Publications by authors named "Denise Cloutier"

29 Publications

  • Page 1 of 1

Functional status in rural and urban adults: The Canadian Longitudinal Study on Aging.

J Rural Health 2021 Apr 22. Epub 2021 Apr 22.

Department of Geography, University of Victoria, Victoria, British Columbia, Canada.

Purpose: To document the prevalence of functional impairment in middle-aged and older adults from rural regions and to determine urban-rural differences.

Methods: We have conducted a secondary analysis using data from an ongoing population-based cohort study, the Canadian Longitudinal Study on Aging (CLSA). We used a cross-sectional sample from the baseline wave of the "tracking cohort." The definition of rurality was the same as the one used in the CLSA sampling frame and based on the 2006 census. This definition includes rural areas, defined as all territory lying outside of population centers, and population centers, which collectively cover all of Canada. We grouped these into "Urban," "Peri-urban," "Mixed" (areas with both rural and urban areas), and "Rural," and compared functional status across these groups. Functional status was measured using the Older Americans Resource Survey (OARS) and categorized as not impaired versus having any functional impairment. Logistic regression models were constructed for the outcome of functional status and adjusted for covariates.

Findings: No differences were found in functional status between those living in rural, mixed, peri-urban, and urban areas in unadjusted analyses and in analyses adjusting for sociodemographic and health-related factors. There were no rural-urban differences in any of the individual items on the OARS scales.

Conclusions: We found no rural-urban differences in functional status.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jrh.12578DOI Listing
April 2021

A prospective clinical and transcriptomic feasibility study of oral-only hormonal therapy with radiation for unfavorable prostate cancer in men 70 years of age and older or with comorbidity.

Cancer 2021 Apr 21. Epub 2021 Apr 21.

Department of Radiation and Cellular Oncology, University of Chicago Medicine, Chicago, Illinois.

Background: Androgen deprivation therapy (ADT) improves outcomes in unfavorable-risk prostate cancer (PCa) treated with radiation therapy (RT). It was hypothesized that replacing luteinizing hormone-releasing hormone (LHRH) agonists with a 5-α-reductase inhibitor (5-ARI) would improve hormonal health-related quality of life (HRQOL) without differentially suppressing androgen-responsive (AR) gene expression.

Methods: Patients with localized unfavorable-risk PCa, aged ≥70 years or Charlson Comorbidity Index score ≥2 were treated with oral ADT (oADT), consisting of 4 months of bicalutamide, a 5-ARI, and RT at 78 Gy. The primary end point was Expanded Prostate Cancer Index Composite HRQOL at 6 months ≤30%, and improvement compared with a synchronous standard of care (SOC) cohort receiving 4 months of bicalutamide and long-term LHRH agonist with RT. RNA sequencing was performed from matched pre-/post-ADT prostate tumor biopsies in a subset of men. Differential gene and pathway expressional changes were examined using gene set enrichment.

Results: Between 2011 and 2018, 40 and 30 men were enrolled in the oADT and SOC cohorts, respectively. Median follow-up was 40 months. Those with ≤30% decline in hormonal HRQOL at 6 months was 97% (oADT) and 93% (SOC). The average 6-month hormonal decline was 1% (oADT) versus 12% (SOC; P = .04). The 4-year freedom from biochemical failure was 88% (oADT) versus 81% (SOC; P = .48). RNA sequencing (n = 9) showed similar numbers of downregulated and upregulated genes between the treatment groups (fold-change = 2; false-discovery rate-adjusted P ≤ .05). Both treatments comparably decreased the expression of 20 genes in canonical androgen receptor signaling.

Conclusions: For men with PCa undergoing RT, oral versus standard ADT may improve 6-month QOL and appears to have a similar impact on androgen-responsive gene expression.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/cncr.33556DOI Listing
April 2021

Healthcare utilisation among Canadian adults in rural and urban areas - The Canadian Longitudinal Study on Aging.

Can J Rural Med 2021 Apr-Jun;26(2):69-79

Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.

Objective: The objective is to determine the use of health-care services (physician visits, emergency department use and hospitalisations) in rural areas and examine differences in four geographic areas on a rural to urban spectrum.

Methods: We conducted a secondary analysis of cross-sectional data from a population-based prospective cohort study, the Canadian Longitudinal Study on Aging (CLSA). Participants included community-dwelling adults aged 45-85 years old from the tracking cohort of the CLSA (n = 21,241). Rurality was classified based on definitions from the CLSA sampling frame and similar to the 2006 census. Main outcome measures included self-reported family physician and specialist visits, emergency department visits and hospitalisations within the previous 12 months. Results were compared for four geographic areas on a rural-urban continuum. Univariate and bivariate analyses were performed on data from the 'tracking cohort' of the CLSA, Chi-square tests were used for categorical variables. Logistic regression models were created for the main outcome measures.

Results: Participants in rural and mixed rural and urban areas were less likely to have seen a family physician or a specialist physician compared to urban areas. Those living in rural and peri-urban areas were more likely to visit an emergency department compared to urban areas. These differences persisted after adjusting for sociodemographic and health-related variables. There were no significant rural-urban differences in hospitalisations.

Conclusion: Rural-urban differences were found in visits to family physicians, specialists and emergency departments.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4103/CJRM.CJRM_43_20DOI Listing
April 2021

"We are to be like machines…fill the bed before it gets cold": Exploring the emotional geographies of healthcare providers caring for dying residents in long-term care facilities.

Soc Sci Med 2021 Mar 6;272:113749. Epub 2021 Feb 6.

