Publications by authors named "Guiping Liu"

44 Publications

External validation of the modified LACE+, LACE+, and LACE scores to predict readmission or death after hospital discharge.

J Eval Clin Pract 2021 May 8. Epub 2021 May 8.

Centre for Health Evaluation & Outcome Sciences (CHÉOS), Vancouver, Canada.

Background: Unplanned hospital readmissions are common adverse events. The LACE+ score has been used to identify patients at the highest risk of unplanned readmission or death, yet the external validity of this score remains uncertain.

Methods: We constructed a cohort of patients admitted to hospital between 1 October 2014 and 31 January 2017 using population-based data from British Columbia (Canada). The primary outcome was a composite of urgent hospital readmission or death within 30 days of index discharge. The primary analysis sought to optimize clinical utility and international generalizability by focusing on the modified LACE+ (mLACE+) score, a variation of the LACE+ score which excludes the Case Mix Group score. Predictive performance was assessed using model calibration and discrimination.

Results: Among 368,154 hospitalized individuals, 31,961 (8.7%) were urgently readmitted and 5428 (1.5%) died within 30 days of index discharge (crude composite risk of readmission or death, 9.95%). The mLACE+ score exhibited excellent calibration (calibration-in-the-large and calibration slope no different than ideal) and adequate discrimination (c-statistic, 0.681; 95%CI, 0.678 to 0.684). Higher risk dichotomized mLACE+ scores were only modestly associated with the primary outcome (positive likelihood ratio 1.95, 95%CI 1.93 to 1.97). Predictive performance of the mLACE+ score was similar to that of the LACE+ and LACE scores.

Conclusion: The mLACE+, LACE+ and LACE scores predict hospital readmission with excellent calibration and adequate discrimination. These scores can be used to target interventions designed to prevent unplanned hospital readmission.
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http://dx.doi.org/10.1111/jep.13579DOI Listing
May 2021

Physician Financial Incentives to Reduce Unplanned Hospital Readmissions: an Interrupted Time Series Analysis.

J Gen Intern Med 2021 May 4. Epub 2021 May 4.

Centre for Health Evaluation & Outcome Sciences (CHÉOS), Vancouver, Canada.

Background: In 2012, the Ministry of Health in British Columbia, Canada, introduced a $75 incentive payment that could be claimed by hospital physicians each time they produced a written post-discharge care plan for a complex patient at the time of hospital discharge.

Objective: To examine whether physician financial payments incentivizing enhanced discharge planning reduce subsequent unplanned hospital readmissions.

Design: Interrupted time series analysis of population-based hospitalization data.

Participants: Individuals with one or more eligible hospitalizations occurring in British Columbia between 2007 and 2017.

Main Measures: The proportion of index hospital discharges with subsequent unplanned hospital readmission within 30 days, as measured each month of the 11-year study interval. We used interrupted time series analysis to determine if readmission risk changed after introduction of the incentive payment policy.

Key Results: A total of 40,588 unplanned hospital readmissions occurred among 409,289 eligible index hospitalizations (crude 30-day readmission risk, 9.92%). Policy introduction was not associated with a significant step change (0.393%; 95CI, - 0.190 to 0.975%; p = 0.182) or change-in-trend (p = 0.317) in monthly readmission risk. Policy introduction was associated with significantly fewer prescription fills for potentially inappropriate medications among older patients, but no improvement in prescription fills for beta-blockers after cardiovascular hospitalization and no change in 30-day mortality. Incentive payment uptake was incomplete, rising from 6.4 to 23.5% of eligible hospitalizations between the first and last year of the post-policy interval.

Conclusion: The introduction of a physician incentive payment was not associated with meaningful changes in hospital readmission rate, perhaps in part because of incomplete uptake by physicians. Policymakers should consider these results when designing similar interventions elsewhere.

Trial Registration: ClinicalTrials.gov ID, NCT03256734.
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http://dx.doi.org/10.1007/s11606-021-06803-8DOI Listing
May 2021

Tidal Effects on the Longitudinal Structures of the Martian Thermosphere and Topside Ionosphere Observed by MAVEN.

J Geophys Res Space Phys 2020 Dec 1;126(2). Epub 2021 Feb 1.

Laboratory for Atmospheric and Space Physics, University of Colorado, Boulder, CO, USA.

Longitudinal structures in the Martian thermosphere and topside ionosphere between 150 and 200 km altitudes are studied using in situ electron and neutral measurements from the NASA Mars Atmosphere and Volatile EvolutioN (MAVEN) mission. Four time intervals are selected for comparison, during which MAVEN sampled similar local time (9.3-10.3 h) and latitude (near 20°S) regions but at different solar longitude positions (two near northern summer solstice, one each at northern vernal and autumnal equinoxes). Persistent and pronounced tidal oscillations characterize the ionosphere and thermosphere, whose longitudinal variations in density are generally in-phase with each other. Our analysis of simultaneous and collocated neutral and electron data provides direct observational evidence for thermosphere-ionosphere coupling through atmospheric tides. We conclude that the ionosphere is subject to modulation by upward-propagating thermal tides, via both tide-induced vertical displacement and photochemical reactions. Atmospheric tides constitute a ubiquitous and significant perturbation source to the ionospheric electron density, up to ~15% near 200 km.
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http://dx.doi.org/10.1029/2020ja028562DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8011558PMC
December 2020

Comparing patient-reported outcomes across countries: An assessment of methodological challenges.

J Health Serv Res Policy 2021 Jul 7;26(3):163-171. Epub 2021 Feb 7.

Clinical Associate Professor, Section of Colorectal Surgery, Department of Surgery, University of British Columbia, Vancouver, Canada.

Objectives: There is little published literature on the comparison of patient-reported outcomes between countries. This study aimed to assess pre- and postoperative health among samples of patients undergoing elective groin hernia repair procedures in the National Health Service (NHS), England, and groin hernia patients in Vancouver, Canada.

Methods: We used datasets from two different sources. For the English NHS we used published anonymized patient-level data files which include the EQ-5D(3L) patient-reported outcome measure and a number of demographic and clinical characteristics. For Vancouver, we used data from a sample of Vancouver patients who completed the same instrument during a similar time frame. English patients were matched with Vancouver participant's characteristics using propensity score methods. A linear regression model was used to measure differences in postoperative visual analogue scale values between countries, adjusting for patient characteristics.

