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The growth of the number of persons pursuing education outside of their home country has created a relatively new population of transnationally mobile students who experience a pivotal developmental period crossing and across international borders. There are few suitable theoretical models to examine the developmental experiences of this growing population. In his last publication, Urie Bronfenbrenner acknowledged his ecological model was a developmental yet evolving model to be tested and amended by incorporating new evidence. This conceptual paper draws from existing empirical work to advance the ecological model and revise it to be more applicable to and explanatory of developmental experiences of international students in the United States. The resulting model, which we call the Spanning Systems model, can be used to identify spaces of potential contradictions or learning in a student’s development.

Objectives The aim of this study was to compare the incidence and prognostic significance of prosthesis-patient mismatch (PPM) after transcatheter aortic valve replacement (TAVR) according to racial groups. Background PPM after TAVR may be of more concern in Asian populations considering their relatively small annular and valve sizes compared with Western populations. Methods TP-TAVR (Transpacific TAVR Registry) was an international multicenter cohort study of patients with severe aortic stenosis who underwent TAVR in the United States and South Korea from January 2015 to November 2019. PPM was defined as moderate (0.65-0.85 cm2/m2) or severe ( Results Among 1,101 eligible patients (533 Asian and 569 non-Asian), the incidence of PPM was significantly lower in the Asian population (33.6%; moderate, 26.5%; severe, 7.1%) than in the non-Asian population (54.5%; moderate, 29.8%; severe, 24.7%). The 1-year rate of the primary outcome was similar between the PPM and non-PPM groups (27.5% vs 28.1%; P = 0.69); this pattern was consistent between Asian (25.4% vs 25.2%; P = 0.31) and non-Asian (28.7% vs 32.1%; P = 0.97) patients. After multivariable adjustment, the risk for the primary outcome did not significantly differ between the PPM and non-PPM groups in the overall population (HR: 0.95; 95% CI: 0.74-1.21), in Asian patients (HR: 1.07; 95% CI: 0.74-1.55), and in non-Asian patients (HR: 0.86; 95% CI: 0.63-1.19). Conclusions In this study of patients with severe aortic stenosis who underwent TAVR, the incidence of PPM was significantly lower in Asian patients than in non-Asian patients. The 1-year risk for the primary composite outcome was similar between the PPM and non-PPM groups regardless of racial group. (Transpacific TAVR Registry [TP-TAVR]; NCT03826264 )

The aim of this study was to systematically review the impact of antepartum depression on exclusive breastfeeding. A total of 15 studies were included in the review and 12 studies were used for the meta-analysis. The mean values of antepartum depression indicated that women who breastfed exclusively between 3 and 6 months had less antepartum depression symptoms (Mean Difference = −0.55, 95% CI = −0.76 to −0.35). The analysis also showed that the existence of antepartum depression was negatively related to continuing exclusive breastfeeding for longer than 3 months postpartum as well as for 8 weeks postpartum (OR = 0.48, 95% CI = 0.26–0.88 and OR = 0.83, 95% CI = 0.75–0.91, respectively). The cumulative evidence is conclusive that antepartum depressive symptoms are negatively associated with exclusive breastfeeding, particularly between 3 and 6 months postpartum. This review supports the necessity of screening and follow-up for depression throughout the perinatal period to promote exclusive breastfeeding for 6 months.

ObjectiveTo compare 18-year (2000–2017) temporal trends in ischemic stroke rates by ethnicity, sex, and age.MethodsData are from a population-based stroke surveillance study conducted in Nueces County, Texas, a geographically isolated, biethnic, urban community. Active (screening hospital admission logs, hospital wards, intensive care units) and passive (screening inpatient/emergency department discharge diagnosis codes) surveillance were used to identify cases aged ≥45 (n = 4,875) validated by stroke physicians using a consistent stroke definition over time. Ischemic stroke rates were derived from Poisson regression using annual population counts from the US Census to estimate the at-risk population.ResultsIn those aged 45–59 years, rates increased in non-Hispanic Whites (104.3% relative increase; p < 0.001) but decreased in Mexican Americans (−21.9%; p = 0.03) such that rates were significantly higher in non-Hispanic Whites in 2016–2017 (p for ethnicity–time interaction < 0.001). In those age 60–74, rates declined in both groups but more so in Mexican Americans (non-Hispanic Whites −18.2%, p = 0.05; Mexican Americans −40.1%, p = 0.002), resulting in similar rates for the 2 groups in 2016–2017 (p for ethnicity–time interaction = 0.06). In those aged ≥75, trends did not vary by ethnicity, with declines noted in both groups (non-Hispanic Whites −33.7%, p = 0.002; Mexican Americans −26.9%, p = 0.02). Decreases in rates were observed in men (age 60–74, −25.7%, p = 0.009; age ≥75, −39.2%, p = 0.002) and women (age 60–74, −34.3%, p = 0.007; age ≥75, −24.0%, p = 0.02) in the 2 older age groups, while rates did not change in either sex in those age 45–59.ConclusionPreviously documented ethnic stroke incidence disparities have ended as a result of declining rates in Mexican Americans and increasing rates in non-Hispanic Whites, most notably in midlife.

Client-specific knowledge is essential for auditors to plan audits effectively, to assess related audit risks and to interpret audit evidence properly. One of the important sources of such knowledge is information about the client’s major customers that contribute significant proportions of revenues and operating profits. Thus, auditors with privileged access to information about the client’s major customers can provide higher-quality audits than those without such access. This paper investigates whether auditors who audit both supplier firms and their major customer firms at the same time, which we refer to as supply chain common (SCC) auditors, exhibit higher audit quality than non-SCC auditors. We find that SCC auditors are better able to constrain opportunistic earnings management using accruals and thereby provide high audit quality. SCC auditors also reduce the possibility that their clients restate financial statements in the future to correct previously inflated earnings. Our results are robust even after controlling for possible endogeneity with respect to SCC auditor choice. The finding suggests that auditing along the supply chain allows auditors to accumulate client-specific knowledge, which in turn helps them to provide high-quality audit service.