Institute on Aging and Lifelong Health, University of Victoria, 3800 Finnerty Road, Victoria, BC, V8P 5C2, Canada. Electronic address:

The end-of-life context is imbued with emotions, with death and dying transforming everyday places, like long-term care facilities, into entirely new emotional topographies that can evoke profound effects on those who live and work within these settings. Despite their significant role, healthcare providers' emotions and their interconnections with 'place' have received relatively little attention from researchers, including geographers of care and caregiving. This secondary thematic analysis attempts to address this notable gap by exploring the emotional geographies of healthcare providers caring for dying residents in four long-term care facilities in western Canada. By drawing upon interview and focus group data with administrators (n = 12) and direct care provider (n = 80) participants, findings reveal that experiences of caring for dying residents were often charged with negative emotions (e.g., distress, frustration, grief). These emotions were not only influenced by social and physical aspects of 'place', but the temporal process of caring for a dying resident, which included: (1) Identifying a resident as in need of a palliative approach to care; (2) Actively dying; and (3) Following a resident's death. Findings indicate that providers' emotions shifted in scale at each of these temporal phases, ranging from association with the facility as a whole to the micro-scale of the body. Broader structural forces that influence the physical and social place of long-term care facilities were also found to shape experiences of emotional labor among staff. With an increasing number of deaths occurring within long-term care facilities throughout the Global North, such findings contribute critical experiential knowledge that can inform policy and programs on ways to help combat staff burnout, facilitate worker satisfaction, and foster resilience among long-term care providers, ensuring they receive the necessary supports to continue fulfilling this valuable caring role.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.socscimed.2021.113749DOI Listing
March 2021

A prospective trial of stereotactic body radiation therapy for unresectable pancreatic cancer testing ablative doses.

J Gastrointest Oncol 2020 Dec;11(6):1399-1407

Department of Medical Oncology, University of Chicago Medical Center, Chicago, IL, USA.

Background: We explored the safety and efficacy of ablative doses of stereotactic body radiation therapy (SBRT) for unresectable pancreatic cancer.

Methods: This phase I/II trial included patients with unresectable pancreatic cancer previously treated with any number of cycles of induction chemotherapy. Patients were enrolled according to a 3+3 dose escalation design at 10, 12.5, and 15 Gy ×3, with subsequent patients at the maximally tolerated dose (MTD). Treatment was delivered to gross tumor delineated with MRI fusion using image-guidance to fiducial markers. Dose-limiting toxicity (DLT) was defined as grade 3+ toxicity within 30 days. Secondary endpoints included late gastrointestinal (GI) toxicity, freedom from local failure (FFLF), and survival.

Results: Fifteen patients received a median 10 cycles of chemotherapy. There were no DLTs, and the MTD was 15 Gy ×3. Thirty-day toxicity included grade 2 nausea (46%) and grade 2 diarrhea (7%). Median survival after SBRT was 12.8 months (23 months after diagnosis) and median relapse-free survival was 7 months. At 1-year, FFLF was 80%. Four patients had grade 3+ GI bleeding after 30 days (median 6 months). Grade 3+ GI bleeding was associated with tumor volume (P=0.01), heterogeneity of dose within the planning target volume (PTV) (V120, P=0.03), and duodenal dose (V26-30 Gy, P<0.2).

Conclusions: This aggressive SBRT regimen demonstrated limited 30-day morbidity, a moderate degree of local control, and a moderate risk for late GI bleeding. Further work is necessary to define the most appropriate hypofractionated radiation therapy (RT) regimen in the ablative dose range.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.21037/jgo-20-187DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7807259PMC
December 2020

Is health literacy of family carers associated with carer burden, quality of life, and time spent on informal care for older persons living with dementia?

PLoS One 2020 20;15(11):e0241982. Epub 2020 Nov 20.

HØKH-Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway.

Introduction: Family carers are cornerstones in the care of older people living with dementia. Family carers report extensive carer burden, reduced health-related quality of life (HRQoL), and extensive time spent on informal care (Time). Health literacy (HL) is a concept associated with people's ability to access health services, and navigate the healthcare system. This study's aim was to investigate HL among family carers, and investigate the associations between HL and carer burden, HRQoL, and Time spent on informal care.

Method: We designed a self-administered survey comprising validated instruments, including the Health Literacy Scale (HLS-N-Q12) to measure HL, Relative Stress Scale (RSS) to measure carer burden, the EQ-5D-5L instrument to measure HRQoL, and some modified questions from the Resource Utilization in Dementia (RUD) questionnaire to measure time spent on informal care (Time). Descriptive analysis in addition to bivariate and multiple linear regressions were undertaken. In multiple linear regression analysis, we used HL as the independent variable to predict the outcomes (carer burden, HRQoL, Time). Analyses were adjusted for the effects of explanatory independent variables: age, gender, education levels, urban residency, having worked as health personnel, caring for someone with severe/mild dementia, and being born abroad.

Findings: In a non-probability sample of 188 family carers from across Norway, most of them female and over the age of 60, we found high levels of HL. In the bivariate analysis, carer burden and HRQoL (EQvalue) showed significant associations with HL. In the multiple regression analyses, HL was statistically significantly associated with carer burden (B = -0.18 CI:-0.33,-0.02 p = 0.02), HRQoL (EQvalue: B = 0.003 with 95% CI: 0.001, 0.006 p = 0.04), and Time (B = -0.03 with 95% CI: -0.06, 0.000, p = 0.046), after adjusting for the effect of independent variables.

Conclusion: This is one of the first studies to investigate the associations between HL and different outcomes for family carers of older people living with dementia. Additional research into the associations identified here is needed to further develop our understanding of how to support family carers in their roles. Targeted support that increases family carers' HL may have potential to enhance their ability to provide sustainable care over time.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0241982PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7678960PMC
December 2020

Team-Based Integrated Knowledge Translation for Enhancing Quality of Life in Long-term Care Settings: A Multi-method, Multi-sectoral Research Design.

Int J Health Policy Manag 2020 04 1;9(4):138-142. Epub 2020 Apr 1.

Faculty of Nursing and School of Public Health, University of Alberta, Edmonton, AB, Canada.

