Publications by authors named "Lee Alexander"

136 Publications

Diagnostic Accuracy of Ultrasonography for Rotator Cuff Tears: A Systematic Review and Meta-analysis.

Orthop J Sports Med 2021 Oct 11;9(10):23259671211035106. Epub 2021 Oct 11.

Harvard Medical School, Boston, Massachusetts, USA.

Background: With recent improvements in transducer strength, image resolution, and operator training, ultrasound (US) provides an excellent alternative imaging modality for the diagnosis of rotator cuff tears.

Purpose: To evaluate the diagnostic accuracy of US for partial- and full-thickness rotator cuff tears and biceps tendon tears, compare diagnostic values with those of magnetic resonance imaging (MRI) using arthroscopy as the reference standard, assess longitudinal improvements in accuracy, and compare diagnostic values from operators with different training backgrounds.

Study Design: Systematic review; Level of evidence, 3.

Methods: The PubMed and Cochrane Library databases were systematically searched for full-text journal articles published between January 1, 2010, and April 1, 2020. The inclusion criteria were studies that evaluated the diagnostic accuracy of US for rotator cuff tears or biceps tendon tears utilizing arthroscopy as the reference standard. The exclusion criteria were studies with <10 patients, studies including massive tears without reporting diagnostic data for specific tendons, and studies lacking diagnostic outcome data. Extracted outcomes included diagnostic accuracy, sensitivity, specificity, negative predictive value, and positive predictive value. The mean difference and 95% confidence interval were calculated for both US and MRI diagnostic values, and meta-analysis was conducted using the Mantel-Haenszel random-effects model.

Results: In total, 23 eligible studies involving 2054 shoulders were included. US demonstrated a higher median diagnostic accuracy for supraspinatus tendon tears (0.83) and biceps tendon tears (0.93) as compared with subscapularis tendon tears (0.76). US was found to have a higher median accuracy (0.93) for full-thickness supraspinatus tears than partial-thickness tears (0.81). US had superior median sensitivity for partial-thickness supraspinatus tears when performed by radiologists as opposed to surgeons (0.86 vs 0.57). Meta-analysis of the 5 studies comparing US and MRI demonstrated no statistically significant difference in diagnostic sensitivity, specificity, or accuracy for any thickness supraspinatus tears = .31-.55), full-thickness tears = .63-.97), or partial-thickness tears ( = .13-.81).

Conclusion: For experienced operators, US is a highly sensitive and specific diagnostic modality for the diagnosis of supraspinatus tears and demonstrates statistically equivalent capability to MRI in the diagnosis of both full- and partial-thickness rotator cuff tears.
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http://dx.doi.org/10.1177/23259671211035106DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8511934PMC
October 2021

Clinical and Functional Outcomes by Graft Type in Superior Capsular Reconstruction: A Systematic Review and Meta-analysis.

Am J Sports Med 2021 Oct 11:3635465211040440. Epub 2021 Oct 11.

Mount Sinai Hospital, New York, New York, USA.

Background: In recent years, superior capsular reconstruction (SCR) has emerged as a promising treatment for massive rotator cuff tears and has been performed with an array of graft options, most commonly dermal allograft and tensor fascia lata (TFL) autograft.

Purpose: To compare the clinical outcomes, functional outcomes, and complication rates after SCR performed with dermal allograft, TFL autograft, long head of the biceps tendon (LHBT) autograft, and porcine xenograft.

Study Design: Meta-analysis; Level of evidence, 4.

Methods: PubMed, Cochrane Library, and Embase were systematically reviewed for studies that enrolled ≥10 patients who underwent SCR and presented clinical outcome data at a minimum follow-up of 12 months. When available, pre- and postoperative patient-reported outcome scores and clinical examination data were extracted. Outcome data were then compared by graft type. A meta-analysis was also conducted of graft tear and reoperation rates after SCR with dermal allograft and TFL autograft.

Results: Human dermal allograft and TFL autograft were each utilized in 7 studies, LHBT autograft in 2 studies, and porcine xenograft in 1 study. Dermal allograft, TFL autograft, and LHBT autograft demonstrated comparable median (range) postoperative American Shoulder and Elbow Surgeons scores of 85.3 (77.5-89), 88.6 (73.7-94.3), and 82.7 (80-85.4), respectively. The median postoperative pain scores per visual analog scale for dermal allograft, TFL autograft, and LHBT autograft were 0.8, 2.5, and 1.4. Median postoperative forward elevation was 159.0°, 147.0°, 163.8°, and 151.4° for dermal allograft, TFL autograft, LHBT autograft, and porcine xenograft. Meta-analysis demonstrated a comparable pooled graft tear rate between TFL autograft (9%; 95% CI, 4%-16%) and dermal allograft (7%; 95% CI, 2%-13%). Similarly, the pooled reoperation rate was similar for TFL autograft (3%; 95% CI, 0%-7%) and dermal allograft (6%; 95% CI, 2%-12%). Among the 3 studies with pre- and postoperative information on pseudoparalysis, 73 of 76 (96%) patients with an intact/repairable subscapularis had a reversal of their pseudoparalysis after SCR.

Conclusion: Dermal allograft, TFL autograft, and LHBT autograft are all suitable options for SCR and demonstrate significant improvements in American Shoulder and Elbow Surgeons score, pain score per visual analog scale, and forward elevation. Moreover, dermal allograft and TFL autograft have comparable rates of graft tear and reoperation.
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http://dx.doi.org/10.1177/03635465211040440DOI Listing
October 2021

Reassembling protein complexes after controlled disassembly by top-down mass spectrometry in native mode.

Int J Mass Spectrom 2021 Jul 27;465. Epub 2021 Mar 27.

Departments of Chemistry, Chemical and Biological Engineering, and Molecular Biosciences, the Chemistry of Life Processes Institute, and the Proteomics Center of Excellence, Northwestern University, 2170 Tech Dr., Silverman Hall, 60208, Evanston, IL, USA.