Objective Brain arteriovenous malformations (bAVMs) are a leading cause of hemorrhagic stroke and neurological deficits in children and young adults, however, no pharmacological intervention is available to treat these patients. Although more than 95% of bAVMs are sporadic without family history, the pathogenesis of sporadic bAVMs is largely unknown, which may account for the lack of therapeutic options. KRAS mutations are frequently observed in cancer, and a recent unprecedented finding of these mutations in human sporadic bAVMs offers a new direction in the bAVM research. Using a novel adeno-associated virus targeting brain endothelium (AAV-BR1), the current study tested if endothelial KRASG12V mutation induces sporadic bAVMs in mice. Methods Five-week-old mice were systemically injected with either AAV-BR1-GFP or -KRASG12V . At 8 weeks after the AAV injection, bAVM formation and characteristics were addressed by histological and molecular analyses. The effect of MEK/ERK inhibition on KRASG12V -induced bAVMs was determined by treatment of trametinib, a US Food and Drug Administration (FDA)-approved MEK/ERK inhibitor. Results The viral-mediated KRASG12V overexpression induced bAVMs, which were composed of a tangled nidus mirroring the distinctive morphology of human bAVMs. The bAVMs were accompanied by focal angiogenesis, intracerebral hemorrhages, altered vascular constituents, neuroinflammation, and impaired sensory/cognitive/motor functions. Finally, we confirmed that bAVM growth was inhibited by trametinib treatment. Interpretation Our innovative approach using AAV-BR1 confirms that KRAS mutations promote bAVM development via the MEK/ERK pathway, and provides a novel preclinical mouse model of bAVMs which will be useful to develop a therapeutic strategy for patients with bAVM. ANN NEUROL 2021;89:926-941.

Adult-onset Still’s disease (AOSD) is an obscure disease that is usually diagnosed after the exclusion of other febrile diseases, including other autoimmune, infectious, and malignant diseases. Although definitive diagnostic criteria and treatment guidelines for AOSD are thus far lacking, the typical manifestations of AOSD have been identified and effective medications for remission and maintenance have been proposed. The pathophysiology of the AOSD is unclear, but diagnostic criteria and treatment guidelines for AOSD can be established by determining its core etiology and conducting clinical trials of previously tested immunosuppressants and biologics. (Korean J Med 2021;96:30-35)

Myocardial systolic longitudinal function has been known to decrease in patients with severe aortic stenosis (AS). Preoperative peak systolic myocardial velocity at the septal mitral valve annulus (S'), measured using Doppler tissue imaging, was used as an indicator for myocardial systolic longitudinal function. The prognostic value and natural course of S' after surgical aortic valve replacement for severe AS have not been elucidated. This retrospective observational study included patients from January 2006 to December 2018. The patients were divided to 2 groups (pre-S'

Prior studies document that media plays a significant role in the financial market by discovering and disseminating company information. However, whether and to what extent the media improves price efficiency remain unaddressed in Korea. Analyzing an unprecedented dataset of Korean business press articles from 2000 to 2017, we report that business press coverage is positively related to idiosyncratic volatility of stock returns, seemingly indicating the incorporation of firm-specific information into stock prices. We then ask whether or not the business articles convey relevant information consistent with firm fundamentals. Based on fundamental value-to-price ratios as a proxy for stock mispricing, we find robust evidence that 1) media coverage is in fact significantly associated with stock mispricing, 2) the mispricing in media-covered stocks is salient only for undervalued firms, and 3) the business articles covering undervalued stocks tend to use negative tones. These findings collectively suggest that the pessimistic tone of the Korean business press is associated with stock undervaluation. Our findings are consistent with prior literature that documents a sentiment effect of media coverage (e.g., Tetlock 2007). The initial evidence reported in this study not only provides practical insights for managers, market participants, and regulators, but also opens a new research avenue for future research.

With increasing biobanking efforts connecting electronic health records and national registries to germline genetics, the time-to-event data analysis has attracted increasing attention in the genetics studies of human diseases. In time-to-event data analysis, the Cox proportional hazards (PH) regression model is one of the most used approaches. However, existing methods and tools are not scalable when analyzing a large biobank with hundreds of thousands of samples and endpoints, and they are not accurate when testing low-frequency and rare variants. Here, we propose a scalable and accurate method, SPACox (a saddlepoint approximation implementation based on the Cox PH regression model), that is applicable for genome-wide scale time-to-event data analysis. SPACox requires fitting a Cox PH regression model only once across the genome-wide analysis and then uses a saddlepoint approximation (SPA) to calibrate the test statistics. Simulation studies show that SPACox is 76–252 times faster than other existing alternatives, such as gwasurvivr, 185–511 times faster than the standard Wald test, and more than 6,000 times faster than the Firth correction and can control type I error rates at the genome-wide significance level regardless of minor allele frequencies. Through the analysis of UK Biobank inpatient data of 282,871 white British European ancestry samples, we show that SPACox can efficiently analyze large sample sizes and accurately control type I error rates. We identified 611 loci associated with time-to-event phenotypes of 12 common diseases, of which 38 loci would be missed within a logistic regression framework with a binary phenotype defined as event occurrence status during the follow-up period.

Rationale & Objective Patients with multiple comorbid conditions are less likely to use an arteriovenous fistula (AVF) for hemodialysis vascular access. Some dialysis facilities have high rates of AVF placement despite having patients with many comorbid conditions. This study describes variation in facility-level use of AVFs across the facility-level burden of patient comorbid conditions. Study Design Retrospective cohort study. Setting & Participants Medicare patients receiving hemodialysis for 1 year or more in US dialysis facilities. Predictors Facility-level burden of patient comorbid conditions; patient characteristics. Outcomes Odds of AVFs versus other access types; facility-level use of AVFs. Analytical Approach Facility-level comorbidity burden was calculated by summing individual comorbid conditions, determining the average per patient, then defining 11 groups based on facility percentile ranking. Generalized estimating equations with a logit link were used to estimate the odds of AVF placement at the patient level. For the facility-level analysis, a generalized estimating equation model with the identity link was fit to characterize the percentage of AVF use at each facility. Results Overall, AVF use was 65.8% in 315,919 prevalent hemodialysis patients among 5,813 facilities. After adjustment for patient characteristics, AVF use was 0.27, 0.30, 1.05, and 1.74 percentage points lower than the median among facilities in the 61st to 70th, 71st to 80th, 81st to 90th, and 91st to 99th percentiles of comorbidity, respectively, and 0.42, 0.63, 1.34, and 1.90 percentage points higher than the median among facilities in the 31st to 40th, 21st to 30th, 11th to 20th, and 1st to 10th percentiles of comorbidity, respectively. Facilities in the greater than 99th percentile of comorbidity burden had AVF use that was 3.47 percentage points lower than the median. Facilities in the less than 1st percentile of comorbidity burden had AVF use that was 2.64 percentage points greater than the median. Limitations Limited to Medicare dialysis-dependent patients treated for 1 year or more. Conclusions After adjustment for patient characteristics, we found small differences in facility rates of AVF use except in the extremes of high or low levels of comorbidity burden. Our study demonstrates that dialysis facilities with a relatively high patient comorbidity burden can achieve similar fistula rates as facilities with healthier patients. Although high comorbidity burden does not explain low facility AVF use, additional study is needed to understand differences in AVF use rates between facilities with similar comorbidity burdens.

