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The objective of this study was to assess the effects of treatment with propylene glycol (PG) and cyanocobalamin (B12) on health, milk production, and reproductive outcomes of cows diagnosed with hyperketonemia (HK), hypoglycemia (HG), or concurrent HKHG. Glucose and β-hydroxybutyric acid (BHBA) concentrations were assessed in whole blood using a handheld device in lactating dairy cows (n = 2,418) between 3 and 9 d postpartum. Cows categorized as HK (n = 232, BHBA ≥1.2 mmol/L), HG (n = 161, glucose ≤2.2 mmol/L), and concurrent HKHG (n = 204, BHBA ≥1.2 mmol/L, and glucose ≤2.2 mmol/L) were randomized to receive treatment or to remain untreated (control). Treatment consisted of a single dose of B12 (10 mg, intramuscularly) and 300 mL of PG orally for 5 d, starting on the day of cow-side testing. Milk production, health, and reproductive outcomes were analyzed according to groups. Statistical analysis was carried out using SAS version 9.4 (SAS/STAT, SAS Institute Inc.). Treatment in HG cows decreased clinical ketosis, increased milk production in the fifth week of lactation for multiparous cows, and tended to increase 305-d mature-equivalent milk yield (305ME) for primiparous cows compared with untreated cows with the same metabolic profile. For cows with HKHG, treatment increased 305ME in multiparous cows and tended to increase 305ME in primiparous cows. No differences were found for treatment among any of the metabolic groups regarding reproductive outcomes, nor were any treatment effects found among HK cows. Glycemic status may help identify metabolically challenged early postpartum dairy cows, which may have differential response to PG and B12 treatment.

Hypocretin/Orexin (HCRT) is a neuropeptide that is associated with both stress and reward systems in humans and rodents. The different contributions of signaling at hypocretin-receptor 1 (HCRT-R1) and hypocretin-receptor 2 (HCRT-R2) to compulsive alcohol drinking are not yet fully understood. Thus, the current studies used pharmacological and viral-mediated targeting of HCRT to determine participation in compulsive alcohol drinking and measured HCRT-receptor mRNA expression in the extended amygdala of both alcohol-dependent and non-dependent male rats. Rats were made dependent through chronic intermittent exposure to alcohol vapor and were tested for the acute effect of HCRT-R1-selective (SB-408124; SB-R1), HCRT-R2-selective (NBI-80713; NB-R2), or dual HCRT-R1/2 (NBI-87571; NB-R1/2) antagonism on alcohol intake. NB-R2 and NB-R1/2 antagonists each dose-dependently decreased overall alcohol drinking in alcohol-dependent rats, whereas, SB-R1 decreased alcohol drinking in both alcohol-dependent and non-dependent rats at the highest dose (30 mg/kg). SB-R1, NB-R2, and NB-R1/2 treatment did not significantly affect water drinking in either alcohol-dependent or non-dependent rats. Additional PCR analyses revealed a significant decrease in

Girls’ attitudes towards mathematics can impact their achievement and career choices in STEM fields. Can the introduction of inquiry-based learning (IBL) in mathematics classes generate positive associations between girls’ perceptions of the learning environment and their attitudes towards mathematics? Based in the United Arab Emirates, this study provided important information about the relationships between learning environment factors central to an inquiry method and student engagement. Data collection involved administering two surveys to female mathematics students (N = 291) in four schools: one to assess students’ perceptions of the learning environment and another to assess students’ attitudes towards mathematics. Positive and statistically-significant (p