The combined use of electrospray ionization run in so-called "native mode" with top-down mass spectrometry (nTDMS) is enhancing both structural biology and discovery proteomics by providing three levels of information in a single experiment: the intact mass of a protein or complex, the masses of its subunits and non-covalent cofactors, and fragment ion masses from direct dissociation of subunits that capture the primary sequence and combinations of diverse post-translational modifications (PTMs). While intact mass data are readily deconvoluted using well-known software options, the analysis of fragmentation data that result from a tandem MS experiment - essential for proteoform characterization - is not yet standardized. In this tutorial, we offer a decision-tree for the analysis of nTDMS experiments on protein complexes and diverse bioassemblies. We include an overview of strategies to navigate this type of analysis, provide example data sets, and highlight software for the hypothesis-driven interrogation of fragment ions for localization of PTMs, metals, and cofactors on native proteoforms. Throughout we have emphasized the key features (deconvolution, search mode, validation, other) that the reader can consider when deciding upon their specific experimental and data processing design using both open-access and commercial software.
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http://dx.doi.org/10.1016/j.ijms.2021.116591DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8445521PMC
July 2021

Willingness to use a wearable device capable of detecting and reversing overdose among people who use opioids in Philadelphia.

Harm Reduct J 2021 07 23;18(1):75. Epub 2021 Jul 23.

Perelman School of Medicine, University of Pennsylvania, 3450 Hamilton Walk, Stemmler Building, Office #220, Philadelphia, PA, 19104, USA.

Background: The incidence of opioid-related overdose deaths has been rising for 30 years and has been further exacerbated amidst the COVID-19 pandemic. Naloxone can reverse opioid overdose, lower death rates, and enable a transition to medication for opioid use disorder. Though current formulations for community use of naloxone have been shown to be safe and effective public health interventions, they rely on bystander presence. We sought to understand the preferences and minimum necessary conditions for wearing a device capable of sensing and reversing opioid overdose among people who regularly use opioids.

Methods: We conducted a combined cross-sectional survey and semi-structured interview at a respite center, shelter, and syringe exchange drop-in program in Philadelphia, Pennsylvania, USA, during the COVID-19 pandemic in August and September 2020. The primary aim was to explore the proportion of participants who would use a wearable device to detect and reverse overdose. Preferences regarding designs and functionalities were collected via a questionnaire with items having Likert-based response options and a semi-structured interview intended to elicit feedback on prototype designs. Independent variables included demographics, opioid use habits, and previous experience with overdose.

Results: A total of 97 adults with an opioid use history of at least 3 months were interviewed. A majority of survey participants (76%) reported a willingness to use a device capable of detecting an overdose and automatically administering a reversal agent upon initial survey. When reflecting on the prototype, most respondents (75.5%) reported that they would wear the device always or most of the time. Respondents indicated discreetness and comfort as important factors that increased their chance of uptake. Respondents suggested that people experiencing homelessness and those with low tolerance for opioids would be in greatest need of the device.

Conclusions: The majority of people sampled with a history of opioid use in an urban setting were interested in having access to a device capable of detecting and reversing an opioid overdose. Participants emphasized privacy and comfort as the most important factors influencing their willingness to use such a device.

Trial Registration: NCT04530591.
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http://dx.doi.org/10.1186/s12954-021-00522-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8299455PMC
July 2021

High-Ambient Air Pollution Exposure Among Never Smokers Versus Ever Smokers With Lung Cancer.

J Thorac Oncol 2021 Jul 10. Epub 2021 Jul 10.

Department of Integrative Oncology, British Columbia Cancer Research Institute, Vancouver, British Columbia, Canada; Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada. Electronic address:

Introduction: Air pollution may play an important role in the development of lung cancer in people who have never smoked, especially among East Asian women. The aim of this study was to compare cumulative ambient air pollution exposure between ever and never smokers with lung cancer.

Methods: A consecutive case series of never and ever smokers with newly diagnosed lung cancer were compared regarding their sex, race, and outdoor and household air pollution exposure. Using individual residential history, cumulative exposure to outdoor particulate matter (PM) in a period of 20 years was quantified with a high-spatial resolution global exposure model.

Results: Of the 1005 patients with lung cancer, 56% were females and 33% were never smokers. Compared with ever smokers with lung cancer, never smokers with lung cancer were significantly younger, more frequently Asian, less likely to have chronic obstructive pulmonary disease or a family history of lung cancer, and had higher exposure to outdoor PM but lower exposure to secondhand smoke. Multivariable logistic regression analysis revealed a significant association with never-smoking patients with lung cancer and being female (OR = 4.01, 95% confidence interval [CI]: 2.76-5.82, p < 0.001), being Asian (OR = 6.48, 95% CI: 4.42-9.50, p < 0.001), and having greater exposure to air pollution (OR = 1.79, 95% CI: 1.10-7.2.90, p = 0.019).

Conclusions: Compared with ever-smoking patients with lung cancer, never-smoking patients had strong associations with being female, being Asian, and having air pollution exposures. Our results suggest that incorporation of cumulative exposure to ambient air pollutants be considered when assessing lung cancer risk in combination with traditional risk factors.
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http://dx.doi.org/10.1016/j.jtho.2021.06.015DOI Listing
July 2021

Cost Conversations About Anticoagulation Between Patients With Atrial Fibrillation and Their Clinicians: A Secondary Analysis of a Randomized Clinical Trial.

JAMA Netw Open 2021 Jul 1;4(7):e2116009. Epub 2021 Jul 1.

Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota.

Importance: How patients with atrial fibrillation (AF) and their clinicians consider cost in forming care plans remains unknown.

Objective: To identify factors that inform conversations regarding costs of anticoagulants for treatment of AF between patients and clinicians and outcomes associated with these conversations.

Design, Setting, And Participants: This cohort study of recorded encounters and participant surveys at 5 US medical centers (including academic, community, and safety-net centers) from the SDM4AFib randomized trial compared standard AF care with and without use of a shared decision-making (SDM) tool. Included patients were considering anticoagulation treatment and were recruited by their clinicians between January 30, 2017, and June 27, 2019. Data were analyzed between August and November 2019.

Main Outcomes And Measures: The incidence of and factors associated with cost conversations, and the association of cost conversations with patients' consideration of treatment cost burden and their choice of anticoagulation.