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic disease characterized by incapacitating pelvic pain. Mesenchymal stem cell-derived extracellular vesicles (MSC-EVs) are considered key mediators of the paracrine action of MSCs and show better biological activities than the parent MSCs, especially in the bladder tissue, which may be unfavorable for MSC survival. Here, we produced MSC-EVs using advanced three-dimensional (a3D) culture with exogenous transforming growth factor-β3 (TGF-β3) (T-a3D-EVs). Treatment with T-a3D-EVs led to significantly enhanced wound healing and anti-inflammatory capacities. Moreover, submucosal layer injection of T-a3D-EVs in chronic IC/BPS animal model resulted in restoration of bladder function, superior anti-inflammatory activity, and recovery of damaged urothelium compared to MSCs. Interestingly, we detected increased TGF-β1 level in T-a3D-EVs, which might be involved in the anti-inflammatory activity of these EVs. Taken together, we demonstrate the excellent immune-modulatory and regenerative abilities of T-a3D-EVs as observed by recovery from urothelial denudation and dysfunction, which could be a promising therapeutic strategy for IC/BPS.

Introduction: Brain arteriovenous malformations (bAVMs) are a major risk factor of cerebral hemorrhages in young patients. Recently, somatic KRAS mutation has identified ~60% of human bAVMs, and we confirmed the causal role of endothelial KRAS G12V mutation in bAVM development using a mouse model. Excessive uncontrolled angiogenesis is associated with the abnormal vascular outgrowth in bAVMs. While abnormal VEGF signaling is involved in pathologic angiogenesis, the role in mutant KRAS-induced bAVMs has not been studied. Here, we hypothesized that KRAS mutation induces bAVMs via activation of VEGF signaling, and tested if VEGF inhibition prevents KRAS G12V -induced bAVM development. Methods: We induced bAVMs in mice by systemic injection of AAV-BR1 carrying KRAS G12V mutation (KRAS G12V mice). To determine the effect of KRAS mutation on VEGF signaling, we tested the expression of VEGF-A and VEGFR2 in KRAS G12V -induced bAVMs in vivo and cultured mouse endothelial cells (ECs) overexpressing KRAS G12V in vitro . Furthermore, we performed the tube formation assay to test angiogenesis by KRAS G12V mutation in the cultured EC. Finally, we treated VEGFR2 inhibitor (SU5416) in the KRAS G12V mice and measured the bAVM size and numbers in the latex-casted brains. Results: We found that the expression of VEGF-A, VEGFR2, and phospho(p)-VEGFR2 were significantly increased in KRAS G12V -induced bAVMs in mice. We also found that KRAS G12V transfection up-regulates expression of VEGF-A, VEGFR2, and p-VEGFR2, and increased tube formation in cultured ECs. Finally, we confirmed that SU5416 treatment significantly reduced the numbers and size of bAVMs in KRAS G12V mice. Conclusions: Our data show that endogenous VEGF signaling is activated by KRAS mutation. The VEGF inhibition study suggests that the endogenously activated VEGF signaling would be essential to mediate the mutant KRAS-induced bAVM development.

Increased soluble endoglin (sENG) has been observed in human brain arteriovenous malformations (bAVMs). In addition, the overexpression of sENG in concurrence with vascular endothelial growth factor (VEGF)-A has been shown to induce dysplastic vessel formation in mouse brains. However, the underlying mechanism of sENG-induced vascular malformations is not clear. The evidence suggests the role of sENG as a pro-inflammatory modulator, and increased microglial accumulation and inflammation have been observed in bAVMs. Therefore, we hypothesized that microglia mediate sENG-induced inflammation and endothelial cell (EC) dysfunction in bAVMs. In this study, we confirmed that the presence of sENG along with VEGF-A overexpression induced dysplastic vessel formation. Remarkably, we observed increased microglial activation around dysplastic vessels with the expression of NLRP3, an inflammasome marker. We found that sENG increased the gene expression of VEGF-A, pro-inflammatory cytokines/inflammasome mediators (TNF-α, IL-6, NLRP3, ASC, Caspase-1, and IL-1β), and proteolytic enzyme (MMP-9) in BV2 microglia. The conditioned media from sENG-treated BV2 (BV2-sENG-CM) significantly increased levels of angiogenic factors (Notch-1 and TGFβ) and pERK1/2 in ECs but it decreased the level of IL-17RD, an anti-angiogenic mediator. Finally, the BV2-sENG-CM significantly increased EC migration and tube formation. Together, our study demonstrates that sENG provokes microglia to express angiogenic/inflammatory molecules which may be involved in EC dysfunction. Our study corroborates the contribution of microglia to the pathology of sENG-associated vascular malformations.

Although CT radiomics has shown promising results in the evaluation of vertebral fractures, the need for manual segmentation of fractured vertebrae limited the routine clinical implementation of radiomics. Therefore, automated segmentation of fractured vertebrae is needed for successful clinical use of radiomics. In this study, we aimed to develop and validate an automated algorithm for segmentation of fractured vertebral bodies on CT, and to evaluate the applicability of the algorithm in a radiomics prediction model to differentiate benign and malignant fractures. A convolutional neural network was trained to perform automated segmentation of fractured vertebral bodies using 341 vertebrae with benign or malignant fractures from 158 patients, and was validated on independent test sets (internal test, 86 vertebrae [59 patients]; external test, 102 vertebrae [59 patients]). Then, a radiomics model predicting fracture malignancy on CT was constructed, and the prediction performance was compared between automated and human expert segmentations. The algorithm achieved good agreement with human expert segmentation at testing (Dice similarity coefficient, 0.93–0.94; cross-sectional area error, 2.66–2.97%; average surface distance, 0.40–0.54 mm). The radiomics model demonstrated good performance in the training set (AUC, 0.93). In the test sets, automated and human expert segmentations showed comparable prediction performances (AUC, internal test, 0.80 vs 0.87, p = 0.044; external test, 0.83 vs 0.80, p = 0.37). In summary, we developed and validated an automated segmentation algorithm that showed comparable performance to human expert segmentation in a CT radiomics model to predict fracture malignancy, which may enable more practical clinical utilization of radiomics.

Rare Cold Inducible 2s (RCI2s) are hydrophobic proteins in cell membranes that participate in abiotic stress tolerance mechanisms. Additionally, they are used as traceable membrane trafficking markers in endocytosis studies. Plants regulate cell homeostasis through endocytosis by limiting the activity of plasma membrane transporter proteins to adapt to stressful conditions. In this study, we found high temperature (HT) stress-induced membrane trafficking of RCI2D in Camelina sativa L. The gene expression and protein synthesis were increased by HT stress at 37 °C. Moreover, rapid membrane trafficking of CsRCI2D was traced by multiple-phase membrane fractionation using sucrose density gradients and compared with CsRCI2E/F/G from the same protein family subgroup. The distribution of CsRCI2s was shown to be similar to that of the clathrin heavy chain, which is known as a major endocytosis protein. Subcellular localization of CsRCI2D was observed in the plasma membrane and endo-membranes and overlapped with membrane lipids. CsRCI2D co-localized with lipids, and its overexpression increased the intracellular lipid content compared to that of wild-type camelina. Moreover, transgenic camelina lines showed enhanced HT stress tolerance during germination and hypocotyl elongation when compared to the wild type. These results suggest that HT-induced CsRCI2D membrane trafficking enhances HT stress tolerance in camelina.