BackgroundIn this genome wide association study (GWAS) we aimed to discover single nucleotide polymorphisms (SNPs) associated with motor recovery post-stroke.MethodsWe used the Vitamin Intervention for Stroke Prevention (VISP) dataset of 2,100 genotyped patients with non-disabling stroke. Of these, 488 patients had motor impairment at enrollment. Genotyped data underwent strict quality control and imputation. The GWAS utilized logistic regression models with generalized estimating equations (GEE) to leverage the repeated NIH Stroke Scale (NIHSS) motor score measurements spanning 6 time points over 24 months. The primary outcome was a decrease in the motor drift score of ≥ 1 vs.<1 at each timepoint. Our model estimated the odds ratio of motor improvement for each SNP after adjusting for age, sex, race, days from stroke to visit, initial motor score, VISP treatment arm, and principal components.ResultsAlthough no associations reached genome-wide significance (p<5 × 10−8), our analysis detected 115 suggestive associations (p<5 × 10−6). Notably, we found multiple SNP clusters near genes with plausible neuronal repair biology mechanisms. The CLDN23 gene had the most convincing association which affects blood-brain barrier integrity, neurodevelopment, and immune cell transmigration.ConclusionWe identified novel suggestive genetic associations with the first ever motor-specific post stroke recovery GWAS. The results seem to describe a distinct stroke recovery phenotype compared to prior genetic stroke outcome studies that use outcome measures, like the mRS. Replication and further mechanistic investigation are warranted. Additionally, this study demonstrated a proof-of-principle approach to optimize statistical efficiency with longitudinal datasets for genetic discovery.

Parkinson’s disease dementia (PDD) and dementia with Lewy bodies (DLB) are characterized by diffuse spread of alpha-synuclein (α-syn) throughout the brain. Patients with PDD and DLB have a neuropsychological pattern of deficits that include executive dysfunction, such as abnormalities in planning, timing, working memory, and behavioral flexibility. The prefrontal cortex (PFC) plays a major role in normal executive function and often develops α-syn aggregates in DLB and PDD. To investigate the consequences of α-syn pathology in the cortex, we injected human α-syn pre-formed fibrils into the PFC of wildtype mice. We report that PFC PFFs: 1) induced α-syn aggregation in multiple cortical and subcortical regions with sparse aggregation in midbrain and brainstem nuclei; 2) did not affect interval timing or spatial learning acquisition but did mildly alter behavioral flexibility as measured by intraday reversal learning; 3) increased open field exploration; and 4) did not affect susceptibility to an inflammatory challenge. This model of cortical-dominant pathology aids in our understanding of how local α-syn aggregation might impact some symptoms in PDD and DLB.

Objective: To perform a genome wide association study (GWAS) of stroke recovery phenotypes as defined by the trajectories of patients’ NIH stroke scale scores over time. Background: Stroke recovery research entails tracking multiple domains of neurologic impairment over time that are measured on differing scales. This presents challenges for analytic approaches commonly used to study stroke genetics. Here, we present a novel approach using a network science-based method, Trajectory Profile Clustering (TPC), to define stroke recovery phenotypes for GWAS. Design/Methods: We analyzed data from 3,679 patients in the VISP dataset (Vitamin Intervention for Stroke Prevention) on 15 NIHSS impairment measures at 6 time points spanning 24 months post-stroke. The 4 identified TPC profiles (Figure, Panel A), were used as phenotypes for a subsequent GWAS on the 2,099 genotyped VISP patients. We used a multinomial generalized regression with TPC profiles as the response variable. The model adjusted for age, sex, treatment group, and the first ten principal components. Results: TOPMed imputation and strict quality control resulted in 6,392,745 SNPs. Although none of our loci reached genome wide significance, the GWAS identified several suggestive loci (p Conclusion: Phenotypes defined using TPC, even in this limited sample, identified multiple suggestive genetic associations with biological relevance for both stroke risk and stroke recovery.

Background: Mechanical thrombectomy (MT) is standard of care for patients with cerebral large vessel occlusions (LVO). Efficacy of MT depends on the timeliness of reperfusion. Establishing a pre-alert criteria to activate the stroke team prior to patient arrival in the emergency department (ED) may help rapidly identify candidates for MT. Objective: To determine whether establishment of pre-alert criteria can improve door-to-groin (DTG) and door-to-reperfusion (DTR) times. Methods: We retrospectively reviewed electronic prehospital and hospital records of stroke-alerted patients prior to (pre-protocol) and after (post-protocol) implementation of our stroke pre-alert protocol. We initiated our protocol in November 2022 to pre-alert patients that EMS found with (1) positive on Cincinnati Pre-Hospital Stroke Scale with last known well (LKW) 8, (3) glucose 60-400mg/dL, (4) systolic blood pressure >90, (5) oxygen saturation >90%, and (6) no seizures at presentation. Patients stroke-alerted in the ED prior to protocol (April 1, 2020-November 10, 2021) were historical controls. Results: EMS presented 667 (49% female) patients to our hospital, of which 195 patients arrived after pre-alert protocol initiation. Among post-protocol patients, 13.8% (27/195) underwent MT, while 11% (52/472) of pre-protocol patients underwent MT. Among patients who underwent MT, 26 post-protocol patients (96%) and 22 pre-protocol patients (42%) were pre-alerted [X 2 =21, p Conclusion: Establishment of a reasonable pre-alert criteria facilitates stroke alert activation and reduces time to MT intervention in patients presenting to the ED with an LVO. More studies are needed to determine an optimal pre-alert criteria to further reduce MT delays.

