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Fisher M. Mechanisms of Cerebral Microvascular Disease in Chronic Kidney Disease. J Stroke Cerebrovasc Dis 2020; 30:105404. [PMID: 33272863 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 09/30/2020] [Accepted: 10/08/2020] [Indexed: 10/22/2022] Open
Abstract
Numerous studies report linkage between chronic kidney disease (CKD) and cerebrovascular disease. This association has been particularly strong for cerebral small vessel disease. Significant findings have emerged from studies ranging from case reports, small case series, and larger cohort investigations. The latter show a relationship between declining renal function, microvascular disease, and cognitive impairment. One troubling aspect has been the relative paucity of mechanistic investigations addressing the CKD-cerebrovascular disease linkage. Nevertheless, mechanistic observations have begun to emerge, showing cerebral microhemorrhage development in animal models of CKD independent of hypertension, an important co-morbidity in clinical studies. Initial cell culture studies show endothelial monolayer disruption by CKD serum, consistent with blood-brain barrier injury. It is noteworthy that CKD serum is known to contain multiple plausible mediators of microvascular injury. Further studies are on the horizon to address the critical question of potential linkage of renal dysfunction with vascular cognitive impairment.
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Fisher M, Phoenix D, Powell S, Mousa M, Rosenberg S, Greenia D, Corrada MM, Kawas C, Paganini-Hill A. Cognition and Political Ideology in Aging. J Am Geriatr Soc 2020; 69:762-766. [PMID: 33128770 DOI: 10.1111/jgs.16935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/21/2020] [Accepted: 10/22/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The impact of cognitive function and decline on political ideology is unknown. We studied the relationship between cognition and both political orientation and political policy choices in a population of older persons. DESIGN Longitudinal investigation. SETTING A retirement community and its surroundings in Southern California. PARTICIPANTS 151 members of a longitudinal investigation of aging and dementia in the oldest-old (the 90+ Study), mean age 95 years. MEASUREMENTS Participants self-reported their political ideology (7-point scale from extremely liberal to extremely conservative) and policy preferences for federal spending on public schooling, aid to the poor, and protecting the environment, as well as on preferences on immigration rates, death penalty, and university admission. The same political survey was mailed to participants twice: at time one and 6-months later. Cognitive function based on neurological examination and cognitive testing was classified as normal (55%), cognitive impairment/not dementia (CIND) (33%), or dementia (12%). We calculated rank correlations between ideology and policy choices, stratified by cognitive status, and agreement between Surveys 1 and 2. RESULTS Political ideology/orientation was highly consistent over a six-month period (84% agreement) among the 122 who returned the second survey, with no significant relationship to cognitive status. Among cognitively impaired (CIND and dementia), however, there was significant loss of consistency between an individual's political orientation and their policy choices. Level of political engagement was high for participants, with more than 90% voting in the 2016 presidential election. CONCLUSION In this population of older persons, political identification on the liberal-conservative spectrum was resilient despite cognitive decline, but its meaning and function were changed. For the cognitively impaired it remained a self-defining label, but no longer operated as a higher order framework for orienting specific policy preferences. There appeared to be loss of coherence between the political orientation and political policy choices of cognitively impaired individuals. Given the high level of political engagement of these individuals, these results have substantial public policy implications.
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Fisher M, Lau WL. Of Microbiomes and Microbleeds: A New Piece of the Puzzle? Stroke 2020; 51:3489-3491. [PMID: 33148141 DOI: 10.1161/strokeaha.120.032422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Khand A, Obeidat M, Campbell M, Batouskaya K, Mullen L, Fisher M, Neoh K, Johnson C, Chew P, Carlton E, Backus B. Modified HEART score, utilising a single high-sensitive troponin sample, allows early, safe discharge of suspected acute coronary syndrome: a prospective multicentre cohort study of 3016 patients. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Combining HSTnT (high sensitive troponin T) values at low levels with composite risk scores may improve early safe, discharge in suspected acute coronary syndromes (ACS). We tested this hypothesis by a prospective study of 3016 consecutive patients with suspected ACS in 2 large hospitals.
Methods
Consecutive chest pain (CP) presentations with HSTnT sampled and ECG undertaken at presentation were prospectively defined in 2 time periods (2011-12, n=1642 [derivation] 2018, n=1376 [validation]).
The HstnT input was modified: dichotomous HSTnT input was lowered to <5 (limit of detection, LOD) or ≥5ng/l (mod TIMI and GRACE), HEART score was re-calibrated (<5 = 0 [LOD], ≥5–14 = 1, >14 = 2 [99th percentile]). All biomarker positive CP index and re-admissions to any regional hospital (catchment population 2.6 million) were independently adjudicated for MI by 2 experienced physicians. Primary outcome was MACE (adjudicated type 1 MI, unplanned coronary revascularisation and all cause death) at 6 weeks.
Results
In the 2 cohorts demographic factors were similar: median age 59 and 56, male 52% and 52%, previous MI 20% and 14% for 2011-12 and 2018 respectively. At 6 weeks 180 (11%) and 75 (5.4%) suffered type 1 MI and 211 (12.9%) and 92 (6.7%) patients suffered MACE in the 2011-12 and 2018 cohorts respectively.
