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UNSTRUCTURED For many older Americans, aging in place is their preferred living arrangement. Minoritized and socioeconomically disadvantaged older adults are up to three times more likely to experience disability than other groups, which increases their likelihood of being unable to age in place. Bold ideas to facilitate aging in place, particularly among vulnerable populations, are needed. One such idea is the Unite care model, a community-initiated, academic supported, cross-sector initiative that combines two sectors: housing and health care. The Unite care model co-locates a Federally Qualified Health Center (FQHC) clinic on an older adult affordable housing campus in Flint, Michigan. A concurrent exploratory mixed methods approach will be used to evaluate the implementation of the Unite care model. We will first assess the implementation and impact of the Unite care model in terms of acceptability, adoption, and penetration among key stakeholder groups using an exploratory mixed methods design. We will then determine which older adults utilize the Unite care model and whether the model promotes aging in place through risk factor reduction and improvement in physical and social environment. If successful, the Unite care model could serve as a new care model to promote aging in place among older adults living in poverty and older Black Americans. The results of this proposal will inform whether larger-scale testing of this new model of care is warranted.

Introduction: Mexican Americans (MAs) use less preventative healthcare than NHWs and this may result in in more emergency department (ED) visits or readmissions. We sought to explore ethnic differences in ED and hospital utilization immediately before and after stroke. Methods: BASIC is a stroke epidemiologic study in Corpus Christi TX. We performed probabilistic matching to identify hospital claims for all BASIC-identified index strokes (ischemic or ICH) from 2010-2020 continuously enrolled in Medicare fee-for-service (FFS). Matching was performed using demographics (including date of birth), stroke admission/discharge dates, vascular risk factors, comorbidities, and in-hospital procedures. All emergency department (ED) visits and hospital readmissions within 90 days before and after the index stroke were identified using Medicare claims. Logistic regression models were used to determine the association of MA ethnicity (compared to NHWs) with prior ED/inpatient visits and cox regression models were used to estimate the associations with subsequent ED visits/readmissions (censoring at death), adjusting for patient age, sex, stroke severity, and stroke type. Results: We identified 1,180 incident BASIC strokes that could be matched with Medicare FFS inpatient claims: 84% with ischemic stroke, 46.2% NHWs vs 45.7% MAs, mean age 76.4, median (IQR) NIHSS 5 (2-13). Both ED visits and hospitalizations were relatively common before and after stroke (Table). Compared to NHWs, MAs were more likely to have ED visits before stroke than NHWs (OR 1.5, 95%CI [1.1-2.1]) and hospitalizations after stroke (HR 1.3, [1.1-1.7], but no ethinc differences were observed in pre-stroke hospitalizations or post-stroke ED visits. ( Table ) Conclusion: The increased rate of pre-stroke ED visits in MAs suggests the potential for missed opportunities to prevent stroke may exist and merits further scrutiny.

Background: Dementia is a common disease in aging populations. The treatment has mainly focused on memory decline prevention and behavior control. Nonpharmacological treatments, such as cognition training, physical exercise, and music therapy have been effective in slowing memory decline. Chinese calligraphy handwriting (CCH) through breath regulation and fine hand control involves high concentration levels, emotion regulation, and self-awareness. CCH is a mind and body activity that is culturally relevant to older Chinese adults. This study evaluated the beneficial effects of CCH on mild cognitive impairment. Methods: In 2018, we conducted 8 weeks of CCH training at the Tri-Service General Hospital. The participants were asked to copy a regular script. At the end of the course, they gave oral presentations and showed their work. Self-report questionnaires on emotion, memory, upper limb coordination, attention, and language were collected before and after training. Results: The five questionnaires showed significantly positive feelings after CCH training. The conditions of emotional stability, concentration, hand movement, memory, and speech improved. Conclusions: CCH training stimulated the brain and improved cognition, psychological symptoms, and hand stability. It is inexpensive and worthwhile for elderly Chinese individuals with mild cognitive impairment to take time daily to practice calligraphy.