Introduction: Patients with acute ischemic stroke (IS) experience varying length of stay (LOS), which is a key hospital outcome linked with resource allocation and cost. We investigated predictive performance of socio-economic and clinical factors of prolonged LOS in the National Inpatient Sample (NIS) data set. Methods: We performed a retrospective analysis on the NIS data set containing patients with an IS diagnosis (I63*) from years 2016 to 2019. We investigated differences between patients with a LOS 14 ≥ vs &lt 14 days. We utilized a LASSO regression to select predictors of LOS 14 ≥ vs &lt 14 prior to a ROC analysis. We included: age, sex, race/ethnicity, hypertension, Diabetes II, Atrial fibrillation, congestive heart failure, NIHSS categories, insurance payer, income, teaching hospital and bed size, thrombolytic therapy, mechanical thrombectomy (MT), intubation, tracheostomy, and percutaneous endoscopic gastrostomy (PEG) tube. Results: The cohort (n=137,370; 51% male) had a mean (SD) age of 68.39(± 14.01) years and admitted NIHSS of 6.32 (± 6.81). All differences between LOS 14 ≥ vs &lt 14 were significant (p ≤ 0.021). Groups were similar in age (66.31 ± 13.91 vs 69.50 ± 13.99), but differed in metrics of stroke severity including NIHSS &gt 15 (41.61% vs 10.55%), MT (21.04% vs 6.40%), intubation (23.4% vs 1.60%), tracheostomy (11.54% vs 0.11%), and PEG tube (34.06% vs 1.89%). They were more likely to have Medicaid (19.74% vs 8.78%) and identify as Black (27.86% vs 16.93%). LASSO regression identified 13 predictive variables (Pseudo-R2 0.264) with an ROC AUC of 0.84 discriminating between LOS ≥ 14 vs $lt 14 ( Figure) . Conclusion: Independent of stroke severity and procedure, Medicaid insurance and identifying as black were significant predictors of prolonged acute stroke hospitalization. Although the ROC curve was highly accurate in identifying prolonged LOS, the LASSO only accounted for 26% of the variance. Further research into novel predictors of LOS is warranted.

Introduction: Social and environment factors are associated with increased stroke risk. It is unclear if favorable cardiovascular health may attenuate this risk. We evaluated the impact of neighborhood socioeconomic characteristics on stroke incidence, and if levels of cardiovascular health modify this relationship. Methods: We conducted a longitudinal cohort study of Black and White participants using data from the Reasons for Geographic and Racial Differences in Stroke. We included all stroke-free participants and geocoded their home addresses to the census-tract level. Our primary exposure was neighborhood socioeconomic condition index (nSES; in quartiles) constructed using data from the U.S. Census on income, education, and occupation of residents by census tract. We evaluated cardiovascular health based on the American Heart Association’s Life Simple 7 (ideal, adequate, inadequate). We used a Cox proportional hazards model to regress nSES and its interaction with Life Simple 7 on stroke incidence, adjusting for individual demographics, socioeconomic status, and clinical characteristics. Results: We included 26,941 adults with a mean follow-up of 11.6 years (SD ± 5.2). During the study, 1,596 (5.9%) participants had a first incidence of stroke. Participants within the lowest nSES quartile, compared to those in the highest, were more likely to be Black, have lower household income, and an inadequate Life Simple 7 score. In multivariable models, there was a non-significant increased incidence of stroke (HR-1.13; 95% CI: 0.95-1.35) between the lowest and highest nSES quartiles. The interaction between nSES and Life Simple 7 was also non-significant for stroke incidence with worse cardiovascular health across all quartiles. Discussion: Among a national cohort of Black and White adults, we found a non-significant difference in stroke incidence between adults who live in worse neighborhood socioeconomic conditions and have inadequate cardiovascular health. Characterizing the potential contribution of social, environmental, and health behaviors could inform clinical and public health strategies to mitigate stroke risk.