Mesenchymal stromal cells (MSCs) release extracellular vesicles (MSC-EVs) containing various cargoes. Although MSC-EVs show significant therapeutic effects, the low production of EVs in MSCs hinders MSC-EV-mediated therapeutic development.Here, we developed an advanced three-dimensional (a3D) dynamic culture technique with exogenous transforming growth factor beta-3 (TGF-β3) treatment (T-a3D) to produce potent MSC-EVs.Our system enabled preparation of a highly concentrated EV-containing medium for efficient EV isolation and purification with higher yield and efficacy.MSC spheroids in T-a3D system (T-a3D spheroids) showed high expression of CD9 and TGF-β3, which was dependent on TGF-β signaling. Treatment with EVs produced under T-a3D conditions (T-a3D-EVs) led to significantly improved migration of dermal fibroblasts and wound closure in an excisional wound model. The relative total efficacy (relative yield of single-batch EVs (10-11-fold) × relative regeneration effect of EVs (2-3-fold)) of T-a3D-EVs was approximately up to 33-fold higher than that of 2D-EVs. Importantly the quantitative proteomic analyses of the T-a3D spheroids and T-a3D-EVs supported the improved EV production as well as the therapeutic potency of T-a3D-EVs.TGF-β signalling differentially regulated by fluid shear stress produced in our system and exogenous TGF-β3 addition was confirmed to play an important role in the enhanced production of EVs with modified protein cargoes. We suggest that the T-a3D system leads to the efficient production of MSC-EVs with high potential in therapies and clinical development.

In the context of time-to-event analysis, a primary objective is to model the risk of experiencing a particular event in relation to a set of observed predictors. The Concordance Index (C-Index) is a statistic frequently used in practice to assess how well such models discriminate between various risk levels in a population. However, the properties of conventional C-Index estimators when applied to left-truncated time-to-event data have not been well studied, despite the fact that left-truncation is commonly encountered in observational studies. We show that the limiting values of the conventional C-Index estimators depend on the underlying distribution of truncation times, which is similar to the situation with right-censoring as discussed in Uno et al. (2011) [On the C-statistics for evaluating overall adequacy of risk prediction procedures with censored survival data. Statistics in Medicine 30(10), 1105-1117]. We develop a new C-Index estimator based on inverse probability weighting (IPW) that corrects for this limitation, and we generalize this estimator to settings with left-truncated and right-censored data. The proposed IPW estimators are highly robust to the underlying truncation distribution and often outperform the conventional methods in terms of bias, mean squared error, and coverage probability. We apply these estimators to evaluate a predictive survival model for mortality among patients with end-stage renal disease.

Background and Purpose: Informal (unpaid) caregiving usually provided by family is important poststroke. We studied whether the prevalence of informal caregiving after stroke differs between Mexican Americans (MAs) and non-Hispanic Whites (NHWs). Methods: Between October 2014 and December 2018, participants in the BASIC (Brain Attack Surveillance in Corpus Christi) project in Nueces County, Texas, were interviewed 90 days after stroke to determine which activities of daily living they required help with and whether family provided informal caregiving. Ethnic differences between MAs and NHWs were determined by logistic regression. The logistic models were stratified by formal (paid) care status. Odds ratios (95% CIs) are reported with NHW as the referent group. Fisher exact tests were used to assess the association of ethnicity with relationship of caregiver and with individual activities of daily living. Results: Eight hundred thirty-one patients answered the caregiving questions. Of these, 242 (29%) received family caregiving (33% of MAs and 23% of NHWs), and 142 (17%) received paid caregiving (21% of MAs and 10% of NHWs). There were no ethnic differences in stroke severity. In logistic regression analyses, among those without formal, paid care, MAs were more likely to have informal caregiving (odds ratio, 1.75 [95% CI, 1.12–2.73]) adjusted for age, National Institutes of Health Stroke Scale, prestroke modified Rankin Scale, and insurance. No ethnic differences in informal care were found among those who had formal care. There were no differences between ethnic groups in which family members provided the informal care. MAs were more likely to require help compared with NHWs for walking ( P P P =0.0012), eating ( P =0.0004), dressing ( P P =0.0304), and toileting ( P =0.0003). Conclusions: MAs required more help poststroke than NHWs for assistance with activities of daily living. MAs received more help for activities of daily living through informal, unpaid caregiving than NHWs if they were not also receiving formal, paid care. Efforts to help minority and low-resource populations provide stroke care are needed.

Purpose Physical activity (PA) has been evaluated for reducing side effects of cancer treatment and improving quality of life. Understanding the factors that affect participation in PA is essential to improve strategies for health promotion. We evaluated the determinants of PA among prostate cancer patients. Methods Ninety patients were divided into 'inactive or minimally active' or 'health enhancing physical activity' groups, based on their PA levels measured using the International Physical Activity Questionnaire (IPAQ). IPAQ score was used as the dependent variable. Clinical characteristics, including demographics, difficulties in urination or defecation, socioeconomic status, physical status and functions were used as the independent variables. Univariate and multivariate logistic regression analyses were performed. Results Univariate logistic regression analyses identified that urination and defecation difficulties were associated with lower PA. Multivariate logistic regression analyses revealed that urinary difficulties were associated with lower PA. Conclusion Knowledge of the factors that influence PA will allow physicians to identify patients who are expected to have less PA and intervene early. Urinary difficulties had a statistically significant association with lower PA, representing a barrier to PA. Early intervention is needed to overcome urinary difficulties considering the importance of PA in achieving optimal health outcomes.

Objectives: The aim of the study was to determine the frequency and natural history of infantile idiopathic cholestasis (IC) in a large, prospective, multicenter cohort of infants. Methods: We studied 94 cholestatic infants enrolled up to 6 months of age in the NIDDK ChiLDReN (Childhood Liver Disease Research Network) “PROBE” protocol with a final diagnosis of IC; they were followed up to 30 months of age. Results: Male sex (66/94; 70%), preterm birth (22/90 with data; 24% born at < 37 weeks’ gestational age), and low birth weight (25/89; 28% born at 1 mg/dL and/or ALT > 35 U/L; n = 7), and exited healthy (resolved disease per study site report but without documented biochemical resolution; n = 34). Biochemical resolution occurred at median of 9 months of age. GGT was