Results: Our study revealed a range of methodological issues concerning the comparability of patient-reported outcomes following hernia repair surgery in the two health systems. These related to differences in approaches to collecting patient-reported outcome measures and the nature of explanatory variables (self-report vs. administrative data), among other challenges. As a consequence, there were differences between the matched samples and the NHS data, indicating a healthy participant bias. Unadjusted results found that Vancouver patients (N = 280) reported more problems in domains of mobility, self care, usual activities and anxiety/depression than the matched cohort of NHS patients (N = 840). Interpreting differences is challenging given different sampling designs.

Conclusions: There are significant hurdles facing comparisons of surgical patients' outcomes between countries, including adjusting for patient differences, health system factors and approaches to survey administration. While between-country comparisons of surgical outcomes using patient-reported outcomes shows significant promise, much work on standardizing sampling design, variables and analytic methods is needed.
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http://dx.doi.org/10.1177/1355819621990696DOI Listing
July 2021

Measuring the impact of delayed access to elective cholecystectomy through patient's cost-utility: an observational cohort study.

Int J Qual Health Care 2021 Feb;33(1)

Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, Canada.

Background: Deferral of surgeries due to COVID-19 has negatively affected access to elective surgery and may have deleterious consequences for patient's health. Delays in access to elective surgery are not uniform in their impact on patients with different attributes. The objective of this study is to measure the change in patient's cost utility due to delayed elective cholecystectomy.

Methods: This study is based on retrospective analysis of a longitudinal sample of participants who have had elective cholecystectomy and completed the EQ-5D(3L) measuring health status preoperatively and postoperatively. Emergent cases were excluded. Patients younger than 19 years of age, unable to communicate in English or residing in a long-term care facility were ineligible. Quality-adjusted life years attributable to cholecystectomy were calculated by comparing health state utility values between the pre- and postoperative time points. The loss in quality-adjusted life years due to delayed access was calculated under four assumed scenarios regarding the length of the delay. The mean cost per quality-adjusted life years are shown for the overall sample and by sex and age categories.

Results: Among the 646 eligible patients, 30.1% of participants (N = 195) completed their preoperative and postoperative EQ-5D(3L). A delay of 12 months resulted in a mean loss of 6.4%, or 0.117, of the quality-adjusted life years expected without the delay. Among patients older than 70 years of age, a 12-month delay in their surgery corresponded with a 25.1% increase in the cost per quality-adjusted life years, from $10 758 to $13 463.

Conclusions: There is a need to focus on minimizing loss of quality of life for patients affected by delayed surgeries. Faced with equal delayed access to elective surgery, triage may need to prioritize older patients to maximize their health over their remaining life years.
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http://dx.doi.org/10.1093/intqhc/mzab018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7928948PMC
February 2021

The minimally important difference of the Gastrointestinal Quality of Life Index for symptomatic gallstone surgery.

Surg Endosc 2021 Jan 4. Epub 2021 Jan 4.

Section of Colorectal Surgery, Department of Surgery, University of British Columbia, Vancouver, Canada.

Introduction: The Gastrointestinal Quality of Life Index (GQLI) is used to measure domains of health and symptoms among people with gastrointestinal disorders. The objective of this study is to calculate the smallest change in the GQLI that is perceived by patients as meaningful among a sample of English-speaking adult patients undergoing elective laparoscopic cholecystectomy for treatment of symptomatic gallbladder disease.

Materials And Methods: The study is based on retrospective analyses of a sample of participants completing the GQLI and the EQ-5D(3L) preoperatively and six months postoperatively in Vancouver, Canada. Patients are excluded if they are less than 19 years of age, cannot communicate in English, or reside in a long-term care facility. The MID is calculated for the GQLI's domains using distribution and anchor-based methods.

Results: Among eligible patients, the participation rate was 51%. The estimated MID for the overall GQLI value ranged between 4.32 and 11.44. There were no statistically significant differences in the GQLI's MID values between sexes or age subgroups. There were statistically significant differences in the GQLI's MID values by baseline health status.

Discussion: This study should provide some comfort that the MID values used in discussing change in health and symptoms with elective cholecystectomy patients are robust to sex. Although the sample size may have been inadequate for age-based analyses, the study found large differences in MID values between age subgroups. Statistically significant differences in MID values based on preoperative health supports reporting MID values separately by baseline value. Further research should explore whether age-based differences in MID values exist using larger samples.
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http://dx.doi.org/10.1007/s00464-020-08205-zDOI Listing
January 2021

Sensitivity study for ICON tidal analysis.

Prog Earth Planet Sci 2020 22;7(1):18. Epub 2020 May 22.

Space Sciences Laboratory, University of California Berkeley, Berkeley, USA.

Retrieval of the properties of the middle and upper atmosphere can be performed using several different interferometric and photometric methods. The emission-shape and Doppler shift of both atomic and molecular emissions can be observed from the ground and space to provide temperature and bulk velocity. These instantaneous measurements can be combined over successive times/locations along an orbit track, or successive universal/local times from a ground station to quantify the motion and temperature of the atmosphere needed to identify atmospheric tides. In this report, we explore how different combinations of space-based wind and temperature measurements affect the retrieval of atmospheric tides, a ubiquitous property of planetary atmospheres. We explore several scenarios informed by the use of a tidally forced atmospheric circulation model, an empirically based emissions reference, and a low-earth orbit satellite observation geometry based on the ICON mission design. This capability provides a necessary tool for design of an optimal mission concept for retrieval of atmospheric tides from ICON remote-sensing observations. Here it is used to investigate scenarios of limited data availability and the effects of rapid changes in the total wave spectrum on the retrieval of the correct tidal spectrum. An approach such as that described here could be used in the design of future missions, such as the NASA DYNAMIC mission (National Research Council, Solar and space physics: a science for a technological society, 2013).
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http://dx.doi.org/10.1186/s40645-020-00330-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7319356PMC
May 2020

Incisional hernia repair surgery improves patient reported outcomes.

Am J Surg 2020 05 27;219(5):874-878. Epub 2020 Mar 27.

Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada.

