Publications by authors named "James Wright"

728 Publications

Putting the Patient First: A Scoping Review of Patient Desires in Canada.

Healthc Policy 2021 May;16(4):46-69

Director, North American Observatory on Health Systems and Policies; Professor, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON.

Patient-centred care is a key priority for governments, providers and stakeholders, yet little is known about the care preferences of patient groups. We completed a scoping review that yielded 193 articles for analysis. Five health states were used to account for the diversity of possible preferences based on health needs. Five broad themes were identified and expressed differently across the health states, including personalized care, navigation, choice, holistic care and care continuity. Patients' perspectives must be considered to meet the diverse needs of targeted patient groups, which can inform health system planning, quality improvement initiatives and targeting of investments.
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http://dx.doi.org/10.12927/hcpol.2021.26499DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8200834PMC
May 2021

Risks and Benefits of Benzodiazepines.

JAMA 2021 06;325(21):2208-2209

Institute of Pharmaceutical Sciences, King's College London, London, England.

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http://dx.doi.org/10.1001/jama.2021.4513DOI Listing
June 2021

Functional limitations caused by simple bone cysts.

J Child Orthop 2021 Apr;15(2):178-182

Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada.

Purpose: Relatively little is known about the impact of benign bone lesions on function. The aim of this study was to create a more complete understanding of the impact of functional disability from simple bone cysts (SBCs) by combining qualitative and quantitative methods.

Methods: This study followed a convergent parallel mixed methods design. The quantitative arm included 130 children with SBC and used the Activities Scale for Kids (ASK) to measure physical function. In the qualitative arm ten children and their parents participated in interviews related to activity participation and interactions with their physical and social environments. The two data sets were analyzed independently and then the results were integrated.

Results: The ASK demonstrated 35% of children achieving the maximum score. In total, 65% of children responded "I had no medical needs" confirming that SBC, while being present throughout childhood, is largely perceived as not a chronic illness. Qualitatively most children reported minimal or no changes in activity participation but reported thinking about being more cautious during play, confirming that SBC affects effort not participation in play.

Conclusion: The diagnosis of SBC did not have a significant impact on physical function, but did alter children's thoughts about physical activity participation. This finding suggests that physical function scores may have unappreciated ceiling effects. Outcome tools that combine both illness perceptions and physical function may help to better assess functional outcomes of SBC.

Level Of Evidence: III.
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http://dx.doi.org/10.1302/1863-2548.15.200169DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8138791PMC
April 2021

Evaluation of Risk of Gastrostomy and Ventriculoperitoneal Shunt Placement in Pediatric Patients: A Systematic Review of the Literature.

World Neurosurg 2021 May 24. Epub 2021 May 24.

Case Western Reserve University, School of Medicine, Cleveland, Ohio, USA; Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA. Electronic address:

A subset of patients with neurologic deficits require ventriculoperitoneal shunt (VPS) placement in addition to gastrostomy tubes (GTs). At present, the literature is inconsistent with respect to the sequence and time period between procedures that yields the lowest risk profile for GT and VPS placement. The purpose of this systematic literature review was to determine if time elapsed between VPS and GT placement was associated with infection (peritoneal and/or CSF). A systematic literature review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 guidelines. PubMEd/MEDLINE, Scopus, Ovid, Cochrane, and EMBASE databases were queried. Precise search terminology is available in the body of the manuscript. The initial database query yielded 88 unique articles. After abstract screening, 28 articles were identified and 6 met criteria for inclusion in the final analysis. The included studies were all retrospective analyses and reported data for 217 patients between the years of 1988 and 2016. Across all included studies, the infection rate after VPS and GT placement during the studies' surveillance period was 15.2% (n = 33/217). The cumulative rate of all reported complications in patients with both VPS and GT was 24.0% (n = 52/217). These studies suggest that placement of GT in patients with preexisting VPS does not significantly contribute to increased shunt or intraperitoneal infection. Future studies should determine the optimal time interval between VPS and GT placement and to identify the most appropriate prophylactic antibiotic regimen.
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http://dx.doi.org/10.1016/j.wneu.2021.05.044DOI Listing
May 2021

A systematic review of telehealth for the delivery of emergent neurosurgical care.

J Telemed Telecare 2021 May 18:1357633X211015548. Epub 2021 May 18.

Department of Neurosurgery, University of Minnesota, USA.

Introduction: In 2017, the American Association of Neurological Surgeons and Congress of Neurological Surgeons published a statement in support of adopting telemedicine technologies in neurosurgery. The position statement detailed the principles for use and summarised the active efforts at the time to address barriers that limited expansion of use, such as reimbursement, liability, credentialing and patient confidentiality. The primary aim of this systematic literature review was to identify the available published literature on the application of telemedicine to neurosurgical patient care, with a specific focus on neurotrauma and emergent neurological conditions.

Methods: This Level II systematic review of the literature was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 guidelines. Following removal of duplicates, 359 studies were yielded from database query. Following application of inclusion and exclusion criteria, 78 articles were identified for full-text review.

Results: Full-text screening yielded a total of 11 studies for the final analysis. The study interventions took place in seven unique countries and included both developed and developing nations. Data captured spanned the years 1997 to 2019. The total cumulative number of patients who received neurosurgical telemedicine consultations captured by this review was 37,224.

Discussion: This review of the literature suggests that telemedicine in emergent settings offers safe, feasible, and cost-reducing methods of increasing access to high acuity neurosurgical care and may serve to limit unnecessary inter-facility transfers. As infrastructure and regulatory guidelines continue to evolve, neurosurgical patients, both domestic and abroad, will benefit from improved access to expertise afforded by telemedicine technologies.
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http://dx.doi.org/10.1177/1357633X211015548DOI Listing
May 2021

Why we need a single independent international hypertension clinical practice guideline.

Hypertens Res 2021 May 12. Epub 2021 May 12.

Cochrane Hypertension Review Group, University of British Columbia, Vancouver, BC, Canada.

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http://dx.doi.org/10.1038/s41440-021-00666-6DOI Listing
May 2021

Impact of race on care, readmissions, and survival for patients with glioblastoma: an analysis of the National Cancer Database.

Neurooncol Adv 2021 Jan-Dec;3(1):vdab040. Epub 2021 Mar 6.

Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.

