Publications by authors named "Robert Foley"

229 Publications

Chest X-ray in suspected lung cancer is harmful.

Eur Radiol 2021 Jan 30. Epub 2021 Jan 30.

Department of Radiology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Avon, Bath, BA1 3NG, UK.

Objectives: The aim of this study was to analyse the use of the chest radiograph (CXR) as the first-line investigation in primary care patients with suspected lung cancer.

Methods: Of 16,945 primary care referral CXRs (June 2018 to May 2019), 1,488 were referred for suspected lung cancer. CXRs were coded as follows: CX1, normal but a CT scan is recommended to exclude malignancy; CX2, alternative diagnosis; or CX3, suspicious for cancer. Kaplan-Meier survival analysis was undertaken by stratifying patients according to their CX code.

Results: In the study period, there were 101 lung cancer diagnoses via a primary care CXR pathway. Only 10% of patients with a normal CXR (CX1) underwent subsequent CT and there was a significant delay in lung cancer diagnosis in these patients (p < 0.001). Lung cancer was diagnosed at an advanced stage in 50% of CX1 patients, 38% of CX2 patients and 57% of CX3 patients (p = 0.26). There was no survival difference between CX codes (p = 0.42).

Conclusion: Chest radiography in the investigation of patients with suspected lung cancer may be harmful. This strategy may falsely reassure in the case of a normal CXR and prioritises resources to advanced disease.

Key Points: • Half of all lung cancer diagnoses in a 1-year period are first investigated with a chest X-ray. • A normal chest X-ray report leads to a significant delay in the diagnosis of lung cancer. • The majority of patients with a normal or abnormal chest X-ray have advanced disease at diagnosis and there is no difference in survival outcomes based on the chest X-ray findings.
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http://dx.doi.org/10.1007/s00330-021-07708-0DOI Listing
January 2021

Automated calculation of the right ventricle to left ventricle ratio on CT for the risk stratification of patients with acute pulmonary embolism.

Eur Radiol 2021 Jan 18. Epub 2021 Jan 18.

Department of Radiology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Avon, Bath, BA1 3NG, UK.

Objectives: To assess the feasibility and reliability of the use of artificial intelligence post-processing to calculate the RV:LV diameter ratio on computed tomography pulmonary angiography (CTPA) and to investigate its prognostic value in patients with acute PE.

Methods: Single-centre, retrospective study of 101 consecutive patients with CTPA-proven acute PE. RV and LV volumes were segmented on 1-mm contrast-enhanced axial slices and maximal ventricular diameters were derived for RV:LV ratio using automated post-processing software (IMBIO LLC, USA) and compared to manual analysis in two observers, via intraclass coefficient correlation analysis. Each CTPA report was analysed for mention of the RV:LV ratio and compared to the automated RV:LV ratio. Thirty-day all-cause mortality post-CTPA was recorded.

Results: Automated RV:LV analysis was feasible in 87% (n = 88). RV:LV ratios ranged from 0.67 to 2.43, with 64% (n = 65) > 1.0. There was very strong agreement between manual and automated RV:LV ratios (ICC = 0.83, 0.77-0.88). The use of automated analysis led to a change in risk stratification in 45% of patients (n = 40). The AUC of the automated measurement for the prediction of all-cause 30-day mortality was 0.77 (95% CI: 0.62-0.99).

Conclusion: The RV:LV ratio on CTPA can be reliably measured automatically in the majority of real-world cases of acute PE, with perfect reproducibility. The routine use of this automated analysis in clinical practice would add important prognostic information in patients with acute PE.

Key Points: • Automated calculation of the right ventricle to left ventricle ratio was feasible in the majority of patients and demonstrated perfect intraobserver variability. • Automated analysis would have added important prognostic information and altered risk stratification in the majority of patients. • The optimal cut-off value for the automated right ventricle to left ventricle ratio was 1.18, with a sensitivity of 100% and specificity of 54% for the prediction of 30-day mortality.
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http://dx.doi.org/10.1007/s00330-020-07605-yDOI Listing
January 2021

Fulminant immune-mediated necrotising myopathy (IMNM) mimicking myocardial infarction with non-obstructive coronary arteries (MINOCA).

BMJ Case Rep 2020 Nov 2;13(11). Epub 2020 Nov 2.

Radiology Department, Royal United Hospital Bath NHS Trust, Bath, UK

A 74-year-old man, with inflammatory arthritis, recently commenced on adalimumab, presented with a 4-week history of left-sided chest pain, malaise and shortness of breath. Admission ECG showed age-indeterminate left bundle branch block. Troponin T was 4444 ng/L (normal range <15 ng/L) and acute coronary syndrome treatment was commenced. Catheter angiogram revealed mild-burden non-obstructive coronary disease. Cardiac magnetic resonance (CMR) was performed to refine the differential diagnosis and demonstrated no myocardial oedema or late gadolinium enhancement. Extracardiac review highlighted oedema and enhancement of the left shoulder girdle muscles consistent with acute myositis. Creatine kinase was subsequently measured and significantly elevated at 7386 IU/L (normal range 30-200 IU/L in men). Electrophoresis clarified that this was of predominantly skeletal muscle origin. Myositis protocol MRI revealed florid skeletal muscle oedema. The MR findings, together with positive anti-Scl-70 antibodies, suggested fulminant immune-mediated necrotising myopathy presenting as a rare mimic of myocardial infarction with non-obstructive coronary arteries, diagnosed by careful extracardiac CMR review.
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http://dx.doi.org/10.1136/bcr-2020-236603DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7607567PMC
November 2020

Pleural, pancreatic and prostatic involvement in IgG4-related disease mimicking pancreatic head malignancy.

BJR Case Rep 2020 Sep 29;6(2):20190110. Epub 2020 Sep 29.

