory levels or advisories. Regional stakeholders (consultants, regulators, and others) need technical background and tools to mitigate risks associated with exposure to PFAS-affected groundwater.Objectives:The aim was to identify challenges faced by stakeholders to extend best practices to other regions experiencing PFAS releases and to establish a framework for research strategies and best management practices.Methods and Approach:Management challenges were identified during stakeholder engagement events connecting attendees with PFAS experts in focus areas, including fate/transport, toxicology, and regulation. Review of the literature provided perspective on challenges in all focus areas. Publicly available data were used to characterize sources of PFAS impacts in groundwater and conduct a geospatial case study of potential source locations relative to drinking water aquifers in Rhode Island.Discussion:Challenges in managing PFAS impacts in drinking water arise from the large number of relevant PFASs, unconsolidated information regarding sources, and limited studies on some PFASs. In particular, there is still considerable uncertainty regarding human health impacts of PFASs. Frameworks sequentially evaluating exposure, persistence, and treatability can prioritize PFASs for evaluation of potential human health impacts. A regional case study illustrates how risk-based, geospatial methods can help address knowledge gaps regarding potential sources of PFASs in drinking water aquifers and evaluate risk of exposure.Conclusion:Lessons learned from stakeholder engagement can assist in developing strategies for management of PFASs in other regions. However, current management practices primarily target a subset of PFASs for which in-depth studies are available. Exposure to less-studied, co-occurring PFASs remains largely unaddressed. Frameworks leveraging the current state of science can be applied toward accelerating this process and reducing exposure to total PFASs in drinking water, even as research regarding health effects continues. https://doi.org/10.1289/EHP2727