Only Mod HEART ≤3 and undetectable HSTnT, with a nonischaemic ECG, achieved prespecified NPV of >99.5% in both derivation and validation cohorts (table). However Modified HEART ≤3 score could discharge approximately 12% more patients as compared to undetectable HSTnT strategy.
Conclusion
Modified HEART score ≤3, with the use of a single HSTnT, appears the optimum early discharge strategy for suspected ACS
Funding Acknowledgement
Type of funding source: Public Institution(s). Main funding source(s): Liverpool university Hospitals, North-West Educational Cardiac Group
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MacKechnie-Guire R, Fisher M, Pfau T. Effect of a Half Pad on Pressure Distribution in Sitting Trot and Canter Beneath a Saddle Fitted to Industry Guidelines. J Equine Vet Sci 2020; 96:103307. [PMID: 33349411 DOI: 10.1016/j.jevs.2020.103307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 10/13/2020] [Accepted: 10/13/2020] [Indexed: 11/17/2022]
Abstract
Using a half pad beneath a saddle can be beneficial for improving saddle fit. However, there is a paucity of evidence on half pad use when used beneath a correctly fitted saddle. The aim was to quantify the effect that three different half pads have on pressure distribution beneath a saddle fitted following industry guidelines. Twelve nonlame horses were ridden by experienced riders in sitting trot and canter on each rein (three repeats). Saddle fit, with a high-withered cotton saddle cloth (control) compared with three half pads (viscoelastic gel, wool, and medical-grade, closed-cell foam), was evaluated by five qualified saddle fitters. A Pliance (Novel) pressure mat determined saddle pressures. Mean and peak pressures (kPa) beneath the saddle were compared using a general linear mixed model with horse as a random factor and half pad type and rein as fixed factors with a Bonferroni post hoc correction (P ≤ .05). In sitting trot, in the cranial region, peak (P = .008) and mean pressures (P = .03) were highest when using the gel half pad compared with the control. In the caudal region in sitting trot, mean pressures were lowest when using the wool half pad (P = .0002). In canter, increased peak (P = .04) and mean (P = .02) pressures were found in the cranial region of the saddle with the gel half pad. In canter, with the foam half pad, reduced mean pressure (P = .002) in the caudal region was found. It is essential that the use and type of a half pad, to be used beneath a well-fitted saddle, is discussed with a qualified saddle fitter.
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Baum F, Townsend B, Fisher M, Freeman T, Harris P, Browne-Yung K, Friel S. Gaining political will for actions to achieve health equity: lessons from Australia for advocates. Eur J Public Health 2020. [DOI: 10.1093/eurpub/ckaa165.1125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
There has been an accumulation of evidence on the importance of action on the social determinants of health to reduce global and national health equity. Yet there has been little effective systematic action by governments. This is commonly attributed to the absence of political will. Despite its importance, however, little research has examined how political will might be created or prevented.
Methods
This paper reports on the results of eight case studies of the extent to which Australian public policy is likely to contribute to reducing health inequities. 192 participants were interviewed including public servants, politicians and their staff, non-government organisation workers and community members. The transcripts were interrogated with the assistance of NVivo software to determine lessons about the creation or destruction of political will. The case studies were of: national primary health care policy, crucial determinants of health (work conditions, internet access, urban planning, social welfare, trade) and an automotive plant closure.
Results
We found the following factors to be important in determining the extent of political will for health equity, whether: path dependency was present; the issue would impact on staying in or winning government; political philosophies stressed collectivism or individualism; there were negative or positive social constructions of groups affected by the policies; economic and/or biomedical framings were dominant; elites (especially business interests) lobbied against the policies; and there was effective civil society and policy advocacy in favour of the policies.
Conclusions
Building on our insights from our case studies of action for political will, we conclude with a series of questions to guide the work of public health activists and policy advocates working to support existing and to create new political will in multiple contexts.
Key messages
The creation of political will is vital to the adoption of policies supportive of health equity. Analysis of 8 policy case studies points to how advocacy can most effectively create political will.
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Baum F, Anaf J, Fisher M. How can corporate HIA help shape regulatory environments for Trans-National Corporations? Eur J Public Health 2020. [DOI: 10.1093/eurpub/ckaa165.1171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Transnational Corporations (TNCs) exercise considerable sway over population health. They now comprise 157 of the 200 largest economies in the world and shape our food choices and degree of exploitation of our natural environment. This paper will analyse data from two corporate health impact assessments exercise (food and extractive industries) to determine what government and international agency regulatory actions are required to minimize the health harm causes by the actions of TNCs.
Methods
We used a Corporate Health Impact Assessment (CHIA) framework, data sourced through document and media analyses, and semi-structured interviews to examine the practices of McDonalds in Australia and Rio Tinto in Australia and South Africa. Data were mapped against the CHIA framework's three sections which are: i) the impact of regulatory environments ii) How TNC practices and products impact on health and equity ii) the direct impact of TNCs practices on daily living conditions.