Multi-sectoral, interdisciplinary health research is increasingly recognizing integrated knowledge translation (iKT) as essential. It is characterized by diverse research partnerships, and iterative knowledge engagement, translation processes and democratized knowledge production. This paper reviews the methodological complexity and decision-making of a large iKT project called Seniors - Adding Life to Years (SALTY), designed to generate evidence to improve late life in long-term care (LTC) settings across Canada. We discuss our approach to iKT by reviewing iterative processes of team development and knowledge engagement within the LTC sector. We conclude with a brief discussion of the important opportunities, challenges, and implications these processes have for LTC research, and the sector more broadly.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.15171/ijhpm.2019.123DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7182150PMC
April 2020

Applying the concept of structural empowerment to interactions between families and home-care nurses.

Nurs Inq 2020 01 23;27(1):e12313. Epub 2019 Jul 23.

Institute on Aging and Lifelong Health, University of Victoria, Victoria, British Columbia, Canada.

Interpretations of family carer empowerment in much nursing research, and in home-care practice and policy, rarely attend explicitly to families' choice or control about the nature, extent or length of their involvement, or control over the impact on their own health. In this article, structural empowerment is used as an analytic lens to examine home-care nurses' interactions with families in one Western Canadian region. Data were collected from 75 hrs of fieldwork in 59 interactions (18 nurses visiting 16 families) and interviews with 12 nurses and 11 family carers. Generally, nurses prioritized client empowerment, and their practice with families appeared oriented to supporting their role and needs as carers (i.e. rather than as unique individuals beyond the caring role), and reinforcing the caring role through validation and recognition. Although families generally expressed appreciation for these interactions, a structural empowerment lens illustrates how the broad context of home care shapes the interpretation and practice of empowerment in ways that can, paradoxically, be disempowering for families. Opportunities to effectively support family choice and control when a client is being cared for at home are discussed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/nin.12313DOI Listing
January 2020

Reduction of Autophagic Accumulation in Pompe Disease Mouse Model Following Gene Therapy.

Curr Gene Ther 2019 ;19(3):197-207

Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL, United States.

Background: Pompe disease is a fatal neuromuscular disorder caused by a deficiency in acid α-glucosidase, an enzyme responsible for glycogen degradation in the lysosome. Currently, the only approved treatment for Pompe disease is enzyme replacement therapy (ERT), which increases patient survival, but does not fully correct the skeletal muscle pathology. Skeletal muscle pathology is not corrected with ERT because low cation-independent mannose-6-phosphate receptor abundance and autophagic accumulation inhibits the enzyme from reaching the lysosome. Thus, a therapy that more efficiently targets skeletal muscle pathology, such as adeno-associated virus (AAV), is needed for Pompe disease.

Objective: The goal of this project was to deliver a rAAV9-coGAA vector driven by a tissue restrictive promoter will efficiently transduce skeletal muscle and correct autophagic accumulation.

Methods: Thus, rAAV9-coGAA was intravenously delivered at three doses to 12-week old Gaa-/- mice. 1 month after injection, skeletal muscles were biochemically and histologically analyzed for autophagy-related markers.

Results: At the highest dose, GAA enzyme activity and vacuolization scores achieved therapeutic levels. In addition, resolution of autophagosome (AP) accumulation was seen by immunofluorescence and western blot analysis of autophagy-related proteins. Finally, mice treated at birth demonstrated persistence of GAA expression and resolution of lysosomes and APs compared to those treated at 3 months.

Conclusion: In conclusion, a single systemic injection of rAAV9-coGAA ameliorates vacuolar accumulation and prevents autophagic dysregulation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2174/1566523219666190621113807DOI Listing
July 2020

From home to 'home': Mapping the caregiver journey in the transition from home care into residential care.

J Aging Stud 2017 Dec 14;43:32-39. Epub 2017 Sep 14.

Institute on Aging & Lifelong Health, University of Victoria, PO Box 1700 STN CSC, Victoria, BC V8P 2Y2, Canada; Department of Sociology, University of Victoria, PO Box 1700 STN CSC, Victoria, BC V8W 2Y2, Canada.

Family caregivers play a pivotal role in supporting the functional independence and quality of life of older relatives, often taking on a wide variety of care-related activities over the course of their caregiving journey. These activities help family members to remain in the community and age-in-place for as long as possible. However, when needs exceed family capacities to provide care, the older family member may need to transition from one care environment to another (e.g., home care to nursing home care), or one level of care to another (from less intense to more intensive services). Drawing upon qualitative interview data collected in a populous health region in British Columbia, Canada, this study explores the roles and responsibilities of family caregivers for family members making the care transition from home care to residential care. A thematic analysis of the interview transcripts resulted in the development of a conceptual framework to characterize the "Caregiver Journey" as a process that could be divided into at least three phases: 1) Precursors to transition - recognizing frailty in family members and caregivers prior to transition; 2) Preparing to transition into residential nursing home care (RC) and 3) Post-transition: Finding a new balance - where caregivers adjust and adapt to new caregiving responsibilities. Our analyses revealed that the second phase is the most complex involving a consideration of the various activities, and roles that family caregivers take on to prepare for the care transition including: information gathering, advocacy and system navigation. We conclude that there is a need for family caregivers to be better supported during care transitions; notably through ongoing and enhanced investments in strategies to support caregiver communication and education.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jaging.2017.09.003DOI Listing
December 2017

Social Engagement and Antipsychotic Use in Addressing the Behavioral and Psychological Symptoms of Dementia in Long-Term Care Facilities.

Can J Nurs Res 2017 Dec 4;49(4):144-152. Epub 2017 Oct 4.

5 Research and Knowledge Translation, Interior Health Authority, Research Affiliate, 27355 Fraser Health Authority, British Columbia, Canada.