Background: The objective of this study was to explore racial/ethnic factors that may be associated with survival in patients with glioblastoma by querying the National Cancer Database (NCDB).

Methods: The NCDB was queried for patients diagnosed with glioblastoma between 2004 and 2014. Patient demographic variables included age at diagnosis, sex, race, ethnicity, Charlson-Deyo score, insurance status, and rural/urban/metropolitan location of zip code. Treatment variables included surgical treatment, extent of resection, chemotherapy, radiation therapy, type of radiation, and treatment facility type. Outcomes included 30-day readmission, 30- and 90-day mortality, and overall survival. Multivariable Cox regression analyses were performed to evaluate variables associated with race and overall survival.

Results: A total of 103 652 glioblastoma patients were identified. There was a difference in the proportion of patients for whom surgery was performed, as well as the proportion receiving radiation, when stratified by race ( < .001). Black non-Hispanics had the highest rates of unplanned readmission (7.6%) within 30 days (odds ratio [OR]: 1.39 compared to White non-Hispanics, < .001). Asian non-Hispanics had the lowest 30- (3.2%) and 90-day mortality (9.8%) when compared to other races (OR: 0.52 compared to White non-Hispanics, = .031). Compared to White non-Hispanics, we found Black non-Hispanics (hazard ratio [HR]: 0.88, < .001), Asian non-Hispanics (HR: 0.72, < .001), and Hispanics (HR: 0.69, < .001) had longer overall survival.

Conclusions: Differences in treatment and outcomes exist between races. Further studies are needed to elucidate the etiology of these race-related disparities and to improve outcomes for all patients.
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http://dx.doi.org/10.1093/noajnl/vdab040DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8086235PMC
March 2021

Over half of clinical practice guidelines use non-systematic methods to inform recommendations: A methods study.

PLoS One 2021 22;16(4):e0250356. Epub 2021 Apr 22.

Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, Cochrane Hypertension Review Group, Therapeutics Initiative, University of British Columbia, Vancouver, BC, Canada.

Introduction: Assessing the process used to synthesize the evidence in clinical practice guidelines enables users to determine the trustworthiness of the recommendations. Clinicians are increasingly dependent on guidelines to keep up with vast quantities of medical literature, and guidelines are followed to avoid malpractice suits. We aimed to assess whether systematic methods were used when synthesizing the evidence for guidelines; and to determine the type of review cited in support of recommendations.

Methods: Guidelines published in 2017 and 2018 were retrieved from the TRIP and Epistemonikos databases. We randomly sorted and sequentially screened clinical guidelines on all topics to select the first 50 that met our inclusion criteria. Our primary outcomes were the number of guidelines using either a systematic or non-systematic process to gather, assess, and synthesise evidence; and the numbers of recommendations within guidelines based on different types of evidence synthesis (systematic or non-systematic reviews). If a review was cited, we looked for evidence that it was critically appraised, and recorded which quality assessment tool was used. Finally, we examined the relation between the use of the GRADE approach, systematic review process, and type of funder.

Results: Of the 50 guidelines, 17 (34%) systematically synthesised the evidence to inform recommendations. These 17 guidelines clearly reported their objectives and eligibility criteria, conducted comprehensive search strategies, and assessed the quality of the studies. Of the 29/50 guidelines that included reviews, 6 (21%) assessed the risk of bias of the review. The quality of primary studies was reported in 30/50 (60%) guidelines.

Conclusions: High quality, systematic review products provide the best available evidence to inform guideline recommendations. Using non-systematic methods compromises the validity and reliability of the evidence used to inform guideline recommendations, leading to potentially misleading and untrustworthy results.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0250356PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8062080PMC
April 2021

Underutilization of Social Determinants of Health Billing Codes May Bias Surgical Disparities Research.

Spine (Phila Pa 1976) 2021 Jun;46(12):E702-E703

Department of Neurosurgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH.

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http://dx.doi.org/10.1097/BRS.0000000000004055DOI Listing
June 2021

Adoption of a laboratory EMR system and inappropriate laboratory testing in Ontario: a cross-sectional observational study.

BMC Health Serv Res 2021 Apr 6;21(1):307. Epub 2021 Apr 6.

Ontario Medical Association, Economics, Policy & Research Department, 150 Bloor St. W, Suite 900, Toronto, ON, M5S 3C1, Canada.

Background: Electronic medical record (EMR) systems have the potential to facilitate appropriate laboratory testing. We examined three common medical tests in primary care-hemoglobin A1c (HbA1c), lipid, and thyroid stimulating hormone (TSH)- to assess whether adoption of a laboratory EMR system in Ontario had an impact on the rate of inappropriate testing among primary care physicians.

Methods: We used FY2016-17 population-level laboratory data to estimate the association between adoption of a laboratory EMR system and the rate of inappropriate testing. Inappropriate testing was assessed based on recommendations for screening, monitoring, and follow-up that take into account risk factors related to patient age and certain clinical conditions. To overcome the problem of potential endogeneity of physician choice to use the EMR, the EMR penetration rate in the physician's geographical area of practice was used as an instrumental variable in an ordinary least squares (OLS) regression. We then simulated the change in the rate of inappropriate testing, by physician payment model, as the EMR penetration rate increased from the baseline percentage.

Results: The simulation models showed that an increase in the rate of EMR penetration from a baseline average was associated with a statistically significant decrease in inappropriate hbA1c and lipid testing, but a statistically insignificant increase in inappropriate TSH testing. The impact of EMR penetration also varied by payment model.

Conclusions: This study demonstrated a positive association between availability of an EMR system and appropriate service utilization. Varying impacts of the EMR system availability by primary care payment model may be reflective of different incentives or attributes inherent in payment models. Policies to encourage physicians to increase their use of laboratory EMR systems could improve the quality and continuity of patient care.
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http://dx.doi.org/10.1186/s12913-021-06296-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8025377PMC
April 2021

Virtual reality in presurgical patient education: A scoping review and recommended trial design guidelines.

Am J Surg 2021 Mar 16. Epub 2021 Mar 16.

Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.

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http://dx.doi.org/10.1016/j.amjsurg.2021.03.022DOI Listing
March 2021

The nexus between improved water supply and water-borne diseases in urban areas in Africa: a scoping review protocol.

AAS Open Res 2020 8;3:12. Epub 2020 Dec 8.