Results: A total of 830 encounters (out of 922 enrolled participants) were recorded. Patients' mean (SD) age was 71.0 (10.4) years; 511 patients (61.6%) were men, 704 (86.0%) were White, 303 (40.9%) earned between $40 000 and $99 999 in annual income, and 657 (79.2%) were receiving anticoagulants. Clinicians' mean (SD) age was 44.8 (13.2) years; 75 clinicians (53.2%) were men, and 111 (76%) practiced as physicians, with approximately half (69 [48.9%]) specializing in either internal medicine or cardiology. Cost conversations occurred in 639 encounters (77.0%) and were more likely in the SDM arm (378 [90%] vs 261 [64%]; OR, 9.69; 95% CI, 5.77-16.29). In multivariable analysis, cost conversations were more likely to occur with female clinicians (66 [47%]; OR, 2.85; 95% CI, 1.21-6.71); consultants vs in-training clinicians (113 [75%]; OR, 4.0; 95% CI, 1.4-11.1); clinicians practicing family medicine (24 [16%]; OR, 12.12; 95% CI, 2.75-53.38]), internal medicine (35 [23%]; OR, 3.82; 95% CI, 1.25-11.70), or other clinicians (21 [14%]; OR, 4.90; 95% CI, 1.32-18.16) when compared with cardiologists; and for patients with an annual household income between $40 000 and $99 999 (249 [82.2%]; OR, 1.86; 95% CI, 1.05-3.29) compared with income below $40 000 or above $99 999. More patients who had cost conversations reported cost as a factor in their decision (244 [89.1%] vs 327 [69.0%]; OR 3.66; 95% CI, 2.43-5.50), but cost conversations were not associated with the choice of anticoagulation agent.

Conclusions And Relevance: Cost conversations were common, particularly for middle-income patients and with female and consultant-level primary care clinicians, as well as in encounters using an SDM tool; they were associated with patients' consideration of treatment cost burden but not final treatment choice. With increasing costs of care passed on to patients, these findings can inform efforts to promote cost conversations in practice.

Trial Registration: ClinicalTrials.gov Identifier: NCT02905032.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.16009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8278261PMC
July 2021

Artificial Intelligence-Augmented Electrocardiogram Detection of Left Ventricular Systolic Dysfunction in the General Population.

Mayo Clin Proc 2021 Oct 10;96(10):2576-2586. Epub 2021 Jun 10.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN. Electronic address:

Objective: To validate an artificial intelligence-augmented electrocardiogram (AI-ECG) algorithm for the detection of preclinical left ventricular systolic dysfunction (LVSD) in a large community-based cohort.

Methods: We identified a randomly selected community-based cohort of 2041 subjects age 45 years or older in Olmsted County, Minnesota. All participants underwent a study echocardiogram and ECG. We first assessed the performance of the AI-ECG to identify LVSD (ejection fraction ≤40%). After excluding participants with clinical heart failure, we further assessed the AI-ECG to detect preclinical LVSD among all patients (n=1996) and in a high-risk subgroup (n=1348). Next we modelled an imputed screening program for preclinical LVSD detection where a positive AI-ECG triggered an echocardiogram. Finally, we assessed the ability of the AI-ECG to predict future LVSD. Participants were enrolled between January 1, 1997, and September 30, 2000; and LVSD surveillance was performed for 10 years after enrollment.

Results: For detection of LVSD in the total population (prevalence, 2.0%), the area under the receiver operating curve for AI-ECG was 0.97 (sensitivity, 90%; specificity, 92%); in the high-risk subgroup (prevalence 2.7%), the area under the curve was 0.97 (sensitivity, 92%; specificity, 93%). In an imputed screening program, identification of one preclinical LSVD case would require 88.3 AI-ECGs and 8.7 echocardiograms in the total population and 65.7 AI-ECGs and 5.5 echocardiograms in the high-risk subgroup. The unadjusted hazard ratio for a positive AI-ECG for incident LVSD over 10 years was 2.31 (95% CI, 1.32 to 4.05; P=.004).

Conclusion: Artificial intelligence-augmented ECG can identify preclinical LVSD in the community and warrants further study as a screening tool for preclinical LVSD.
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http://dx.doi.org/10.1016/j.mayocp.2021.02.029DOI Listing
October 2021

COVID-19: A Comprehensive Analysis of the Pandemic's Effect on an Emergency Department.

Disaster Med Public Health Prep 2021 Jun 8:1-4. Epub 2021 Jun 8.

Department of Emergency Medicine, Life Lion EMS, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.

Objective: Coronavirus disease 2019 (COVID-19, caused by severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) is a historic pandemic severely impacting health care. This study examines its early effect on a busy academic emergency department.

Methods: A retrospective analysis of patients from an academic tertiary care Level I trauma, cardiac and stroke center's emergency department seeing an average of 54,000 adults and 21,000 pediatric patients per year. Total visits, reasons for patient visits, demographics, disposition, and length of stay were analyzed from January through July 2020 and compared with the same time period in the previous 2 y.

Results: From March through July 2020 there were statistically significant decreases in the total number of patient visits (-47%) especially among pediatric (-73%) and elderly (-43%) patients and those with cardiovascular (-39%), neurological (-63%) complaints, headaches (-60%), back pain (-64%), abdominal pain (-51%), and minor trauma (-71%). There was, however, a significant increase in pulmonary complaints (+54%), as well as admissions (+32%), and length of stay (+40%).

Conclusions: There was a significant drop in overall patients and select groups early in the pandemic, while admissions and emergency department length of stay both increased. This has implications for future pandemic planning.
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http://dx.doi.org/10.1017/dmp.2021.182DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8314046PMC
June 2021

Myocardial Histopathology in Patients With Obstructive Hypertrophic Cardiomyopathy.

J Am Coll Cardiol 2021 May;77(17):2159-2170

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.

Background: Hypertrophic cardiomyopathy (HCM) is characterized by multiple pathological features including myocyte hypertrophy, myocyte disarray, and interstitial fibrosis.

Objectives: This study sought to correlate myocardial histopathology with clinical characteristics of patients with obstructive HCM and post-operative outcomes following septal myectomy.

Methods: The authors reviewed the pathological findings of the myocardial specimens from 1,836 patients with obstructive HCM who underwent septal myectomy from 2000 to 2016. Myocyte hypertrophy, myocyte disarray, interstitial fibrosis, and endocardial thickening were graded and analyzed.

Results: The median age at operation was 54.2 years (43.5 to 64.3 years), and 1,067 (58.1%) were men. A weak negative correlation between myocyte disarray and age at surgery was identified (ρ = -0.22; p < 0.001). Myocyte hypertrophy (p < 0.001), myocyte disarray (p < 0.001), and interstitial fibrosis (p < 0.001) were positively associated with implantable cardioverter-defibrillator implantation. Interstitial fibrosis (p < 0.001) and endocardial thickening (p < 0.001) were associated with atrial fibrillation pre-operatively. In the Cox survival model, older age (p < 0.001), lower degree of myocyte hypertrophy (severe vs. mild hazard ratio: 0.41; 95% confidence interval: 0.19 to 0.86; p = 0.040), and lower degree of endocardial thickening (moderate vs. mild hazard ratio: 0.75; 95% confidence interval: 0.58 to 0.97; p = 0.019) were independently associated with worse post-myectomy survival. Among 256 patients who had genotype analysis, patients with pathogenic or likely pathogenic variants (n = 62) had a greater degree of myocyte disarray (42% vs. 15% vs. 20%; p = 0.022). Notably, 13 patients with pathogenic or likely pathogenic genetic variants of HCM had no myocyte disarray.