Background: Advance care planning (ACP) is recommended to align treatment with patient goals, although there has been little study of the impact of ACP on in-hospital stroke treatment. Objective: To examine the association between ACP and transitions to comfort measures after stroke. Design: Prospective cohort study. Setting/Subjects: Hospitalized stroke patients 45 years and older and surrogate decision makers from a population-based study in Corpus Christi, TX. Measurements: Surrogates were interviewed to assess presence of patient prestroke ACP, categorized as none, informal conversations only, or formal documentation. Patient records were reviewed for time from admission to transition to comfort measures only (CMO) (defined as in-hospital comfort measures or discharge with hospice services). Cox proportional-hazards models assessed the relationship between ACP and time to transition to CMO. Results: Of 148 included stroke patients, 37% transitioned to CMO (median time five days). For ACP, 44% had only informal conversations, 38% had formal documentation (98% of which also reported informal conversations), and 18% had neither. After adjustment for age, severity, and baseline disability, informal conversations alone (hazard ratio [HR] 3.55; 95% confidence interval [CI]: 1.35-9.33) and formal documentation (HR 2.85; 95% CI: 1.05-7.72) were associated with earlier transition to comfort measures compared to no ACP. There was no difference between formal documentation and informal conversations on time to comfort measures (HR 0.80, 95% CI: 0.40-1.63). Conclusions: There was no additional association of formal ACP documentation over informal conversations on time to transition to comfort measures after stroke. Further study of formal ACP is warranted.

To identify factors affecting blood loss and operation time (OT) during robotic myomectomy (RM), we reviewed a total of 448 patients who underwent RM at Seoul Asan Hospital between 1 January 2019, and 28 February 2021, at Seoul Asan Hospital. To avoid variations in surgical proficiency, only 242 patients managed by two surgeons who each performed &gt, 80 RM procedures during the study period were included in this study. All cases of RM were performed with a reduced port technique. We obtained the following data from each patient’s medical chart: age, gravidity, parity, body mass index, and history of previous abdominal surgery including cesarean section. We also collected information on the maximal diameter and type of myomas, number and weight of removed myomas, concomitant surgery, total OT from skin incision to closure, estimated blood loss (EBL), and blood transfusion. Data on preoperative use of gonadotropin-releasing hormone agonists (GnRHas) and perioperative use of hemostatic agents (tranexamic acid or vasopressin) were also collected. Data on the length of hospital stay, postoperative fever within 48 h, and any complications related to RM were also obtained. The primary endpoint in this study was the identification of factors affecting EBL and the secondary endpoint was the identification of factors affecting the total OT during multiport RM. Univariate and multivariate analyses were used to identify the factors affecting EBL and OT during multiport RM. The medians of the maximal diameter and weight of the removed myomas were 9.00 (interquartile range [IQR], 7.00 to 10.00) cm and 249.75 (IQR, 142.88 to 401.00) g, respectively. The median number of myomas was two (IQR, one to four), ranging from 1 to 34. Of the cases, 155 had low EBL and 87 had high EBL. Most myomas were of the intramural type (n = 179). The odds of EBL &gt, 320 mL increased by 251% (odds ratio [OR], 2.51, 95% confidence interval [CI], 1.16–5.42) for five to nine myomas and by 647% (OR, 6.47, 95% CI, 1.87–22.33) for ≥10 myomas. The odds of subserosal-type myomas decreased by 67% compared with intramural-type myomas (OR, 0.33, 95% CI, 0.14–0.80). History of abdominal surgery other than cesarean section was positively correlated with EBL. The weight of the removed myomas and a history of previous cesarean section were not correlated with the EBL. Conclusion: The number of myomas (5–9 and ≥10), maximal myoma diameter, and history of abdominal surgery other than cesarean section affect the EBL in RM.

Biliary atresia is a progressive fibroinflammatory cholangiopathy of infancy that is associated with activation of innate and adaptive immune responses targeting bile ducts. A recently completed multicenter phase I/IIA trial of intravenous immunoglobulin in biliary atresia did not improve serum total bilirubin levels at 90 days after hepatoportoenterostomy or survival with the native liver at 1 year. A mechanistic aim of this trial was to determine if the peripheral blood immunophenotype was associated with clinical outcomes. Flow cytometry of peripheral blood cell markers (natural killer [NK], macrophage subsets, T‐ and B‐cell subsets, regulatory T cells), neutrophils, and activation markers (clusters of differentiation [CD]38, CD69, CD86, human leukocyte antigen‐DR isotype [HLA‐DR]) was performed on 29 patients with biliary atresia at baseline and at 60, 90, 180, and 360 days after hepatoportoenterostomy. Plasma cytokines and neutrophil products were also measured. Spearman correlations of change of an immune marker from baseline to day 90 with change in serum bilirubin revealed that an increase in total bilirubin correlated with 1) increased percentage of HLA‐DR+CD38+ NK cells and expression of NK cell activation markers CD69 and HLA‐DR, 2) decreased percentage of regulatory T cells, and 3) increased interleukin (IL)‐8 and associated neutrophil products (elastase and neutrophil extracellular traps). Cox modeling revealed that the change from baseline to day 60 of the percentage of HLA‐DR+CD38+ NK cells and plasma IL‐8 levels was associated with an increased risk of transplant or death by day 360. Conclusion: Poor outcomes in biliary atresia correlated with higher peripheral blood NK cells and IL‐8 and lower regulatory T cells. Future studies should include immunotherapies targeting these pathways in order to protect the biliary tree from ongoing damage.

Background: Living donor liver transplantation (LDLT) has been associated with massive bleeding and increased blood transfusion requirements. However, information on indicators predicting bleeding and transfusion in LDLT is limited. Recent studies have reported a correlation between red cell distribution width (RDW) and bleeding risk. This study investigates the association between RDW and intraoperative blood transfusion in patients receiving LDLT.Methods: This retrospective study analyzed 2548 patients who underwent LDLT between January 2010 and October 2019. The patients were divided into four groups based on preoperative RDW quartiles: Q1 ( The risk factors for intraoperative transfusion were evaluated by multivariate regression analysis. The predictive power of RDW was assessed through receiver operating characteristic (ROC) and integrated discrimination improvement (IDI) analysis.Results: There were significant differences in incidence of intraoperative transfusion according to preoperative RDW quartile (Q1 vs Q2 vs Q3 vs Q4: 47.3% vs. 78.1% vs. 91.8% vs. 96.2%, P<0.001). Q4 had poor surgical outcomes, such as acute kidney injury (adjusted odds ratio [OR]: 1.91, 95% CI: 1.44–2.54, P<0.001). In the multivariate logistic analysis, RDW, age, sex, diabetes mellitus, coronary artery disease, model for end-stage liver disease scores, and total ischemic time were risk factors for transfusion. In ROC and IDI analysis, RDW had predictive power for intraoperative transfusion (P=0.023 in IDI).Conclusions: Preoperative RDW is a potential predictor of intraoperative transfusion and postoperative acute kidney injury in patients receiving LDLT.