Department of Radiology, Royal United Hospital, Bath, United Kingdom.

We describe the case of a gentleman with pleural thickening. On follow-up imaging, dilatation of the main pancreatic and common biliary ducts was noted and an initial diagnosis of pancreatic malignancy was made. During his preoperative workup for pancreatic head malignancy, a PET-CT was performed, which demonstrated increased uptake in the pancreas, in the pleura and in the prostate gland. This raised the possibility of immunoglobulin G4-related disease (IgG4-RD), which was effectively treated with oral steroids. IgG4-RD is a well-described cause of autoimmune pancreatitis but can affect other regions, including the pleura and prostate. It is essential that radiologists are aware of the imaging findings in IgG4-RD and can direct clinicians towards this important multisystem diagnosis.
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http://dx.doi.org/10.1259/bjrcr.20190110DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7527011PMC
September 2020

Applying dental microwear texture analysis to the living: Challenges and prospects.

Am J Phys Anthropol 2021 Mar 13;174(3):542-554. Epub 2020 Sep 13.

Leverhulme Centre for Human Evolutionary Studies, Department of Archaeology, University of Cambridge, Cambridge, UK.

Objectives: The food that people and animals consume leaves microscopic traces on teeth in predictable ways, and analyses of these markings-known as dental microwear analyses-allow us to reverse engineer the characteristics of diet. However, the microwear features of modern human diets are most often interpreted through the lens of ethnographic records. Given the subtle variation within human diets when compared to other species, we need better models of how foods and processing techniques produce marks on teeth. Here, we report on the second study to target the occlusal surface microwear of living human populations, and the first to target populations other than foragers.

Methods: We collected 150 dental impressions from five Kenyan communities: El Molo, Turkana (Kerio), Luhya (Webuye), Luhya (Port Victoria), and Luo (Port Victoria), representing a range of subsistence strategies and associated staple diets-fishing, pastoralism, and agriculture. Our results suggest that the occlusal microwear of these groups records differences in diet. However, biofilm obscured most of the molds obtained despite the steps taken to remove it, resulting in only 38 usable surfaces.

Results: Due to the biofilm problem and final sample size, the analysis did not have enough power to demonstrate the differences observed statistically. The results and problems encountered are here explained.

Conclusions: Considering that in vivo studies of dental microwear texture analysis have the potential to increase our understanding of the association between patterns of dental microwear and complex, mixed human diets, resolution of the current pitfalls of the technique is critical.
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http://dx.doi.org/10.1002/ajpa.24133DOI Listing
March 2021

Computed tomography appearances of the lung parenchyma in pulmonary hypertension.

Br J Radiol 2021 Jan 11;94(1117):20200830. Epub 2020 Sep 11.

Department of Radiology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Avon, Bath, United Kingdom.

Computed tomography (CT) is a valuable tool in the workup of patients under investigation for pulmonary hypertension (PH) and may be the first test to suggest the diagnosis. CT parenchymal lung changes can help to differentiate the aetiology of PH. CT can demonstrate interstitial lung disease, emphysema associated with chronic obstructive pulmonary disease, features of left heart failure (including interstitial oedema), and changes secondary to miscellaneous conditions such as sarcoidosis. CT also demonstrates parenchymal changes secondary to chronic thromboembolic disease and venous diseases such as pulmonary venous occlusive disease (PVOD) and pulmonary capillary haemangiomatosis (PCH). It is important for the radiologist to be aware of the various manifestations of PH in the lung, to help facilitate an accurate and timely diagnosis. This pictorial review illustrates the parenchymal lung changes that can be seen in the various conditions causing PH.
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http://dx.doi.org/10.1259/bjr.20200830DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7774692PMC
January 2021

Issues of theory and method in the analysis of Paleolithic mortuary behavior: A view from Shanidar Cave.

Evol Anthropol 2020 Sep 11;29(5):263-279. Epub 2020 Jul 11.

McDonald Institute for Archaeological Research, University of Cambridge, Cambridge, UK.

Mortuary behavior (activities concerning dead conspecifics) is one of many traits that were previously widely considered to have been uniquely human, but on which perspectives have changed markedly in recent years. Theoretical approaches to hominin mortuary activity and its evolution have undergone major revision, and advances in diverse archeological and paleoanthropological methods have brought new ways of identifying behaviors such as intentional burial. Despite these advances, debates concerning the nature of hominin mortuary activity, particularly among the Neanderthals, rely heavily on the rereading of old excavations as new finds are relatively rare, limiting the extent to which such debates can benefit from advances in the field. The recent discovery of in situ articulated Neanderthal remains at Shanidar Cave offers a rare opportunity to take full advantage of these methodological and theoretical developments to understand Neanderthal mortuary activity, making a review of these advances relevant and timely.
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http://dx.doi.org/10.1002/evan.21854DOI Listing
September 2020

A risk calculator to inform the need for a prostate biopsy: a rapid access clinic cohort.

BMC Med Inform Decis Mak 2020 07 3;20(1):148. Epub 2020 Jul 3.

Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin, Ireland.

Background: Prostate cancer (PCa) represents a significant healthcare problem. The critical clinical question is the need for a biopsy. Accurate risk stratification of patients before a biopsy can allow for individualised risk stratification thus improving clinical decision making. This study aims to build a risk calculator to inform the need for a prostate biopsy.

Methods: Using the clinical information of 4801 patients an Irish Prostate Cancer Risk Calculator (IPRC) for diagnosis of PCa and high grade (Gleason ≥7) was created using a binary regression model including age, digital rectal examination, family history of PCa, negative prior biopsy and Prostate-specific antigen (PSA) level as risk factors. The discrimination ability of the risk calculator is internally validated using cross validation to reduce overfitting, and its performance compared with PSA and the American risk calculator (PCPT), Prostate Biopsy Collaborative Group (PBCG) and European risk calculator (ERSPC) using various performance outcome summaries. In a subgroup of 2970 patients, prostate volume was included. Separate risk calculators including the prostate volume (IPRCv) for the diagnosis of PCa (and high-grade PCa) was created.