Results
The CHIA exercise indicated an absence of effective international regulation on the actions of TNCs and that national regulatory regimes can encourage more responsible behavior from TNCs, for example in occupational health and safety. We identified the need for a much higher level of global and national regulation to: i) prevent the many conflicts of interest we found ii) reduce the extent to which TNC products are unhealthy iii) enforce healthy employment practices iv) prevent externalization of the costs of TNCs v) prevent taxation minimization.
Conclusions
The study highlighted the ways in which TNCs can use their power and size to maintain a de-regulated environment. Concerted global and national action is required to regulate in favour of human health and safety and that of the environment. Our findings support the need for an enforceable international treaty.
Key messages
Transnational corporations have a massive impact on population health. A health impact assessment can identify the pathways of impact and be used to inform regulatory action to promote health.
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Burgess JT, Rose M, Boucher D, Plowman J, Molloy C, Fisher M, O'Leary C, Richard DJ, O'Byrne KJ, Bolderson E. The Therapeutic Potential of DNA Damage Repair Pathways and Genomic Stability in Lung Cancer. Front Oncol 2020; 10:1256. [PMID: 32850380 PMCID: PMC7399071 DOI: 10.3389/fonc.2020.01256] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/17/2020] [Indexed: 12/16/2022] Open
Abstract
Despite advances in our understanding of the molecular biology of the disease and improved therapeutics, lung cancer remains the most common cause of cancer-related deaths worldwide. Therefore, an unmet need remains for improved treatments, especially in advanced stage disease. Genomic instability is a universal hallmark of all cancers. Many of the most commonly prescribed chemotherapeutics, including platinum-based compounds such as cisplatin, target the characteristic genomic instability of tumors by directly damaging the DNA. Chemotherapies are designed to selectively target rapidly dividing cells, where they cause critical DNA damage and subsequent cell death (1, 2). Despite the initial efficacy of these drugs, the development of chemotherapy resistant tumors remains the primary concern for treatment of all lung cancer patients. The correct functioning of the DNA damage repair machinery is essential to ensure the maintenance of normal cycling cells. Dysregulation of these pathways promotes the accumulation of mutations which increase the potential of malignancy. Following the development of the initial malignancy, the continued disruption of the DNA repair machinery may result in the further progression of metastatic disease. Lung cancer is recognized as one of the most genomically unstable cancers (3). In this review, we present an overview of the DNA damage repair pathways and their contributions to lung cancer disease occurrence and progression. We conclude with an overview of current targeted lung cancer treatments and their evolution toward combination therapies, including chemotherapy with immunotherapies and antibody-drug conjugates and the mechanisms by which they target DNA damage repair pathways.
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Duffy D, Eby A, Fisher M, GE M. Influence of Barbed Epitendinous Suture in Combination with a Core Locking Loop Suture for Flexor Tendon Repair in a Canine Cadaveric Translational Laceration Model. Vet Comp Orthop Traumatol 2020. [DOI: 10.1055/s-0040-1714942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Fisher M, Lu SM, Chen K, Zhang B, Di Maggio M, Bradley JP. Facial Feminization Surgery Changes Perception of Patient Gender. Aesthet Surg J 2020; 40:703-709. [PMID: 31676906 DOI: 10.1093/asj/sjz303] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The goal of facial feminization surgery (FFS) is to feminize the sexually dimorphic characteristics of the face and enable transwomen to be correctly gendered as female. Studies have demonstrated high patient satisfaction with FFS. However, the correct gendering of patients after FFS has never been objectively studied. OBJECTIVES The aim of this study was to determine if FFS changed the perceived gender of patients in the public eye. METHODS An online survey platform with control photographs of cis-gender males and cis-gender females as well as preoperative and postoperative FFS patients was created. Respondents were asked to identify patients as "male" or "female" and to assign a confidence score ranging from -10 (masculine) to +10 (feminine) (n = 802). RESULTS Cis-gender male and female controls were gendered correctly 99% and 99.38% of the time and with a confidence metric (CM) of -8.96 and 8.93, respectively. Preoperative FFS patients were gendered as female 57.31% of the time with a CM of 1.41 despite hormone therapy, makeup, and hairstyle. Postoperative FFS patients were gendered as female 94.27% of the time with a CM of 7.78. Ninety-five percent of patients showed a significant improvement in CM after FFS. CONCLUSIONS This study illustrates that FFS changes the social perception of a patient's gender. Patients after FFS are more likely to be identified as female and with greater confidence than before surgery. This is despite preoperative female hormone therapy, and nonsurgical methods that patients use to feminize their appearance. LEVEL OF EVIDENCE: 4
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Brooks J, Gibson M, Kite K, Czeisler E, Fisher M, Xiao C, Polymeropoulos C, Polymeropoulos M. 1004 Smith-<Magenis Syndrome (SMS) Circadian Abnormalities And Biological Rhythms. Sleep 2020. [DOI: 10.1093/sleep/zsaa056.1000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
SMS is a rare neurodevelopmental disorder that manifests with craniofacial abnormalities, behavioral disturbances, and a severe sleep disorder. It has been reported that many SMS patients have an inverted melatonin secretion pattern (peaking during the daytime) although a small minority have near normal patterns. The goal of this study was to better characterize the intra- and inter-patient variability of melatonin secretion patterns and investigate a potential relationship with sleep behavior in SMS patients.