Diffusely infiltrating gliomas are associated with high morbidity and mortality due to the infiltrative nature of tumor spread. They are morphologically complex tumors, with a high degree of proteomic variability across both the tumor itself and its heterogenous microenvironment. The malignant potential of these tumors is enhanced by the dysregulation of proteins involved in several key pathways, including processes that maintain cellular stability and preserve the structural integrity of the microenvironment. Although there have been numerous bulk and single-cell glioma analyses, there is a relative paucity of spatial stratification of these proteomic data. Understanding differences in spatial distribution of tumorigenic factors and immune cell populations between the intrinsic tumor, invasive edge, and microenvironment offers valuable insight into the mechanisms underlying tumor proliferation and propagation. Digital spatial profiling (DSP) represents a powerful technology that can form the foundation for these important multilayer analyses. DSP is a method that efficiently quantifies protein expression within user-specified spatial regions in a tissue specimen. DSP is ideal for studying the differential expression of multiple proteins within and across regions of distinction, enabling multiple levels of quantitative and qualitative analysis. The DSP protocol is systematic and user-friendly, allowing for customized spatial analysis of proteomic data. In this experiment, tissue microarrays are constructed from archived glioblastoma core biopsies. Next, a panel of antibodies is selected, targeting proteins of interest within the sample. The antibodies, which are preconjugated to UV-photocleavable DNA oligonucleotides, are then incubated with the tissue sample overnight. Under fluorescence microscopy visualization of the antibodies, regions of interest (ROIs) within which to quantify protein expression are defined with the samples. UV light is then directed at each ROI, cleaving the DNA oligonucleotides. The oligonucleotides are microaspirated and counted within each ROI, quantifying the corresponding protein on a spatial basis.

Removal of baseline wander (BW) is an important preprocessing step before manually or automatically interpreting electrocardiogram (ECG) records. It is a challenging issue to fully remove BW while preserving original clinical information because BW is usually mingled with low-frequency ECG components. A dual-adaptive approach based on discrete cosine transform (DCT) is presented in this study. Firstly, the cardiac fundamental frequency (CFF) of ECGs is accurately calculated through DCT domain analysis. Secondly, DCT coefficients of ECGs, whose frequencies are below CFF, are used to construct an amplitude vector in which the optimal cut-point between BW and ECGs is distinctly reflected. Finally, a new filtering technique based on DCT is exploited to suppress BW with its cutoff frequency adjusted to the optimal cut-point. The proposed method is applied to both real ECG records and simulated ECGs with its results compared to those of three previous methods published in the literature. The experimental results show that substantial improvements in performance can be achieved when adopting this dual-adaptive approach.

Binary expression systems are useful genetic tools for experimentally labeling or manipulating the function of defined cells. The Q-system is a repressible binary expression system that consists of a transcription factor QF (and the recently improved QF2/QF2

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Institutional-level disparities in non-small cell lung cancer (NSCLC) survival may be driven by reversible differences in care-delivery processes. We quantified the impact of differences in readily identifiable quality metrics on long-term survival disparities in resected NSCLC.How do reversible differences in oncologic quality of care contribute to institutional-level disparities in early-stage NSCLC survival?We retrospectively analyzed patients in the National Cancer Data Base who underwent NSCLC resection from 2004 through 2015 within institutions categorized as Community, Comprehensive Community, Integrated Network, Academic, and National Cancer Institute (NCI)-Designated Cancer Programs. We estimated percentages and adjusted ORs for six potentially avoidable poor-quality markers: incomplete resection, nonexamination of lymph nodes, nonanatomic resection, non-evidence-based use of adjuvant chemotherapy, non-evidence-based use of adjuvant radiation therapy, and 60-day postoperative mortality. By sequentially eliminating patients with poor-quality markers and calculating adjusted hazard ratios, we quantified their overall survival impact.Of 169,775 patients, 7%, 46%, 10%, 24%, and 12% underwent surgery at Community, Comprehensive Community, Integrated Network, Academic, and NCI-Designated Cancer Programs, with 5-year overall survival rates of 52%, 56%, 58%, 60% and 66%, respectively. After the sequential elimination process, using NCI-Designated Cancer Centers as a reference, the adjusted hazard ratio for 5-year overall survival changed from 1.47 (95% CI, 1.41-1.53), 1.29 (95% CI, 1.25-1.33), 1.18 (95% CI, 1.14-1.23), and 1.20 (95% CI, 1.16-1.24) for Community, Comprehensive Community, Integrated Networks, and Academic Cancer Programs to 1.35 (95% CI, 1.28-1.42), 1.22 (95% CI, 1.17-1.26), 1.16 (95% CI, 1.11-1.22), and 1.17 (95% CI, 1.12-1.21), respectively (P .001 for all comparisons with NCI-designated programs). Differences in quality of surgical resection and postoperative care accounted for 11% to 26% of the interinstitutional survival disparities.Targeting six readily identified poor-quality markers narrowed, but did not eliminate, institutional survival disparities. The greatest impact was in community programs. Residual factors driving persistent institution-level long-term NSCLC survival disparities must be characterized to eliminate them.