Results: IPRC area under the curve (AUC) for the prediction of PCa and high-grade PCa was 0.6741 (95% CI, 0.6591 to 0.6890) and 0.7214 (95% CI, 0.7018 to 0.7409) respectively. This significantly outperforms the predictive ability of cancer detection for PSA (0.5948), PCPT (0.6304), PBCG (0.6528) and ERSPC (0.6502) risk calculators; and also, for detecting high-grade cancer for PSA (0.6623) and PCPT (0.6804) but there was no significant improvement for PBCG (0.7185) and ERSPC (0.7140). The inclusion of prostate volume into the risk calculator significantly improved the AUC for cancer detection (AUC = 0.7298; 95% CI, 0.7119 to 0.7478), but not for high-grade cancer (AUC = 0.7256; 95% CI, 0.7017 to 0.7495). The risk calculator also demonstrated an increased net benefit on decision curve analysis.

Conclusion: The risk calculator developed has advantages over prior risk stratification of prostate cancer patients before the biopsy. It will reduce the number of men requiring a biopsy and their exposure to its side effects. The interactive tools developed are beneficial to translate the risk calculator into practice and allows for clarity in the clinical recommendations.
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http://dx.doi.org/10.1186/s12911-020-01174-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7333322PMC
July 2020

Charcot foot reconstruction outcomes: A systematic review.

J Clin Orthop Trauma 2020 May-Jun;11(3):357-368. Epub 2020 Apr 20.

Department of Orthopaedics, King's College Hospital NHS Trust, London, United Kingdom.

Background: Charcot neuroarthropathy is a complex condition characterised by progressive deformity, limited treatment options and a high amputation rate. Surgical reconstruction of Charcot foot has been proposed as a method to preserve the foot. However, limited information exists on the different methods of reconstruction available, their outcomes and complications.

Methods: We systematically analysed published data from Jan 1993 to Dec 2018 to assess methods of fixation and associated outcomes for the surgical reconstruction in Charcot neuroarthropathy. Statistical analyses were undertaken to determine the amputation rates, return to ambulation and complications associated with these techniques.

Results: A total of 1116 feet (1089 patients) were reported to have undergone reconstruction with significant heterogeneity in patient selection. Of these, 726 (65%) were reported to undergo internal fixation, 346 feet (31%) external fixation and 44 (4%) undergoing simultaneous internal and external fixation. No single technique demonstrated a significant benefit over the other. Overall, the bone fusion rate was 86.1%. Complications directly attributable to the technique employed were noted in 36% of individuals. The reported post-reconstruction amputation rate was only 5.5% with 91% apparently returning to ambulation.

Conclusions: Although no preferential method of fixation was identified, we find that the current options for surgical reconstruction could offer limb salvage with a low amputation risk in a highly selected population. However, the lack of controlled studies, inconsistent reporting of outcomes and heterogeneity of patient selection mean that the quality of evidence is low.
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http://dx.doi.org/10.1016/j.jcot.2020.03.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7211810PMC
April 2020

Terrestrial habitats decouple the relationship between species and subspecies diversification in mammals.

Proc Biol Sci 2020 03 18;287(1923):20192702. Epub 2020 Mar 18.

Leverhulme Centre for Human Evolutionary Studies, Cambridge, UK.

Darwin proposed that lineages with higher diversification rates should evidence this capacity at both the species and subspecies level. This should be the case if subspecific boundaries are evolutionary faultlines along which speciation is generally more likely to occur. This pattern has been described for birds, but remains poorly understood in mammals. To investigate the relationship between species richness (SR) and subspecies richness (SSR), we calculated the strength of the correlation between the two across all mammals. Mammalian taxonomic richness correlates positively, but only very weakly, between the species and subspecies level, deviating from the pattern found in birds. However, when mammals are separated by environmental substrate, the relationship between generic SR and average SSR in non-terrestrial taxa is stronger than that reported for birds (Kendall's = 0.31, < 0.001). By contrast, the correlation in terrestrial taxa alone weakens compared to that for all mammals (Kendall's = 0.11, < 0.001). A significant interaction between environmental substrate and SR in phylogenetic regressions confirms a role for terrestrial habitats in disrupting otherwise linked dynamics of diversification across the taxonomic hierarchy. Further, models including species range size as a predictor show that range size affects SSR more in terrestrial taxa. Taken together, these results suggest that the dynamics of diversification of terrestrial mammals are more affected by physical barriers or ecological heterogeneity within ranges than those of non-terrestrial mammals, at two evolutionary levels. We discuss the implication of these results for the equivalence of avian and mammalian subspecies, their potential role in speciation and the broader question of the relationship between microevolution and macroevolution.
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http://dx.doi.org/10.1098/rspb.2019.2702DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7126033PMC
March 2020

Treatment Strategies in CKD Patients With Suspected Coronary Artery Disease.

Authors:
Robert N Foley

Am J Kidney Dis 2019 10;74(4):438-440

Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, MN. Electronic address:

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http://dx.doi.org/10.1053/j.ajkd.2019.06.004DOI Listing
October 2019

Time to thrombectomy is associated with increased risk for dialysis catheter placement.

J Ren Care 2019 Dec 26;45(4):232-238. Epub 2019 Aug 26.

Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA.

Background: Arteriovenous dialysis access, fistulae (AVF) or grafts (AVG), are associated with significant rates of thrombosis. Timely thrombectomy may have a significant impact on immediate and long-term access survival. However, switching to a catheter is associated with higher rates of morbidity and mortality compared with those who have an AVF or AVG.