Wangari Maathai Institute for Peace and Environmental Studies, University of Nairobi, Nairobi, Kenya.

: Currently, an estimated two thirds of the world population is water insufficient. As of 2015, one out of every five people in developing countries do not have access to clean sufficient drinking water. In an attempt to share the limited resource, water has been distributed at irregular intervals in cities in developing countries. Residents in these cities seek alternative water sources to supplement the inadequate water supplied. Some of these alternative sources of water are unsafe for human consumption, leading to an increased risk in water-borne diseases. Africa contributes to 53% of the diarrheal cases reported globally, with contaminated drinking water being the main source of transmission. Water-borne diseases like diarrhea, cholera, typhoid, amoebiasis, dysentery, gastroenteritis, cryptosporidium, cyclosporiasis, giardiasis, guinea worm and rotavirus are a major public health concern. The main objective of this scoping review is to map the available evidence to understand the sources of water among residents in cities in Africa and the relationship between clean water sufficiency and water-borne diseases in urban Africa. : The search strategy will identify studies published in scientific journals and reports that are directly relevant to African cities that have a population of more than half a million residents as of 2014 AND studies on the ten emerging water-borne diseases, which are diarrhea, cholera, typhoid, amoebiasis, dysentery, gastroenteritis, cryptosporidium, cyclosporiasis, giardiasis, guinea worm and rotavirus. This scoping review did not require any formal ethical approval. The findings will be published in a peer-reviewed journal.
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http://dx.doi.org/10.12688/aasopenres.13063.2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7883317PMC
December 2020

Trends in prevalence of chronic disease and multimorbidity in Ontario, Canada.

CMAJ 2021 Feb;193(8):E270-E277

Economics, Policy & Research Department (Steffler, Li, Weir, Shaikh, Murtada, Wright, Kantarevic), Ontario Medical Association; Canadian Centre for Health Economics (Steffler, Weir, Kantarevic), University of Toronto, Toronto, Ont.; University of Western Ontario (Murtada), London, Ont.; Departments of Surgery and Public Health Sciences (Wright), and Institute of Health Policy, Management and Evaluation (Wright, Kantarevic), and Deparment of Economics (Kantarevic), University of Toronto, Toronto, Ont.; Institute of Labour Economics (Kantarevic), Deutsche Post Foundation, Bonn, Germany.

Background: New case-mix tools from the Canadian Institute for Health Information offer a novel way of exploring the prevalence of chronic disease and multimorbidity using diagnostic data. We took a comprehensive approach to determine whether the prevalence of chronic disease and multimorbidity has been rising in Ontario, Canada.

Methods: In this observational study, we applied case-mix methodology to a population-based cohort. We used 10 years of patient-level data (fiscal years 2008/09 to 2017/18) from multiple care settings to compute the rolling 5-year prevalence of 85 chronic diseases and multimorbidity (i.e., the co-occurrence of 2 or more diagnoses). Diseases were further classified based on type and severity. We report both crude and age- and sex-standardized trends.

Results: The number of patients with chronic disease increased by 11.0% over the 10-year study period to 9.8 million in 2017/18, and the number with multimorbidity increased 12.2% to 6.5 million. Overall increases from 2008/09 to 2017/18 in the crude prevalence of chronic conditions and multimorbidity were driven by population aging. After adjustments for age and sex, the prevalence of patients with ≥ 1 chronic conditions decreased from 70.2% to 69.1%, and the prevalence of multimorbidity decreased from 47.1% to 45.6%. This downward trend was concentrated in minor and moderate diseases, whereas the prevalence of many major chronic diseases rose, along with instances of extreme multimorbidity (≥ 8 conditions). Age- and sex-standardized resource intensity weights, which reflect relative expected costs associated with patient diagnostic profiles, increased 4.6%.

Interpretation: Evidence of an upward trend in the prevalence of chronic disease was mixed. However, the change in case mix toward more serious conditions, along with increasing patient resource intensity weights overall, may portend a future need for population health management and increased health system spending above that predicted by population aging.
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http://dx.doi.org/10.1503/cmaj.201473DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8034347PMC
February 2021

Aldred Scott Warthin.

Authors:
James R Wright

Arch Pathol Lab Med 2021 Jan 27. Epub 2021 Jan 27.

From the Departments of Pathology & Laboratory Medicine and Paediatrics, University of Calgary/Calgary Laboratory Services Alberta Children's Hospital, Calgary, Canada.

Context.—: Aldred Scott Warthin, MD, PhD, was professor of pathology and director of the pathological laboratory at the University of Michigan during the first third of the 20th century.

Objective.—: To explore the life and accomplishments of Dr. Warthin and his impact on academic anatomic and clinical pathology.

Design.—: Available primary and secondary historic sources were reviewed.

Results.—: After studying music, biology, and botany, Warthin attended medical school at the University of Michigan, graduating in 1891; he remained in Ann Arbor for 40 years, almost single-handedly transforming a rundown department into a top academic department. He was a dedicated teacher who produced 2 important pathology textbooks. His research interests were diverse. In 1913, he published 1 of the first papers unambiguously documenting heritability of cancers; subsequent research on 1 of his cancer families resulted in the description of Lynch Syndrome. He published extensively in the fields of surgical pathology and experimental pathology. He was a recognized expert on syphilis and pathology of aging.

Conclusions.—: Warthin's name is eponymously associated with Warthin-Finkeldey giant cells in measles, Warthin's tumor of the parotid, and Warthin-Starry stain for the diagnosis of syphilis as well as Warthin's sign in the clinical diagnosis of pericarditis.
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http://dx.doi.org/10.5858/arpa.2020-0474-HPDOI Listing
January 2021

Effect of atorvastatin on testosterone levels.

Cochrane Database Syst Rev 2021 01 22;1:CD013211. Epub 2021 Jan 22.

Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, Canada.

Background: Statins are one of the most prescribed classes of drugs worldwide. Atorvastatin, the most prescribed statin, is currently used to treat conditions such as hypercholesterolaemia and dyslipidaemia. By reducing the level of cholesterol, which is the precursor of the steroidogenesis pathway, atorvastatin may cause a reduction in levels of testosterone and other androgens. Testosterone and other androgens play important roles in biological functions. A potential reduction in androgen levels, caused by atorvastatin might cause negative effects in most settings. In contrast, in the setting of polycystic ovary syndrome (PCOS), reducing excessive levels of androgens with atorvastatin could be beneficial.