Female subjects have poorer outcomes in left main coronary artery (LMCA) disease compared with male subjects. However, limited information is available on the long-term prognostic impact of sex and sex-treatment interactions in patients with LMCA disease undergoing coronary revascularization.The goal of this study was to investigate the long-term effects of sex and related differential outcomes after percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in LMCA disease.The extended PRECOMBAT (Premier of Randomized Comparison of Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease) trial evaluated the10-year clinical outcomes in patients with LMCA disease randomized to undergo PCI with drug-eluting stents (n = 300) or CABG (n = 300). The primary outcome was major adverse cardiac or cerebrovascular events (MACCE) (composite of death, myocardial infarction, stroke, or ischemia-driven target vessel revascularization) at 10 years.Of the 600 patients, 459 (76.5%) were male. The 10-year rates of MACCE were similar between male and female subjects in the overall cohort (27.3% vs 27.0%; adjusted hazard ratio [aHR]: 1.06; 95% confidence interval [CI]: 0.70-1.59), the PCI arm (30.6% vs 27.1%; aHR: 1.19; 95% CI: 0.69-2.05), and the CABG arm (24.0% vs 26.9%; aHR: 0.93; 95% CI: 0.53-1.62). The 10-year risks for MACCE did not significantly differ between PCI and CABG in both male (aHR: 1.37; 95% CI: 0.95-1.97) and female (aHR: 1.07; 95% CI: 0.56-2.07) subjects. There was no significant sex-treatment interaction regarding the adjusted risk of MACCE at 10 years (In this 10-year follow-up of the PRECOMBAT trial, there was no sex-related impact on the long-term risk of MACCE after PCI and CABG for LMCA disease. (Ten-Year Outcomes of PRECOMBAT Trial; NCT03871127).

Introduction: Although stroke severity is increased in patients with diabetes (e.g., higher mortality, larger infarcts, and worse neurological deficits), the underlying mechanism(s) of the worse outcomes is not clear. Evidence shows that hypothalamic-pituitary-adrenal (HPA) axis is dysregulated and cortisol levels are increased in diabetes. Based on the role of HPA axis in immunity, we hypothesized that diabetes-enhanced stress response contributes to stroke injury via regulating inflammation. Methods: Diabetes was induced in C57BL/6 mice by feeding a diabetogenic diet and injecting streptozotocin. Mice were subjected to 30 min middle cerebral artery occlusion. Infarct volume and neurological scores were measured at 24h-post stroke. We measured expression of factors related to stress response, plasma corticosterone, c-Fos and corticotropin-releasing factor (CRH) in hypothalamus, and proopiomelanocortin (POMC) and corticotropin-releasing hormone receptor 1 (CRHR1) in pituitary. Inflammatory cytokine levels were also determined in the ischemic brain. Results: Diabetic mice showed hyperglycemia and delayed glucose clearance in blood. At 1d-post stroke, diabetic mice showed larger infarct and worse neurological score. Plasma corticosterone levels were significantly increased in diabetic mice. We also found increased c-Fos in hypothalamus, and CRHR1 and POMC in pituitary. These were accompanied by increased IL-1β, TNF-α, and IL-6 mRNA in the ischemic brain. Conclusion: Our results indicate that stress response is enhanced in diabetic conditions, and associated with increased inflammation in ischemic brain and worse stroke outcomes. It suggests that regulation of stress response may improve stroke outcomes in diabetic conditions.

Background and Purpose: We analyzed differences in 90-day poststroke outcomes between Mexican Americans born in the United States (nonimmigrant) compared with those born outside the United States (immigrant). Methods: We performed a retrospective analysis of prospective data from the population-based Brain Attack Surveillance in Corpus Christi project. We identified stroke cases from 2008 to 2016 and quantified functional, cognitive, and neurological outcomes. Associations between outcome scores and immigration status were analyzed using weighted linear regression models. Results: Eighty-three Mexican American stroke cases (n=935) were immigrants, and 852 stroke cases were nonimmigrants. Average length of stay in the United States for immigrants was 47 years. Immigrants were older (69 versus 66 years), more likely men (60% versus 49%), had less education on average, and were more likely to have atrial fibrillation compared with nonimmigrants. No differences in other comorbidities existed between groups. After adjustment for confounders, immigrants had better functional outcomes (activities of daily living/instrumental activities of daily living; mean difference, −0.22; P =0.02; 1–4, higher scores worse) and no difference in neurological outcomes (log-National Institutes of Health Stroke Scale; mean difference, −0.15; P =0.15; 0–44, higher scores worse) or cognitive outcomes (3 Mini-Mental State Examination; mean difference, −0.79; P =0.64; 0–100, lower scores worse). Conclusions: Long-term Mexican American immigrants in this community display better stroke functional outcomes than nonimmigrant Mexican Americans and comparable neurological and cognitive outcomes.

Background and Purpose: Stroke incidence and mortality are declining rapidly in developed countries. Little data on ethnic-specific stroke recurrence trends exist. Fourteen-year stroke recurrence trend estimates were evaluated in Mexican Americans and non-Hispanic whites in a population-based study. Methods: Recurrent stroke was ascertained prospectively in the population-based BASIC (Brain Attack Surveillance in Corpus Christi) project in Texas, between 2000 and 2013. Incident cases were followed forward to determine 1- and 2-year recurrence. Fine & Gray subdistribution hazard models were used to estimate adjusted trends in the absolute recurrence risk and ethnic differences in the secular trends. The ethnic difference in the secular trend was examined using an interaction term between index year and ethnicity in the models adjusted for age, sex, hypertension, diabetes mellitus, smoking, atrial fibrillation, insurance, and cholesterol and relevant interaction terms. Results: From January 1, 2000 to December 31, 2013 (N=3571), the cumulative incidence of 1-year recurrence in Mexican Americans decreased from 9.26% (95% CI, 6.9%–12.43%) in 2000 to 3.42% (95% CI, 2.25%–5.21%) in 2013. Among non-Hispanic whites, the cumulative incidence of 1-year recurrence in non-Hispanic whites decreased from 5.67% (95% CI, 3.74%–8.62%) in 2000 to 3.59% (95% CI, 2.27%–5.68%) in 2013. The significant ethnic disparity in stroke recurrence existed in 2000 (risk difference, 3.59% [95% CI, 0.94%–6.22%]) but was no longer seen by 2013 (risk difference, −0.17% [95% CI, −1.96% to 1.5%]). The competing 1-year mortality risk was stable over time among Mexican Americans, while for non-Hispanic whites it was decreasing over time (difference between 2000 and 2013: −4.67% [95% CI, −8.72% to −0.75%]). Conclusions: Mexican Americans had significant reductions in stroke recurrence despite a stable death rate, a promising indicator. The ethnic disparity in stroke recurrence present early in the study was gone by 2013.