Objectives The use of antipsychotics, mainly to address the behavioral and psychological symptoms of dementia (BPSD), remains a common and frequent practice in long-term care facilities (LTCFs) despite their associated risks. The objective of this study was to explore the association between social engagement (SE) and the use of antipsychotics in addressing the BPSD in newly admitted residents to LTCFs. Methods A cross-sectional study was undertaken using administrative data, primarily the Resident Assessment Instrument Minimum Data Set (Version 2.0) that collected between 2008 and 2011 (Fraser Health region, British Columbia, Canada). The data analysis conducted on a sample of 2,639 newly admitted residents aged 65 or older with a diagnosis of Alzheimer's disease or other dementias as of their first full or first quarterly assessment. Multivariate logistic regression analyses were undertaken to predict antipsychotic use based on SE. Results SE was found to be a statistically significant predictor of antipsychotic use when controlling for sociodemographic variables (odds ratio ( OR) = .86, p < .0001, confidence interval (CI) [0.82, 0.90]). However, the association disappeared when controlling for health variables ( OR = .97, p = .21, CI [0.97, 1.0]). Conclusion The prediction of antipsychotic use in newly admitted residents to LTCFs by SE is complex. Further research is warranted for further examination of the association of antipsychotic use in newly admitted residents to LTCFs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0844562117726253DOI Listing
December 2017

"When I Said I Wanted to Die at Home I Didn't Mean a Nursing Home": Care Trajectories at the End of Life.

Innov Aging 2017 Mar 30;1(1):igx011. Epub 2017 Aug 30.

Fraser Health Authority, Surrey, British Columbia, Canada.

Background And Objectives: Little is known regarding the care trajectories older adults experience at the end of life (EOL). We drew on a structural/institutional life course perspective to examine the trajectories evident among older adults transitioning through the Canadian formal long-term care system. The sequence of care transitions as well as the impact of social location, social and economic resources, and health-related factors on these trajectories were examined.

Research Design And Methods: To identify EOL care trajectories, we used administrative data collected on older adults (aged 65+) who received publicly subsidized long-term care services (e.g., nursing home and home and community-based care) in one health region in British Columbia, Canada from January 1, 2008 through December 31, 2011 and who died by March 31, 2012 ( = 11,816). Multinomial logistic regression analyses assessed the impact of selected covariates on these trajectories.

Results: The majority of those studied (65.4%) died outside of acute hospital settings. The most common trajectories involved transitions from home care to nursing home/residential care to non-hospital death (39.5%) and transitions from in-home care to hospital death (22.4%). These and other trajectories were shaped by social structural factors, access to social and economic resources, as well as health status and prior hospitalizations.

Discussion And Implications: Despite calls for minimizing hospital-based deaths and maximizing home-based deaths, older LTC recipients often experience EOL care trajectories that end in death in a nursing home care setting. Our findings point to the value of a structural/institutional life course perspective in informing an understanding of who experiences this and other major EOL care trajectories. In doing so, they also provide direction for policy and practice designed to address inequalities and enhance the quality of EOL care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/geroni/igx011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6177103PMC
March 2017

Long-Term Care Service Trajectories and Their Predictors for Persons Living With Dementia: Results From a Canadian Study.

J Aging Health 2019 01 17;31(1):139-164. Epub 2017 Aug 17.

1 University of Victoria, British Columbia, Canada.

Objective: We used latent transition analysis to explore common long-term care (LTC) service trajectories and their predictors for older adults with dementia.

Method: Using linked administrative data collected over a 4-year interval (2008-2011), the study sample included 3,541 older persons with dementia who were clients of publicly funded LTC in British Columbia, Canada.

Results: Our results revealed relatively equal reliance on home care (HC) and facility-based residential care (RC) as starting points. HC service users were further differentiated into "intermittent HC" and "continuous HC" groups. Mortality was highest for the RC group. Age, changes in cognitive performance, and activities of daily living were important predictors of transitions into HC or RC.

Discussion: Reliance on HC and RC by persons with dementia raises critical questions about ensuring that an adequate range of services is available in local communities to support aging in place and to ensure appropriate timing for entry into institutions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0898264317725618DOI Listing
January 2019

Janus at the Crossroads: Perspectives on Long-term Care Trajectories for Older Women With Dementia in a Canadian Context.

Gerontologist 2017 02 16;57(1):68-81. Epub 2016 Nov 16.

Department of Sociology, Institute on Aging and Lifelong Health, University of Victoria, British Columbia, Canada.

Purpose Of The Study: Janus, the two-faced, Roman god of beginnings and transitions, is used as a metaphor to explore our personal narratives and our quantitative research on the experiences of older women with dementia in long-term care (LTC). Two research questions are addressed: (a) How do our quantitative data map onto our mothers' experiences? (b) What lessons do our mothers' experiences offer for the care of older women with dementia?

Design And Methods: Informed by a life-course perspective, we triangulate administrative data on 3,717 women with dementia receiving LTC in British Columbia, Canada, with personal narratives-the stories of our mothers who made the transition from home care into residential (nursing home) care.

Results: Our quantitative data reveal that the home care to residential care transition is the most common LTC trajectory for women with dementia who are most likely to be widowed and living alone in suburban areas. On entry into residential care, they exhibit greater frailty in terms of activities of daily living, cognition, aggression, and incontinence. Our personal narrative data on our mothers reveals that the relatively straightforward pathways through LTC for women with dementia, are often considerably more complex in a real-world context. Attention is drawn to the public and private services, hospitalization patterns, and substantial communication gaps experienced by our moms and families.

Implications: A life-course perspective, and qualitative and quantitative data facilitate understanding the care journeys-health and service trajectories of older women with dementia.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/geront/gnw158DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5241789PMC
February 2017

Long-term Care Trajectories in Canadian Context: Patterns and Predictors of Publicly Funded Care.

J Gerontol B Psychol Sci Soc Sci 2018 08;73(6):1077-1087

Fraser Health Authority, Surrey, British Columbia, Canada.

Objectives: Drawing on a structural life course perspective (LCP), we examined the most common trajectories experienced by older long-term care (LTC; home and community-based care, assisted living, and nursing home care) recipients. The overall sequencing of care transitions was considered along with the role of social structural location, social and economic resources, and health factors in influencing them.