Conclusions: Histopathology was associated with clinical manifestations including the age of disease onset and arrhythmias. Myocyte hypertrophy and endocardial thickening were negatively associated with post-myectomy mortality.
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http://dx.doi.org/10.1016/j.jacc.2021.03.008DOI Listing
May 2021

Retrospective Quality Improvement Study of Insulin-Induced Hypoglycemia and Implementation of Hospital-Wide Initiatives.

J Diabetes Sci Technol 2021 07 21;15(4):733-740. Epub 2021 Apr 21.

Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Background: Hospitalized patients who are receiving antihyperglycemic agents are at increased risk for hypoglycemia. Inpatient hypoglycemia may lead to increased risk for morbidity, mortality, prolonged hospitalization, and readmission within 30 days of discharge, which in turn may lead to increased costs. Hospital-wide initiatives targeting hypoglycemia are known to be beneficial; however, their impact on patient care and economic measures in community nonteaching hospitals are unknown.

Methods: This retrospective quality improvement study examined the effects of hospital-wide hypoglycemia initiatives on the rates of insulin-induced hypoglycemia in a community hospital setting from January 1, 2016, until September 30, 2019. The potential cost of care savings has been calculated.

Results: Among 49 315 total patient days, 2682 days had an instance of hypoglycemia (5.4%). Mean ± SD hypoglycemic patient days/month was 59.6 ± 16.0. The frequency of hypoglycemia significantly decreased from 7.5% in January 2016 to 3.9% in September 2019 ( = .001). Patients with type 2 diabetes demonstrated a significant decrease in the frequency of hypoglycemia (7.4%-3.8%; < .0001), while among patients with type 1 diabetes the frequency trended downwards but did not reach statistical significance (18.5%-18.0%; = 0.08). Based on the reduction of hypoglycemia rates, the hospital had an estimated cost of care savings of $98 635 during the study period.

Conclusions: In a community hospital setting, implementation of hospital-wide initiatives targeting hypoglycemia resulted in a significant and sustainable decrease in the rate of insulin-induced hypoglycemia. These high-leverage risk reduction strategies may be translated into considerable cost savings and could be implemented at other community hospitals.
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http://dx.doi.org/10.1177/19322968211008513DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8258511PMC
July 2021

Inpatient Insulin Pen Implementation, Waste, and Potential Cost Savings: A Community Hospital Experience.

J Diabetes Sci Technol 2021 07 12;15(4):741-747. Epub 2021 Apr 12.

Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Background: Insulin pen injectors ("pens") are intended to facilitate a patient's self-administration of insulin and can be used in hospitalized patients as a learning opportunity. Unnecessary or duplicate dispensation of insulin pens is associated with increased healthcare costs.

Methods: Inpatient dispensation of insulin pens in a 240-bed community hospital between July 2018 and July 2019 was analyzed. We calculated the percentage of insulin pens unnecessarily dispensed for patients who had the same type of insulin pen assigned. The estimated cost of insulin pen waste was calculated. A pharmacist-led task force group implemented hospital-wide awareness and collaborated with hospital leadership to define goals and interventions.

Results: 9516 insulin pens were dispensed to 3121 patients. Of the pens dispensed, 6451 (68%) were insulin aspart and 3065 (32%) were glargine. Among patients on insulin aspart, an average of 2.2 aspart pens was dispensed per patient, but only an estimated 1.2 pens/patient were deemed necessary. Similarly, for inpatients prescribed glargine, an average of 2.1 pens/patient was dispensed, but only 1.3 pens/patient were necessary. A number of gaps were identified and interventions were undertaken to reduce insulin pen waste, which resulted in a significant decrease in both aspart (p = 0.0002) and glargine (p = 0.0005) pens/patient over time. Reductions in pen waste resulted in an estimated cost savings of $66 261 per year.

Conclusions: In a community hospital setting, identification of causes leading to unnecessary insulin dispensation and implementation of hospital-wide staff education led to change in insulin pen dispensation practice. These changes translated into considerable cost savings and facilitated diabetes self-management education.
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http://dx.doi.org/10.1177/19322968211002514DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8258519PMC
July 2021

Effectiveness of a Weight Loss Program Using Digital Health in Adolescents and Preadolescents.

Child Obes 2021 07 6;17(5):311-321. Epub 2021 Apr 6.

Department of Cardiovascular Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.

To identify an efficacious intervention on treating adolescents with overweight and obesity, this might result in health benefits. Adolescents with overweight or obesity aged 10-17 years with BMI percentile ≥85th were included in this historical observational analysis. Subjects used an entirely remote weight loss program combining mobile applications, frequent self-weighing, and calorie restriction with meal replacement. Body weight changes were evaluated at 42, 60, 90, and 120 days using different metrics including absolute body weight, BMI, and BMI z-score. Chi-square or Fisher exact tests (categorical variables) and Student's -test (continuous variables) were used to compare subjects. In total, 2,825 participants, mean age 14.4 ± 2.2 years, (54.8% girls), were included from October 27, 2016, to December 31, 2017, in mainland China; 1355 (48.0%) had a baseline BMI percentile ≥97th. Mean BMI and BMI z-score were 29.20 ± 4.44 kg/m and 1.89 ± 0.42, respectively. At day 120, mean reduction in body weight, BMI, and BMI z-score was 8.6 ± 0.63 kg, 3.13 ± 0.21 kg/m, and 0.42 ± 0.03; 71.4% had lost ≥5% body weight, 69.4% of boys and 73.2% of girls, respectively. Compared with boys, girls achieved greater reduction on BMI z-score at all intervals ( < 0.004 for all comparisons). Higher BMI percentile at baseline and increased frequency of use of the mobile application were directly associated with more significant weight loss. An entirely remote digital weight loss program is effective in facilitating weight loss in adolescents with overweight or obesity in the short term and mid term.
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http://dx.doi.org/10.1089/chi.2020.0317DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8236388PMC
July 2021

Early detection of SARS-CoV-2 and other infections in solid organ transplant recipients and household members using wearable devices.

Transpl Int 2021 06 5;34(6):1019-1031. Epub 2021 May 5.

Department of Genetics, Stanford University School of Medicine, Stanford, CA, USA.