Methods
In this observational study, sleep behaviors of patients (N=8, 1 female, ages: 7 - 35) with SMS were characterized through caretaker surveys. On 3 separate occasions, patients had hourly serum melatonin levels sampled for 36 hours. From these data, peak serum melatonin concentration and time of peak concentration were determined. Inter- and intra-patient variability was characterized by zero lag correlation of the melatonin concentration timeseries across and within patients, respectively. The relationship between peak melatonin concentration, peak time, and sleep latency was analyzed by a generalized linear model, GLM.
Results
Peak melatonin concentrations varied across SMS patients with a range of 3.55pg/ml - 49.65pg/ml (mean 14.18 ± 15.19pg/ml). Time of peak melatonin concentrations ranged from 0400h-2100h (mean 1422 ± 6h). Correlation coefficients characterizing intra-patient variability ranged from -0.0098 to 0.89 (mean 0.55 ± 0.2533). Correlation coefficients characterizing inter-patient variability ranged from -0.75 to 0.79 (mean of 0.18 ± 0.52). Sleep latency ranged from 8.4min - 36.35min (mean of 21.99 ± 9.77 min). GLM analysis demonstrated a significant, positive effect of peak time with sleep latency (p=0.022).
Conclusion
Consistent with previous findings, our study confirms that SMS patients have abnormal circadian rhythms. Our work extends this body of literature by demonstrating a significant degree of inter-patient variability with relatively stable intra-patient variability. Preliminary evidence suggests that the timing of melatonin peak may be related to sleep onset latency.
Support
This work was supported by Vanda Pharmaceuticals Inc.
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Brooks J, Gibson M, Kite K, Czeisler E, Fisher M, Xiao C, Polymeropoulos C, Polymeropoulos M. 1161 Tasimelteon Shows Persistence Of Efficacy In Improving Sleep Disturbances In Patients With Smith-Magenis Syndrome (SMS) In Open-Label Extension Study. Sleep 2020. [DOI: 10.1093/sleep/zsaa056.1155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Smith-Magenis Syndrome (SMS) is a rare (1/15,000 - 25,000 births) neurodevelopmental disorder resulting from an interstitial deletion of chromosome 17p11.2, or from a point mutation in the RAI1 gene. Severe sleep disorder is almost universal in patients with SMS and poses a significant challenge to patients and their families. Tasimelteon improved sleep symptoms in a randomized, double-blind, two-period, crossover study; and here we show that this effect persists for up to four years in an open-label extension. To our knowledge, this is the largest interventional study of SMS patients to date.
Methods
Following the 4-week crossover study, all eligible participants had the option to enroll in an open-label extension. 31/39 (79.4%) of all individuals who participated in the efficacy study have continued on tasimelteon treatment. Participants in the open-label extension provided daily diary sleep quality (DDSQ), and daily diary total sleep time (DDTST) measures via parental post sleep questionnaire and characterized behavior using the Aberrant Behavior Checklist (ABC).
Results
In the open-label extension, tasimelteon continued to show improvement in the primary endpoints of 50% worst sleep quality (mean = 0.7, SD = 0.94) and 50% worst total nighttime sleep duration (mean = 53.3, SD = 59.01) when compared to baseline. Tasimelteon also improved overall sleep quality (mean=0.7, SD=0.83) and overall total nighttime sleep duration (mean = 51.9, SD=53.03). ABC scores also improved with tasimelteon (mean= -16.3, SD = 15.82).
Conclusion
Tasimelteon continues to demonstrate persistence in efficacy (longest approximately 4 years) with similar magnitudes observed in the 4-week crossover study for sleep quality and total sleep time. Interestingly, daytime behavior also demonstrates long-term improvement in patients with SMS treated with tasimelteon. These results further confirm tasimelteon as a novel therapy for the treatment of sleep disorders in patients with SMS and may provide benefit for behavioral symptoms.
Support
This work was supported by Vanda Pharmaceuticals Inc.
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Vidal G, Debusk K, Gautam S, Vlahiotis A, Fisher M, Pulgar S. 174P Occurrence of brain metastasis and treatment patterns among patients with HER2-positive metastatic breast cancer. Ann Oncol 2020. [DOI: 10.1016/j.annonc.2020.03.274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Lau WL, Fisher M, Greenia D, Floriolli D, Fletcher E, Singh B, Sajjadi SA, Corrada MM, Whittle C, Kawas C, Paganini-Hill A. Cystatin C, cognition, and brain MRI findings in 90+-year-olds. Neurobiol Aging 2020; 93:78-84. [PMID: 32473464 DOI: 10.1016/j.neurobiolaging.2020.04.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 04/19/2020] [Accepted: 04/21/2020] [Indexed: 01/08/2023]
Abstract
Chronic kidney disease is emerging as a novel risk factor for cerebrovascular disease, but this association remains largely unexplored in older adults. Cystatin C is a more accurate measure than creatinine of kidney function in the elderly. We evaluated cystatin C, cognitive function, and brain imaging in 193 participants from The 90+ Study neuroimaging component. The mean age was 93.9 years; 61% were women. Mean cystatin C was 1.62 mg/L with estimated glomerular filtration rate 39.2 mL/min/1.73 m2. Performance on measures of global cognition, executive function, and visual-spatial ability declined at higher tertiles of cystatin C (lower kidney function). Higher cystatin C was significantly associated with infratentorial microbleeds and lower gray matter volume. Adjusted risk of incident dementia was increased in the middle and high cystatin C tertile groups compared with the low group (hazard ratio in highest tertile 3.81 [95% confidence interval 1.14-12.7]), which appeared to be explained in part by the presence of cerebral microbleeds. Overall, cystatin C was associated with cognitive performance, brain imaging pathology, and decline to dementia in this oldest-old cohort.