Objectives: Primary objective To quantify the magnitude of the effect of atorvastatin on total testosterone in both males and females, compared to placebo or no treatment. Secondary objectives To quantify the magnitude of the effects of atorvastatin on free testosterone, sex hormone binding globin (SHBG), androstenedione, dehydroepiandrosterone sulphate (DHEAS) concentrations, free androgen index (FAI), and withdrawal due to adverse effects (WDAEs) in both males and females, compared to placebo or no treatment.

Search Methods: The Cochrane Hypertension Information Specialist searched the following databases for randomized controlled trials (RCTs) up to 9 November 2020: the Cochrane Hypertension Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; Embase; ;two international trials registries, and the websites of the US Food and Drug Administration, the European Patent Office and the Pfizer pharmaceutical corporation. These searches had no language restrictions. We also contacted authors of relevant articles regarding further published and unpublished work.

Selection Criteria: RCTs of daily atorvastatin for at least three weeks, compared with placebo or no treatment, and assessing change in testosterone levels in males or females.

Data Collection And Analysis: Two review authors independently screened the citations, extracted the data and assessed the risk of bias of the included studies. We used the mean difference (MD) with associated 95% confidence intervals (CI) to report the effect size of continuous outcomes,and the risk ratio (RR) to report effect sizes of the sole dichotomous outcome (WDAEs). We used a fixed-effect meta-analytic model to combine effect estimates across studies, and risk ratio to report effect size of the dichotomous outcomes. We used GRADE to assess the certainty of the evidence.

Main Results: We included six RCTs involving 265 participants who completed the study and their data was reported. Participants in two of the studies were male with normal lipid profile or mild dyslipidaemia (N = 140); the mean age of participants was 68 years. Participants in four of the studies were female with PCOS (N = 125); the mean age of participants was 32 years. We found no significant difference in testosterone levels in males between atorvastatin and placebo, MD -0.20 nmol/L (95% CI -0.77 to 0.37). In females, atorvastatin may reduce total testosterone by -0.27 nmol/L (95% CI -0.50 to -0.04), FAI by -2.59 nmol/L (95% CI -3.62 to -1.57), androstenedione by -1.37 nmol/L (95% CI -2.26 to -0.49), and DHEAS by -0.63 μmol/l (95% CI -1.12 to -0.15). Furthermore, compared to placebo, atorvastatin increased SHBG concentrations in females by 3.11 nmol/L (95% CI 0.23 to 5.99). We identified no studies in healthy females (i.e. females with normal testosterone levels) or children (under age 18). Importantly, no study reported on free testosterone levels.

Authors' Conclusions: We found no significant difference between atorvastatin and placebo on the levels of total testosterone in males. In females with PCOS, atorvastatin lowered the total testosterone, FAI, androstenedione, and DHEAS. The certainty of evidence ranged from low to very low for both comparisons. More RCTs studying the effect of atorvastatin on testosterone are needed.
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http://dx.doi.org/10.1002/14651858.CD013211.pub2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8094971PMC
January 2021

Prone Position Ventilation in Neurologically Ill Patients: A Systematic Review and Proposed Protocol.

Crit Care Med 2021 03;49(3):e269-e278

Department of Medicine, Division of Pulmonary and Critical Care, University Hospitals Cleveland Medical Center, Cleveland, OH.

Objectives: Prone positioning has been shown to be a beneficial adjunctive supportive measure for patients who develop acute respiratory distress syndrome. Studies have excluded patients with reduced intracranial compliance, whereby patients with concomitant neurologic diagnoses and acute respiratory distress syndrome have no defined treatment algorithm or recommendations for management. In this study, we aim to determine the safety and feasibility of prone positioning in the neurologically ill patients.

Design And Setting: A systematic review of the literature, performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses 2009 guidelines, yielded 10 articles for analysis. Using consensus from these articles, in combination with review of multi-institutional proning protocols for patients with nonneurologic conditions, a proning protocol for patients with intracranial pathology and concomitant acute respiratory distress syndrome was developed.

Measurements And Main Results: Among 10 studies included in the final analysis, we found that prone positioning is safe and feasible in the neurologically ill patients with acute respiratory distress syndrome. Increased intracranial pressure and compromised cerebral perfusion pressure may occur with prone positioning. We propose a prone positioning protocol for the neurologically ill patients who require frequent neurologic examinations and intracranial monitoring.

Conclusions: Although elevations in intracranial pressure and reductions in cerebral perfusion pressure do occur during proning, they may not occur to a degree that would warrant exclusion of prone ventilation as a treatment modality for patients with acute respiratory distress syndrome and concomitant neurologic diagnoses. In cases where intracranial pressure, cerebral perfusion pressure, and brain tissue oxygenation can be monitored, prone position ventilation should be considered a safe and viable therapy.
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http://dx.doi.org/10.1097/CCM.0000000000004820DOI Listing
March 2021

The Alexafication of Adult Social Care: Virtual Assistants and the Changing Role of Local Government in England.

Authors:
James Wright

Int J Environ Res Public Health 2021 01 19;18(2). Epub 2021 Jan 19.

The Alan Turing Institute, London NW1 2DB, UK.

Voice controlled virtual assistants, delivered via consumer devices such as smart speakers and tablets, are being trialled by local authorities across England as a convenient and low-cost supplement or potential alternative to "traditional" telecare. Few papers have explored this increasingly widespread phenomenon, despite its growing importance. This article looks at choices by some local authorities to trial Alexa, within the context of the ongoing care crisis in England, with councils facing depleted funds, a lack of expert guidance on care technologies, and an increasingly complex and fragmented care technology marketplace. It draws on interviews with managers from eight English local authorities involved in the commissioning and trialling of technologies for adult social care to examine how and why virtual assistants are being implemented, and what implications their use might hold for care. Scaling up the application of such technologies could shift the role of local authorities towards one of an app developer and data broker, while generating considerable risks of reliance on the precarious technological infrastructure of global corporations that may have little interest in or sensitivity towards local care concerns. The findings suggest an urgent need for a national social care technology strategy and increased support for local authorities.
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http://dx.doi.org/10.3390/ijerph18020812DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7832831PMC
January 2021

Cranial Surgical Site Infection Interventions and Prevention Bundles: A Systematic Review of the Literature.