Objectives: The goal of this study was to evaluate whether time to thrombectomy increases the risk for loss of dialysis access and subsequent placement of a dialysis catheter at hospital discharge, at 6 months, 12 months, and data at any time after discharge.

Methods: Using retrospective data, 444 patients were identified as having undergone thrombectomy for dialysis access dysfunction between January 2008 and April 2015, with 122 hospital admissions primarily for thrombectomy.

Results: The mean age was 60.4 years, 65% were male, and 44.3% had an arteriovenous fistula as their dialysis access. The mean time to thrombectomy was 10.8 hours, and 14 patients utilised a catheter for haemodialysis as primary access upon discharge. After adjustment for prior access intervention, access type, and time to thrombectomy, the adjusted odds ratios (AOR) of a one-day delay in thrombectomy was associated with a twofold increase in requirement for catheter at discharge and at 6 months. This association remained present at any time after discharge.

Conclusion: In this study of patients cared for within an academic health system, a single day delay in thrombectomy nearly doubled the risk of needing a dialysis catheter at hospital discharge, 6 months, or any time after discharge.
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http://dx.doi.org/10.1111/jorc.12295DOI Listing
December 2019

Carbon and nitrogen isotopic signatures of hair, nail, and breath from tropical African human populations.

Rapid Commun Mass Spectrom 2019 Nov;33(22):1761-1773

Leverhulme Centre for Human Evolutionary Studies, Department of Archaeology, University of Cambridge, Fitzwilliam Street, Cambridge, CB2 1QH, UK.

Rationale: Stable isotopic analyses are increasingly used to study the diets of past and present human populations. Yet, the carbon and nitrogen isotopic data of modern human diets collected so far are biased towards Europe and North America. Here, we address this gap by reporting on the dietary isotopic signatures of six tropical African communities: El Molo, Turkana (Kerio), Luhya (Webuye), Luhya (Port Victoria), and Luo (Port Victoria) from Kenya, and Baka from Cameroon; representing four subsistence strategies: fishing, pastoralism, agriculturalism, and hunter-gatherer.

Methods: We used an elemental analyser coupled in continuous-flow mode to an isotope ratio mass spectrometer to measure the carbon and nitrogen isotopic ratios of hair (n = 134) and nail (n = 80) and the carbon isotopic ratios of breath (n = 184) from these communities, as well as the carbon and nitrogen isotopic ratios of some food samples from the Kenyan communities.

Results: We expand on the known range of δ C values in human hair through the hunter-gatherer Baka, with a diet based on C plants, and through the agriculturalist Luhya (Webuye), with a diet based on C plants. In addition, we found that the consumption of fish from East African lakes is difficult to detect isotopically due to the combined effects of high nitrogen isotopic ratios of plants and the low nitrogen isotopic ratios of fish. Finally, we found that some of the communities studied are markedly changing their diets through increasing sedentism and urbanisation.

Conclusions: Our findings contribute substantially to the understanding of the environmental, demographic, and economic dynamics that affect the dietary landscape of different tropical populations of Africa. These results highlight the importance of studying a broader sample of human populations and their diet, with a focus on their precise context - from both isotopic and more general anthropological perspectives.
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http://dx.doi.org/10.1002/rcm.8524DOI Listing
November 2019

Trends in Angiotensin-Converting Enzyme Inhibitor and Angiotensin II Receptor Blocker Use among Those with Impaired Kidney Function in the United States.

J Am Soc Nephrol 2019 07 5;30(7):1314-1321. Epub 2019 Jun 5.

Department of Medicine, University of Minnesota, Minneapolis, Minnesota

Background: Although hypertension is common in CKD and evidence-based treatment of hypertension has changed considerably, contemporary and nationally representative information about use of angiotensin-converting enzyme (ACEs) inhibitors or angiotensin II receptor blockers (ARBs) in CKD is lacking.

Methods: We examined ACE/ARB trends from 1999 to 2014 among 38,885 adult National Health and Nutrition Examination Survey participants with creatinine-based eGFR<60 ml/min per 1.73 m or urinary albumin-to-creatinine ratio ≥30 mg/g.

Results: Of 7085 participants with CKD, 34.9% used an ACE/ARB. Across four eras studied, rates of use rose significantly (rates were 25.5% in 1999-2002, 33.3% in 2003-2006, 39.0% in 2007-2010, and 40.1% in 2011-2014) but appeared to plateau after 2003. Among those with CKD, use was significantly greater among non-Hispanic white and black individuals (36.1% and 38.2%, respectively) and lower among Hispanic individuals (26.7%) and other races/ethnicities (29.3%). In age-, sex-, and race/ethnicity-adjusted models, ACE/ARB use was significantly associated with era (adjusted odds ratios [aOR], 1.41; 95% confidence interval [95% CI], 1.14 to 1.74 for 2003-2006, 1.84; 95% CI, 1.48 to 2.28 for 2007-2010, and 2.02; 95% CI, 1.61 to 2.53 for 2011-2014 versus 1999-2002); it also was significantly associated with non-Hispanic black versus non-Hispanic white race/ethnicity (aOR, 1.40; 95% CI, 1.19 to 1.66). Other multivariate associations included older age, men, elevated BMI, diabetes mellitus, treated hypertension, cardiac failure, myocardial infarction, health insurance, and receiving medical care within the prior year.

Conclusions: Rates of ACE/ARB use increased in the early 2000s among United States adults with CKD, but for unclear reasons, use appeared to plateau in the ensuing decade. Research examining barriers to care and other factors is needed.
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http://dx.doi.org/10.1681/ASN.2018100971DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6622408PMC
July 2019

3D analysis of computed tomography (CT)-derived lumbar spine models for the estimation of sex.