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Loftus RW, Dexter F, Goodheart MJ, McDonald M, Keech J, Noiseux N, Pugely A, Sharp W, Sharafuddin M, Lawrence WT, Fisher M, McGonagill P, Shanklin J, Skeete D, Tracy C, Erickson B, Granchi T, Evans L, Schmidt E, Godding J, Brenneke R, Persons D, Herber A, Yeager M, Hadder B, Brown JR. The Effect of Improving Basic Preventive Measures in the Perioperative Arena on Staphylococcus aureus Transmission and Surgical Site Infections: A Randomized Clinical Trial. JAMA Netw Open 2020; 3:e201934. [PMID: 32219407 PMCID: PMC11071519 DOI: 10.1001/jamanetworkopen.2020.1934] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Importance Surgical site infections increase patient morbidity and health care costs. The Centers for Disease Control and Prevention emphasize improved basic preventive measures to reduce bacterial transmission and infections among patients undergoing surgery. Objective To assess whether improved basic preventive measures can reduce perioperative Staphylococcus aureus transmission and surgical site infections. Design, Setting, and Participants This randomized clinical trial was conducted from September 20, 2018, to September 20, 2019, among 19 surgeons and their 236 associated patients at a major academic medical center with a 60-day follow-up period. Participants were a random sample of adult patients undergoing orthopedic total joint, orthopedic spine, oncologic gynecological, thoracic, general, colorectal, open vascular, plastic, or open urological surgery requiring general or regional anesthesia. Surgeons and their associated patients were randomized 1:1 via a random number generator to treatment group or to usual care. Observers were masked to patient groupings during assessment of outcome measures. Interventions Sustained improvements in perioperative hand hygiene, vascular care, environmental cleaning, and patient decolonization efforts. Main Outcomes and Measures Perioperative S aureus transmission assessed by the number of isolates transmitted and the incidence of transmission among patient care units (primary) and the incidence of surgical site infections (secondary). Results Of 236 patients (156 [66.1%] women; mean [SD] age, 57 [15] years), 106 (44.9%) and 130 (55.1%) were allocated to the treatment and control groups, respectively, received the intended treatment, and were analyzed for the primary outcome. Compared with the control group, the treatment group had a reduced mean (SD) number of transmitted perioperative S aureus isolates (1.25 [2.11] vs 0.47 [1.13]; P = .002). Treatment reduced the incidence of S aureus transmission (incidence risk ratio; 0.56; 95% CI, 0.37-0.86; P = .008; with robust variance clustering by surgeon: 95% CI, 0.42-0.76; P < .001). Overall, 11 patients (4.7%) experienced surgical site infections, 10 (7.7%) in the control group and 1 (0.9%) in the treatment group. Transmission was associated with an increased risk of surgical site infection (8 of 73 patients [11.0%] with transmission vs 3 of 163 [1.8%] without; risk ratio, 5.95; 95% CI, 1.62-21.86; P = .007). Treatment reduced the risk of surgical site infection (hazard ratio, 0.12; 95% CI, 0.02-0.92; P = .04; with clustering by surgeon: 95% CI, 0.03-0.51; P = .004). Conclusions and Relevance Improved basic preventive measures in the perioperative arena can reduce S aureus transmission and surgical site infections. Trial Registration ClinicalTrials.gov Identifier: NCT03638947.