World Neurosurg 2021 Apr 4;148:206-219.e4. Epub 2021 Jan 4.

Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA; Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.

Background: Cranial surgical site infections (cSSIs) are associated with significant morbidity. Measures to reduce cSSI are necessary to reduce patient morbidity as well as hospital costs and resource utilization.

Objective: To identify and characterize interventions or bundled interventions aimed at reduction of the incidence of cranial surgical site infections.

Methods: A systematic review of the literature was conducted according to the PRISMA guidelines. The search strategy included randomized trials, quasi-experimental studies, cohort studies, and case series published between 2000 and 2020 that evaluated interventions implemented to reduce cSSI. Bias assessments and data extraction were performed on included studies.

Results: The initial search generated 1249 studies. Application of inclusion and exclusion criteria and review of references yielded 15 single-intervention and 6 bundled-intervention studies. The single interventions included handwashing protocols, use of vancomycin powder, hair washing and clipping practices, and incision closure techniques. Bundled interventions addressed a variety of preoperative, intraoperative, and postoperative changes. Despite a lack of strong evidence to support the adoption of statistically significant interventions, the use of vancomycin powder may be effective in reducing cSSI. In addition, bundled interventions that involved cultural changes, such as increased teaching/education, personal accountability, direct observation, and feedback, showed some success in decreasing SSI rates.

Conclusions: The strength of the conclusions is limited by small sample sizes, study heterogeneity, relatively low cSSI incidence, and high case variability. Some evidence supports the use of intraoperative vancomycin powder in adult noncranioplasty cases and the application of accountability, teaching, and surveillance of faculty, particularly those early in training.
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http://dx.doi.org/10.1016/j.wneu.2020.12.137DOI Listing
April 2021

A comparison of conventional and minimally invasive multilevel surgery for children with diplegic cerebral palsy.

Bone Joint J 2021 Jan;103-B(1):192-197

Nuffield Orthopaedic Centre, Oxford, UK.

Aims: To compare changes in gait kinematics and walking speed 24 months after conventional (C-MLS) and minimally invasive (MI-MLS) multilevel surgery for children with diplegic cerebral palsy (CP).

Methods: A retrospective analysis of 19 children following C-MLS, with mean age at surgery of 12 years five months (seven years ten months to 15 years 11 months), and 36 children following MI-MLS, with mean age at surgery of ten years seven months (seven years one month to 14 years ten months), was performed. The Gait Profile Score (GPS) and walking speed were collected preoperatively and six, 12 and 24 months postoperatively. Type and frequency of procedures as part of MLS, surgical adverse events, and subsequent surgery were recorded.

Results: In both groups, GPS improved from the preoperative gait analysis to the six-month assessment with maintenance at 12 and 24 months postoperatively. While reduced at six months in both groups, walking speed returned to preoperative speed by 12 months. The overall pattern of change in GPS and walking speed was similar over time following C-MLS and MI-MLS. There was a median of ten procedures per child as part of both C-MLS (interquartile range (IQR) 8.0 to 11.0) and MI-MLS (IQR 7.8 to 11.0). Surgical adverse events occurred in seven (37%) and 13 (36%) children, with four (21%) and 13 (36%) patients requiring subsequent surgery following C-MLS and MI-MLS, respectively.

Conclusion: This study indicates similar improvements in gait kinematics and walking speed 24 months after C-MLS and MI-MLS for children with diplegic CP. Cite this article: 2021;103-B(1):192-197.
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http://dx.doi.org/10.1302/0301-620X.103B1.BJJ-2020-0714.R1DOI Listing
January 2021

Comparing probability of target attainment against Staphylococcus aureus for ceftaroline fosamil, vancomycin, daptomycin, linezolid, and ceftriaxone in complicated skin and soft tissue infection using pharmacokinetic/pharmacodynamic models.

Diagn Microbiol Infect Dis 2021 Apr 13;99(4):115292. Epub 2020 Dec 13.

Clinical Pharmacology, AstraZeneca, Macclesfield, UK. Electronic address:

For recently licensed antibiotics, such as the cephalosporin ceftaroline fosamil, probability of target attainment (PTA) curves, showing the percentage of patients reaching a predefined pharmacokinetic (PK)/pharmacodynamic (PD) target at different bacterial minimum inhibitory concentrations (MICs), have been used to support and justify dose recommendations across patient populations. However, information on PTA for older antibiotics is limited. A retrospective analysis was conducted to construct PTA curves for 4 antibiotics against Staphylococcus aureus in patients with complicated skin and soft tissue infections (cSSTIs). PK models for vancomycin, linezolid, daptomycin, and ceftriaxone were selected from the literature based on large numbers of subjects with covariates representative of patients in Europe and/or the United States. An existing model was available for ceftaroline fosamil. Standard and high-dosage regimens were used to compare the PTA of each antibiotic at MIC values 0.03 to 64 mg/L for a simulated set of patients with cSSTI caused by S. aureus. These were compared to proportions of S. aureus isolates at each MIC from global surveillance data. Ceftaroline achieved PTAs >99.9% for bacteriostatic and bactericidal targets at the MIC (1 mg/L), whereas the comparators failed to achieve PTAs >90%, at bacteriostatic or bactericidal targets, even when clinical doses were increased beyond those recommended. PTA analysis can be used to compare different drugs with the same simulated patient dataset, subject to availability of an appropriate PK model and robust exposure targets. This analysis shows that some antibiotics commonly used to treat cSSTIs may fail to reach high PTAs relative to contemporary MIC estimates.
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http://dx.doi.org/10.1016/j.diagmicrobio.2020.115292DOI Listing
April 2021

Effect of Strict and Soft Policy Interventions on Laboratory Diagnostic Testing in Ontario, Canada: A Bayesian Structural Time Series Analysis.

Health Policy 2021 Feb 24;125(2):254-260. Epub 2020 Oct 24.