Int J Legal Med 2019 Sep 31;133(5):1497-1506. Epub 2019 Jan 31.

Department of Radiology, University of South Florida Morsani College of Medicine, 2 Tampa General Circle, STC 6097, Tampa, FL, 33606, USA.

When skeletal remains are found scattered or in fragmentary conditions, the establishment of a biological profile of unknown individuals can be proven difficult. Consequently, multiple methods to ascertain the sex of the individual must be developed. The purpose of this study was to demonstrate that computed tomographic (CT)-derived 3D models of lumbar vertebrae could capture the unique morphologies of all five lumbar vertebrae to create equations for sex identification. The models were selected from a modern population consisting of 154 males and females that measured 30 standard linear measurements, the vertebral body wedging angle, and five aspect ratios. These measurements were then used to develop discriminant function equations for sex identification. Each lumbar level was analyzed individually as well as part of the entire lumbar spinal column. The results of this study showed that L1-L5 vertebrae can be used in sex determination with an 81.2-85.1% accuracy. When all five vertebrae are used in conjunction, the accuracy is 92.2%. The accuracy of the sex estimation found in this study for all lumbar vertebrae reinforces the distinct dimorphism between sexes while also providing forensic practitioners with more options or tools for their analyses.
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http://dx.doi.org/10.1007/s00414-019-02001-8DOI Listing
September 2019

Morphometric Analysis of Lumbar Intervertebral Disc Height: An Imaging Study.

World Neurosurg 2018 Dec 20. Epub 2018 Dec 20.

Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA.

Background: Little published data exist regarding normal values of disc height. Current literature relies on plain radiographs making accurate measurements of individual lumbar disc height difficult.

Objective: We seek to establish normal values for lumbar intervertebral discs in different age groups using computed tomography scans in healthy individuals.

Methods: Two hundred forty anonymized abdominal computed tomography scans (131 women) were prospectively collected once institutional review board approval was obtained. Individuals with spinal pathologies were excluded. Disc height measurements were obtained at the anterior edge, center, and posterior edge of each vertebra in the midsagittal plane, averaged, and compared against age and sex.

Results: Average age was 45 (14-83) years for women and 48 (14-89) years for men. Average lumbar disc height was 5.6 ± 1.1 mm for men and 4.8 ± 0.8 mm for women at T12/L1, 6.9 ± 1.3 mm for men and 5.8 ± 0.9 mm for women at L1/2, 8.1 ± 1.4 mm for men and 6.9 ± 1.1 mm for women at L2/3, 8.7 ± 1.5 mm for men and 7.6 ± 1.2 mm for women at L3/4, 9.2 ± 1.6 mm for men and 8.5 ± 1.6 mm for women at L4/5, and 8.8 ± 1.6 mm for men and 8.6 ± 1.8 mm for women at L5/S1. Disc height was significantly smaller for women than men (P < 0.001), except at L5/S1.

Conclusions: Variation in disc height is determined much more by sex than age. The maximum height of the interbody space in the adult lumbar spine was at the L4/5 level (8.9 ± 1.7 mm [men], 8.6 ± 1.8 mm [women]). Based on our findings, >10 mm cage height will result in supraphysiologic interbody space restoration and potentially predispose to complications.
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http://dx.doi.org/10.1016/j.wneu.2018.12.014DOI Listing
December 2018

How should we use imaging in the determination of brainstem death?

BJR Open 2019 7;1(1):20180013. Epub 2018 Nov 7.

University Hospitals Bristol NHS Foundation Trust, Bristol, UK.

Brainstem death is defined as the "irreversible cessation of brainstem function", either due to primary intracranial events or extracranial factors such as hypoxia. The importance of accurate and timely diagnosis of brainstem death in critical care should not be understated, as it allows the withdrawal of treatment when it is no longer deemed to beneficial. Additionally, it may facilitate the process of organ donation. Overall, the diagnosis of brainstem death has four common principles across the world: (1) neurological criteria based on clinical assessment; (2) evidence of irreversible brain damage from known aetiology; (3) demonstrating an absence of a reversible cause; and (4) the use of ancillary studies. The latter in particular has been a controversial issue, with much debate continuing on how imaging should be used. We discuss three key questions surrounding the role of imaging in the diagnosis of brainstem death as well as important issues the radiology community should consider.
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http://dx.doi.org/10.1259/bjro.20180013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7592410PMC
November 2018

Improving safety for medical students and patients during medical electives-a novel simulation-based course.

Ir J Med Sci 2019 Aug 29;188(3):1033-1045. Epub 2018 Oct 29.

Croydon University Hospital, London, UK.

Introduction: The medical elective is a common component of undergraduate medical education in the UK and Ireland. These are often undertaken in varied hospitals and countries across the world, most of which are not related to their parent institutions, in order to explore specialties and regions of interest. However experiences are varied, with goals not always established beforehand, or indeed reached, when present.

Methods: Using a novel 20-item, self-administered questionnaire distributed via social media to 436 medical students and doctors in the UK and Republic of Ireland, we sought to delineate common elective experiences and establish what procedures and clinical scenarios medical students commonly undertake and manage during their medical electives, in order to ascertain their confidence level with each of these tasks at the time of their medical electives. We also looked to determine if there are any adverse effects or events related to these situations. Following this, we developed a simulation-based course to address knowledge and skill gaps identified in the above fields. This course was delivered to two groups of medical students from St George's University London and King's College London medical schools by the same faculty over two separate afternoons.

Results: We found that a significant proportion of medical students feel pressured to perform skills, which are beyond their competence level during their elective placements, putting both patient and student safety at risk. Our simulation course was successful in significantly improving key technical and non-technical skills, which would be useful for students during their medical electives.
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http://dx.doi.org/10.1007/s11845-018-1919-6DOI Listing
August 2019

Population-Wide Associations between Common Viral Pathogens and Self-Reported Arthritis: NHANES 2009-2012.