Background: Incisional hernias are a frequent complication after abdominal surgeries. The aim of this study is to investigate the impact of incisional hernia repair on health related quality of life.

Methods: We prospectively recruited a sample of patients waiting for incisional hernia repairs in the Vancouver Coastal Health Authority, Canada. Study participants self-report their pain, depression and overall quality of life using patient reported outcome measures EQ-5D, PHQ-9 and PEG as they were placed on the waitlist and 6 months after surgery.

Results: There were 87 patients who responded to both the pre and post-operative survey. The average wait for surgery was 20.3 weeks. Patients with poor baseline health pre-operatively had significant improvement in pain, depression and quality of life.

Conclusions: Among patients with poorer baseline health who underwent surgery for incisional hernias, there was a significant benefit in depression, pain and overall quality of life.
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http://dx.doi.org/10.1016/j.amjsurg.2020.03.027DOI Listing
May 2020

Validating the Foot and Ankle Outcome score for measuring foot dysfunction among hallux valgus surgery patients using item response theory.

Foot Ankle Surg 2020 Dec 4;26(8):864-870. Epub 2019 Dec 4.

Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, Canada. Electronic address:

Background: There is an absence of high quality research validating instruments that measure foot and ankle related quality of life among hallux valgus (bunion) patients' perspectives. The Foot and Ankle Outcome Scale is a patient-reported outcome instrument, that when administered to patients with symptomatic hallux valgus, provides a patient-centric perspective of their foot function. The aim of this study is to assess the psychometric properties of the instrument's five subscales among preoperative bunion surgery patients.

Methods: The Foot and Ankle Outcome Scale instrument measures Pain, Symptoms, Activities of Daily Living, Sport and Recreational Activities and Foot/Ankle Related Quality of Life. Preoperative data is collected from a sample of patients scheduled for surgical treatment of their condition in Vancouver, Canada. Classical and item response theory methods are used to report on reliability, validity and differential item functioning among subgroups.

Results: This study included 249 surveys, representing an overall response rate of 44.1% among 564 eligible patients. The instrument demonstrated high reliability for all subscales, though 18 items across subscales, exhibited poor discrimination between item levels. Four items score differently according to patients' sex and one item scored differently by age.

Conclusions: The instrument measures five domains of health important to bunion patients. These findings suggest that the current instrument can be used with an understanding of its limitations, including redundant questions and sex-based differences. Future research should revise a number of items. The results highlight the importance of the psychometric analyses of instruments in specific patient populations.
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http://dx.doi.org/10.1016/j.fas.2019.11.002DOI Listing
December 2020

Evaluation of MALDI-TOF MS for the measurement of glycated hemoglobin.

Clin Chim Acta 2019 Nov 23;498:154-160. Epub 2019 Aug 23.

Department of Laboratory Medicine, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China. Electronic address:

Background: Glycated hemoglobin (Hemoglobin A, HbA) plays a key role in monitoring long-term blood glucose levels in diabetics mellitus. Therefore, it is of great importance to ensure test quality of HbA methods.

Objectives: We aimed to evaluate analytical performances of a matrix assisted laser desorption/ionization time of flight mass spectrometry (MALDI-TOF MS) system for the measurement of HbA.

Methods: We assessed the analytical performances of the method including imprecision, accuracy, and linearity. In addition, comparison with Variant II Turbo 2.0 and Capillarys3 TERA, correlation between glycation rate of α and β globin as well as the influence of most frequent analytical interferences in HbA assays were also investigated.

Results: As measurement of imprecision, within-run CVs and total CVs were lower than 1.6% and 2.4%, respectively. Discrepancy of test results (<0.2%) of IFCC value-assigned external quality control samples indicated a good accuracy of the method. The linearity was excellent with a correlation coefficient of 0.999. The QuanTOF results were well correlated with those obtained by Variant II Turbo 2.0 and Capillarys3 TERA. Good correlation between glycation rates of α and β globin were found. QuanTOF was not prone to common interferences including bilirubin, triglyceride, labile A, and carbamylated hemoglobin. However, unacceptable positive bias was observed when the amount of HbF were greater than approximately 8.0% or in the presence of HbS.

Conclusions: QuanTOF perform well for the determination of HbA and meet quality criteria requested for clinical use.
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http://dx.doi.org/10.1016/j.cca.2019.08.025DOI Listing
November 2019

Autophagy inhibition of cancer stem cells promotes the efficacy of cisplatin against non-small cell lung carcinoma.

Ther Adv Respir Dis 2019 Jan-Dec;13:1753466619866097

Department of Radiation Oncology, Liaocheng Cancer Hospital, No 45 Jianshe East Road, Liaocheng, Shandong, 252000, China.

Background: Clinical treatment of non-small cell lung carcinoma (NSCLC) by cisplatin eventually results in drug resistance, which cancer stem cells and autophagy are believed to be involved in. In the present study, we aimed to explore the effect of autophagy-inhibited cancer stem cells in NSCLC.

Methods: Cancer stem cells were identified by CD133 expression levels detected by immunochemistry, real-time polymerase chain reaction, western blot, and flow cytometry. Stemness was detected by sphere-forming assays of tumor cells. Autophagy was determined by LC3-II expression at mRNA and protein levels. The effect of chloroquine (CQ) on autophagy was detected by real-time polymerase chain reaction, western blot and sphere-forming assay , and tumor growth in male NOD/SCID mice.

Results: Cisplatin (CDDP) treatment enhanced CD133 cell ratios in clinical NSCLC specimens and NSCLC cell line A549. The CD133 cells enriched by CDDP exhibited higher autophagy levels. Autophagy inhibition by CQ inhibited CD133 stemness and promoted CDDP efficiency in A549 cells. In addition, the combination of CDDP and CQ treatment significantly inhibited autophagy levels and cancer stem cell proportions , and dramatically suppressed tumor growth compared with individual agents.

Conclusion: Autophagy inhibition of cancer stem cells could promote the efficacy of cisplatin against NSCLC.
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http://dx.doi.org/10.1177/1753466619866097DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6676261PMC
March 2020

Detection of a novel hemoglobin variant Hb Liaoning by matrix assisted laser desorption/ionization-time of flight mass spectrometry.