The increasing global prevalence of SARS-CoV-2 and the resulting COVID-19 disease pandemic pose significant concerns for clinical management of solid organ transplant recipients (SOTR). Wearable devices that can measure physiologic changes in biometrics including heart rate, heart rate variability, body temperature, respiratory, activity (such as steps taken per day) and sleep patterns, and blood oxygen saturation show utility for the early detection of infection before clinical presentation of symptoms. Recent algorithms developed using preliminary wearable datasets show that SARS-CoV-2 is detectable before clinical symptoms in >80% of adults. Early detection of SARS-CoV-2, influenza, and other pathogens in SOTR, and their household members, could facilitate early interventions such as self-isolation and early clinical management of relevant infection(s). Ongoing studies testing the utility of wearable devices such as smartwatches for early detection of SARS-CoV-2 and other infections in the general population are reviewed here, along with the practical challenges to implementing these processes at scale in pediatric and adult SOTR, and their household members. The resources and logistics, including transplant-specific analyses pipelines to account for confounders such as polypharmacy and comorbidities, required in studies of pediatric and adult SOTR for the robust early detection of SARS-CoV-2, and other infections are also reviewed.
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http://dx.doi.org/10.1111/tri.13860DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8250335PMC
June 2021

Construction of a Realistic, Whole-Body, Three-Dimensional Equine Skeletal Model using Computed Tomography Data.

J Vis Exp 2021 02 25(168). Epub 2021 Feb 25.

Department of Comparative Biomedical Sciences, Louisiana State University School of Veterinary Medicine;

Therapies based upon whole-body biomechanical assessments are successful for injury prevention and rehabilitation in human athletes. Similar approaches have rarely been used to study equine athletic injury. Degenerative osteoarthritis caused by mechanical stress can originate from chronic postural dysfunction, which, because the primary dysfunction is often distant from the site of tissue injury, is best identified through modeling whole-body biomechanics. To characterize whole-body equine kinematics, a realistic skeletal model of a horse was created from equine computed tomography (CT) data that can be used for functional anatomical and biomechanical modeling. Equine CT data were reconstructed into individual three-dimensional (3D) data sets (i.e., bones) using 3D visualization software and assembled into a complete 3D skeletal model. The model was then rigged and animated using 3D animation and modeling software. The resulting 3D skeletal model can be used to characterize equine postures associated with degenerative tissue changes as well as to identify postures that reduce mechanical stress at the sites of tissue injury. In addition, when animated into 4D, the model can be used to demonstrate unhealthy and healthy skeletal movements and can be used to develop preventative and rehabilitative individualized therapies for horses with degenerative lamenesses. Although the model will soon be available for download, it is currently in a format that requires access to the 3D animation and modeling software, which has quite a learning curve for new users. This protocol will guide users in (1) developing such a model for any organism of interest and (2) using this specific equine model for their own research questions.
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http://dx.doi.org/10.3791/62276DOI Listing
February 2021

Decoding the protein composition of whole nucleosomes with Nuc-MS.

Nat Methods 2021 03 15;18(3):303-308. Epub 2021 Feb 15.

Department of Chemistry, Northwestern University, Evanston, IL, USA.

Current proteomic approaches disassemble and digest nucleosome particles, blurring readouts of the 'histone code'. To preserve nucleosome-level information, we developed Nuc-MS, which displays the landscape of histone variants and their post-translational modifications (PTMs) in a single mass spectrum. Combined with immunoprecipitation, Nuc-MS quantified nucleosome co-occupancy of histone H3.3 with variant H2A.Z (sixfold over bulk) and the co-occurrence of oncogenic H3.3K27M with euchromatic marks (for example, a >15-fold enrichment of dimethylated H3K79me2). Nuc-MS is highly concordant with chromatin immunoprecipitation-sequencing (ChIP-seq) and offers a new readout of nucleosome-level biology.
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http://dx.doi.org/10.1038/s41592-020-01052-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7954958PMC
March 2021

Tobacco perceptions and practices: User groups and demographic characteristics, Mississippi, USA.

Popul Med 2020 Sep;2

American Heart Association Tobacco Center for Regulatory Science, Dallas, United States.

Introduction: Despite decreases in the overall US smoking rate, tobacco use remains more common in some areas and by some groups. Deeper understanding of group differences is needed in order to tailor public health campaigns to the interests, perceptions and experiences of targeted audiences. Although some differences have been identified across African American and Caucasian smokers in the United States, additional insight is needed regarding factors that differentiate these groups. This study examined tobacco-related perceptions and practices, with an emphasis on identifying differences across African American and Caucasian smokers. Toward this goal, we examined key demographic variables of race and age, and tobacco use characteristics.

Methods: The sample consisted of 284 people from the Jackson, Mississippi area who participated in focus groups and completed surveys addressing a variety of tobacco-related topics, including knowledge and perceptions of products as well as use and health information seeking behavior. The selection criteria and recruitment approach ensured a balance across race (black, white), age (18-34, >35 years), sex, and cigarette smoking status (current, former, never). Statistical analyses were performed using SAS (v.9.4).

Results: Differences were observed across demographic subgroups regarding type and pattern of tobacco products used (e.g. mentholated, markers of nicotine dependence, hookah). Differences in preferred sources of health information based on age as well as perceptions of risk as a function of age, smoking status and race were also noted. Exposure to secondhand smoke and perceptions of its risks, quitting efforts and cessation methods differed by race.

Conclusions: Study findings suggest key differences across important subgroups. Knowledge of such differences has the potential to improve strategic public health messaging, allowing health campaigns to more effectively prevent tobacco product uptake as well as promote interest in quitting tobacco.
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http://dx.doi.org/10.18332/popmed/127236DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7842565PMC
September 2020

Construct validity and reliability of the Concussion Knowledge Assessment Tool (CKAT).

J Can Chiropr Assoc 2020 Dec;64(3):201-213

Department of Research and Innovation, Canadian Memorial Chiropractic College.

Objective: To evaluate the test-retest reliability and construct validity of the concussion knowledge assessment tool (CKAT) as a measure of knowledge of concussion and its management among chiropractic subgroups and to compare these properties for two scoring strategies for the CKAT.

Methods: Three chiropractic subgroups (first year students, interns and sports chiropractors) completed the CKAT via SurveyMonkey with as second administration two to six weeks later for a subset of respondents. Scatter plots and Intraclass Correlation Coefficients (ICC) were used for test-retest reliability. A priori hypotheses regarding the relationship of CKAT scores across known subgroups, and with concussion knowledge self-rankings were established prior to data collection. Distributions of CKAT scores were compared across the subgroups using boxplots and ANOVA for known groups validity, and correlation of CKAT scores with concussion knowledge self-ranking was examined.