Gallium doped ZnO (GZO) top electrode thickness dependence of resistive switching characteristic of GZO/ZnO2/ZnO/ITO transparent valence change memory device is investigated. The thickness of the GZO top electrode modulates the resistance of the pristine device. Devices made with thicker GZO layer have higher leakage current; thus, require higher current compliance. An excessively high current compliance leads to a device breakdown upon reset process. Conversely, a very low current compliance may form a tiny conducting filament and is difficult to rejuvenate after the rupture; thus, its cycle-to-cycle characteristic shows a decaying behavior. Nevertheless, transparent valence change devices with a stable endurance and sufficient memory window that operate at a moderate level of current compliance are successfully fabricated by employing an appropriate thickness of the top electrode. We suggest that a good switch-ability of transparent valence change memory devices are strongly affected by the thickness of the top electrode.

Rationale, aims and objectives Little is known about which medical providers, other than neurologists, are involved in the care of neurologic conditions. We aimed to describe the current distribution of outpatient neurologic care by provider type. Methods We conducted a restrospective, cross-sectional analysis using a 20% national sample claims database that contains information on medical care utilizations from adult Fee-for-Service Medicare beneficiaries in 2015. We identified patient visits for evaluation and management services for common neurologic conditions and by medical provider type. The main outcome was the proportion of visits for neurologic conditions by medical provider type, both in aggregate and across neurologic conditions. Results 40% of neurologic visits were performed by primary care providers (PCPs) and 17.5% by neurologists. The most common neurologic conditions were back pain (49.3%), sleep disorders (8.0%), chronic pain/abnormality of gait (6.4%), peripheral neuropathy (5.9%), and stroke (5.5%). Neurologists cared for a large proportion of visits for Parkinson's disease (75.6% vs 20.8%), epilepsy (70.9% vs 26.6%), multiple sclerosis (63.9% vs 26.2%), other central NS disorders (54.2% vs 24.9%), and tremor/RLS/ALS (54.0% vs 31.2%) compared to PCPs. PCPs provided a greater proportion of visits for dizziness/vertigo (57.8% vs 9.3%) and headache/migraine (50.4% vs 35.0%) compared to neurologists. Conclusions PCPs perform more neurologic visits than neurologists. With the anticipated increased demand for neurologic care, strategies to optimize neurologic care delivery could consider expanding access to neurologists as well as supporting PCP care for neurologic conditions.

This study examines the destination image and lifestyle experience via traveler-generated comments. To understand the travelers’ behavior, we first established a crawler, which helps us to gather the travelers’ comments from tourism social media. After conducting a content analysis, text mining, and factor analysis of a sampling of 23,019 travelers’ comments, this study found that travelers based on their activities and experiences constructed their image. Additionally, we also found that the travelers’ emotions and impressions showed up with their images. From the result of factor analysis, we extract the 13 clustering results and perform the one-way ANOVA with Scheffe’s method to compare the difference among each group. Finally, we used the related sentences to draw a relation map to explain the inner difference between travelers. This study’s results suggest that traveler-generated comments can be especially useful for destination image analysis and market segments in tourism marketing and management. This study also highlights the importance of understanding destination image and marketing segment from the travelers’ comments and challenges for those in tourism marketing to narrow the gap.