Background: Most end-of-life decisions after stroke are made by a surrogate decision maker, yet there has been limited study of surrogate assessment of the quality of end-of-life stroke care. Objective: To assess surrogate perceptions of quality of end-of-life care (QEOLC) in stroke and explore factors associated with quality. Design: Cross-sectional analysis of interviewer-administered survey. Settings/subjects: Surrogate decision makers for deceased stroke patients in a population-based study. Measurements: The primary outcome was the validated 10-item family version of the QEOLC scale. The univariate association between prespecified patient and surrogate factors and dichotomized QEOLC score (high: 8-10, low: 0-7) was explored with logistic regression fit using generalized estimating equations. Results: Seventy-nine surrogates for 66 deceased stroke cases were enrolled (median patient age: 76, female patient: 53%, Mexican American patient: 59%, median time from stroke to death: seven days, median surrogate age: 59, and female surrogate: 72%). The overall QEOLC was generally high (median 8.3, quartiles 6.1, 9.6) although several individual items had a high proportion (∼30%-50%) of surrogates who felt that the questions did not apply to the patient's situation. No hypothesized factors were associated with QEOLC score, including demographics, stroke type, location/timing of death, advance directives, health literacy, or understanding of patient wishes. Conclusions: Surrogates reported generally high QEOLC. Although this finding is encouraging, modifications to the QEOLC may be needed in stroke as some surrogates were unable to provide a valid response for certain items.

Objective/background Stroke is often considered a risk factor for central sleep apnea (CSA). The goal of this study was to determine the prevalence and clinical correlates of CSA in patients with ischemic stroke. Patients/methods In this analysis, 1346 participants in the Brain Attack Surveillance in Corpus Christi (BASIC) project underwent a home sleep apnea test shortly after ischemic stroke. Respiratory events during sleep were classified as central apneas, obstructive apneas, or hypopneas. Central apnea index (CAI) was defined as number of central apneas divided by recording time. CSA was defined as CAI ≥5/hour with at least 50% of all scored respiratory events classified as central apneas. Demographics and co-morbidities were ascertained from the medical record. Results Median CAI was 0/hour. Nineteen participants (1.4%) met criteria for CSA. Participants with CSA were more likely to be male, and had lower prevalence of obesity than participants without CSA. There was no association between CSA and other co-morbidities. Conclusions CSA was uncommon in this large cohort of patients with recent ischemic stroke.

ObjectiveTo examine associations between neighborhood socioeconomic status (nSES) and 90-day poststroke outcomes.MethodsThe Brain Attack Surveillance in Corpus Christi Project is a population-based surveillance study in Nueces County, Texas. Patients with strokes were identified between 2010 and 2016 via active and passive surveillance and enrolled in the study. nSES index is a standardized composite of 2010 Census tract–level income, wealth, education, and employment (median −4.56, interquartile range −7.48 to −0.46). The 90-day outcomes were ascertained via interview: functional status measured by the average of 22 activities of daily living/instrumental activities of daily living (range 1–4), biopsychosocial health by the Stroke-Specific Quality of Life scale (range 0–5), and depressive symptoms by the 8-item Patient Health Questionnaire (range 0–24). Associations between nSES and outcomes were estimated using confounder-adjusted generalized estimating equations with an nSES × NIH Stroke Scale score interaction term.ResultsSeven hundred seventy-six survivors made up the analytical sample (52.96% male, 62.24% Mexican American, 52.96% ≥64 years old). Higher compared to lower nSES (mean difference comparing 75th to 25th percentile of nSES) was associated with better function (−0.27, 95% confidence interval [CI] −0.49 to −0.05), better biopsychosocial health (0.26, 95% CI 0.06–0.47), and fewer depressive symptoms (−1.77, 95% CI −3.306 to −0.48) among those with moderate to severe strokes. Among those with minor strokes, higher nSES was associated with better function (−0.13, 95% CI −0.24 to −0.02).ConclusionsnSES may influence poststroke recovery. Studies should identify neighborhood characteristics that contribute to poststroke outcomes, particularly in moderate to severe stroke survivors.

Objective/background Sleep-disordered breathing (SDB) is highly prevalent after stroke and is associated with poor outcomes. Currently, after stroke, objective testing must be used to differentiate patients with and without SDB. Within a large, population-based study, we evaluated the usefulness of a flexible statistical model based on baseline characteristics to predict post-stroke SDB. Patients/methods Within a population-based study, participants (2010–2018) underwent SDB screening, shortly after ischemic stroke, with a home sleep apnea test. The respiratory event index (REI) was calculated as the number of apneas and hypopneas per hour of recording; values ≥10 defined SDB. The distributed random forest classifier (a machine learning technique) was applied to predict SDB with the following as predictors: demographics, stroke risk factors, stroke severity (NIHSS), neck and waist circumference, palate position, and pre-stroke symptoms of snoring, apneas, and sleepiness. Results Within the total sample (n = 1330), median age was 65 years; 47% were women; 32% non-Hispanic white, 62% Mexican American, and 6% African American. SDB was found in 891 (67%). The area under the receiver operating characteristic curve, a measure of predictive ability, applied to the validation sample was 0.75 for the random forest model. Random forest correctly classified 72.5% of validation samples. Conclusions In this large, ethnically diverse, population-based sample of ischemic stroke patients, prediction models based on baseline characteristics and clinical measures showed fair rather than clinically reliable performance, even with use of advanced machine learning techniques. Results suggest that objective tests are still needed to differentiate ischemic stroke patients with and without SDB.

ObjectiveTo identify dysregulated metabolic pathways in amyotrophic lateral sclerosis (ALS) versus control participants through untargeted metabolomics.MethodsUntargeted metabolomics was performed on plasma from ALS participants (n=125) around 6.8 months after diagnosis and healthy controls (n=71). Individual differential metabolites in ALS cases versus controls were assessed by Wilcoxon rank-sum tests, adjusted logistic regression and partial least squares-discriminant analysis (PLS-DA), while group lasso explored sub-pathway-level differences. Adjustment parameters included sex, age and body mass index (BMI). Metabolomics pathway enrichment analysis was performed on metabolites selected by the above methods. Finally, machine learning classification algorithms applied to group lasso-selected metabolites were evaluated for classifying case status.ResultsThere were no group differences in sex, age and BMI. Significant metabolites selected were 303 by Wilcoxon, 300 by logistic regression, 295 by PLS-DA and 259 by group lasso, corresponding to 11, 13, 12 and 22 enriched sub-pathways, respectively. ‘Benzoate metabolism’, ‘ceramides’, ‘creatine metabolism’, ‘fatty acid metabolism (acyl carnitine, polyunsaturated)’ and ‘hexosylceramides’ sub-pathways were enriched by all methods, and ‘sphingomyelins’ by all but Wilcoxon, indicating these pathways significantly associate with ALS. Finally, machine learning prediction of ALS cases using group lasso-selected metabolites achieved the best performance by regularised logistic regression with elastic net regularisation, with an area under the curve of 0.98 and specificity of 83%.ConclusionIn our analysis, ALS led to significant metabolic pathway alterations, which had correlations to known ALS pathomechanisms in the basic and clinical literature, and may represent important targets for future ALS therapeutics.