Clin Chem Lab Med 2019 Nov;57(12):e328-e330

Department of Laboratory Medicine, Peking University Shenzhen Hospital, Lianhua Road No. 1120, Futian District, Shenzhen, Guangdong, P.R. China, Phone: +86-0755-83923333-2299.

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http://dx.doi.org/10.1515/cclm-2019-0300DOI Listing
November 2019

Health and Quality of Life Outcomes Among Patients Undergoing Surgery for End-Stage Ankle Arthritis.

Foot Ankle Int 2019 Oct 19;40(10):1129-1139. Epub 2019 Jun 19.

Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada.

Background: There is little research investigating which aspects of health-related quality of life change following ankle arthrodesis and total ankle replacement surgery. The objective of this study was to report on statistically and clinically relevant changes in multiple dimensions of health-related quality of life among patients undergoing ankle replacement or fusion surgery.

Methods: This study was based on a prospective sample of ankle arthrodesis and total ankle replacement patients. Participants complete the Ankle Osteoarthritis Scale, EuroQoL's EQ-5D-3L, the Patient Health Questionnaire-9, and the pain intensity, interference with enjoyment of life, and general activity pain instrument. Instruments were completed preoperatively and postoperatively. Multivariate regression models were used to measure the change in health-related quality of life outcomes, adjusting for demographic, clinical, and health service utilization.

Results: Participants achieved statistically significant improvements in health-related quality of life in each domain of measurement. The majority of participants reported clinically significant improvement in pain. Mild depressive symptoms were common, and clinically significant improvement in depression symptoms occurred in 22% of patients. Gains in health were more pronounced among participants reporting the worst preoperative health in all domains quality of life measured.

Conclusions: Pain showed a clinically important improvement among 64% of participants whereas 22% reported a clinically meaningful improvement in their depression symptoms postoperatively. Clinically significant gains in health-related quality of life were not experienced by all participants in all dimensions. Further research is warranted to better understand the failure of some patients to improve in dimensions of health studied.

Level Of Evidence: Level III, comparative study.
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http://dx.doi.org/10.1177/1071100719856888DOI Listing
October 2019

A Cost-Utility Study of Laparoscopic Cholecystectomy for the Treatment of Symptomatic Gallstones.

J Gastrointest Surg 2020 06 29;24(6):1314-1319. Epub 2019 May 29.

Department of Surgery, University of Calgary, Calgary, Canada.

Background: Laparoscopic cholecystectomy is a high-volume surgery that is an end-stage treatment for gallstones. There is little understanding of the surgery's effect on the gain in patients' health relative to its cost. The objective of this study is to measure health gain, cost and cost utility of elective laparoscopic cholecystectomy.

Methods: Participants completed the EQ-5D(3L) pre-operatively and post-operatively. Quality adjusted life years attributable to cholecystectomy were calculated by comparing health state utility values between the pre- and post-operative time points. Laparoscopic cholecystectomy cost was calculated from a health system perspective and included hospital and specialists' fees (in 2016 Canadian dollars). Cost per QALY was calculated for the entire sample and demographic sub-groups.

Results: The cohort consisted of 135 participants who completed surveys between February 2013 and June 2017. The response rate among eligible patients was 50%. Assuming that health gain accrued to the participant for 25 years after cholecystectomy, the mean gain in QALYs was 1.7430, corresponding to an average cost per QALY of $2102. Older patients, on average, had less gain in QALYs than younger patients.

Conclusion: Laparoscopic cholecystectomies are inexpensive relative to the gains in health they provide patients. The gains in health were not uniform across age categories. These results should provide health system planners confidence that incremental increases in surgical capacity for elective cholecystectomies is beneficial.
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http://dx.doi.org/10.1007/s11605-019-04268-zDOI Listing
June 2020

Enantioselective Catabolism of Napropamide Chiral Enantiomers in Sphingobium sp. A1 and B2.

J Agric Food Chem 2019 Jun 6;67(24):6819-6827. Epub 2019 Jun 6.

Jiangsu Key Lab for Solid Organic Waste Utilization , Nanjing , Jiangsu 210095 , People's Republic of China.

Napropamide [ N, N-diethyl-2-(1-naphthalenyloxy)propenamide, NAP] is a highly efficient and broad-spectrum amide herbicide. Little is known about the bacterial catabolism of its different enantiomers. Here, we report the isolation of two NAP-degrading strains of Sphingobium sp., A1 and B2, and the different catabolic pathways of different enantiomers in these two strains. Strain A1 dioxygenated NAP at different positions of the naphthalene ring of different enantiomers, leading to the complete degradation of R-NAP while producing a dead-end product from S-NAP. Strain B2 cleaved the amido bonds of both enantiomers, but only the product from S-NAP could be further transformed to form α-naphthol and mineralize in strain B2. The degradation rates of R-NAP and S-NAP in the combination degradation by strains A1 and B2 were 24.8 and 7.5 times that in the single-strain degradation by strain B2 or A1, respectively, showing enhanced synergistic catabolism between strains A1 and B2. This study provides new insights into the enantioselective catabolic network of the chiral herbicide NAP in microorganisms.
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http://dx.doi.org/10.1021/acs.jafc.9b00707DOI Listing
June 2019

The impact of comorbid depression in chronic rhinosinusitis on post-operative sino-nasal quality of life and pain following endoscopic sinus surgery.

J Otolaryngol Head Neck Surg 2019 Apr 30;48(1):18. Epub 2019 Apr 30.

Rhinology, Endoscopic Sinus and Skull Base Surgery, Division of Otolaryngology - Head and Neck Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada.

Background: Depression and chronic pain are debilitating disorders that co-exist with many chronic diseases. Chronic rhinosinusitis (CRS) is no exception. Nonetheless, little is known about the association between these co-related conditions and the treatment of CRS. The objective of this study is to measure outcomes following endoscopic sinus surgery (ESS) in CRS patients reporting significant pre-operative depression and pain.

Methods: This is a prospective longitudinal cohort study examining patients with CRS who had failed maximal medical therapy and subsequently underwent ESS. Participants completed a several patient-reported outcome (PRO) instruments pre-operatively and 6 months post-operatively. The PROs included the Sinonasal Outcome Test-22 (SNOT-22), the Patient Health Questionnaire (PHQ-9) measuring symptoms of depression and an assessment of chronic pain using the pain intensity (P), interference with enjoyment of life (E) and general (G) activity instrument, the PEG instrument.