Acute optic neuritis (ON) is variably treated with glucocorticoids. We aimed to describe factors associated with glucocorticoid use. In this retrospective, longitudinal cohort study of insured patients in the United States (2005–2019), adults 18–50 years old with one inpatient or ≥2 outpatient diagnoses of ON within 90 days were included. Glucocorticoid use was classified as none, any dose, and high-dose (>100 mg prednisone equivalent ≥1 days). The primary outcome was glucocorticoid receipt within 90 days of the first ON diagnosis. Multivariable logistic regression models assessed the relationship between glucocorticoid use and sociodemographics, comorbidities, clinician specialty, visit number, and year. Of 3026 people with ON, 65.8% were women (n = 1991), median age (interquartile range) was 38 years (31,44), and 68.6% were white (n = 2075). Glucocorticoids were received by 46% (n = 1385); 54.6% (n = 760/1385) of whom received high-dose. The odds of receiving glucocorticoids were higher among patients with multiple sclerosis (OR 1.61 [95%CI 1.28–2.04]; P < .001), MRI (OR 1.75 [95%CI 1.09–2.80]; P = .02), 3 (OR 1.80 [95%CI 1.46–2.22]; P < .001) or more (OR 4.08 [95%CI 3.37–4.95]; P < .001) outpatient ON visits, and in certain regions. Compared to ophthalmologists, patients diagnosed by neurologists (OR 1.36 [95%CI: 1.10–1.69], p = .005), emergency medicine (OR 3.97 [95%CI: 2.66–5.94]; P < .001) or inpatient clinicians (OR 2.94 [95%CI: 2.22–3.90]; P < .001) had higher odds of receiving glucocorticoids. Use increased 1.1% annually (P < .001). Demyelinating disease, care intensity, setting, region, and clinician type were associated with glucocorticoid use for ON. To optimize care, future studies should explore reasons for ON care variation, and patient/clinician preferences.

A surgical temporal artery biopsy (TAB) is the gold standard for diagnosis of giant cell arteritis (GCA). The necessity of performing a bilateral biopsy remains under debate. The primary objective of this study was to assess the rate of discordance between pathology results in patients who underwent bilateral TAB for suspected GCA.We performed a retrospective review of patients who underwent bilateral TAB for the diagnosis of GCA between 2011 and 2020. The primary end point was the rate of discordance between specimens for patients with pathology positive GCA. Secondary end points included assessments of the sensitivity of preoperative temporal artery duplex and the effects of specimen length and specialty of referring provider on the diagnostic yield of the biopsy.During the study period, 310 patients underwent bilateral TAB for the diagnosis of GCA. These patients were primarily female (73.9%), elderly (mean age, 70.8 years), and Caucasian (95.8%). Preoperative symptoms for patients were typically bilateral (59%) and included headache (81%), vision changes (45.2%), and temporal tenderness (32.6%). Most patients (85.2%) were on preoperative steroid therapy at the time of surgical biopsy with a mean preoperative duration of steroid therapy of 15.1 days. Overall, 91 patients (29.4%) had a positive pathologic diagnosis after bilateral TAB. Of these patients, 11 had a positive pathology result in only a single specimen, resulting in a discordance rate of 12.1%. Preoperative temporal artery duplex demonstrated a low sensitivity (27.3%) for identifying patients with pathologic positive disease. There were no significant differences between the pathology-positive and -negative patients in terms of mean surgical specimen length (1.67 cm vs 1.64 cm; P = .67) or the specialty of the referring provider (P = .73).At our institution, we observed a 12.1% discordance rate between pathology results in patients who underwent bilateral TAB for diagnosis of GCA. A preoperative temporal artery duplex provided little value in identifying patients with biopsy-proven GCA.