Introduction: While telestroke use is increasing, little is known about its effect on the patient and family perceptions of quality of stroke care. We hypothesized that use of telestroke may negatively impact perceptions of the quality of communication with local physicians. Methods: Stroke patients aged 45 years and older and their surrogate medical decision makers were identified (April 2016-August 2018). Surrogates were asked to rate the main physician in charge of the patient’s care using a validated scale for quality of communication (QOC, range 0-10). Using Tobit regression models, we assessed the relationship of telestroke and in-person neurology consultation with surrogate-rated QOC, adjusted for confounders (with a family-specific random intercept term to account for clustering in families). A subset of surrogates also participated in qualitative interviews about the stroke hospitalization; unprompted discussion of telestroke were summarized. Results: 197 surrogates for 157 patients were included. Surrogates were a median age of 56, 74% female, and 58% Mexican American. 51 patients received telestroke. The mean overall QOC score was 6.7/10. Neither telestroke nor in-person consultation were associated with QOC. However, the direction of the effects suggested a positive association with QOC for in-person consultation and a negative association for telestroke (Table). 32 surrogates underwent qualitative interviews with 3 individuals spontaneously discussing telestroke. In 2 cases, use of telestroke may have highlighted concerns about the competence or lack of resources of the local hospital. The other surrogate felt surprised and “stupid” for not knowing telestroke was possible (Table). Conclusions: We did not identify any association of telestroke use with QOC in the local hospital. However, the direction of the observed effect and unprompted reports of negative feelings about telestroke in qualitative interviews may warrant further study.

Background and Aims: We studied informal (non-paid) caregiving after stroke in a population-based study to determine if differences occurred between Mexican Americans (MAs) and non-Hispanic whites (NHWs). MAs are a less affluent population than NHWs. Family members who provide caregiving may need to interrupt educational and occupational goals to provide this care, which may perpetuate socioeconomic disparities between minority and majority populations. Methods: Between October, 2014 and December, 2016, stroke subjects in Texas, USA, were interviewed 90 days after stroke to determine if family or friends provided informal, unpaid caregiving, and for which activities of daily living (ADLs) they required help. Chi-square tests were used to assess the association of ethnicity and whom provided the caregiving, as well as ethnicity and the ADLs for which they required help. Ethnic differences between MAs and NHWs in receiving informal caregiving were determined using logistic regression. The odds ratio (OR, 95% CI) is reported with NHW as the referent group. Results: 473 subjects answered the caregiving questions. There were no significant differences among the two ethnic groups with respect to age, sex, NIHSS score, marital status, or insurance. MAs were more likely to require help compared with NHWs for walking (p=0.0008), bathing (p=0.0004), hygiene (p=0.0018), eating (p=0.0059), dressing (p Conclusions: In this population-based study, MAs required more help than NHWs for assistance with ADLs, and MAs were more likely to receive this help through informal, unpaid caregiving than NHWs. Efforts to help minority and low-resource populations provide stroke care are needed.

Background/Objective: We studied the association of being born outside of the U.S. (immigrant) or born in the U.S. (non-immigrant) with 90 day post-stroke outcomes in a population-based stroke study in Texas. Methods: Stroke cases from 2008-2016 were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) project. Outcomes among survivors included ADL/IADL score (higher scores worse) for functional assessment, 3MSE (cognition, lower scores worse), and NIHSS Score (neurologic, higher scores worse). Weighted linear regression models were used to assess the effect of immigration status on the outcomes. Analysis was completed using multiple imputation and inverse probability weighting to account for differential attrition. Results: Of 935 Mexican Americans available for analysis, 83 were immigrants and 852 were non-immigrants. Immigrants had resided in the U.S. on average 47 years. Immigrants were significantly older (69 vs. 66 years), more likely male (60% vs. 49%), more likely to have atrial fibrillation and have less education than non-immigrants (all p Conclusions: In this community, there was no evidence of worse stroke outcome among Mexican American immigrants, who had lived in the U.S. for decades, compared with non-immigrants. Further studies of more recent immigrant populations are warranted.

Introduction: Elevated stroke rates in Mexican Americans (MA) compared with non-Hispanic whites (NHW) persisted over the first decade of the 21 st century. Our objective was to investigate recent trends in ischemic stroke (IS) rates by ethnicity and age using data from a longstanding population-based study. Methods: ISs were identified in the Brain Attack Surveillance in Corpus Christi (BASIC) Project (2000-2017) and validated by neurologists using a clinical definition. Race-ethnicity was from medical records. Annual population counts from the US Census estimated the at-risk population. Poisson regression was used to model sex-adjusted rate trends by ethnicity and age. Time was modeled using linear and quadratic terms. Ethnic differences were assessed using interaction terms between ethnicity and time. Results: 4,883 ISs were identified (median age 70 (IQR:59-80); 56% MA). Trends varied by ethnicity and age (figure). In those 45-59, rates increased substantially in NHWs (104%; p Conclusions: New patterns in stroke have emerged. Ethnic disparities have declined as a result of increasing rates in NHWs most notably in midlife. Reasons for increasing rates in recent years are unclear but suggest renewed attention to prevention.

Introduction: Neighborhoods may influence post-stroke recovery. We examined the association between neighborhood socioeconomic status (nSES) and 90-day post-stroke function, depression, cognition, and quality of life (QoL). Methods: Stroke survivors (N=782) were identified from the population-based Brain Attack Surveillance in Corpus Christi (BASIC) Project. An nSES index – composite of 2010 census-tract level income, wealth, education, employment – was the exposure; higher values indicate higher nSES (median -4.56; IQR: -7.48 to -0.46). Function was measured with 22 self-reported activities of daily living/instrumental activities of daily living, depression with Patient Health Questionnaire-8, QoL with the Stroke Specific QoL Scale, and cognition with the Modified Mini Mental State Examination. Confounder-adjusted generalized estimating equations were used to estimate associations between nSES (comparing 75 th to 25 th percentile) and 90-day outcomes. We tested for effect modification by initial stroke severity (NIH Stroke Scale (NIHSS) ≤ 5 or >5) by including interaction terms in adjusted models. Results: Higher nSES was associated with significantly better function, better QoL, and less depression after adjusting for person-level confounders in those with NIHSS >5. Higher nSES was associated with better cognition, but this result was not significant. In those with NIHSS ≤5, higher nSES had a statistically significant (though attenuated) association with function and cognition. Conclusions: Future research should identify features of higher nSES neighborhoods that contribute to more favorable stroke outcomes. Our findings highlight the need for examining the individual and joint influence of neighborhood context and stroke severity on post-stroke recovery.