Method: Latent class and latent transition analyses were conducted using administrative data obtained over a 4-year period for clients aged 65 and older (n = 2,951) admitted into publicly funded LTC in 1 Canadian health region.

Results: Four main LTC trajectories were identified within which a wider range of more specific or secondary subtrajectories were embedded. These were shaped by social structural factors (age, gender, rural-urban residence), social and economic resources (marital status, income, payment for services), and health factors (chronic conditions, functional and cognitive impairment and decline, problematic behaviors).

Discussion: Our findings support the utility of a structural LCP for understanding LTC trajectories in later life. In doing so, they also reveal avenues for enhancing equitable access to care and the need for options that would increase continuity and minimize unnecessary, untimely, or undesirable transitions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/geronb/gbw104DOI Listing
August 2018

A Tale of Two Sites: Lessons on Leadership from the Implementation of a Long-term Care Delivery Model (CDM) in Western Canada.

Healthcare (Basel) 2016 Jan 4;4(1). Epub 2016 Jan 4.

First Nations Health Authority, Vancouver, BC V6C 1A1, Canada.

Residential, long-term care serves vulnerable older adults in a facility-based environment. A new care delivery model (CDM) designed to promote more equitable care for residents was implemented in a health region in Western Canada. Leaders and managers faced challenges in implementing this model alongside other concurrent changes. This paper explores the question: How did leadership style influence team functioning with the implementation of the CDM? Qualitative data from interviews with leadership personnel (directors and managers, residential care coordinators and clinical nurse educators), and direct care staff (registered nurses, licensed practical nurses, health care aides, and allied health therapists), working in two different facilities comprise the main sources of data for this study. The findings reveal that leaders with a servant leadership style were better able to create and sustain the conditions to support successful model implementation and higher team functioning, compared to a facility in which the leadership style was less inclusive and proactive, and more resistant to the change. Consequently, staff at the second facility experienced a greater sense of overload with the implementation of the CDM. This study concludes that strong leadership is key to facilitating team work and job satisfaction in a context of change.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/healthcare4010003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4934537PMC
January 2016

Comparative impact of AAV and enzyme replacement therapy on respiratory and cardiac function in adult Pompe mice.

Mol Ther Methods Clin Dev 2015 25;2:15007. Epub 2015 Mar 25.

Department of Pediatrics, University of Florida , Gainesville, Florida, USA ; Powell Gene Therapy Center, University of Florida , Gainesville, Florida, USA.

Pompe disease is an autosomal recessive genetic disorder characterized by a deficiency of the enzyme responsible for degradation of lysosomal glycogen (acid α-glucosidase (GAA)). Cardiac dysfunction and respiratory muscle weakness are primary features of this disorder. To attenuate the progressive and rapid accumulation of glycogen resulting in cardiorespiratory dysfunction, adult Gaa (-/-) mice were administered a single systemic injection of rAAV2/9-DES-hGAA (AAV9-DES) or bimonthly injections of recombinant human GAA (enzyme replacement therapy (ERT)). Assessment of cardiac function and morphology was measured 1 and 3 months after initiation of treatment while whole-body plethysmography and diaphragmatic contractile function was evaluated at 3 months post-treatment in all groups. Gaa (-/-) animals receiving either AAV9-DES or ERT demonstrated a significant improvement in cardiac function and diaphragmatic contractile function as compared to control animals. AAV9-DES treatment resulted in a significant reduction in cardiac dimension (end diastolic left ventricular mass/gram wet weight; EDMc) at 3 months postinjection. Neither AAV nor ERT therapy altered minute ventilation during quiet breathing (eupnea). However, breathing frequency and expiratory time were significantly improved in AAV9-DES animals. These results indicate systemic delivery of either strategy improves cardiac function but AAV9-DES alone improves respiratory parameters at 3 months post-treatment in a murine model of Pompe disease.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1038/mtm.2015.7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4445006PMC
June 2015

Just the facts: changes in older driver attitudes after exposure to educational interventions.

Traffic Inj Prev 2015 ;16(6):558-64

a Centre on Aging, University of Victoria , Victoria , British Columbia , Canada.

Objectives: To examine the change in cognitive processing as measured by consciousness raising and attitudes toward driving following educational interventions for older adults.

Methods: Older adults who viewed a research-based applied theater production about older driver safety (n = 110) were compared to those who were exposed to a print-based publication available to all drivers (n = 100).

Results: After viewing the play developed with input from older adults and others, older adult viewers' attitudes toward driving shifted in a manner consistent with an increased openness or willingness to consider changing their driving behavior. Conversely, after reading the print-based materials, the older adults felt more empowered to continue drive.

Conclusions: Demonstrating that an intervention that takes into account the views of older drivers can lead to attitudinal outcomes that differ from those achieved with typical "just the facts" programs is an important step in understanding how program content and format affect outcomes. Future interdisciplinary work such as this may enhance our capabilities to understand more about the processes involved in influencing change in attitudes and behaviors.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1080/15389588.2014.992067DOI Listing
July 2015

Immune responses and hypercoagulation in ERT for Pompe disease are mutation and rhGAA dose dependent.

PLoS One 2014 4;9(6):e98336. Epub 2014 Jun 4.

Department of Pediatrics, Powell Gene Therapy Center, University of Florida, Gainesville, Florida, United States of America.