Background and ObjectiveTo assess the accuracy of definitions of drug-resistant epilepsy applied to administrative claims data.MethodsWe randomly sampled 450 patients from a tertiary health system with ≥1 epilepsy/convulsion encounter, ≥2 distinct antiseizure medications (ASMs) from 2014 to 2020, and ≥2 years of electronic medical records (EMR) data. We established a drug-resistant epilepsy diagnosis at a specific visit by reviewing EMR data and using a rubric based on the 2010 International League Against Epilepsy definition. We performed logistic regressions to assess clinically relevant predictors of drug-resistant epilepsy and to inform claims-based definitions.ResultsOf 450 patients reviewed, 150 were excluded for insufficient EMR data. Of the 300 patients included, 98 (33%) met criteria for current drug-resistant epilepsy. The strongest predictors of current drug-resistant epilepsy were drug-resistant epilepsy diagnosis code (odds ratio [OR] 16.9, 95% confidence interval [CI] 8.8–32.2), ≥2 ASMs in the prior 2 years (OR 13.0, 95% CI 5.1–33.3), ≥3 nongabapentinoid ASMs (OR 10.3, 95% CI 5.4–19.6), neurosurgery visit (OR 45.2, 95% CI 5.9–344.3), and epilepsy surgery (OR 30.7, 95% CI 7.1–133.3). We created claims-based drug-resistant epilepsy definitions (1) to maximize overall predictiveness (drug-resistant epilepsy diagnosis; sensitivity 0.86, specificity 0.74, area under the receiver operating characteristics curve [AUROC] 0.80), (2) to maximize sensitivity (drug-resistant epilepsy diagnosis or ≥3 ASMs; sensitivity 0.98, specificity 0.47, AUROC 0.72), and (3) to maximize specificity (drug-resistant epilepsy diagnosis and ≥3 nongabapentinoid ASMs; sensitivity 0.42, specificity 0.98, AUROC 0.70).DiscussionOur findings provide validation for several claims-based definitions of drug-resistant epilepsy that can be applied to a variety of research questions.

Resected lesions from the pineal region are rare specimens encountered by surgical pathologists, and their heterogeneity can pose significant diagnostic challenges. Here, we reviewed 221 pineal region lesions resected at New York-Presbyterian Hospital/Columbia University Irving Medical Center from 1994 to 2019 and found the most common entities to be pineal parenchymal tumors (25.3%), glial neoplasms (18.6%), and germ cell tumors (17.6%) in this predominantly adult cohort of patients. Six cases of a rare midline entity usually found exclusively in the fourth ventricle, the rosette-forming glioneuronal tumor, were identified. These tumors exhibit biphasic morphology, with a component resembling pilocytic astrocytoma admixed with variable numbers of small cells forming compact rosettes and perivascular pseudorosettes. Targeted sequencing revealed a 100% co-occurrence of novel and previously described genetic alterations in the mitogen-activated protein kinase (MAPK) and phosphoinositide 3-kinase (PI3K) signaling pathways, suggesting a synergistic role in tumor formation. The most common recurrent mutation, PIK3CA H1047R, was identified in tumor cells forming rosettes and perivascular pseudorosettes. A review of the literature revealed 16 additional cases of rosette-forming glioneuronal tumors in the pineal region. Although rare, this distinctive low-grade tumor warrants consideration in the differential diagnosis of pineal region lesions.

Stroke is a leading cause of mortality. Over 30% of older adult patients with stroke die within a year of their stroke, of which over half of the deaths are after the hospitalization.1 Posthospitalization mortality is due to various etiologies (e.g., recurrent stroke, ischemic heart disease, and cancer).2 As a consequence, most stroke survivors have both a good reason and sufficient time to engage in advance care planning (ACP).