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MacKechnie-Guire R, MacKechnie-Guire E, Fairfax V, Fisher M, Hargreaves S, Pfau T. The Effect That Induced Rider Asymmetry Has on Equine Locomotion and the Range of Motion of the Thoracolumbar Spine When Ridden in Rising Trot. J Equine Vet Sci 2020; 88:102946. [PMID: 32303298 DOI: 10.1016/j.jevs.2020.102946] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 01/23/2020] [Accepted: 01/27/2020] [Indexed: 11/16/2022]
Abstract
There is a paucity of evidence on the effect that rider asymmetry has on equine locomotion. The aim of this study was to evaluate the effect of rider asymmetry on equine locomotion by using a novel approach to induce rider asymmetry. Ten nonlame horses were recruited for this study. Joint center markers were used to capture 2D kinematics (Quintic Biomechanics) of the horse and rider and horses were equipped with seven inertial sensors positioned at the fifth (T5) and eighteenth (T18) thoracic vertebrae, third lumbar (L3) vertebra, tubera sacrale (TS), and left and right tubera coxae. Rider asymmetry was induced by shortening the ventral aspect of one stirrup by 5 cm. Kinematic data were compared between conditions using a mixed model with the horse defined as a random factor and stirrup condition (symmetrical stirrups and asymmetrical stirrups) and direction (inside and outside) defined as fixed factors. Data from riders where the right stirrup was shortened were mirrored to reflect a left stirrup being shortened. To determine differences between conditions, a significance of P ≤ .05 was set. On the rein with the shortened stirrup on the outside: an increase in lateral bending range of motion (ROM) at T5 (P = .003), L3 (P = .04), and TS (P = .02), an increase in mediolateral displacement at T5 (P = .04), T18 (P = .04), and L3 (0.03) were found. An increase in maximum fetlock extension was apparent for both the front (P = .01) and hind limb (P = .04) on the contralateral side to the shortened stirrup; for the asymmetrical stirrup condition on the rein with the shortened stirrup on the inside: an increase in flexion-extension ROM at T5 (P = .03) and L3 (P = .04), axial rotation at T5 (P = .05), and lateral bending of T5 (P = .03), L3 (P = .04), and TS (P = .02). Asymmetric rider position appears to have an effect on the kinematics of the thoracolumbar spine. These findings warrant further investigation to understand the long-term impact this may have on equine locomotor health.
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Abstract
A small scale survey was conducted among nurse educationalists within Wales as part of the ongoing monitoring of Welsh Office targets for learning disability nursing. This survey showed that there has been very little service user involvement in professional nurse education in Wales. The authors discuss the possible reasons for such low level involvement. Examples of involvement of people with learning disabilities are compared to the much more favourable situation within the mental health field. Possible reasons for the barriers to progress in this area are discussed. The history of service user involvement and the development of advocacy both within the UK and other countries is also highlighted. The impact of various government initiatives on this situation is considered.
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Bain S, Feher M, Fisher M, Hex N, Lee KCS, Mahon J, Russell‐Jones D, Schou H, Wilmot EG, Baxter M. A review of the NG17 recommendations for the use of basal insulin in type 1 diabetes. Diabet Med 2020; 37:219-228. [PMID: 31729775 PMCID: PMC7004078 DOI: 10.1111/dme.14180] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/11/2019] [Indexed: 01/17/2023]
Abstract
AIMS To revisit the data analysis used to inform National Institute of Health and Care Excellence (NICE) NG17 guidance for initiating basal insulin in adults with type 1 diabetes mellitus (diabetes). METHODS We replicated the data, methodology and analysis used by NICE diabetes in the NG17 network meta-analysis (NMA). We expanded this data cohort to a more contemporary data set (extended 2017 NMA) and restricted the studies included to improve the robustness of the data set (restricted 2017 NMA) and in a post hoc analysis, changed the index comparator from neutral protamine Hagedorn (NPH) insulin twice daily to insulin detemir twice daily. RESULTS The absolute changes in HbA1c were similar to those reported in the NG17. However, all 95% credible intervals for change in HbA1c point estimates crossed the line of null effect, except for detemir twice daily (in the NICE and extended 2017 NMAs) and NPH four times daily. In the detemir twice-daily centred post hoc analysis, the 95% credible intervals for change in HbA1c crossed the line of null effect for all basal therapies, except NPH. CONCLUSIONS In NG17, comparisons of basal insulins were based solely on efficacy of glycaemic control. Many of the trials used in this analysis were treat-to-target, which minimize differences in HbA1c . In the NMAs, statistical significance was severely undermined by the wide credible intervals. Despite these limitations, point estimates of HbA1c were used to rank the insulins and formed the basis of NG17 guidance. This study queries whether such analyses should be used to make specific clinical recommendations.
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Suzuki S, Nguyen B, Lara W, Moores L, Kim J, Yuki I, Xu J, Paganini Hill A, Fisher M. Abstract WP210: Preventability of Stroke Due to Large Vessel Occlusion Treated With Thrombectomy. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.wp210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Objective:
Mechanical Thrombectomy (MT) is standard treatment for stroke due to large vessel occlusion (LVO). However, extent of preventability of these strokes is generally not addressed. This study analyzes stroke preventability for patients treated with MT for LVO.
Subjects and Methods:
We conducted retrospective analyses of stroke patients treated with MT for LVO at UC Irvine Medical Center from June 2008 to March 2019. We obtained data including age, NIH Stroke Scale (NIHSS) at onset, and (beginning in 2015) 90-day outcome measured by modified Rankin Scale (mRS). We used the Stroke Preventability Score (SPS, 0-10 points) from our prior work (JAMA Neurology 2016, 73:186), based on how well patients had been treated given their hypertension, hyperlipidemia, atrial fibrillation, and prior stroke history. We examined associations of SPS with age, NIHSS at onset, and mRS.