Int J Rheumatol 2018 1;2018:7684942. Epub 2018 Oct 1.

Associate Professor of Medicine at the University of Minnesota, Division of Renal Diseases and Hypertension, USA.

Objective: Persistent infectious agents have been implicated in chronic and recurrent inflammation, which may trigger or worsen many types of arthritis. Our objective was to determine whether exposure to herpes simplex virus (HSV) and human papillomavirus (HPV) is associated with self-reported arthritis among US adults.

Methods: We used data from two consecutive cycles of the National Health and Nutrition Examination Survey (NHANES) from 2009 until 2012 (N of examined adults ages 20-69 = 9483). Participants were classified as having arthritis by self-report. Viral serology for HSV-1 and HSV-2 and HPV PCR studies from oral rinse and vaginal swabs were available for analysis. We compared HSV-1 and HSV-2 seropositivity as well as oral and vaginal HPV DNA positivity between participants with self-reported arthritis vs. those without, adjusting for age, gender, race, income, education, BMI, and the use of immunosuppressive medications. We used three comparator outcomes, gout, kidney stones, and hypertension, to evaluate whether the associations were specific or not to arthritis.

Results: Arthritis was associated with older age, female gender, non-Hispanic White and Non-Hispanic Black race, higher BMI, and lower socioeconomic status. HSV-2 seropositivity, but not HSV-1 seropositivity, was independently associated with arthritis after adjustment for age, gender, race, income, education, BMI, and the use of immunosuppressive medications: AOR 1.48 (1.10-1.99). Oral HPV DNA positivity was also independently associated with arthritis: AOR 1.63 (1.17-2.28). After adjustment, there was no statistically significant difference in vaginal HPV DNA positivity between those with vs. those without arthritis: AOR 1.22 (0.90-1.66). There were no significant associations between viral exposures and any of the comparator outcomes.

Conclusions: HSV-2 seropositivity and oral HPV DNA positivity were associated with self-reported arthritis and not with comparator outcomes, after adjustment for multiple potential confounders. These findings should be confirmed in longitudinal studies.
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http://dx.doi.org/10.1155/2018/7684942DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6188724PMC
October 2018

The importance of safe working legislation for neuroradiologists.

Br J Radiol 2018 Nov 11;91(1091):20180583. Epub 2018 Oct 11.

3 Department of Anaesthetics, Royal Berkshire NHS Foundation Trust , Reading , UK.

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http://dx.doi.org/10.1259/bjr.20180583DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6475927PMC
November 2018

Race, Ethnicity, and End-of-Life Care in Dialysis Patients in the United States.

J Am Soc Nephrol 2018 09 9;29(9):2387-2399. Epub 2018 Aug 9.

Division of Medicine, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota.

Background: End-of-life care is a prominent consideration in patients on maintenance dialysis, especially when death appears imminent and quality of life is poor. To date, examination of race- and ethnicity-associated disparities in end-of-life care for patients with ESRD has largely been restricted to comparisons of white and black patients.

Methods: We performed a retrospective national study using United States Renal Data System files to determine whether end-of-life care in United States patients on dialysis is subject to racial or ethnic disparity. The primary outcome was a composite of discontinuation of dialysis and death in a nonhospital or hospice setting.

Results: Among 1,098,384 patients on dialysis dying between 2000 and 2014, the primary outcome was less likely in patients from any minority group compared with the non-Hispanic white population (10.9% versus 22.6%, <0.001, respectively). We also observed similar significant disparities between any minority group and non-Hispanic whites for dialysis discontinuation (16.7% versus 31.2%), as well as hospice (10.3% versus 18.1%) and nonhospital death (34.4% versus 46.4%). After extensive covariate adjustment, the primary outcome was less likely in the combined minority group than in the non-Hispanic white population (adjusted odds ratio, 0.55; 95% confidence interval, 0.55 to 0.56; <0.001). Individual minority groups (non-Hispanic Asian, non-Hispanic black, non-Hispanic Native American, and Hispanic) were significantly less likely than non-Hispanic whites to experience the primary outcome. This disparity was especially pronounced for non-Hispanic Native American and Hispanic subgroups.

Conclusions: There appear to be substantial race- and ethnicity-based disparities in end-of-life care practices for United States patients receiving dialysis.
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http://dx.doi.org/10.1681/ASN.2017121297DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6115657PMC
September 2018

Opportunistic CT Screening for Osteoporosis in Patients With Pelvic and Acetabular Trauma: Technique and Potential Clinical Impact.

J Orthop Trauma 2018 08;32(8):408-413

Orthopaedics, and.

Objectives: To present a technique for the use of computed tomography (CT) scans in opportunistic screening for osteoporosis in patients with pelvic and acetabular fractures and to quantify the potential clinical impact in a geriatric trauma population.

Design: Retrospective cohort study.

Setting: Level 1 trauma center.

Patients: A total of 335 patients older than 60 years of age who presented to a Level 1 trauma center with a diagnosis of pelvic or acetabular fracture and were evaluated with a CT scan between the years 2010 and 2016. A subset of 255 patients were evaluated with a dual-energy x-ray absorptiometry scan within 6 months of the CT scan.

Intervention: Measurement of Hounsfield units (HU) was performed at the midpoint of the femoral neck using a standardized, ovoid section, followed by Livewire measurement. Application of this technique retrospectively to a population of geriatric patients with pelvic or acetabular fractures.

Main Outcome Measurements: (1) HUs were measured in a cross section at the midpoint of the femoral neck and, discriminant function analysis was used to establish thresholds for normal bone mineral density, osteopenia, and osteoporosis. (2) Change in the number of diagnoses of osteoporosis after application of the protocol the geriatric trauma cohort.