Results: The study had 142 participants complete their pre-operative and post-operative surveys. The participation rate was 40.1% among eligible patients. The prevalence of at least moderate depression was 22 patients (15.5%) among participants. Compared with non-depressed participants, the pre-operative sino-nasal disease burden and pain scores were higher among depressed participants (p <  0.001) and the gain in health following surgery was smaller (p <  0.001).

Conclusions: Pre-operative disease burden is higher among depressed patients. Post-operative gains in sino-nasal quality of life attributable to endoscopic sinus surgery were significantly smaller among depressed participants. Pre-operative screening for depression could identify opportunities for medical intervention and improve outcomes among CRS patients.
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http://dx.doi.org/10.1186/s40463-019-0340-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6492324PMC
April 2019

Minimally Important Difference in the Foot and Ankle Outcome Score Among Patients Undergoing Hallux Valgus Surgery.

Foot Ankle Int 2019 Jun 15;40(6):694-701. Epub 2019 Mar 15.

2 Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, Canada.

Background: Patient-reported outcomes are increasingly used as measures of effectiveness of interventions. To make the tools more useful, therapeutic thresholds known as minimally important differences have been developed. The objective of this study was to calculate minimally important differences for the domains of the Foot and Ankle Outcome Score for hallux valgus surgery.

Methods: The study was based on a retrospective analysis of patients newly scheduled for bunion correction surgery and completing patient-reported outcomes between October 2013 and January 2018. This study used anchor- and distribution-based approaches to calculate the minimally important difference for the instrument's 5 domains. Confidence intervals were calculated for each approach. There were 91 participants included in the study.

Results: Using anchor- and distribution-based approaches, the minimally important difference for the pain domain ranged from 5.8 to 10.2, from 0.3 to 6.9 for the symptoms domain, 8.3 to 10.3 for the activities of daily living domain, 7.4 to 11.1 for the quality of life domain, and from 7.0 to 15.7 for the sports and recreation domain. Small differences in the activities of daily living domain may be more clinically important for patients with better function.

Discussion: The range of minimally important difference values for each domain indicate how the Foot and Ankle Outcome Score corresponded to bunion correction surgery. The sports and recreation domain showed considerable variability in the range of values and may be associated with the domain's lack of responsiveness. Overall, most minimally important difference values for the domains of FAOS ranged from above 4 to below 16.

Level Of Evidence: Level III, retrospective comparative series.
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http://dx.doi.org/10.1177/1071100719831392DOI Listing
June 2019

Wait lists and adult general surgery: is there a socioeconomic dimension in Canada?

BMC Health Serv Res 2019 Mar 13;19(1):161. Epub 2019 Mar 13.

Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada.

Background: Little is known about whether patients' socioeconomic status influences their access to elective general surgery in Canada. The purpose of this study was to assess the association between socioeconomic status and wait times for elective general surgery.

Methods: Analysis of prospectively recruited participants' data. The setting was six hospitals in the Vancouver Coastal Health Authority, a geographically defined region that includes Vancouver, British Columbia, Canada. Participants had elective general surgery between October 2013 and April 2017, community dwelling, aged 19 years or older and could complete survey forms. The outcome measure was wait time, defined as the number of weeks between being registered for elective general surgery and surgery date.

Results: One thousand three hundred twenty elective general surgery participants were included in the study. The response rate among eligible patients was 53%. Regression analyses found no statistically significant association between patients' wait time with SES, adjusting for health status, cancer status, surgical priority level, comorbidity burden and demographic characteristics. Participants with proven or suspected cancer status had shorter waits relative to participants waiting for surgery for benign conditions. Participants with at least one comorbidity tended to experience shorter waits of approximately 5 weeks (p < 0.01). Pre-operative pain or depression/anxiety were not associated with shorter wait times.

Conclusions: Although this study found no relationship between SES and surgical wait time for elective general surgeries in the study hospitals, patients in lower SES categories reported worse health when assigned to the surgical queue.
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http://dx.doi.org/10.1186/s12913-019-3981-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6416854PMC
March 2019

Do preoperative patient-reported outcomes predict hospital length of stay for surgically-treated end-stage ankle osteoarthritis patients?

Foot Ankle Surg 2020 Feb 2;26(2):175-180. Epub 2019 Feb 2.

Department of Orthopedics, University of British Columbia, 181 Keefer Place, Unit 221, Vancouver, V6B 6C1, Canada. Electronic address:

Background: End-stage ankle arthritis is often debilitating, associated with diminished mobility, pain, and reduced health related quality of life. Direct hospital costs of AA and TAA differ, with hospital length of stay being a major contributor. The objective of this study is to test the association between four patient-reported outcome measures with hospital length of stay, potentially important for preoperative planning and care.

Methods: This study is based on a prospective cohort of patients scheduled for AA or TAA for end-stage ankle arthritis in the Vancouver Coastal Health authority, Canada. Participants completed a condition-specific instrument, the AOS, and three generic instruments, the PHQ-9, PEG and EQ-5D(3L) shortly after being scheduled for surgery. Multivariate mixed-effects Poisson regression models were used to measure the association between preoperative patient-reported outcome measures and length of stay.

Results: Among the 183 patients eligible to participate, the participation rate was 48.5%. There were 89 participants. Participants reported a high level of preoperative ankle impairment and pain. The adjusted results found no relationship between the AOS, EQ-5D(3L) VAS or PHQ-9 values and participants' LOS. Participants with at least one chronic health condition and lowest SES category had longer LOS.

Conclusions: This study found no evidence of an association between four PROs collected prior to AA or TAA with hospital LOS. This finding suggests collecting these PROs preoperatively may not help with discharge planning.
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http://dx.doi.org/10.1016/j.fas.2019.01.008DOI Listing
February 2020

Validation of the Ankle Osteoarthritis Scale Instrument for Preoperative Evaluation of End-Stage Ankle Arthritis Patients Using Item Response Theory.

Foot Ankle Int 2019 Apr 10;40(4):422-429. Epub 2019 Jan 10.

1 Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.