Results: Test-retest ICC for the revised scoring was 0.68 (95%CI 0.51-0.80). First year students had a mean revised CKAT (out of 49) of 36.9 (SD= 4.7), interns 39.9 (SD=3.0) and sports chiropractors 41.8 (SD=3.2) which are significantly different (F=17.54; p<0.0001).

Conclusions: The CKAT distinguished between chiropractic subgroups expected to have different levels of knowledge, supporting construct validity, however, it did not achieve adequate test-retest reliability.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7815174PMC
December 2020

Forever yuck: Oculomotor avoidance of disgusting stimuli resists habituation.

J Exp Psychol Gen 2021 Jan 21. Epub 2021 Jan 21.

Department of Psychology.

Disgust is an adaptation forged under the selective pressure of pathogens. Yet disgust may cause problems in contemporary societies because of its propensity for "false positives" and resistance to corrective information. Here, we investigate whether disgust, as revealed by oculomotor avoidance, might be reduced through the noncognitive process of habituation. In each of three experiments, we repeatedly exposed participants to the same pair of images, one disgusting and one neutral, and recorded gaze. Experiment 1 ( = 104) found no decline in oculomotor avoidance of the disgusting image after 24 prolonged exposures. Experiment 2 ( = 99) replicated this effect and demonstrated its uniqueness to disgust. In Experiment 3 ( = 93), we provided a gaze-contingent reward to ensure perceptual contact with the disgusting image. Participants looked almost exclusively at the disgusting image for 5 min but resumed baseline levels of oculomotor avoidance once the reward ceased. These findings underscore the challenge of reducing disgust. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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http://dx.doi.org/10.1037/xge0001006DOI Listing
January 2021

The night markets of Mellador.

Authors:
M Lee Alexander

Nature 2020 Jan 22. Epub 2020 Jan 22.

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http://dx.doi.org/10.1038/d41586-019-03935-0DOI Listing
January 2020

Intestines of non-uniform stiffness mold the corners of wombat feces.

Soft Matter 2021 Jan 8;17(3):475-488. Epub 2020 Dec 8.

School of Mechanical Engineering, Georgia Institute of Technology, 801 Ferst Drive, MRDC 1308, Atlanta, GA 30332, USA. and School of Biological Science, Georgia Institute of Technology, 801 Ferst Drive, MRDC 1308, Atlanta, GA 30332, USA.

The bare-nosed wombat (Vombatus ursinus) is a fossorial, herbivorous, Australian marsupial, renowned for its cubic feces. However, the ability of the wombat's soft intestine to sculpt flat faces and sharp corners in feces is poorly understood. In this combined experimental and numerical study, we show one mechanism for the formation of corners in a highly damped environment. Wombat dissections show that cubes are formed within the last 17 percent of the intestine. Using histology and tensile testing, we discover that the cross-section of the intestine exhibits regions with a two-fold increase in thickness and a four-fold increase in stiffness, which we hypothesize facilitates the formation of corners by contractions of the intestine. Using a mathematical model, we simulate a series of azimuthal contractions of a damped elastic ring composed of alternating stiff and soft regions. Increased stiffness ratio and higher Reynolds number yield shapes that are more square. The corners arise from faster contraction in the stiff regions and relatively slower movement in the center of the soft regions. These results may have applications in manufacturing, clinical pathology, and digestive health.
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http://dx.doi.org/10.1039/d0sm01230kDOI Listing
January 2021

A hypoenergetic diet with decreased protein intake does not reduce lean body mass in trained females.

Eur J Appl Physiol 2021 Mar 1;121(3):771-781. Epub 2020 Dec 1.

Department of Sport, Exercise and Rehabilitation, Northumbria University, Newcastle, UK.

Purpose: Increasing protein intake during energy restriction (ER) attenuates lean body mass (LBM) loss in trained males. However, whether this relationship exists in trained females is unknown. This study examined the impact of higher compared to lower protein intakes (35% versus 15% of energy intake) on body composition in trained females during 2 weeks of severe ER.

Methods: Eighteen well-trained females completed a 1-week energy balanced diet (HD100), followed by a 2-week hypoenergetic (40% ER) diet (HD60). During HD60, participants consumed either a high protein (HP; 35% protein, 15% fat) or lower protein (CON; 15% protein, 35% fat) diet. Body composition, peak power, leg strength, sprint time, and anaerobic endurance were assessed at baseline, pre-HD60, and post-HD60.

Results: Absolute protein intake was reduced during HD60 in the CON group (from 1.6 to 0.9 g·d·kgBM) and maintained in the HP group (~ 1.7 g·d·kgBM). CON and HP groups decreased body mass equally during HD60 (- 1.0 ± 1.1 kg; p = 0.026 and - 1.1 ± 0.7 kg; p = 0.002, respectively) and maintained LBM. There were no interactions between time point and dietary condition on exercise performance.

Conclusion: The preservation of LBM during HD60, irrespective of whether absolute protein intake is maintained or reduced, contrasts with findings in trained males. In trained females, the relationship between absolute protein intake and LBM change during ER warrants further investigation. Future recommendations for protein intake during ER should be expressed relative to body mass, not total energy intake, in trained females.
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http://dx.doi.org/10.1007/s00421-020-04555-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7892501PMC
March 2021

Nonalcoholic Fatty Liver Disease and Diabetes Mellitus Are Associated With Post-Transjugular Intrahepatic Portosystemic Shunt Renal Dysfunction: An Advancing Liver Therapeutic Approaches Group Study.

Liver Transpl 2021 02 2;27(3):329-340. Epub 2021 Jan 2.

Department of Radiology and Biomedical Imaging, University of California-San Francisco, San Francisco, CA.