The context in which learning takes place, or learning environment, is pivotal to a positive learning experience for students. Although numerous studies have established strong links between a positive learning environment and a range of student outcomes, far less research has examined how teachers might establish such an environment. Amidst growing acknowledgment that opportunities for the co-construction of learning and assessment design could provide a means of developing a more positive learning environment, this case study examined one such journey. Using a case study approach, we argue that student feedback involving a learning environment survey provides a valuable starting point for including students in co-construction and classroom improvement. Our findings indicate that teachers can improve the learning environment by involving students in meaningful co-construction through open tasks.

The global lack of student motivation towards learning science and gender imbalance in STEM careers provided the impetus for this study, which had two key aims: (1) to examine the influence of female students’ perceptions of the psychosocial learning environment on their motivation towards and self-regulation in science learning,; and (2) to investigate the influence of their reported motivation on their self-regulation of effort. Data were collected from 338 female students in grades 6 to 9 science classes across 16 government schools in Abu Dhabi, in the United Arab Emirates. Structural equation modelling was used to explore the hypothesised relationships, which indicated that there were statistically significant relationships between learning environment perceptions, motivation and self-regulation. The results provide exigent information to both teachers, policy-makers and researchers with regard to the influences of the psychosocial learning environment on female students’ motivation towards science, as well as the influence of motivation towards science on their self-regulatory behaviour within science classroom settings.

Terazosin is an α1-adrenergic receptor antagonist that enhances glycolysis and increases cellular ATP by binding to the enzyme phosphoglycerate kinase 1 (PGK1). Recent work has shown that terazosin is protective against motor dysfunction in rodent models of Parkinson’s disease (PD) and is associated with slowed motor symptom progression in PD patients. However, PD is also characterized by profound cognitive symptoms. We tested the hypothesis that terazosin protects against cognitive symptoms associated with PD. We report two main results. First, in rodents with ventral tegmental area (VTA) dopamine depletion modeling aspects of PD-related cognitive dysfunction, we found that terazosin preserved cognitive function and produced a non-statistically significant trend towards protected VTA tyrosine hydroxylase levels. Second, we found that after matching for demographics, comorbidities, and disease duration, PD patients newly started on terazosin, alfuzosin, or doxazosin had a lower hazard of being diagnosed with dementia compared to tamsulosin, an α1-adrenergic receptor antagonist that does not enhance glycolysis. Together, these findings suggest that in addition to slowing motor symptom progression, glycolysis-enhancing drugs protect against cognitive symptoms of PD.

Cognitive dysfunction is common in Parkinson’s disease (PD) and predicts poor clinical outcomes. It is associated primarily with pathologic involvement of basal forebrain cholinergic and prefrontal dopaminergic systems. Impairments in executive functions, attention, and visuospatial abilities are its hallmark features with eventual involvement of memory and other domains. Subtle symptoms in the premotor and early phases of PD progress to mild cognitive impairment (MCI) which may be present at the time of diagnosis. Eventually, a large majority of PD patients develop dementia with advancing age and longer disease duration, which is usually accompanied by immobility, hallucinations/psychosis, and dysautonomia. Dopaminergic medications and deep brain stimulation help motor dysfunction, but may have potential cognitive side effects. Central acetylcholinesterase inhibitors, and possibly memantine, provide modest and temporary symptomatic relief for dementia, although there is no evidence-based treatment for MCI. There is no proven disease-modifying treatment for cognitive impairment in PD. The symptomatic and disease-modifying role of physical exercise, cognitive training, and neuromodulation on cognitive impairment in PD is under investigation. Multidisciplinary approaches to cognitive impairment with effective treatment of comorbidities, proper rehabilitation, and maintenance of good support systems in addition to pharmaceutical treatment may improve the quality of life of the patients and caregivers. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s13311-020-00963-x.