Background:: Significant ankle arthritis results in functional limitations and patient morbidity. There is a need to measure symptoms and the impact of interventions on patient's quality of life using valid and reliable patient-reported measurement instruments. The objective of this research was to validate the Ankle Osteoarthritis Scale instrument in the preoperative setting using factor analysis, item response theory, and differential item function methods.

Methods:: This research is based on secondary analysis of patients scheduled for ankle arthrodesis or total ankle replacement in Vancouver, Canada. Participants completed the instrument between September 2014 and August 2017. Item response theory was used to estimate item difficulty and discrimination parameters, controlling for study participants' underlying level of ankle function. Differential item function was examined for sex, age group, and surgery. There were 88 participants.

Results:: Modification indices suggested that item 10, "walking around the house," would better fit the pain domain rather than the disability domain. Items in the pain domain displayed a range of discrimination and difficulty. Items in the disability domain exhibited a range of discrimination, though the disability domain had low difficulty. Differential item functioning for sex, age group, and ankle arthrodesis or total ankle replacement appeared to be ignorable.

Conclusion:: This evaluation of the Ankle Osteoarthritis Scale found the instrument to be a strong measure of the effect of pain and dysfunction among patients with end-stage ankle arthritis, even when removing items 7 and 8, supporting its prior use in numerous clinical studies.

Level Of Evidence:: Level II, prospective comparative study.
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http://dx.doi.org/10.1177/1071100718818573DOI Listing
April 2019

Cost-Utility Study of the Economics of Bunion Correction Surgery.

Foot Ankle Int 2019 Mar 17;40(3):336-342. Epub 2018 Dec 17.

3 Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada.

Background:: Bunion correction surgery is a very common procedure to improve patients' pain and physical function attributable to a misaligned first metatarsophalangeal joint. The objective of this study was to apply a health utility framework to estimate the cost utility of bunion correction surgery.

Methods:: Patients were prospectively recruited from the population of patients seen in a lower-extremity orthopedic clinic and scheduled for isolated bunion surgery. Participants completed EuroQoL's EQ-5D(3L) to measure patients' current general health preoperatively and 6 months postoperatively. Participants' change in quality-adjusted life years (QALYs) were calculated by comparing the difference between postoperative utility values and preoperative utility values. The study had 95 patients representing 53% of eligible patients.

Results:: The mean preoperative utility value was 0.6816 and the mean postoperative value was 0.7451, a statistically significant difference denoting an improvement in self-reported health. The cost per QALY, assuming gains in health accrued for 15 years, was $4911 (the 95% confidence interval ranged from $4736 to $5088). The cost per QALY was highest among the oldest patients. Assuming gains in health accrued for 20 years, the cost per QALY was $3922.

Conclusion:: This study demonstrated that bunion correction surgery was inexpensive relative to its gains in health compared with commonly applied thresholds for women and men in all age groups, though the gains were not uniformly distributed across age categories. Future research should examine the impact of recurrence on the robustness of these findings.

Level Of Evidence:: Level III, comparative study.
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http://dx.doi.org/10.1177/1071100718815663DOI Listing
March 2019

Relationship of Duration of Wait for Surgery and Postoperative Patient-Reported Outcomes for Hallux Valgus Surgery.

Foot Ankle Int 2019 Mar 21;40(3):259-267. Epub 2018 Oct 21.

3 Department of Surgery, University of Calgary, Calgary, Alberta, Canada.

Background:: Little is known about the effect of delayed access to bunion correction (hallux valgus) surgery on patient-reported outcomes. The objective of this study was to measure the association between preoperative wait time for bunion correction surgery and postoperative patient-reported outcomes.

Methods:: This study prospectively recruited patients to complete preoperative patient-reported outcomes measuring depression, pain, and foot and ankle health, including the Patient Health Questionnaire-9 (PHQ-9); the pain intensity (P), interference with enjoyment (E) of life and general (G) instrument (ie, PEG); and the Foot and Ankle Outcome Score (FAOS), a condition-specific instrument. Patients complete the same patient-reported outcomes 6 months postoperatively. Regression models measured patient-reported outcomes as a function of wait time, adjusting for baseline health, age category, sex, comorbidities, and socioeconomic status. This study included 87 participants, a response rate of 53% among eligible patients.

Results:: Longer waits for bunion correction surgery, adjusting for other factors, were associated with smaller gains in health in 4 of the 5 domains of the FAOS. There was no relationship between postoperative depression and pain scores with duration of wait time, adjusting for patient characteristics.

Conclusion:: At the 6-month postoperative time point, prolonged preoperative wait times were detrimental to foot and ankle outcomes in 4 of the 5 domains of the foot and ankle-specific PRO. Policies for expediting access for symptomatic hallux valgus are warranted to mitigate poorer postoperative outcomes. Further study is required to understand if failure to improve is a permanent finding in the postoperative period.

Level Of Evidence:: Level II, prospective comparative study.
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http://dx.doi.org/10.1177/1071100718805964DOI Listing
March 2019

Relationship between preoperative patient-reported outcomes and hospital length of stay: a prospective cohort study of general surgery patients in Vancouver, Canada.

J Health Serv Res Policy 2019 01 13;24(1):29-36. Epub 2018 Aug 13.

5 Clinical Assistant Professor, Section of Colorectal Surgery, Department of Surgery, University of British Columbia, Canada.

Objectives: As an aging population drives more demand for elective inpatient surgery, one approach to reducing length of stay is enhanced evaluation of patients' preoperative health status. The objective of this research was to determine whether patient-reported outcome measures collected preoperatively can identify patients at risk for longer lengths of stay.

Methods: This study was based on a prospectively recruited cohort of patients who were scheduled for elective inpatient general surgery in Vancouver, Canada. All participants completed a number of patient-reported outcome measures preoperatively, including the EQ-5D for general health status, the Patient Health Questionnaire (PHQ-9) for depression, and the pain intensity (P), interference with enjoyment of life (E), and interference with general activity (G), known as the PEG, for pain. Patient-reported outcome data were linked to hospital discharge summaries. Multivariate regression was performed to estimate risk of longer lengths of stay, adjusting for patient and clinical characteristics. The primary outcome was length of stay and its associated cost. Data collection took place between October 2012 and November 2016.