Results:
For 301 patients treated with MT for LVO, mean ± standard error of age was 60±0.1 years (range 18-97) and NIHSS was 17±0.4 (range 0-37, n=282); one-third (n=96) were male. SPS was calculated for 273 patients, with mean±SE 2.1±0.1 (range 0-8). Over two-thirds (n=184, 67%) demonstrated some degree of preventability (SPS 1 or higher), while 23% (n=64) showed high stroke preventability (SPS 4 or higher). Among 119 patients with mRS data, stroke preventability was associated with age (66±2.5, 69±2.4 and 79±1.7 years for no, low and high SPS, respectively; p<0.002). Stroke preventability was also associated with NIHSS at onset (15±1.3, 16±0.9, and 20±1.4 for no, low and high preventability, respectively; p<0.04). SPS was significantly correlated with age (r=0.33, p<0.0002), NIHSS (r=0.29, p=0.002), and mRS (r=0.22, p=0.02). The partial correlation coefficient for SPS remained significant after adjusting for age and NIHSS.
Conclusion:
Nearly one-quarter of patients, with LVO treated with MT, presented with strokes that were highly preventable. High stroke preventability tended to be seen in older patients, patients with more severe deficits, and (to a lesser extent) patients with poor outcome. While most acute stroke treatment efforts focus on streamlining workflow, these findings demonstrate the enduring importance of stroke prevention in this patient population.
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Kapoor R, Wadi L, Becerra B, Eskander M, Razmara A, Lombardo D, Paganini-Hill A, Kim JK, Fisher M. Abstract WP261: The Left Atrial Septal Pouch: A New Stroke Risk Factor? Stroke 2020. [DOI: 10.1161/str.51.suppl_1.wp261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The left atrial septal pouch (LASP) is a common anatomic variant produced by the incomplete fusion of septa primum and secondum at the inter-atrial septum, thus creating a potential embolic source from an open flap or blind pouch in the left atrium. Our prior work demonstrated increased prevalence of LASP in cryptogenic strokes (Frontiers Neurology 3-24-15). The aim of the current study was to examine the prevalence of LASP in a separate, more recent group of stroke patients and control subjects who underwent transesophageal echocardiography (TEE).
Methods:
We examined consecutive TEE studies performed between July, 2011 and December, 2018 at UC Irvine Medical Center. Prevalence of LASP was determined in TEE studies referred for ischemic stroke or TIA (“stroke subjects”), and compared to LASP prevalence in patients undergoing TEE for other reasons (“control subjects”). Stroke subtyping was performed using TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria.
Results:
TEE studies were performed on 221 cerebrovascular cases and 164 control subjects. Age and sex were 57±1 years (mean±SE) and 53% male for stroke subjects, and 56±1 years and 62% male for control subjects. Prevalence of LASP was 24% (40/164) in control subjects, 17% (24/138) in non-cryptogenic stroke subjects, and 36% (30/83) in cryptogenic stroke subjects. LASP prevalence was significantly higher for cryptogenics compared to the other groups (p=0.007). There was no significant difference between LASP prevalence in controls vs non-cryptogenic stroke. Elimination from analysis of subjects with other inter-atrial septal abnormalities (ie, patent foramen ovale or atrial septal defect) did not significantly change results.
Conclusions:
These findings demonstrate an increased prevalence of LASP in cryptogenic stroke, confirming our prior published findings. Given the plausibility of LASP acting as a thromboembolic nidus, additional studies are needed to determine the generalizability of these findings and their therapeutic implications.
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Fisher M, Bank J, Alba B, Light D, Korn PT, Feingold RS, Israeli R. Umbilical Ablation During Deep Inferior Epigastric Perforator Flap Harvest Decreases Donor Site Complications. Ann Plast Surg 2020; 85:260-265. [PMID: 32000254 DOI: 10.1097/sap.0000000000002191] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Donor site complications are a significant source of morbidity for patients undergoing abdominal-based free flap breast reconstruction, but there is a paucity of data regarding minimizing these postoperative complications. We hypothesize that selective ablation of the umbilicus at the time of deep inferior epigastric perforator (DIEP) harvest decreases the incidence of umbilical and abdominal wall complications in high-risk patients. METHODS A retrospective review was performed of all patients (n = 117) who underwent DIEP harvest with concomitant umbilical ablation from 2010 to 2015. This cohort was paired with 117 patients who underwent DIEP harvest without umbilical ablation. Preoperative risk factors, intraoperative factors, and postoperative complications were compared. RESULTS The umbilical ablation group had significantly higher body mass index (30.9 vs 27.4 kg/m, P < 0.001), presence of umbilical scar (20.9% vs 5.3%, P < 0.001), umbilical hernia (82.9% vs 8.5% P < 0.001), ventral hernia (23.9% vs 1.7%, P < 0.001), and rectus diastasis (10.3% vs 2.6%, P = 0.016). There were no significant differences of smoking, diabetes mellitus, hypertension, prior abdominal surgery, or midline abdominal scar. The umbilical ablation group had a significantly lower rate of postoperative abdominal wound dehiscence and skin loss (11.1% vs 22.2%, P = 0.023) and overall donor site complications (24.8% vs 39.3%, P = 0.017). There was no significant difference in incidence of cellulitis, seroma, or abscess. Mean follow-up time was 1.8 years. CONCLUSIONS Selective umbilical ablation in high-risk patients at the time of abdominal flap harvest can result in significantly fewer donor site wound complications, even in the setting of increased risk factors for poor wound healing. This is likely due to avoidance of umbilical incisions and decreased upper abdominal skin undermining. We conclude that umbilical ablation is a viable option to minimize donor site complications, especially in high-risk patients.