The research reported in this article was part of a larger study which took place in Abu Dhabi, United Arab Emirates. The large-scale education reform, being carried out at the time of the study, required paradigm shifts in practice; from a traditional to a constructivist approach. The education reform posed on-going challenges and posed questions regarding the future impact for teachers, particularly with respect to their beliefs with respect to classroom practice. This article describes the development and validation of a survey to assess teachers’ beliefs in this new context. The survey assesses teachers’ beliefs about their role in the classroom and philosophy of teaching and learning and their classroom practice. The translation validity of the survey was supported by examining the content and face validity. Further, analysis of the data collected 182 Arab teachers was used to provide support for the reliability and validity of the newly developed Teacher Belief Survey in terms of factor structure, internal consistency reliability, discriminant and concurrent validity. This instrument has the potential to be useful for ascertaining teachers’ professional development needs and for understanding the beliefs of student teachers. In regions of cross-cultural diversity the findings may assist in creating understanding and sensitivity of the cultural differences between people, their knowledge, perspectives and practices.

Learning environment research has a long history of significant relationships between the learning environment and student outcomes. This study investigated relationships between the learning environments of mathematics courses in a teacher education program and two outcomes, mathematics teaching self-efficacy and beliefs about mathematics. These two outcomes have been repeatedly shown to influence the future teaching practices of preservice teachers but, to date, their relationships with learning environment have been investigated neither with preservice teachers nor at all in the United Arab Emirates or wider Gulf region. The learning environment was found to be significantly related to preservice teachers’ mathematics teaching self-efficacy and beliefs about mathematics. Learning environments perceived more favourably by preservice teachers were associated with higher self-efficacy for teaching mathematics, but also with more-traditional beliefs, making these findings important for higher education institutes and teacher educators.

Hypothesis and background An elbow contracture in a young person can be a devastating problem. Significant contractures will lead to functional loss of the extremity. Appropriately performed contracture release can have profound implications on the overall well-being of the patient. The purpose of this study was to report improvements in sagittal-plane range of motion and the complication rate following an anterior elbow release for flexion contractures in patients 21 years or younger. Methods We performed a retrospective review of 27 patients with a median age of 16.8 years who were treated surgically for elbow flexion contracture with an anterior approach. Follow-up was possible in 18 of these patients at an average of 31 months. An anterior approach was performed in all 18 patients, with 4 patients undergoing an additional posterior incision to address posterior structures limiting extension. Results Elbow extension improved by an average of 35°, from –54° to –19°. The mean total arc of elbow motion improved by 37°, from 65° to 102°. Two complications occurred: traction-related neurapraxia of the lateral antebrachial cutaneous nerve and transient neurapraxia of the posterior interosseous nerve. Discussion and conclusion Elbow contracture release through an anterior approach is an acceptable surgical option. Significant improvement is obtained with a low risk of complications.

Because students who are considered to be at-risk of academic failure are more likely to experience a range of serious outcomes both at school and later in life, it is important for educators to provide a learning environment that supports these students. The aims of the study were two-fold. First, to better understand how educators might support students considered to be at-risk, we examined whether they perceived their learning environment and self-efficacy differently from their counterparts. Second, to provide insight into how teachers can improve their students’ self-efficacy, we investigated relationships between students’ perceptions of classroom environment and their self-efficacy. A survey was administered to a sample of 609 primary-school students in 31 classes. Practical insights from the results can assist teachers to create supportive learning environments that enhance self-efficacy and learning outcomes for all students, particularly those academically at-risk.

The focus of professional learning on activities has changed to internal growth or change among teachers. Our 3-year whole-school collaborative action research was based on student feedback from a learning environment survey at a secondary school. Quantitative data were obtained by administering a survey in 2012, 2013 and 2014 to 2673 students in 171 classes to assess perceptions of the learning environment. Qualitative information, involving classroom observations and interviews with the principal and professional development coordinator, illuminated how the school incorporated this collaborative action research approach. Statistically-significant differences for numerous aspects of the learning environment were found between the 2012, 2013 and 2014 student groups.