Ontario Medical Association, Economics, Policy & Research Department, 150 Bloor St. W, Suite 900, Toronto, ON, M5S 3C1, Canada. Electronic address:

Applications of behavioral economics targeted at optimizing laboratory utilization among physicians have been implemented in Ontario through different types of nonfinancial interventions. Strict policy interventions restrict Ontario Health Insurance Plan (OHIP) payment for tests to patients with specific conditions or limit ordering to particular physician specialties, while soft policy interventions involve modifications to the laboratory requisition form. This study evaluates the effectiveness of these interventions in terms of changing physician ordering behavior for eight tests that were subject to a strict or soft policy intervention during the study period. We use a Bayesian structural time series model applied to Ontario laboratory claims data for FY2006 through FY2017. Results show a 16-75% reduction in laboratory services with a strict policy intervention and an 8-36% reduction in laboratory services with a soft policy intervention. Although the overall magnitude of change was smaller for soft policy interventions, interventions designed with soft or strict policy mechanisms addressing laboratory utilization management are effective at influencing physicians' test ordering behavior.
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http://dx.doi.org/10.1016/j.healthpol.2020.10.007DOI Listing
February 2021

Influence of opioid prescribing standards on health outcomes among patients with long-term opioid use: a longitudinal cohort study.

CMAJ Open 2020 Oct-Dec;8(4):E869-E876. Epub 2020 Dec 18.

Departments of Anesthesiology, Pharmacology and Therapeutics (Morrow, Bassett, Wright, Carney, Dormuth), Family Practice (Bassett), and Medicine (Wright), University of British Columbia, Vancouver, BC.

Background: The College of Physicians and Surgeons of British Columbia introduced opioid prescribing standards and guidelines in mid-2016 in British Columbia. We evaluated impacts of the standards and guidelines on health outcomes.

Methods: We conducted a longitudinal study with repeated measures using administrative data from December 2013 to March 2017. The study included BC patients with long-term use of prescription opioids. Those with a history of long-term care, palliative care or cancer were excluded. Patients were followed for a 12-month prepolicy period and 10-month postpolicy period and compared with historical controls. We estimated changes in level (sudden changes) and monthly trend (gradual changes) of rates of opioid overdose hospital admission, and secondary outcomes of all-cause hospital admission, all-cause emergency department visits, opioid overdose mortality and all-cause mortality.

Results: The study included 68 113 patients in the main cohort and 68 429 historical controls. We did not find significant changes to opioid overdose hospital admissions in level (adjusted rate ratio [RR] 0.83, 95% confidence interval [CI] 0.45-1.54) or in trend (adjusted RR 1.00, 95% CI 0.91-1.10). All-cause hospital admissions declined in level but may have increased in trend, suggesting that a temporary decrease in hospital admissions may have occurred. We found no significant changes in all-cause emergency department visits, opioid overdose mortality or all-cause mortality.

Interpretation: Among patients with a history of long-term prescription opioid use, the regulatory prescribing standards and guidelines were not associated with changes in opioid overdose hospital admissions, all-cause emergency department visits, opioid overdose mortality or all-cause mortality, or with a sustained reduction in all-cause hospital admissions, over a 10-month period after they were introduced. Future research should investigate whether opioid prescribing standards or guidelines are associated with use of nonopioid analgesic medications or nonpharmacologic treatments.
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http://dx.doi.org/10.9778/cmajo.20200228DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7759098PMC
May 2021

Comment on: COVID-19 in Nursing Homes: Calming the Perfect Storm.

J Am Geriatr Soc 2021 02 31;69(2):324-325. Epub 2020 Dec 31.

SNF/LTC Partners of Virginia, Richmond, Virginia, USA.

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http://dx.doi.org/10.1111/jgs.16995DOI Listing
February 2021

A History of the American Association of Pathologists' Assistants: Creating an Organization, Winning Hearts and Minds, and Building an Invaluable Profession.

Acad Pathol 2020 Jan-Dec;7:2374289520975158. Epub 2020 Dec 8.

University of Calgary, Alberta Precision Laboratories, Alberta Children's Hospital, Calgary, Alberta, Canada.

Thomas D. Kinney and Duke University started the first formal university-based training program for pathologists' assistants in 1969. Over the next 2 years, 2 more university-based programs were established. All 3 programs were affiliated with nearby Veterans Administration Hospitals and were funded as a pilot study by the US Veterans Administration to address a looming shortage of pathologists. Early graduates of these programs discovered that the concept of pathologists' assistants with well-defined skill sets encompassing both surgical and autopsy pathology was not initially accepted by important elements of organized pathology. Indeed, many academic pathologists were opposed to the concept from the outset. In the face of such opposition, a group of practicing pathologists' assistants created and incorporated their own professional organization, the American Association of Pathologists' Assistants, to provide support, advocacy, and continuing education for individual practicing pathologists' assistants. The history of the American Association of Pathologists' Assistants and its role in the establishment and success of the pathologists' assistant profession are described utilizing personal communications as well as published historical sources.
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http://dx.doi.org/10.1177/2374289520975158DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7731594PMC
December 2020

Blood pressure targets in adults with hypertension.

Cochrane Database Syst Rev 2020 12 17;12:CD004349. Epub 2020 Dec 17.

Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, Canada.

Background: This is the first update of this review first published in 2009. When treating elevated blood pressure, doctors usually try to achieve a blood pressure target. That target is the blood pressure value below which the optimal clinical benefit is supposedly obtained. "The lower the better" approach that guided the treatment of elevated blood pressure for many years was challenged during the last decade due to lack of evidence from randomised trials supporting that strategy. For that reason, the standard blood pressure target in clinical practice during the last years has been less than 140/90 mm Hg for the general population of patients with elevated blood pressure. However, new trials published in recent years have reintroduced the idea of trying to achieve lower blood pressure targets. Therefore, it is important to know whether the benefits outweigh harms when attempting to achieve targets lower than the standard target.

Objectives: The primary objective was to determine if lower blood pressure targets (any target less than or equal to 135/85 mm Hg) are associated with reduction in mortality and morbidity as compared with standard blood pressure targets (less than or equal to 140/ 90 mm Hg) for the treatment of patients with chronic arterial hypertension. The secondary objectives were: to determine if there is a change in mean achieved systolic blood pressure (SBP) and diastolic blood pressure (DBP associated with "lower targets" as compared with "standard targets" in patients with chronic arterial hypertension; and to determine if there is a change in withdrawals due to adverse events with "lower targets" as compared with "standard targets", in patients with elevated blood pressure.