Results: Patients with osteopenia were identified correctly 67.5% of the time (14.3% were incorrectly grouped as normal, and 18.3% were grouped as having osteopenia). Patients with osteoporosis were identified correctly 88.9% of the time (the remaining 11.1% were assigned to osteopenic). The results of discriminant function analysis were used to establish CT thresholds for osteopenia (345 HUs) and osteoporosis (262 HUs).

Conclusion: CT imaging obtained for pelvic and acetabular fractures can identify patients with osteoporosis without additional radiation exposure or cost. The fitted ovoid region of interest is a standard feature in most CT scan platforms and is quite simple to perform.

Level Of Evidence: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001231DOI Listing
August 2018

The prehistoric peopling of Southeast Asia.

Science 2018 07;361(6397):88-92

Centre for GeoGenetics, Natural History Museum of Denmark, Copenhagen, Denmark.

The human occupation history of Southeast Asia (SEA) remains heavily debated. Current evidence suggests that SEA was occupied by Hòabìnhian hunter-gatherers until ~4000 years ago, when farming economies developed and expanded, restricting foraging groups to remote habitats. Some argue that agricultural development was indigenous; others favor the "two-layer" hypothesis that posits a southward expansion of farmers giving rise to present-day Southeast Asian genetic diversity. By sequencing 26 ancient human genomes (25 from SEA, 1 Japanese Jōmon), we show that neither interpretation fits the complexity of Southeast Asian history: Both Hòabìnhian hunter-gatherers and East Asian farmers contributed to current Southeast Asian diversity, with further migrations affecting island SEA and Vietnam. Our results help resolve one of the long-standing controversies in Southeast Asian prehistory.
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http://dx.doi.org/10.1126/science.aat3628DOI Listing
July 2018

Acoustic neuroma quality of life: are we missing the point?

Authors:
Robert W Foley

Eur Arch Otorhinolaryngol 2019 05 14;276(5):1549-1550. Epub 2018 Jun 14.

Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.

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http://dx.doi.org/10.1007/s00405-018-5037-xDOI Listing
May 2019

Design of a clinical risk calculator for major clinical outcomes in patients with atherosclerotic renovascular disease.

Nephrol Dial Transplant 2019 08;34(8):1377-1384

Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, Greater Manchester, UK.

Background: Risk stratification in atherosclerotic renovascular disease (ARVD) can influence treatment decisions and facilitate patient selection for revascularization. In this study, we aim to use variables with the best predictive value to design a risk calculator that can assist clinicians with risk stratification and outcome prediction.

Methods: Patients with a radiological diagnosis of ARVD referred to our tertiary renal centre were recruited into this prospective cohort study between 1986 and 2014. Primary clinical endpoints included: death, progression to end-stage kidney disease and cardiovascular events (CVE). A stepwise regression model was used to select variables with the most significant hazard ratio for each clinical endpoint. The risk calculator was designed using Hypertext Markup Language. Survival and CVE-free survival were estimated at 1, 5 and 10 years.

Results: In total, 872 patients were recruited into the Salford ARVD study with a median follow-up period of 54.9 months (interquartile range 20.2-96.0). Only models predicting death and CVE showed good performance (C-index >0.80). Survival probabilities obtained from the risk calculator show that most patients with ARVD have reduced long-term survival. Revascularization improved outcomes in patients with higher baseline estimated glomerular filtration rate and lower proteinuria but not in those with co-existing comorbidities and higher levels of baseline proteinuria.

Conclusions: Although this risk calculator requires further independent validation in other ARVD cohorts, this study shows that a small number of easily obtained variables can help predict clinical outcomes and encourage a patient-specific therapeutic approach.
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http://dx.doi.org/10.1093/ndt/gfy157DOI Listing
August 2019

The influence of leg-to-body ratio, arm-to-body ratio and intra-limb ratio on male human attractiveness.

R Soc Open Sci 2018 May 16;5(5):171790. Epub 2018 May 16.

Department of Psychology, University of Cambridge, Cambridge, UK.

Human mate choice is influenced by limb proportions. Previous work has focused on leg-to-body ratio (LBR) as a determinant of male attractiveness and found a preference for limbs that are close to, or slightly above, the average. We investigated the influence of two other key aspects of limb morphology: arm-to-body ratio (ABR) and intra-limb ratio (IR). In three studies of heterosexual women from the USA, we tested the attractiveness of male physiques that varied in LBR, ABR and IR, using figures that ranged from -3 to +3 standard deviations from the population mean. We replicated previous work by finding that the optimally attractive LBR is approximately 0.5 standard deviations above the baseline. We also found a weak effect of IR, with evidence of a weak preference for the baseline proportions. In contrast, there was no effect of ABR on attractiveness, and no interactions between the effects of LBR, ABR and IR. Our results indicate that ABR is not an important determinant of human mate choice for this population, and that IR may exert some influence but that this is much smaller than the effects of LBR. We discuss possible reasons for these results, including the limited variability in upper limb proportions and the potentially weak fitness-signal provided by this aspect of morphology.
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http://dx.doi.org/10.1098/rsos.171790DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5990728PMC
May 2018

Who were the Nataruk people? Mandibular morphology among late Pleistocene and early Holocene fisher-forager populations of West Turkana (Kenya).

J Hum Evol 2018 08 29;121:235-253. Epub 2018 May 29.