BACKGROUND To the authors' knowledge, little is known regarding the impact of the Patient Protection and Affordable Care Act (ACA) on people living with HIV and cancer (PLWHC), who have lower cancer treatment rates and worse cancer outcomes. To investigate this research gap, the authors examined the effects of the ACA on insurance coverage and receipt of cancer treatment among PLWHC in the United States. METHODS HIV-infected individuals aged 18 to 64 years old with cancer diagnosed between 2011 and 2015 were identified in the National Cancer Data Base. Health insurance coverage and cancer treatment receipt were compared before and after implementation of the ACA in non-Medicaid expansion and Medicaid expansion states using difference-in-differences analysis. RESULTS Of the 4794 PLWHC analyzed, approximately 49% resided in nonexpansion states and were more often uninsured (16.7% vs 4.2%), nonwhite (65.2% vs 60.2%), and of low income (36.3% vs 26.9%) compared with those in Medicaid expansion states. After 2014, the percentage of uninsured individuals decreased in expansion states (from 4.9% to 3%; P = .01) and nonexpansion states (from 17.6% to 14.6%; P = .06), possibly due to increased Medicaid coverage in expansion states (from 36.9% to 39.2%) and increased private insurance coverage in nonexpansion states (from 29.5% to 34.7%). There was no significant difference in cancer treatment receipt noted between Medicaid expansion and nonexpansion states. However, the percentage of PLWHC treated at academic facilities increased significantly only in expansion states (from 40.2% to 46.7% [P

Background Growing evidence shows links between septicaemia and non-multiple sclerosis demyelinating syndromes (NMSDS); nevertheless, epidemiological data are still very limited. This study aimed to explore the relationship between septicaemia and NMSDS in a general population. Methods The study included 482 781 individuals diagnosed with septicaemia and 1 892 825 age/sex-matched non-septicaemia patients for the comparison. Data were drawn from a population-based nationwide National Health Insurance Research Database Taiwan, from 1 January 2002 to 31 December 2011. The two cohorts of patients with and without septicaemia were followed up for the occurrence of NMSDS. The Cox-proportional hazard regression model was performed to estimate adjusted HR after multivariate adjustment. Results Individuals with septicaemia had a 4.17-fold (95% CI 3.21 to 5.4, p < 0.001) higher risk to develop NMSDS compared with those without septicaemia. Patients aged Conclusions Our results indicated that patients with septicaemia were likely to develop NMSDS. A possible contributing role of septicaemia in increasing the hazard of NMSDS is proposed, based on the outcome that individuals with higher severity of septicaemia carried elevated threat of encountering NMSDS.

Background Primary headache disorders (PHDs) are associated with sleep problems. It is suggested that headache and sleep disorder share anatomical and physiological characteristics. We hypothesised that patients with PHDs were exposed to a great risk for developing sleep apnoea (SA). Methods In this retrospective longitudinal study, the data obtained from the Longitudinal Health Insurance Database in Taiwan were analysed. The study included 1346 patients with PHDs who were initially diagnosed and 5348 patients who were randomly selected and age/sex matched with the study group as controls. PHDs, SA, comorbidities and other confounding factors were defined based on International Classification of Diseases, Ninth Revision, Clinical Modification. Cox proportional hazards regressions were employed to examine adjusted HRs after adjusting with confounding factors. Results Our data revealed that patients with PHDs had a higher risk (HR 2.17, 95% CI 1.259 to 3.739, p Conclusion Our results suggest that PHDs are linked to an increased risk for SA with sex-dependent and time-dependent characteristics.

OBJECTIVE: To determine the association of a neurologist visit with health care use and cost outcomes for patients with incident epilepsy. METHODS: Using health care claims data for individuals insured by United Healthcare from 2001 to 2016, we identified patients with incident epilepsy. The population was defined by an epilepsy/convulsion diagnosis code (ICD codes 345.xx/780.3x, G40.xx/R56.xx), an antiepileptic prescription filled within the succeeding 2 years, and neither criterion met in the 2 preceding years. Cases were defined as patients who had a neurologist encounter for epilepsy within 1 year after an incident diagnosis; a control cohort was constructed with propensity score matching. Primary outcomes were emergency room (ER) visits and hospitalizations for epilepsy. Secondary outcomes included measures of cost (epilepsy related, not epilepsy related, and antiepileptic drugs) and care escalation (including EEG evaluation and epilepsy surgery). RESULTS: After participant identification and propensity score matching, there were 3,400 cases and 3,400 controls. Epilepsy-related ER visits were more likely for cases than controls (year 1: 5.9% vs 2.3%, p < 0.001), as were hospitalizations (year 1: 2.1% vs 0.7%, p < 0.001). Total medical costs for epilepsy care, nonepilepsy care, and antiepileptic drugs were greater for cases (p ≤ 0.001). EEG evaluation and epilepsy surgery occurred more commonly for cases (p ≤ 0.001). CONCLUSIONS: Patients with epilepsy who visited a neurologist had greater subsequent health care use, medical costs, and care escalation than controls. This comparison using administrative claims is plausibly confounded by case disease severity, as suggested by higher nonepilepsy care costs. Linking patient-centered outcomes to claims data may provide the clinical resolution to assess care value within a heterogeneous population.