Search Methods: The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to May 2019: the Cochrane Hypertension Specialised Register, CENTRAL (2019, Issue 4), Ovid MEDLINE, Ovid Embase, the WHO International Clinical Trials Registry Platform, and ClinicalTrials.gov. We also contacted authors of relevant papers regarding further published and unpublished work. The searches had no language restrictions.

Selection Criteria: Randomised controlled trials (RCTs) comparing patients allocated to lower or to standard blood pressure targets (see above).

Data Collection And Analysis: Two review authors (JAA, VL) independently assessed the included trials and extracted data. Primary outcomes were total mortality; total serious adverse events; myocardial infarction, stroke, congestive heart failure, end stage renal disease, and other serious adverse events. Secondary outcomes were achieved mean SBP and DBP, withdrawals due to adverse effects, and mean number of antihypertensive drugs used. We assessed the risk of bias of each trial using the Cochrane risk of bias tool and the certainty of the evidence using the GRADE approach.  MAIN RESULTS: This update includes 11 RCTs involving 38,688 participants with a mean follow-up of 3.7 years. This represents 7 new RCTs compared with the original version. At baseline the mean weighted age was 63.1 years and the mean weighted blood pressure was 155/91 mm Hg. Lower targets do not reduce total mortality (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.86 to 1.05; 11 trials, 38,688 participants; high-certainty evidence) and do not reduce total serious adverse events (RR 1.04, 95% CI 0.99 to 1.08; 6 trials, 18,165 participants; moderate-certainty evidence). This means that the benefits of lower targets do not outweigh the harms as compared to standard blood pressure targets. Lower targets may reduce myocardial infarction (RR 0.84, 95% CI 0.73 to 0.96; 6 trials, 18,938 participants, absolute risk reduction (ARR) 0.4%, number needed to treat to benefit (NNTB) 250 over 3.7 years) and congestive heart failure (RR 0.75, 95% CI 0.60 to 0.92; 5 trials, 15,859 participants, ARR 0.6%, NNTB  167 over 3.7 years) (low-certainty for both outcomes). Reduction in myocardial infarction and congestive heart failure was not reflected in total serious adverse events. This may be due to an increase in other serious adverse events (RR 1.44, 95% CI 1.32 to 1.59; 6 trials. 18,938 participants, absolute risk increase (ARI) 3%,  number needed to treat to harm (NNTH) 33 over four years) (low-certainty evidence). Participants assigned to a "lower" target received one additional antihypertensive medication and achieved a significantly lower mean SBP (122.8 mm Hg versus 135.0 mm Hg, and a lower mean DBP (82.0 mm Hg versus 85.2 mm Hg, than those assigned to "standard target".

Authors' Conclusions: For the general population of persons with elevated blood pressure, the benefits of trying to achieve a lower blood pressure target rather than a standard target (≤ 140/90 mm Hg) do not outweigh the harms associated with that intervention. Further research is needed to see if some groups of patients would benefit or be harmed by lower targets. The results of this review are primarily applicable to older people with moderate to high cardiovascular risk. They may not be applicable to other populations.
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http://dx.doi.org/10.1002/14651858.CD004349.pub3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8094587PMC
December 2020

Use of Telemedicine to Improve Interfacility Communication and Aid in Triage of Patients with Intracerebral Hemorrhage: A Pilot Study.

World Neurosurg 2021 Mar 10;147:e189-e199. Epub 2020 Dec 10.

Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA.

Introduction: Over the past several years there has been a dramatic increase in the implementation of telemedicine technology to aid in the delivery of care across community, inpatient, and emergency settings. This technology has proved valuable for acute life-threatening clinical scenarios. We aimed to pilot a novel neurosurgical telemedicine program within an academic tertiary care center to assist in consultation of patients with high-grade intracranial hemorrhage (ICH) (ICH score 4, 5).

Methods: A quality improvement conceptual framework was developed. Subsequently, a process map and improvement interventions were created. Patients in community hospitals with high-grade ICH or pre-existing Do Not Resuscitate/Do Not Intubate orders with an admitting diagnosis of ICH triggered a TeleNeurosurgery consultation. Patients who met the inclusion criteria, with consent of their decision makers, were enrolled in the study. Post-encounter physician surveys were used to evaluate overall satisfaction with the implementation.

Results: This 18-month pilot study proved feasible, with an enrollment of 63.6% (n = 14 of 22) of patients who met criteria. All patients who were enrolled in the study and participated in TeleNeurosurgery consultation remained at the presenting facility for end-of-life care and palliative medicine consultation. Both community emergency physicians and subspecialists who performed the consultations reported satisfaction with the TeleNeurosurgery consultation process and a perceived benefit both to patients, families, and emergency medicine physicians.

Conclusions: The program proved feasible and several areas in need of improvement within the health system were identified. Emergency physicians reported comfort with the process, program effectiveness, and improved access to care by implementation of this program.
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http://dx.doi.org/10.1016/j.wneu.2020.12.010DOI Listing
March 2021

Trends and determinants of newborn mortality in Kyrgyzstan: a Countdown country case study.

Lancet Glob Health 2021 03 10;9(3):e352-e360. Epub 2020 Dec 10.

Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada; Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan. Electronic address:

Background: Kyrgyzstan has made considerable progress in reducing child mortality compared with other countries in the region, despite a comparatively low economic standing. However, maternal mortality is still high. Given the availability of an established birth registration system, we aimed to comprehensively assess the trends and determinants of reproductive, maternal, newborn, and child health in Kyrgyzstan.

Methods: For this Countdown to 2030 country case study, we used publicly available data repositories and the national birth registry of Kyrgyzstan to examine trends and inequalities of reproductive, maternal, and newborn health and mortality between 1990 and 2018, at a national and subnational level. Coverage of newborn and maternal health interventions was assessed and disaggregated by equity dimensions. We did Oaxaca-Blinder decomposition to determine the contextual factors associated with the observed decline in newborn mortality rates. We also undertook a comprehensive review of national policies and programmes, as well as a prospective Lives Saved Tool analysis, to highlight interventions that have the potential to avert the most maternal, neonatal, and child deaths.