School climates are known to be associated with a range of student outcomes (including academic, social, behavioural and affective), and much work to date has focused on gathering students’ perceptions of their school climate to inform ongoing improvement efforts. However, parents and caregivers, as well as students, are also influenced by the psychosocial school climate. Although less attention has been given to capturing parents’ and caregivers’ perceptions, the way parents and caregivers feel about a school can affect their children’s attitudes towards the school as well as the parents’ and caregivers’ engagement with the school. Therefore, the perceptions of parents and caregivers with respect to the school climate offer critical information about both strengths and areas for improvement in terms of ensuring that schools are places that foster students’ wellbeing and achievement. In this article, we report the development and validation of the Parent and Caregiver Survey (PaCS) for gathering parents’ and caregivers’ perceptions of the socioemotional school climate. The PaCS is underpinned by strength-based and culturally-responsive perspectives on parent and caregiver engagement, as well as a socioecological perspective of child and adolescent development. Responses to the PaCS from 1276 parents and caregivers at 23 Australian schools confirmed the validity and reliability of the instrument. Given its theoretical underpinnings and successful validation, the PaCS could be useful for researchers and practitioners seeking to support parent engagement and school improvement.

Cognitive dysfunction is one of the most prevalent non-motor symptoms in patients with Parkinson's disease (PD). While it tends to worsen in the later stages of disease, it can occur at any time, with 15-20% of patients exhibiting cognitive deficits at diagnosis (Aarsland et al., 2010; Goldman and Sieg, 2020). The characteristic features of cognitive dysfunction include impairment in executive function, visuospatial abilities, and attention, which vary in severity from subtle impairment to overt dementia (Martinez-Horta and Kulisevsky, 2019). To complicate matters, cognitive dysfunction is prone to fluctuate in PD patients, impacting diagnosis and the ability to assess progression and decision-making capacity. The diagnosis of cognitive impairment or dementia has a huge impact on patient independence, quality of life, life expectancy and caregiver burden (Corallo et al., 2017; Lawson et al., 2016; Leroi et al., 2012). It is therefore essential that physicians caring for patients with PD provide education, screening and treatment for this aspect of the disease. In this chapter, we provide a practical guide for the assessment and management of various degrees of cognitive dysfunction in patients with PD by approaching the disease at different stages. We address risk factors for cognitive dysfunction, prevention strategies prior to making the diagnosis, available tools for screening. Lastly, we review aspects of care, management and considerations, including decision-making capacity, that occur after the patient has been diagnosed with cognitive dysfunction or dementia.

Background: Cervical Artery Dissection (CeAD) is an important cause of stroke in the young. Data on incidence and associations of recurrent CeAD are lacking. Increased Vertebral Artery Tortuosity Index (VTI) has been reported in patients with CeAD and associated with earlier age of arterial dissection in patients with connective tissue disease. We hypothesized that VTI may be associated with recurrent CeAD. Methods: We reviewed data from a large single-center registry of CeAD patients enrolled between 2011-2021. CT angiography (CTA) was reviewed for neck length, vertebral artery length (VAL), linear distance from the vertebral artery origin to the vertebrobasilar junction (VOBJ), and VTI [((VAL/VOBJ)–1)*100]. Recurrence was defined as radiographic diagnosis of a new dissection during a follow-up period between initial CTA imaging and July 1, 2021. Incidence rate of recurrent dissection was calculated using Poisson regression. Differences between groups were analyzed using the Kruskal-Wallis rank sum test and Fisher’s exact test. Results: The cohort included 155 patients: women (56%), mean (SD) age 42 (±10) years, and 116 single (carotid or vertebral) and 39 multiple artery dissections. Eight (5%) had a recurrence with a 10 year incidence rate (95% CI) of 1.23 events (0.53, 2.38) per 100 person-years. The recurrent group had a lower mean VTI than the nonrecurrent group (39.2 vs. 45.8; p = 0.024) and trended towards a lower mean age (34.6 vs. 42.3; p = 0.058). Participants with vertebral artery dissection were younger than those with carotid artery dissection with mean ages of 38.5 and 45.1 respectively (p < 0.001) and did not differ in mean VTI (46.0 vs. 44.9; p = 0.747). Morphometric characteristics of height, neck length, and BMI were not associated with recurrence. Conclusion: In this single center cohort of patients with CeAD, greater VTI was associated with a decreased risk of recurrent dissection. This finding is hypothesis generating as adults with recurrent dissections may have distinct mechanistic or genetic factors contributing to their risk of dissection. This study is limited by relatively small sample size and the retrospective analysis. Further study of VTI and risk of incident CeAD in larger independent cohorts is warranted.