Enzyme replacement therapy (ERT) with recombinant human acid-α-glucosidase (rhGAA) is the only FDA approved therapy for Pompe disease. Without ERT, severely affected individuals (early onset) succumb to the disease within 2 years of life. A spectrum of disease severity and progression exists depending upon the type of mutation in the GAA gene (GAA), which in turn determines the amount of defective protein produced and its enzymatic activity. A large percent of the early onset patients are also cross reactive immunological material negative (CRIM-) and develop high titer immune responses to ERT with rhGAA. New insights from our studies in pre-clinical murine models reveal that the type of Gaa mutation has a profound effect on the immune responses mounted against ERT and the associated toxicities, including activation of clotting factors and disseminated intravascular coagulation (DIC). Additionally, the mouse strain affects outcomes, suggesting the influence of additional genetic components or modifiers. High doses of rhGAA (20 mg/kg) are currently required to achieve therapeutic benefit. Our studies indicate that lower enzyme doses reduce the antibody responses to rhGAA, reduce the incidence of immune toxicity and avoid ERT-associated anaphylaxis. Therefore, development of rhGAA with increased efficacy is warranted to limit immunotoxicities.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0098336PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4045583PMC
March 2015

Exploring the Influence of Environment on the Spatial Behavior of Older Adults in a Purpose-Built Acute Care Dementia Unit.

Am J Alzheimers Dis Other Demen 2014 Jun 31;29(4):311-9. Epub 2013 Dec 31.

Department of Geography and Centre on Aging, Victoria, BC, V8P 5C2, Canada

Limited research explores the experience of individuals with dementia in acute care geriatric psychiatry units. This observational case study examines the influence of the physical environment on behavior (wandering, pacing, door testing, congregation and seclusions) among residents in a traditional geriatric psychiatry unit who were then relocated to a purpose-built acute care unit. Purpose-built environments should be well suited to the needs of residents with dementia. Observed trends revealed differences in spatial behaviors in the pre- and post- environments attributable to the physical environment. Person-centred modifications to the current environment including concerted efforts to know residents are meaningful in fostering quality of life. Color coded environments (rooms vs dining areas etc.) to improve wayfinding and opportunities to personalize rooms that address the `hominess' of the setting also have potential. Future research could also seek the opinions of staff about the impact of the environment on them as well as residents.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1533317513517033DOI Listing
June 2014

Preclinical toxicology and biodistribution studies of recombinant adeno-associated virus 1 human acid α-glucosidase.

Hum Gene Ther Clin Dev 2013 Sep;24(3):127-33

1 Department of Pediatrics, University of Florida College of Medicine , Gainesville, FL, 32610.

A biodistribution and toxicology study was performed to test the acute toxicities of intradiaphragmatic injection of a recombinant adeno-associated virus (rAAV) 2/1-human acid alpha-Glucosidase (hGAA) driven by a cytomegalovirus (CMV) promoter (rAAV1-CMV-hGAA) in New Zealand white rabbits and in the rodent Pompe disease model by injecting at the right quadriceps. Studies performed using fluoroscopy and AAV2-GFP demonstrated spread upon intradiaphragmatic injection, and the ability of AAV to infect and express acid α-glucosidase (GAA) throughout the diaphragm. For the preclinical study, 10 rabbits (5 male, 5 female) were divided into two groups, vehicle control (Lactated Ringer's) and test article (1.5×10(12) vector genomes [vg] rAAV1-CMV-hGAA), and euthanized on day 21. After direct visualization, the left hemidiaphragm was injected at three locations. There was up to a 2,500-fold increase in circulating anti-AAV1 antibodies directed to the vector capsids. In addition, up to an 18-fold increase in antibodies against the GAA protein was generated. Injection sites maintained up to 1.0×10(5) vg/μg genomic DNA (gDNA), while uninjected sites had up to 1.0×10(4) vg/μg gDNA. Vector DNA was present in blood at 24 hr postinjection at up to 1.0×10(6) vg/μg gDNA, followed by a decrease to 1.0×10(3) vg/μg gDNA at euthanization on day 21. Nominal amounts of vector DNA were present in peripheral organs, including the brain, spinal cord, gonads, and skeletal muscle. Upon histopathological examination, fibroplasias of the serosal surface were noted at diaphragm injections sites of both groups. In addition, an increase in mononuclear cell infiltration in the diaphragm and esophagus in vector-dosed animals was found. Elevated creatine phosphokinase levels, an indicator of muscle repair, was observed in all animals postprocedure but persisted in vector-injected rabbits until euthanization. A follow-up study suggested that this was directed against the human transgene expression in a foreign species. Overall, this study demonstrates diffusion of vector throughout the diaphragm after localized injections.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1089/humc.2013.147DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4003472PMC
September 2013

Intrapleural administration of AAV9 improves neural and cardiorespiratory function in Pompe disease.

Mol Ther 2013 Sep 4;21(9):1661-7. Epub 2013 Jun 4.

Department of Pediatrics, College of Medicine, University of Florida, Gainesville, Florida 32610-0296, USA.

Pompe disease is a neuromuscular disease resulting from deficiency in acid α-glucosidase (GAA), results in cardiac, skeletal muscle, and central nervous system (CNS) pathology. Enzyme replacement therapy (ERT) has been shown to partially correct cardiac and skeletal muscle dysfunction. However, ERT does not cross the blood-brain barrier and progressive CNS pathology ensues. We tested the hypothesis that intrapleural administration of recombinant adeno-associated virus (rAAV9)-GAA driven by a cytomegalovirus (CMV) or desmin (DES) promoter would improve cardiac and respiratory function in Gaa(-/-) mice through a direct effect and retrograde transport to motoneurons. Cardiac magnetic resonance imaging revealed significant improvement in ejection fraction in rAAV9-GAA-treated animals. Inspiratory phrenic and diaphragm activity was examined at baseline and during hypercapnic respiratory challenge. Mice treated with AAV9 had greater relative inspiratory burst amplitude during baseline conditions when compared with Gaa(-/-). In addition, efferent phrenic burst amplitude was significantly correlated with diaphragm activity in both AAV9-DES and AAV9-CMV groups but not in Gaa(-/-). This is the first study to indicate improvements in cardiac, skeletal muscle, and respiratory neural output following rAAV administration in Pompe disease. These results further implicate a role for the CNS in Pompe disease pathology and the critical need to target the neurologic aspects in developing therapeutic strategies.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1038/mt.2013.96DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3776643PMC
September 2013

Pompe disease gene therapy.

Hum Mol Genet 2011 Apr 25;20(R1):R61-8. Epub 2011 Apr 25.