Transjugular intrahepatic portosystemic shunt (TIPS) is an effective intervention for portal hypertensive complications, but its effect on renal function is not well characterized. Here we describe renal function and characteristics associated with renal dysfunction at 30 days post-TIPS. Adults with cirrhosis who underwent TIPS at 9 hospitals in the United States from 2010 to 2015 were included. We defined "post-TIPS renal dysfunction" as a change in estimated glomerular filtration rate (ΔeGFR) ≤-15 and eGFR ≤ 60 mL/min/1.73 m or new renal replacement therapy (RRT) at day 30. We identified the characteristics associated with post-TIPS renal dysfunction by logistic regression and evaluated survival using adjusted competing risk regressions. Of the 673 patients, the median age was 57 years, 38% of the patients were female, 26% had diabetes mellitus, and the median MELD-Na was 17. After 30 days post-TIPS, 66 (10%) had renal dysfunction, of which 23 (35%) required new RRT. Patients with post-TIPS renal dysfunction, compared with those with stable renal function, were more likely to have nonalcoholic fatty liver disease (NAFLD; 33% versus 17%; P = 0.01) and comorbid diabetes mellitus (42% versus 24%; P = 0.001). Multivariate logistic regressions showed NAFLD (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.00-4.17; P = 0.05), serum sodium (Na; OR, 1.06 per mEq/L; 95% CI, 1.01-1.12; P = 0.03), and diabetes mellitus (OR, 2.04; 95% CI, 1.16-3.61; P = 0.01) were associated with post-TIPS renal dysfunction. Competing risk regressions showed that those with post-TIPS renal dysfunction were at a higher subhazard of death (subhazard ratio, 1.74; 95% CI, 1.18-2.56; P = 0.01). In this large, multicenter cohort, we found NAFLD, diabetes mellitus, and baseline Na associated with post-TIPS renal dysfunction. This study suggests that patients with NAFLD and diabetes mellitus undergoing TIPS evaluation may require additional attention to cardiac and renal comorbidities before proceeding with the procedure.
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http://dx.doi.org/10.1002/lt.25949DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8053375PMC
February 2021

Is there referral bias in outcomes of septal myectomy for hypertrophic cardiomyopathy?

J Thorac Cardiovasc Surg 2020 Oct 9. Epub 2020 Oct 9.

Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn. Electronic address:

Purpose: To determine the potential impact of referral bias on short- and long-term outcomes following septal myectomy for hypertrophic cardiomyopathy.

Methods: We reviewed 2303 adult patients who underwent transaortic septal myectomy for obstructive hypertrophic cardiomyopathy from January 1993 to April 2016. Patients were divided into 3 groups according to their permanent address: local (state) residents (n = 324), regional (surrounding 5 states) patients (n = 515), and national (outside 5 states) patients (n = 1464).

Results: Patient groups were similar for age, sex, preoperative New York Heart Association class, and left ventricular ejection fraction. Local patients had increased prevalence of diabetes mellitus (13%, 11%, 8%; P = .006), coronary artery disease (25%, 21%, 19%; P = .031), severe chronic lung disease (2.3%, 1.9%, 0.4%; P < .001), and atrial fibrillation (24%, 18%, 19%; P = .045) when compared with regional and national patients. Echocardiographic features did not differ between the 3 groups, including prevalence of moderate or greater mitral regurgitation (59%, 61%, 56%; P = .161). Local and regional patients were more likely to undergo concomitant procedures than national patients (P < .001). Mitral valve surgery was performed in 9.6% of the patients, more commonly in local and regional patients (12%, 12%, 8%; P = .018). There were 11 operative deaths (0.5%), and early mortality was similar among the groups. Geographic origin did not impact overall late survival.

Conclusions: Compared with distant referrals, local patients who undergo septal myectomy at our institution have more comorbid conditions, and require more concomitant surgical procedures. Despite these differences, referral patterns did not impact early or late outcomes following transaortic septal myectomy.
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http://dx.doi.org/10.1016/j.jtcvs.2020.08.118DOI Listing
October 2020

Nitrogen dioxide exposures from LPG stoves in a cleaner-cooking intervention trial.

Environ Int 2021 01 4;146:106196. Epub 2020 Nov 4.

Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.

Background: Liquefied petroleum gas (LPG) stoves have been promoted in low- and middle-income countries (LMICs) as a clean energy alternative to biomass burning cookstoves.

Objective: We sought to characterize kitchen area concentrations and personal exposures to nitrogen dioxide (NO) within a randomized controlled trial in the Peruvian Andes. The intervention included the provision of an LPG stove and continuous fuel distribution with behavioral messaging to maximize compliance.

Methods: We measured 48-hour kitchen area NO concentrations at high temporal resolution in homes of 50 intervention participants and 50 control participants longitudinally within a biomass-to-LPG intervention trial. We also collected 48-hour mean personal exposures to NO among a subsample of 16 intervention and 9 control participants. We monitored LPG and biomass stove use continuously throughout the trial.

Results: In 367 post-intervention 24-hour kitchen area samples of 96 participants' homes, geometric mean (GM) highest hourly NO concentration was 138 ppb (geometric standard deviation [GSD] 2.1) in the LPG intervention group and 450 ppb (GSD 3.1) in the biomass control group. Post-intervention 24-hour mean NO concentrations were a GM of 43 ppb (GSD 1.7) in the intervention group and 77 ppb (GSD 2.0) in the control group. Kitchen area NO concentrations exceeded the WHO indoor hourly guideline an average of 1.3 h per day among LPG intervention participants. GM 48-hour personal exposure to NO was 5 ppb (GSD 2.4) among 35 48-hour samples of 16 participants in the intervention group and 16 ppb (GSD 2.3) among 21 samples of 9 participants in the control group.

Discussion: In a biomass-to-LPG intervention trial in Peru, kitchen area NO concentrations were substantially lower within the LPG intervention group compared to the biomass-using control group. However, within the LPG intervention group, 69% of 24-hour kitchen area samples exceeded WHO indoor annual guidelines and 47% of samples exceeded WHO indoor hourly guidelines. Forty-eight-hour NO personal exposure was below WHO indoor annual guidelines for most participants in the LPG intervention group, and we did not measure personal exposure at high temporal resolution to assess exposure to cooking-related indoor concentration peaks. Further research is warranted to understand the potential health risks of LPG-related NO emissions and inform current campaigns which promote LPG as a clean-cooking option.
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http://dx.doi.org/10.1016/j.envint.2020.106196DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8173774PMC
January 2021

Outcomes of Liver Transplantation Among Older Recipients With Nonalcoholic Steatohepatitis in a Large Multicenter US Cohort: the Re-Evaluating Age Limits in Transplantation Consortium.

Liver Transpl 2020 11 13;26(11):1492-1503. Epub 2020 Oct 13.

Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Palo Alto, CA.