Introduction: The Cincinnati Pre-Hospital Stroke Scale (CPSS) is one of the most utilized, validated tools for stroke assessment by emergency medical services (EMS) providers. While the CPSS was developed to convey that a patient has a positive or negative finding, EMS providers designate some patients with “inconclusive” CPSS. To date, there is no data concerning the clinical presentation or stroke diagnosis of this cohort of patients. Methods: Retrospectively reviewed prehospital electronic medical records from 26 EMS agencies linked with hospital data of patients stroke alerted between April 1, 2020 to July 12, 2021 in our institution. The National Emergency Medical Services Information System Technical Assistance Center (NEMSIS TAC) 2020 Dataset was also evaluated. Data collected included CPSS, EMS chief complaint, EMS primary impression, and final discharge diagnosis. Results: At our institution 362 patients arrived by EMS and were stroke alerted at the hospital, of which 311 patients had a recorded prehospital CPSS. CPSS was recorded as inconclusive in 33.4% (104/311), positive in 52.1% (162/311), and negative in 14.5% (45/311) of patients. Neurological symptoms accounted for 76.9% (80/104) of EMS primary impression for those classified as inconclusive. Sixty percent (48/80) and 18.8% (15/80) of those were stroke-like symptoms and altered mental status, respectively. Stroke/TIA was the discharge diagnosis for 30.8% (32/104) of inconclusive, 63.6% (103/162) of positive, and 37.8% (17/45) of negative CPSSs. Nationally, 7.3% (142,422/1,955,591) of prehospital patients with recorded CPSS had an inconclusive finding. Among patients with primary impression of stroke-like symptoms with recorded prehospital CPSS, 17.3% (21,740/125,581) had an inconclusive label. Conclusion: Inconclusive CPSS designations in the prehospital setting are common. Although these patients present commonly with stroke-like symptoms, they have a low rate of stroke diagnosis. More studies with available prehospital linked hospital data are needed at a national level to understand the inconclusive prehospital CPSS designation and inform proper EMS education on in-practice use of stroke screening tools that reduce the number of inconclusive CPSS.

Introduction: Genetic reference panels and imputation approaches have improved greatly in the last 10 years. The development of the TOPMed reference plane has led to enhanced imputation quality and quantity of single nucleotide polymorphisms (SNPs) due to greater sample diversity among various population ancestries. We revisited our prior GWAS of recurrent stroke by utilizing the TOPMed imputation server. Methods: This GWAS used a Cox proportional hazards model of time to recurrent stroke with the Vitamin Intervention for Stroke Prevention clinical trial cohort. There were 2,100 genotyped patients (64% male) in total with an average age of 67.2 (±10.8) years and ancestry distribution of 1,725 (82%) European, 258 (12%) African, and 117 (6%) Other or Mixed ancestry. Genotyped samples underwent a strict quality control process. We utilized TOPMed for imputation which totaled 10,467,887 biallelic SNPs which was 14 times greater in number compared the original analysis. Results: Recurrent stroke was observed in 182 (8.7%) patients. We identified seven novel SNPS on chromosome 1 in addition to our previous finding, rs6664786. Interestingly all chromosome 1 SNPs were located within the LINCO1362 gene. This gene has an acute change in expression in the presence of smoking even after adjustment of relevant clinical factors. Two novel SNPs were found on chromosome 16 located in gene desert nearest the pseudo-gene RNU6-21P in an intergenic region downstream of the Cadherin-8 (CDH8) gene. Both SNPs and RNU6-21P have no previously reported clinical relevance, except for their relative position to CDH8. CDH8 is highly expressed in brain tissue. Conclusions: We identified several novel SNPs associated with recurrent stroke. Capitalizing on genetic imputation advancements allows potential new insights and discoveries with past trial cohorts. Understanding these insights may provide further mechanistic knowledge of recurrent stroke to develop potential therapeutic targets.