To evaluate targetable mutations and molecular genetic pathways in conjunctival melanoma with clinical correlation.Observational case series.Patients with conjunctival melanoma.Mutational profile of the tumor by next-generation sequencing (NGS), alternative lengthening of telomeres (ALT) by fluorescence in situ hybridization (FISH), and ATRX immunohistochemistry. Outcomes at 2 years and 5 years of tumor-related metastasis and death were recorded.Of the 101 patients, mean age at presentation was 60 years, 52% were male, and 88% were White. The NGS panels initially targeted BRAF only (n = 6, 6%), BRAF/NRAS (n = 17, 17%), and BRAF/NRAS/NF1 (n = 10, 10%). Sixty-eight tumors were tested with the expanded 592-gene panel. Next-generation sequencing identified high-frequency mutations in NF1 (29/74, 39%), BRAF (31/101, 31%), NRAS (25/95, 26%), and ATRX (17/68, 25%). Of those with an ATRX mutation, 12 (71%) had an additional NF1 mutation. A subset analysis of 21 melanomas showed that the ATRX mutation was associated with loss of ATRX protein expression and ALT. Loss of ATRX expression and ALT were present in both intraepithelial and invasive tumors, suggesting that an ATRX mutation is an early event in conjunctival melanoma progression. The NF1 and ATRX mutations were associated with tarsal (vs. nontarsal) tumors (NF1: 28% vs. 9%, P = 0.035, ATRX: 41% vs. 14%, P = 0.021) and orbital (vs. nonorbital) tumors (ATRX: 24% vs. 2%, P = 0.007). ATRXThis study confirms the high frequency of previously documented BRAF and NRAS mutations and recently reported ATRX and NF1 mutations in conjunctival melanoma. An NRAS mutation implied increased risk for metastasis and death. Loss of ATRX and ALT may be early events in conjunctival melanoma development.

Introduction: Acute stroke treatments are underutilized in the USA. Enhancing stroke preparedness, the recognition of stroke symptoms, and intent to call emergency medical services (EMS) could reduce delay in hospital arrival thereby increasing eligibility for time-sensitive stroke treatments. Whether higher stroke preparedness is associated with higher tissue plasminogen activator (tPA) treatment rates is however uncertain. We therefore set out to determine the contribution of stroke preparedness to regional variation in tPA treatment. Methods: The region was defined by hospital service area (HSA). Stroke preparedness was determined by using Behavioral Risk Factor Surveillance System survey questions assessing stroke symptom recognition and intent to call 911 in response to a stroke. We used Medicare data to determine the percentage of tPA-treated hospitalized stroke patients in 2007, 2009, and 2011, adjusting for number of stroke hospitalizations in each HSA (primary outcome). We performed multivariate linear regression to estimate the association of regional stroke preparedness on log-transformed tPA treatment rates controlling for demographic, EMS, and hospital characteristics. Results: The adjusted percentage of stroke patients receiving tPA ranged from 1.4% (MIN) to 11.3% (MAX) of stroke/TIA hospitalizations. Across HSAs, a median (IQR) of 86% (81–90%) of responses to a witnessed stroke indicated intent to call 911, and a median (IQR) of 4.4 (4.2–4.6) out of 6 stroke symptoms was recognized. Every 1% increase in an HSA’s intent to call 911 was associated with a 0.44% increase in adjusted tPA treatment rate (p = 0.05). Lower accuracy of recognition of stroke symptoms was associated with higher adjusted tPA treatment rates (p = 0.05). Conclusions: There was little regional variation in intent to call EMS and stroke symptom recognition. Intent to call EMS and stroke symptom recognition are modest contributors to regional variation in tPA treatment.