Leverhulme Centre for Human Evolutionary Studies, Department of Archaeology, University of Cambridge, Fitzwilliam Street, Cambridge CB2 1QH, United Kingdom; Turkana Basin Institute, Kenya. Electronic address:

Africa is the birthplace of the species Homo sapiens, and Africans today are genetically more diverse than other populations of the world. However, the processes that underpinned the evolution of African populations remain largely obscure. Only a handful of late Pleistocene African fossils (∼50-12 Ka) are known, while the more numerous sites with human fossils of early Holocene age are patchily distributed. In particular, late Pleistocene and early Holocene human diversity in Eastern Africa remains little studied, precluding any analysis of the potential factors that shaped human diversity in the region, and more broadly throughout the continent. These periods include the Last Glacial Maximum (LGM), a moment of extreme aridity in Africa that caused the fragmentation of population ranges and localised extinctions, as well as the 'African Humid Period', a moment of abrupt climate change and enhanced connectivity throughout Africa. East Africa, with its range of environments, may have acted as a refugium during the LGM, and may have played a critical biogeographic role during the heterogene`ous environmental recovery that followed. This environmental context raises a number of questions about the relationships among early Holocene African populations, and about the role played by East Africa in shaping late hunter-gatherer biological diversity. Here, we describe eight mandibles from Nataruk, an early Holocene site (∼10 Ka) in West Turkana, offering the opportunity of exploring population diversity in Africa at the height of the 'African Humid Period'. We use 3D geometric morphometric techniques to analyze the phenotypic variation of a large mandibular sample. Our results show that (i) the Nataruk mandibles are most similar to other African hunter-fisher-gatherer populations, especially to the fossils from Lothagam, another West Turkana locality, and to other early Holocene fossils from the Central Rift Valley (Kenya); and (ii) a phylogenetic connection may have existed between these Eastern African populations and some Nile Valley and Maghrebian groups, who lived at a time when a Green Sahara may have allowed substantial contact, and potential gene flow, across a vast expanse of Northern and Eastern Africa.
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http://dx.doi.org/10.1016/j.jhevol.2018.04.013DOI Listing
August 2018

Can the Ottawa Subarachnoid Haemorrhage Rule help reduce investigation rates for suspected subarachnoid haemorrhage?

Am J Emerg Med 2019 01 10;37(1):155. Epub 2018 May 10.

Royal Berkshire NHS Foundation Trust, United Kingdom.

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http://dx.doi.org/10.1016/j.ajem.2018.05.015DOI Listing
January 2019

Tissue-Specific Transcriptome for Reveals Evidence for Genetic Adaptation Related to the Evolution of a Placental Fish.

G3 (Bethesda) 2018 07 2;8(7):2181-2192. Epub 2018 Jul 2.

Institute for Systems Genomics and Department of Molecular and Cell Biology, University of Connecticut, Storrs, CT 06269

The evolution of the placenta is an excellent model to examine the evolutionary processes underlying adaptive complexity due to the recent, independent derivation of placentation in divergent animal lineages. In fishes, the family Poeciliidae offers the opportunity to study placental evolution with respect to variation in degree of post-fertilization maternal provisioning among closely related sister species. In this study, we present a detailed examination of a new reference transcriptome sequence for the live-bearing, matrotrophic fish, , from multiple-tissue RNA-seq data. We describe the genetic components active in liver, brain, late-stage embryo, and the maternal placental/ovarian complex, as well as associated patterns of positive selection in a suite of orthologous genes found in fishes. Results indicate the expression of many signaling transcripts, "non-coding" sequences and repetitive elements in the maternal placental/ovarian complex. Moreover, patterns of positive selection in protein sequence evolution were found associated with live-bearing fishes, generally, and the placental , specifically, that appear independent of the general live-bearer lifestyle. Much of the observed patterns of gene expression and positive selection are congruent with the evolution of placentation in fish functionally converging with mammalian placental evolution and with the patterns of rapid evolution facilitated by the teleost-specific whole genome duplication event.
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http://dx.doi.org/10.1534/g3.118.200270DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6027864PMC
July 2018

Prescription Medication Use Among Community-Based U.S. Adults With Chronic Low Back Pain: A Cross-Sectional Population Based Study.

J Pain 2018 10 17;19(10):1104-1112. Epub 2018 Apr 17.

Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, Minnesota.

Many classes of medications have been evaluated in chronic low back pain (cLBP), however their utilization in the community remains unclear. We examined patterns of prescription medication use among Americans with cLBP in a nationally representative, community-based sample. The Back Pain Survey was administered to a representative sample of U.S. adults aged 20 to 69 years (N = 5,103) during the 2009 to 2010 cycle of the National Health and Nutrition Examination Survey. cLBP was defined as self-reported pain in the area between the lower posterior margin of the ribcage and the horizontal gluteal fold on most days for at least 3 months (N = 700). Home-based interviews with pill bottle verification were used to capture commonly prescribed medications for chronic pain. Among the sample of U.S. adults with cLBP aged 20 to 69 years, 36.9% took at least 1 prescription pain medication in the past 30 days; of them, 18.8% used opioids, 9.7% nonsteroidal anti-inflammatory drugs, 8.5% muscle relaxants, and 6.9% gabapentin or pregabalin. Nonpain antidepressants and hypnotics were used by 17.8% and 4.7%, respectively. Opioids were used long-term in 76.9% of cases (median = 2 years) and were frequently coadministered with antidepressants, benzodiazepines, or hypnotics. Ninety-four percent of prescription opioids in the cLBP population were used by individuals with less than a college education. Opioids were the most widely used prescription analgesic class in community-based U.S. adults with cLBP and were often coadministered with other central nervous system-active medications. Opioid use was highly prevalent among less educated Americans with cLBP.

Perspective: Because prescription opioid use is an issue of national concern, we examined pain-related prescription medication use in community-dwelling U.S. adults with cLBP. Opioids were the most common prescription pain medication, typically used long-term, in combination with other central nervous system-active agents, and disproportionately among individuals with less than a college education.
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http://dx.doi.org/10.1016/j.jpain.2018.04.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6163076PMC
October 2018