Department of Pediatrics, University of Florida, 1600 SW Archer Road, Gainesville, FL 32610, USA.

Pompe disease is an autosomal recessive metabolic myopathy caused by the deficiency of the lysosomal enzyme acid alpha-glucosidase and results in cellular lysosomal and cytoplasmic glycogen accumulation. A wide spectrum of disease exists from hypotonia and severe cardiac hypertrophy in the first few months of life due to severe mutations to a milder form with the onset of symptoms in adulthood. In either condition, the involvement of several systems leads to progressive weakness and disability. In early-onset severe cases, the natural history is characteristically cardiorespiratory failure and death in the first year of life. Since the advent of enzyme replacement therapy (ERT), the clinical outcomes have improved. However, it has become apparent that a new natural history is being defined in which some patients have substantial improvement following ERT, while others develop chronic disability reminiscent of the late-onset disease. In order to improve on the current clinical outcomes in Pompe patients with diminished clinical response to ERT, we sought to address the cause and potential for the treatment of disease manifestations which are not amenable to ERT. In this review, we will focus on the preclinical studies that are relevant to the development of a gene therapy strategy for Pompe disease, and have led to the first clinical trial of recombinant adeno-associated virus-mediated gene-based therapy for Pompe disease. We will cover the preliminary laboratory studies and rationale for a clinical trial, which is based on the treatment of the high rate of respiratory failure in the early-onset patients receiving ERT.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/hmg/ddr174DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3095055PMC
April 2011

Gel-mediated delivery of AAV1 vectors corrects ventilatory function in Pompe mice with established disease.

Mol Ther 2010 Mar 26;18(3):502-10. Epub 2010 Jan 26.

Powell Gene Therapy Center, University of Florida, Gainesville, Florida 32610, USA.

Pompe disease is a muscular dystrophy that results in respiratory insufficiency. We characterized the outcomes of targeted delivery of recombinant adeno-associated virus serotype 1 (rAAV2/1) vector to diaphragms of Pompe mice with varying stages of disease progression. We observed significant improvement in diaphragm contractile strength in mice treated at 3 months of age that is sustained at least for 1 year and enhanced contractile strength in mice treated at 9 and 21 months of age, measured 3 months post-treatment. Ventilatory parameters including tidal volume/inspiratory time ratio, minute ventilation/expired CO2 ratio, and peak inspiratory airflow were significantly improved in mice treated at 3 months and tested at 6 months. Despite early improvement, mice treated at 3 months and tested at 1 year had diminished normoxic ventilation, potentially due to attenuation of correction over time or progressive degeneration of nontargeted accessory tissues. However, for all rAAV2/1-treated mice (treated at 3, 9, and 21 months, assayed 3 months later; treated at 3 months, assayed at 1 year), minute ventilation and peak inspiratory flows were significantly improved during respiratory challenge. These results demonstrate that gel-mediated delivery of rAAV2/1 vectors can significantly augment ventilatory function at initial and late phases of disease in a model of muscular dystrophy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1038/mt.2009.305DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2839425PMC
March 2010

Physiological correction of Pompe disease by systemic delivery of adeno-associated virus serotype 1 vectors.

Mol Ther 2007 Mar 23;15(3):501-7. Epub 2007 Jan 23.

Powell Gene Therapy Center, University of Florida, Gainesville, Florida, USA.

Pompe disease is caused by a lack of functional lysosomal acid alpha-glucosidase (GAA) and can ultimately lead to fatal hypertrophic cardiomyopathy and respiratory insufficiency. Previously, we demonstrated the ability of recombinant adeno-associated virus serotype 1 (rAAV2/1) vector to restore the therapeutic levels of cardiac and diaphragmatic GAA enzymatic activity in vivo in a mouse model of Pompe disease. We have further characterized cardiac and respiratory function in rAAV2/1-treated animals 1 year post-treatment. Similar to the patient population, electrocardiogram measurements (P-R interval) are significantly shortened in the Pompe mouse model. In rAAV2/1-treated mice, we show a significant improvement in cardiac conductance with prolonged P-R intervals of 39.34+/-1.6 ms, as compared to untreated controls (35.58+/-0.57 ms) (P
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1038/sj.mt.6300100DOI Listing
March 2007

Recombinant adeno-associated virus serotype 9 leads to preferential cardiac transduction in vivo.

Circ Res 2006 Aug 27;99(4):e3-9. Epub 2006 Jul 27.

Center for Fetal Monkey Gene Transfer for Heart, Lung and Blood Diseases, California National Primate Research Center, Davis, USA.

Heart disease is often the end result of inherited genetic defects, which may potentially be treatable using a gene-transfer approach. Recombinant adeno-associated virus (rAAV)-mediated gene delivery has emerged as a realistic method for the treatment of such disorders. Here, we demonstrate and compare the natural affinity of specific AAV serotype capsids for transduction of cardiac tissue. We compared the previously accepted optimal rAAV serotype for transduction of skeletal muscle, rAAV2/1, with rAAV2/8 and the newer rAAV2/9 vectors carrying the CMV-lacZ construct in their respective abilities to transcend vasculature and transduce myocardium following intravenous delivery of 1x10(11) vector genomes in neonatal mice. We found that both rAAV2/8 and rAAV2/9 are able to transduce myocardium at approximately 20- and 200-fold (respectively) higher levels than rAAV2/1. Biodistribution analysis revealed that rAAV2/9 and rAAV2/8 demonstrate similar behavior in extracardiac tissue. Vector genome quantification showed an increase in genome copy numbers in cardiac tissue for several weeks following administration, which corresponds to expression data. In addition, we intravenously administered 1x10(11) vector genomes of rAAV2/9-CMV-lacZ into adult mice and achieved an expression biodistribution profile similar to that found following delivery to newborns. Although higher doses of virus will be necessary to approach those levels observed following neonatal injections, adult myocardium is also readily transduced by rAAV2/9. Finally, we have demonstrated physiological disease correction by AAV9 gene transfer in a mouse model of Pompe disease via ECG tracings and that intravenous delivery of the same vector preferentially transduces cardiac tissue in nonhuman primates.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/01.RES.0000237661.18885.f6DOI Listing
August 2006

Rescue of enzyme deficiency in embryonic diaphragm in a mouse model of metabolic myopathy: Pompe disease.