The liver transplantation (LT) population is aging, with the need for transplant being driven by the growing prevalence of nonalcoholic steatohepatitis (NASH). Older LT recipients with NASH may be at an increased risk for adverse outcomes after LT. Our objective is to characterize outcomes in these recipients in a large multicenter cohort. All primary LT recipients ≥65 years from 2010 to 2016 at 13 centers in the Re-Evaluating Age Limits in Transplantation (REALT) consortium were included. Of 1023 LT recipients, 226 (22.1%) were over 70 years old, and 207 (20.2%) had NASH. Compared with other LT recipients, NASH recipients were older (68.0 versus 67.3 years), more likely to be female (47.3% versus 32.8%), White (78.3% versus 68.0%), Hispanic (12.1% versus 9.2%), and had higher Model for End-Stage Liver Disease-sodium (21 versus 18) at LT (P < 0.05 for all). Specific cardiac risk factors including diabetes with or without chronic complications (69.6%), hypertension (66.3%), hyperlipidemia (46.3%), coronary artery disease (36.7%), and moderate-to-severe renal disease (44.4%) were highly prevalent among NASH LT recipients. Graft survival among NASH patients was 90.3% at 1 year and 82.4% at 3 years compared with 88.9% at 1 year and 80.4% at 3 years for non-NASH patients (log-rank P = 0.58 and P = 0.59, respectively). Within 1 year after LT, the incidence of graft rejection (17.4%), biliary strictures (20.9%), and solid organ cancers (4.9%) were comparable. Rates of cardiovascular (CV) complications, renal failure, and infection were also similar in both groups. We observed similar posttransplant morbidity and mortality outcomes for NASH and non-NASH LT recipients. Certain CV risk factors were more prevalent in this population, although posttransplant outcomes within 1 year including CV events and renal failure were similar to non-NASH LT recipients.
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http://dx.doi.org/10.1002/lt.25863DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7960487PMC
November 2020

Influence of structural and functional brain connectivity on age-related differences in fluid cognition.

Neurobiol Aging 2020 12 12;96:205-222. Epub 2020 Sep 12.

Brain Imaging and Analysis Center, Duke University Medical Center, Durham, NC, USA; Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

We used graph theoretical measures to investigate the hypothesis that structural brain connectivity constrains the influence of functional connectivity on the relation between age and fluid cognition. Across 143 healthy, community-dwelling adults 19-79 years of age, we estimated structural network properties from diffusion-weighted imaging and functional network properties from resting-state functional magnetic resonance imaging. We confirmed previous reports of age-related decline in the strength and efficiency of structural networks, as well as in the connectivity strength within and between structural network modules. Functional networks, in contrast, exhibited age-related decline only in system segregation, a measure of the distinctiveness among network modules. Aging was associated with decline in a composite measure of fluid cognition, particularly tests of executive function. Functional system segregation was a significant mediator of age-related decline in executive function. Structural network properties did not directly influence the age-related decline in functional system segregation. The raw correlational data underlying the graph theoretical measures indicated that structural connectivity exerts a limited constraint on age-related decline in functional connectivity.
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http://dx.doi.org/10.1016/j.neurobiolaging.2020.09.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7722190PMC
December 2020

Assessment of Shared Decision-making for Stroke Prevention in Patients With Atrial Fibrillation: A Randomized Clinical Trial.

JAMA Intern Med 2020 09;180(9):1215-1224

Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota.

Importance: Shared decision-making (SDM) about anticoagulant treatment in patients with atrial fibrillation (AF) is widely recommended but its effectiveness is unclear.

Objective: To assess the extent to which the use of an SDM tool affects the quality of SDM and anticoagulant treatment decisions in at-risk patients with AF.

Design, Setting, And Participants: This encounter-randomized trial recruited patients with nonvalvular AF who were considering starting or reviewing anticoagulant treatment and their clinicians at academic, community, and safety-net medical centers between January 30, 2017 and June 27, 2019. Encounters were randomized to either the standard care arm or care that included the use of an SDM tool (intervention arm). Data were analyzed from August 1 to November 30, 2019.

Interventions: Standard care or care using the Anticoagulation Choice Shared Decision Making tool (which presents individualized risk estimates and compares anticoagulant treatment options across issues of importance to patients) during the clinical encounter.

Main Outcomes And Measures: Quality of SDM (which included quality of communication, patient knowledge about AF and anticoagulant treatment, accuracy of patient estimates of their own stroke risk [within 30% of their estimate], decisional conflict, and satisfaction), decisions made during the encounter, duration of the encounter, and clinician involvement of patients in the SDM process.

Results: The clinical trial enrolled 922 patients (559 men [60.6%]; mean [SD] age, 71 [11] years) and 244 clinicians. A total of 463 patients were randomized to the intervention arm and 459 patients to the standard care arm. Participants in both arms reported high communication quality, high knowledge, and low decisional conflict, demonstrated low accuracy in their risk perception, and would similarly recommend the approach used in their encounter. Clinicians were significantly more satisfied after intervention encounters (400 of 453 encounters [88.3%] vs 277 of 448 encounters [61.8%]; adjusted relative risk, 1.49; 95% CI, 1.42-1.53). A total of 747 of 873 patients (85.6%) chose to start or continue receiving an anticoagulant medication. Patient involvement in decision-making (as assessed through video recordings of the encounters using the Observing Patient Involvement in Decision Making 12-item scale) scores were significantly higher in the intervention arm (mean [SD] score, 33.0 [10.8] points vs 29.1 [13.1] points, respectively; adjusted mean difference, 4.2 points; 95% CI, 2.8-5.6 points). No significant between-arm difference was found in encounter duration (mean [SD] duration, 32 [16] minutes in the intervention arm vs 31 [17] minutes in the standard care arm; adjusted mean between-arm difference, 1.1; 95% CI, -0.3 to 2.5 minutes).

Conclusion And Relevance: The use of an SDM encounter tool improved several measures of SDM quality and clinician satisfaction, with no significant effect on treatment decisions or encounter duration. These results help to calibrate expectations about the value of implementing SDM tools in the care of patients with AF.

Trial Registration: ClinicalTrials.gov Identifier: NCT02905032.
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http://dx.doi.org/10.1001/jamainternmed.2020.2908DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7372497PMC
September 2020

Virtually competent: remote delivery of clinical competency examinations.

J Dent Educ 2020 Aug 28. Epub 2020 Aug 28.

Integration of Technology, Curriculum, and Learning Environments, College of Dental Medicine, Western University of Health Sciences, Pomona, California, USA.

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http://dx.doi.org/10.1002/jdd.12405DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7460926PMC
August 2020

The socially distanced signature: Contactless paper form approvals from faculty.

J Dent Educ 2020 Jul 11. Epub 2020 Jul 11.

Dental Informatics, College of Dental Medicine, Western University of Health Sciences, Pomona, California, USA.

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http://dx.doi.org/10.1002/jdd.12308DOI Listing
July 2020
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