Introduction: Emergency medical services (EMS) are often the first point of medical contact for patients suffering from acute stroke. EMS must identify and triage patients appropriately for them to receive the best care. Several prehospital stroke scales exist to assist prehospital providers in identifying acute stroke in the field, but their real-world applications are poorly characterized. Understanding prehospital stroke treatment provides the opportunity to identify areas of improvement across the stroke continuum of care. Methods: We retrospectively reviewed data from the 2019 National EMS Information System (NEMSIS) dataset from the United States of America. NEMSIS contains standardized information reported by states on EMS activations. Observations included were transported by ground ambulance and had an EMS provider documented stroke assessment with a primary impression of stroke or TIA. Observations excluded interfacility transfers and were limited to activations that documented pre-notification of hospital-based stroke specialty team resources. Results: EMS providers used a variety of stroke scales in 2019. Of 30,436 observations, the Cincinnati Prehospital Stroke Scale was the most common with 17,462 uses (57.37%). The F.A.S.T. Exam came second with 3366 (11.05%) uses and the Los Angeles Prehospital Stroke Scale with 3,146 (10.33%). EMS providers recorded “Other Stroke Scale Type” 4362 (14.33%) times. EMS providers documented either a negative or inconclusive stroke score 10,390 (34.13%) times. EMS documented stroke specialty team notifications 17,391 (57.14%) of the time. EMS did not pre-notify the stroke specialty team for 13,045 (42.86%) of patients. 3,576 (27.41%) of these patients received a negative stroke scale score, 1,745 (13.38%) inconclusive and 7,724 (59.21%) positive respectively. Among cases where EMS notified a stroke specialty team 1,590 (9.14%) received a negative, 2,479 (14.25%) an inconclusive and 13,322 (76.60%) a positive stroke scale score. Conclusion: US EMS stroke care documentation has substantial variability and is ripe for standardization. This fact necessitates research to understand its causes and achieve pre-hospital stroke care optimization on a national scale.

Introduction: Acute strokes necessitate streamlined communication between first responders and physicians regarding stroke signs ascertained in the field. Stroke alert protocols that dictate hospital resource activation contribute to the speed in which potential cases are assessed and treated. We studied associations between EMS stroke pre-notification and ED stroke alert activation behavior at a Comprehensive Stroke Center. Methods: This retrospective chart review identified patients who arrived via EMS and were ultimately stroke alerted from the ED between April 2020 and July 2021. Data was collected manually through a state-wide EMS record exchange and internal hospital databases to include EMS documentation of attempts to alert the ED to stroke, time of ED stroke alert activation, and final discharge diagnosis. Descriptive statistics are presented as counts and percentages. Results: Among the 472 cases of stroke alerted patients, 214 (45.3%) were discharged with a final diagnosis of acute stroke. There were 167 (35.4%) patients where EMS documented attempts to pre-notify the hospital of a potential stroke, versus 210 (45%) whose records lacked explicit note of pre-notification. EMS records could not be found in 94 (20.2%) cases. Among 167 known cases where EMS attempted hospital pre-notification, the ED activated a stroke alert prior to hospital arrival in 69 (41.3%). Among 210 cases where EMS did not record pre-notification, the ED stroke pre-alerted 23 (11.0%), suggesting gaps in EMS documentation of completed stroke pre-notifications. Of 94 patients who lacked EMS records, 29 (30.9%) were pre-alerted to stroke by the ED. Finally, among 214 patients discharged with acute stroke, 96 (44.9%) had documented EMS stroke pre-notifications, of which 46 (21.5%) received ED pre-alerts. An additional 24 (11.2%) stroke patients who lacked sufficient documentation were stroke alerted by the ED prior to hospital arrival. Conclusions: Quality in communications spanning from EMS to physicians is a crucial prerequisite to timely stroke care. Gaps in EMS records and ED stroke alert activation lend support to a need for standardization in stroke documentation and stroke alert protocols, which may streamline data access and improve patient experience of care.