Results: Participation among the population of 2307 eligible patients was 50.5%, providing 1165 participants. Preoperative patient-reported outcomes were not concordant with hospital reported diagnoses of depression or pain. Patients' preoperative depression and pain scores were independently positively associated with longer length of stay after adjusting for patient-level characteristics. Patients whose PHQ-9 score was 10, representing clinically significant depression, were estimated to have a 1.53 day longer hospitalization, which was associated with an estimated incremental hospital cost of $1667.

Conclusions: Preoperative self-reported assessment of depression and pain can assist with identifying patients at higher risk of longer lengths of stay. Patient's self-reported preoperative measures of depression and pain should be incorporated into patient pathways. They provide opportunities for improving management of general surgery patients and possibly play a role in aligning hospital funding with patients' needs.
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http://dx.doi.org/10.1177/1355819618791634DOI Listing
January 2019

On the Specification of Upward-Propagating Tides for ICON Science Investigations.

Space Sci Rev 2017 Oct 3;212(1-2):697-713. Epub 2017 Aug 3.

Department of Aerospace Engineering Sciences, University of Colorado, Boulder, CO 80305.

The National Center for Atmospheric Research (NCAR) Thermosphere Ionosphere Electrodynamics General Circulation Model (TIEGCM) will provide a physics-based context for the interpretation of ICON measurements. To optimize the realism of the model simulations, ICON wind and temperature measurements near the ~97 km lower boundary of the TIEGCM will be used to specify the upward-propagating tidal spectrum at this altitude. This will be done by fitting a set of basis functions called Hough Mode Extensions (HMEs) to 27-day mean tidal winds and temperatures between 90 and 105 km altitude and between 12°S and 42°N latitude on a day-by-day basis. The current paper assesses the veracity of the HME fitting methodology given the restricted latitude sampling and the UT-longitude sampling afforded by the MIGHTI instrument viewing from the ICON satellite, which will be in a circular 27° inclination orbit. These issues are investigated using the output from a reanalysis-driven global circulation model, which contains realistic variability of the important tidal components, as a mock data set. ICON sampling of the model reveals that the 27-day mean diurnal and semidiurnal tidal components replicate well the 27-day mean tidal components obtained from full synoptic sampling of the model, but the terdiurnal tidal components are not faithfully reproduced. It is also demonstrated that reconstructed tidal components based on HME fitting to the model tides between 12°S and 42°N latitude provide good approximations to the major tidal components expected to be encountered during the ICON mission. This is because the constraints provided by fitting both winds and temperatures over the 90-105 km height range are adequate to offset the restricted sampling in latitude. The boundary conditions provided by the methodology described herein will greatly enhance the ability of the TIEGCM to provide a physical framework for interpreting atmosphere-ionosphere coupling in ICON observations due to atmospheric tides.
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http://dx.doi.org/10.1007/s11214-017-0401-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6077998PMC
October 2017

Curcumin sensitized the antitumour effects of irradiation in promoting apoptosis of oesophageal squamous-cell carcinoma through NF-κB signalling pathway.

J Pharm Pharmacol 2018 Oct 18;70(10):1340-1348. Epub 2018 Jul 18.

Department of Radiotherapy, Liaocheng People's Hospital, Liaocheng, Shandong, China.

Objectives: To investigate the potential synergistic effect of curcumin with irradiation (IR) in oesophageal squamous-cell carcinoma (ESCC) and elucidate the underlying molecular mechanisms.

Methods: The ESCC cell lines were established from clinical samples. Cell apoptosis post-treatment was stained by Annexin V/PI staining and analysed by flow cytometry. Cells survived IR was evaluated with clonogenic assay. Xenograft tumour model was established by subcutaneous inoculation, and tumour progression was monitored. The NF-κB pathway was characterized by immunoblotting.

Key Findings: Curcumin enhanced the pro-apoptotic effect of IR in ESCC cells. Pretreatment with curcumin significantly sensitized ESCC cells to IR in a dose-dependent manner. Coadministration with curcumin remarkably extended the median survival time of ESCC xenograft mice while exposed to IR therapy. The xenograft tumour progression was significantly suppressed as well. Mechanistically, curcumin treatment was demonstrated to efficiently inhibited NF-κB signalling.

Conclusions: We have well-recapitulated the pathological properties and therapeutic response of ESCC with established cell lines derived from clinical samples. We further demonstrated the significantly synergistic effect of curcumin on IR-elicited cell apoptosis in ESCC both in vitro and in vivo. Our data suggested the potential therapeutic values of curcumin for future clinical investigations.
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http://dx.doi.org/10.1111/jphp.12981DOI Listing
October 2018

Measuring quality of life in patients with stress urinary incontinence: is the ICIQ-UI-SF adequate?

Qual Life Res 2018 08 8;27(8):2189-2194. Epub 2018 May 8.

Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, 201-2206 East Mall, Vancouver, V6T 1Z3, Canada.

Purpose: The International Consultation on Incontinence Questionnaire Short Form (ICIQ-UI-SF) is a widely used four-item patient-reported outcome (PRO) measure. Evaluations of this instrument are limited, restraining user's confidence in the instrument. This study conducts a comprehensive evaluation of the ICIQ-UI-SF on a sample of urological surgery patients in Canada.

Methods: One hundred and seventy-seven surgical patients with stress urinary incontinence completed the ICIQ-UI-SF pre-operatively. Methods drawing from confirmatory factor analysis (CFA), measures of reliability, item response theory (IRT), and differential item functioning were applied. Ceiling effects were examined.

Results: Ceiling effects were identified. In the CFA, the factor loadings of items one and two differed significantly (p < 0.001) from item three indicating possible multidimensionality. The first two items reflect symptom severity not quality of life. Reliability was moderate as measured by Cronbach's alpha (0.63) and McDonald's coefficient (0.65). The IRT found the instrument does not discriminate between individuals with low incontinence-related quality of life.

Conclusions: Due to low/moderate reliability, the ICIQ-UI-SF can be used as a complement to other data or used to report aggregated surgical outcomes among surgical patients. If the primary objective is to measure quality of life, other PROs should be considered.
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http://dx.doi.org/10.1007/s11136-018-1872-xDOI Listing
August 2018

Quantifying Patient-Reported Disability and Health While Waiting for Bunion Surgery.

Foot Ankle Int 2018 09 7;39(9):1047-1055. Epub 2018 May 7.