Findings: Over the past two decades, Kyrgyzstan reduced newborn mortality rates by 46% and mortality rates of children younger than 5 years by 69%, whereas maternal mortality rates were reduced by 7% and stillbirth rates by 29%. The leading causes of neonatal deaths were prematurity and asphyxia or hypoxia, and preterm small-for-gestational-age infants were more than 80 times more likely to die in their first month of life compared with those born appropriate-for-gestational age at term. Except for contraceptive use, coverage of essential interventions has increased and is generally high, with limited sociodemographic inequities. With scale-up of a few essential neonatal and maternal interventions, 39% of neonatal deaths, 11% of stillbirths, and 19% of maternal deaths could be prevented by 2030.

Interpretation: Kyrgyzstan has reduced newborn mortality rates considerably, with the potential for further reduction. To achieve and exceed the Sustainable Development Goal 3 targets for newborn survival and reducing stillbirths, Kyrgyzstan needs to scale up packages of interventions for the care of small and sick babies, assure quality of care in all health-care facilities with regionalised perinatal care, and create a linked national registry for mothers and neonates with rapid feedback and accountability.

Funding: US Fund for UNICEF under the Countdown to 2015, UNICEF Kyrgyzstan Office.
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http://dx.doi.org/10.1016/S2214-109X(20)30460-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7886658PMC
March 2021

GENCODE 2021.

Nucleic Acids Res 2021 01;49(D1):D916-D923

European Molecular Biology Laboratory, European Bioinformatics Institute, Wellcome Genome Campus, Hinxton, Cambridge CB10 1SD, UK.

The GENCODE project annotates human and mouse genes and transcripts supported by experimental data with high accuracy, providing a foundational resource that supports genome biology and clinical genomics. GENCODE annotation processes make use of primary data and bioinformatic tools and analysis generated both within the consortium and externally to support the creation of transcript structures and the determination of their function. Here, we present improvements to our annotation infrastructure, bioinformatics tools, and analysis, and the advances they support in the annotation of the human and mouse genomes including: the completion of first pass manual annotation for the mouse reference genome; targeted improvements to the annotation of genes associated with SARS-CoV-2 infection; collaborative projects to achieve convergence across reference annotation databases for the annotation of human and mouse protein-coding genes; and the first GENCODE manually supervised automated annotation of lncRNAs. Our annotation is accessible via Ensembl, the UCSC Genome Browser and https://www.gencodegenes.org.
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http://dx.doi.org/10.1093/nar/gkaa1087DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7778937PMC
January 2021

A pilot study of stereotactic boost for malignant epidural spinal cord compression: clinical significance and initial dosimetric evaluation.

Radiat Oncol 2020 Nov 18;15(1):267. Epub 2020 Nov 18.

Juravinski Cancer Centre, Department of Radiation Oncology, McMaster University, 3rd Floor, 699 Concession Street, Hamilton, ON, L8V 5C2, Canada.

Purpose: Metastatic epidural spinal cord compression (MESCC) is a devastating complication of advanced malignancy, which can result in neurologic complications and significant deterioration in overall function and quality of life. Most patients are not candidates for optimal surgical decompression and as a result, receive urgent 3D conformal radiotherapy (3DCRT) to prevent or attempt to reverse neurologic progression. Multiple trials indicate that response and ambulatory rates after 3DCRT are inferior to surgery. The advent of stereotactic body radiation therapy (SBRT) has created a method with which a "radiosurgical decompression" boost may facilitate improve outcomes for MESCC patients.

Methods: We are conducting a pilot study to investigate SBRT boost after urgent 3D CRT for patients with MESCC. The aim of the study is to establish feasibility of this two-phase treatment regimen, and secondarily to characterize post-treatment ambulation status, motor response, pain control, quality of life and survival.

Discussion: We describe the study protocol and present a case report of one patient. A quality assurance review was conducted after the first seven patients, and resultant dose-constraints were revised to improve safety and feasibility of planning through more conservative organ at risk constraints. There have been no severe adverse events (grade 3-5) to date. We have illustrated clinical and dosimetric data of an example case, where a patient regained full strength and ambulatory capacity.

Conclusions: Our study aims to determine if SBRT is a feasible option in addition to standard 3DCRT for MESCC patients, with the goal to consider future randomized trials if successful. Having a robust quality assurance process in this study ensures translatability going forward if future trials with multicenter and increased patient representation are to be considered.

Trial Registration: clinicaltrials.gov; registration no. NCT03529708; https://clinicaltrials.gov/ct2/show/NCT03529708 ; First posted May 18, 2018.
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http://dx.doi.org/10.1186/s13014-020-01710-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7672889PMC
November 2020

A Survey of Clinical Usage of Non-steroidal Intra-Articular Therapeutics by Equine Practitioners.

Front Vet Sci 2020 22;7:579967. Epub 2020 Oct 22.

Department of Clinical Sciences, Auburn University, Auburn, AL, United States.

There are several non-steroidal intra-articular therapeutics (NSIATs) available for use by equine practitioners for the treatment of performance-limiting joint-related pathology. Information is limited on perceived clinical efficacy, recommended treatment protocols, and associated complications. Our objective with this cross-sectional survey was to investigate the current clinical usage of NSIATs by equine practitioners. An electronic cross-sectional convenience survey inquiring about the use of steroidal and NSIATS (platelet-rich plasma, autologous conditioned serum, autologous protein solution, cellular therapies, and polyacrylamide hydrogel) was distributed internationally to equine practitioners. A total of 353 surveys were completed. NSIATs were used by 87.5% of the participants. Corticosteroids and hyaluronic acid remain the intra-articular therapeutic of choice among practitioners, followed by autologous conditioned serum, platelet-rich plasma and autologous conditioned protein. Polyacrylamide hydrogel was the least used. Practitioners were more likely to use NSIATs if their caseload was > 50% equine ( < 0.001), they treated more than 10 horses intra-articularly per month ( < 0.001), and horses treated were considered English sport horses ( = 0.02). Years in practice and practice location did not influence the use of NSIATs. One of the most common reasons why NSIATs were chosen was to treat acute articular pathologies. As survey limitations, answers to questions regarding clinical response and complication rates were based on subjective estimation and practitioners recall, not clinical records. In conclusion, corticosteroids remain the most widely used intra-articular therapeutic. Among the NSIATs, blood-based products are more commonly used by practitioners, followed by cellular and synthetic products. Equine practitioners frequently use NSIATs, choosing to treat acute joint pathology more than previously reported.
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http://dx.doi.org/10.3389/fvets.2020.579967DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7642446PMC
October 2020