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Cho AH, Wadi L, Chow D, Chang P, Floriolli D, Shah K, Paganini-Hill A, Fisher M. Cerebral Microbleeds in a Stroke Prevention Clinic. Diagnostics (Basel) 2019; 10:diagnostics10010018. [PMID: 31905954 PMCID: PMC7168200 DOI: 10.3390/diagnostics10010018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 12/24/2019] [Accepted: 12/25/2019] [Indexed: 01/27/2023] Open
Abstract
The objective of this study was to assess the effectiveness of a stroke clinic in stroke prevention and progression of cerebral microbleeds (CMB). We conducted a retrospective observational study of patients who visited a stroke clinic between January 2011 and March 2017. Susceptibility-weighted imaging (SWI) MRI studies were obtained at baseline and follow-up visits to identify new infarctions and CMB progression. Patients with CMB who also underwent brain computed tomography (CT) imaging were identified and their cerebral arterial calcification was quantified to evaluate the relationship between the extent of intracranial calcification and CMB burden. A total of 64 stroke patients (mean age 73.1 ± 11.0, 47% males) had CMB on baseline and follow-up MRI studies. During a mean follow-up period of 22.6 months, four strokes occurred (4/64, 6%; 3 ischemic, 1 hemorrhagic), producing mild neurological deficit. Progression of CMB was observed in 54% of patients with two MRIs and was significantly associated with length of follow-up. Subjects with intracranial calcification score > 300 cm3 had higher CMB count than those with scores <300 cm3 at both baseline (12.6 ± 11.7 vs. 4.9 ± 2.2, p = 0.02) and follow-up (14.1 ± 11.8 vs. 5.6 ± 2.4, p = 0.03) MRI evaluations. Patients with CMB had a relatively benign overall clinical course. The association between CMB burden and intracranial calcification warrants further study.
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Langelier C, Graves M, Kalantar K, Caldera S, Durrant R, Fisher M, Backman R, Tanner W, DeRisi JL, Leung DT. Microbiome and Antimicrobial Resistance Gene Dynamics in International Travelers. Emerg Infect Dis 2019; 25:1380-1383. [PMID: 31211676 PMCID: PMC6590773 DOI: 10.3201/eid2507.181492] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
We used metagenomic next-generation sequencing to longitudinally assess the gut microbiota and antimicrobial resistomes of international travelers to clarify global exchange of resistant organisms. Travel resulted in an increase in antimicrobial resistance genes and a greater proportion of Escherichia species within gut microbial communities without impacting diversity.
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Polymeropoulos C, Czeisler E, Fisher M, Birznieks G, Xiao C, Polymeropoulos M. Study of the effects of a 5 hour and 8 hour circadian phase advance as a model of JET Lag disorder. Sleep Med 2019. [DOI: 10.1016/j.sleep.2019.11.853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Reaney SM, Mackay EB, Haygarth PM, Fisher M, Molineux A, Potts M, Benskin CMH. Identifying critical source areas using multiple methods for effective diffuse pollution mitigation. JOURNAL OF ENVIRONMENTAL MANAGEMENT 2019; 250:109366. [PMID: 31494409 DOI: 10.1016/j.jenvman.2019.109366] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 08/02/2019] [Accepted: 08/04/2019] [Indexed: 06/10/2023]
Abstract
Diffuse pollution from agriculture constitutes a key pressure on the water quality of freshwaters and is frequently the cause of ecological degradation. The problem of diffuse pollution can be conceptualised with a source-mobilisation-pathway (or delivery)-impact model, whereby the combination of high source risk and strong connected pathways leads to 'critical source areas' (CSAs). These areas are where most diffuse pollution will originate, and hence are the optimal places to implement mitigation measures. However, identifying the locations of these areas is a key problem across different spatial scales within catchments. A number of approaches are frequently used for this assessment, although comparisons of these assessments are rarely carried out. We evaluate the CSAs identified via traditional walkover surveys supported by three different approaches, highlighting their benefits and disadvantages. These include a custom designed smartphone app; a desktop geographic information system (GIS) and terrain analysis-based SCIMAP (Sensitive Catchment Integrated Modelling and Analysis Platform) approach; and the use of a high spatial resolution drone dataset as an improved input data for SCIMAP modelling. Each of these methods captures the locations of the CSAs, revealing similarities and differences in the prioritisation of CSA features. The differences are due to the temporal and spatial resolution of the three methods such as the use of static land cover information, the ability to capture small scale features, such as gateways and the incomplete catchment coverage of the walkover survey. The relative costs and output resolutions of the three methods indicate that they are suitable for application at different catchment scales in conjunction with other methods. Based on the results in this paper, it is recommended that a multi-evidence-based approach to diffuse pollution management is taken across catchment spatial scales, incorporating local knowledge from the walkover with the different data resolutions of the SCIMAP approach.
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