3 Department of Surgery, University of Calgary, Calgary, AB, Canada.

Background: Many patients with hallux valgus progress to experiencing pain and loss of function that requires corrective surgery when nonoperative treatments fail. The primary goal of this study was to measure changes in participants' health while patients waited for their operative correction.

Methods: Patients were prospectively recruited to complete a number of patient-reported outcome measures preoperatively. Baseline data collection was initiated in October 2014, and participants' second surveys were returned by August 2017. The setting of the study was Vancouver, Canada. There were 80 participants in the study. The participation rate among eligible patients was 52.7%.

Results: The average wait time for surgery exceeded 8 months, with a mean wait of 35.7 weeks. Baseline pain among participants was high. Only in the domain of foot- and ankle-related quality of life was the duration of wait time associated with participants' change in health. The other 4 domains of foot function remained stable over the preoperative period.

Conclusion: Preoperative health in this study was consistent with other research showing high pain and compromised foot function among patients failing nonoperative therapies for treatment of hallux valgus. This study found high pain and compromised foot function among patients waiting for hallux valgus surgery but only minor relationships between participants' duration of wait time for operative correction of the first metatarsophalangeal joint and changes in patient-reported outcome scores.

Level Of Evidence: Level III, comparative study.
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http://dx.doi.org/10.1177/1071100718772037DOI Listing
September 2018

Psychometric validation of the Stoma-QOL questionnaire in a Canadian cross-sectional sample of colostomy and ileostomy patients.

Scand J Gastroenterol 2018 06 5;53(6):721-726. Epub 2018 Apr 5.

a Centre for Health Services and Policy Research, School of Population and Public Health , University of British Columbia , Vancouver , Canada.

Objectives: The Stoma-QOL questionnaire is a patient-reported outcome (PRO) used to measure quality of life in patients with ileostomy or colostomy. This study assesses the Stoma-QOL's overall and item-level psychometric characteristics in patients with temporary stomas, and whether stoma-related quality of life differs by demographic characteristics.

Materials And Methods: Analysis of cross-sectional observational PRO data from hospitals in Vancouver, Canada. Patients registered for elective ileostomy or colostomy closure, over the age of 18, and able to read English were eligible for participation. Emergent and cancer-related cases were excluded. One-way analysis of variance was used to test for demographic differences in Stoma-QOL scores. Cronbach's alpha was used for reliability, and Rasch item-response theory was used to assess overall and item characteristics.

Results: 120 patients were included. No statistically significant difference in Stoma-QOL scores was found by age, sex, or socioeconomic status. Reliability was 0.93. Mean item responses ranged from 1.77 to 3.55 and item-total correlation ranged from 0.51 to 0.77. The Rasch item-response theory model demonstrated significant misfit, likely due to the misfit of item 9, which asks about sexuality, and high residual correlations between item pairs 6 and 8 about fatigue, and items 16 and 17 about social relationships.

Conclusions: The Stoma-QOL questionnaire is a well-designed PRO for measuring stoma-related quality of life. Demographic variables do not appear to have a strong influence on Stoma-QOL scores. Item 9 demonstrated misfit but removal likely does not improve the instrument. Future research should focus on revising items 6, 8, 16, and 17.
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http://dx.doi.org/10.1080/00365521.2018.1457713DOI Listing
June 2018

Evaluation of the Fecal Incontinence Quality of Life Scale (FIQL) using item response theory reveals limitations and suggests revisions.

Qual Life Res 2018 06 5;27(6):1613-1623. Epub 2018 Mar 5.

Section of Colorectal Surgery, Department of Surgery, University of British Columbia, Vancouver, Canada.

Purpose: The Fecal Incontinence Quality of Life Scale (FIQL) is a commonly used patient-reported outcome measure for fecal incontinence, often used in clinical trials, yet has not been validated in English since its initial development. This study uses modern methods to thoroughly evaluate the psychometric characteristics of the FIQL and its potential for differential functioning by gender.

Methods: This study analyzed prospectively collected patient-reported outcome data from a sample of patients prior to colorectal surgery. Patients were recruited from 14 general and colorectal surgeons in Vancouver Coastal Health hospitals in Vancouver, Canada. Confirmatory factor analysis was used to assess construct validity. Item response theory was used to evaluate test reliability, describe item-level characteristics, identify local item dependence, and test for differential functioning by gender.

Results: 236 patients were included for analysis, with mean age 58 and approximately half female. Factor analysis failed to identify the lifestyle, coping, depression, and embarrassment domains, suggesting lack of construct validity. Items demonstrated low difficulty, indicating that the test has the highest reliability among individuals who have low quality of life. Five items are suggested for removal or replacement. Differential test functioning was minimal.

Conclusions: This study has identified specific improvements that can be made to each domain of the Fecal Incontinence Quality of Life Scale and to the instrument overall. Formatting, scoring, and instructions may be simplified, and items with higher difficulty developed. The lifestyle domain can be used as is. The embarrassment domain should be significantly revised before use.
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http://dx.doi.org/10.1007/s11136-018-1826-3DOI Listing
June 2018

MAVEN Observations of the Effects of Crustal Magnetic Fields on Electron Density and Temperature in the Martian Dayside Ionosphere.

Geophys Res Lett 2017 Nov 26;44(21):10812-10821. Epub 2017 Oct 26.

Space Sciences Laboratory, University of California Berkeley, Berkeley, CA, USA.

Mars lacks a global magnetic field but possesses concentrated regions of crustal magnetic field that influence the planet's interaction with the solar wind and the structure of the Martian ionosphere. In this study we survey 17 months of MAVEN Langmuir Probe and Waves dayside electron density and temperature measurements to study how these quantities are affected in regions with strong crustal magnetic fields. Above 200 km altitude, we find that regions of strong crustal magnetic fields feature cooler electron temperatures and enhanced electron densities compared to regions with little or no crustal magnetic field. Neutral densities and temperatures are not significantly affected. Closed field lines on which electrons can be trapped are more prevalent in strong crustal field regions than elsewhere. Trapped on closed field lines, electrons are protected against loss processes involving the solar wind. This would lead to longer plasma lifetimes, higher densities, and lower temperatures.
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http://dx.doi.org/10.1002/2017gl075367DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7458087PMC
November 2017