Development 2004 Jun;131(12):3007-19

Powell Gene Therapy Center, and Departments of Molecular Genetics and Microbiology and Pediatrics, University of Florida College of Medicine, Gainesville, Florida 32610, USA.

Several human genetic diseases that affect striated muscle have been modeled by creating knockout mouse strains. However, many of these are perinatal lethal mutations that result in death from respiratory distress within hours after birth. As the diaphragm muscle does not contract until birth, the sudden increase in diaphragm activity creates permanent injury to the muscle causing it to fail to meet respiratory demands. Therefore, the impact of these mutations remains hidden throughout embryonic development and early death prevents investigators from performing detailed studies of other striated muscle groups past the neonatal stage. Glycogen storage disease type II (GSDII), caused by a deficiency in acid alpha-glucosidase (GAA), leads to lysosomal accumulation of glycogen in all cell types and abnormal myofibrillogenesis in striated muscle. Contractile function of the diaphragm muscle is severely affected in both infantile-onset and late-onset individuals, with death often resulting from respiratory failure. The knockout mouse model of GSDII survives well into adulthood despite the gradual weakening of all striated muscle groups. Using this model, we investigated the delivery of recombinant adeno-associated virus (rAAV) vectors encoding the human GAA cDNA to the developing embryo. Results indicate specific high-level transduction of diaphragm tissue, leading to activity levels up to 10-fold higher than normal and restoration of normal contractile function. Up to an estimated 50 vector copies per diploid genome were quantified in treated diaphragms. Histological glycogen staining of treated diaphragms revealed prevention of lysosomal glycogen accumulation in almost all fibers when compared with untreated controls. This method could be employed with disease models where specific rescue of the diaphragm would allow for increased survival and thus further investigation into the impact of the gene deletion on other striated muscle groups.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1242/dev.01169DOI Listing
June 2004

The effect of pharmacist intervention and patient education on lipid-lowering medication compliance and plasma cholesterol levels.

Can J Clin Pharmacol 2003 ;10(3):101-6

Outcomes Research, Pfizer Canada Inc., 17300 Trans-Canada Highway, Kirkland, Quebec H9J 2M5, Canada.

Background: Dyslipidemias are a modifiable risk factor for coronary heart disease. The benefits of cholesterol reduction drug therapies are limited by poor patient compliance with drug regimens.

Objectives: To determine the impact of a community pharmacist pilot disease-management program on patient compliance with lipid-lowering drug therapy and on serum cholesterol levels.

Methods: One hundred forty-nine patients who were nonadherent to prescribed hypolipidemic drug regimens were recruited for this six-month prospective study. Each subject served as their own control. Pharmacists educated these patients on lipid disorders, the benefit of medication compliance and lifestyle modifications that reduce the risk for coronary heart disease. Pharmacists followed up participants by telephone at two-month intervals. Drug renewal rates were monitored throughout the study and plasma lipid levels were measured at study outset and study end.

Results: Pharmacist intervention and patient-education programs significantly increased medication compliance, as shown by a 15.3% increase (P<0.05) in the number of compliant patients and an 11 day (P<0.001) reduction in the average number of days to prescription renewal. Concurrently, levels of total cholesterol, triglycerides and low-density lipoprotein (LDL) cholesterol, were reduced by 6%, 16.2%, and 8.5% (P<0.001, 0.01, 0.01), respectively. High density lipoprotein (HDL) cholesterol remained relatively unchanged (+0.7%) so that the LDL to HDL ratio was improved by 17.2% overall (P<0.01). Almost all of the patients (99.2%) were satisfied with the program and expressed a willingness to pay an average $34.50 per 30 min consultation for the pharmacist services offered.

Conclusion: Pharmacists can contribute significantly to disease management of dyslipidemic individuals.
View Article and Find Full Text PDF

Download full-text PDF

Source
October 2003

Correction of the enzymatic and functional deficits in a model of Pompe disease using adeno-associated virus vectors.

Mol Ther 2002 May;5(5 Pt 1):571-8

Powell Gene Therapy Center, University of Florida College of Medicine, Gainesville, Florida 32610, USA.

Pompe disease is a lysosomal storage disease caused by the absence of acid alpha-1,4 glucosidase (GAA). The pathophysiology of Pompe disease includes generalized myopathy of both cardiac and skeletal muscle. We sought to use recombinant adeno-associated virus (rAAV) vectors to deliver functional GAA genes in vitro and in vivo. Myotubes and fibroblasts from Pompe patients were transduced in vitro with rAAV2-GAA. At 14 days postinfection, GAA activities were at least fourfold higher than in their respective untransduced controls, with a 10-fold increase observed in GAA-deficient myotubes. BALB/c and Gaa(-/-) mice were also treated with rAAV vectors. Persistent expression of vector-derived human GAA was observed in BALB/c mice up to 6 months after treatment. In Gaa(-/-) mice, intramuscular and intramyocardial delivery of rAAV2-Gaa (carrying the mouse Gaa cDNA) resulted in near-normal enzyme activities. Skeletal muscle contractility was partially restored in the soleus muscles of treated Gaa(-/-) mice, indicating the potential for vector-mediated restoration of both enzymatic activity and muscle function. Furthermore, intramuscular treatment with a recombinant AAV serotype 1 vector (rAAV1-Gaa) led to nearly eight times normal enzymatic activity in Gaa(-/-) mice, with concomitant glycogen clearance as assessed in vitro and by proton magnetic resonance spectroscopy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1006/mthe.2002.0580DOI Listing
May 2002