Insertable cardiac monitoring results in higher rates of atrial fibrillation diagnosis and oral anticoagulation prescription after ischaemic stroke.

AIMS: After an ischaemic stroke, atrial fibrillation (AF) detection allows for improved secondary prevention strategies. This study aimed to compare AF detection and oral anticoagulant (OAC) initiation in patients with an insertable cardiac monitor (ICM) vs. external cardiac monitor (ECM) after ischaemic stroke. METHODS AND RESULTS: Medicare Fee-for-Service (FFS) insurance claims and Abbott Labs device registration data were used to identify patients hospitalized with an ischaemic stroke in 2017-2019 who received an ICM or ECM within 3 months. Patients with continuous Medicare FFS insurance and prescription drug enrolment in the prior year were included. Patients with prior AF, atrial flutter, cardiac devices, or OAC were excluded. Insertable cardiac monitor and ECM patients were propensity score matched 1:4 on demographics, comorbidities, and stroke hospitalization characteristics. The outcomes of interest were AF detection and OAC initiation evaluated with Kaplan-Meier and Cox proportional hazard regression analyses. A total of 5702 Medicare beneficiaries (ICM, n = 444; ECM, n = 5258) met inclusion criteria. The matched cohort consisted of 2210 Medicare beneficiaries (ICM, n = 442; ECM, n = 1768) with 53% female, mean age 75 years, and mean CHA2DS2-VASc score 4.6 (1.6). Insertable cardiac monitor use was associated with a higher probability of AF detection [(hazard ratio (HR) 2.88, 95% confidence interval (CI) (2.31, 3.59)] and OAC initiation [HR 2.91, CI (2.28, 3.72)] compared to patients monitored only with ECM. CONCLUSION: Patients with an ischaemic stroke monitored with an ICM were almost three times more likely to be diagnosed with AF and to be prescribed OAC compared to patients who received ECM only.

Type 1 Diabetes Management With Technology: Patterns of Utilization and Effects on Glucose Control Using Real-World Evidence.

This retrospective cohort study evaluated diabetes device utilization and the effectiveness of these devices for newly diagnosed type 1 diabetes. Investigators examined the use of continuous glucose monitoring (CGM) systems, self-monitoring of blood glucose (SMBG), continuous subcutaneous insulin infusion (CSII), and multiple daily injection (MDI) insulin regimens and their effects on A1C. The researchers identified 6,250 patients with type 1 diabetes, of whom 32% used CGM and 37.1% used CSII. A higher adoption rate of either CGM or CSII in newly diagnosed type 1 diabetes was noted among White patients and those with private health insurance. CGM users had lower A1C levels than nonusers (P = 0.039), whereas no difference was noted between CSII users and nonusers (P = 0.057). Furthermore, CGM use combined with CSII yielded lower A1C than MDI regimens plus SMBG (P <0.001).

Intermolecular interactions underlie protein/peptide phase separation irrespective of sequence and structure at crowded milieu.

Liquid-liquid phase separation (LLPS) has emerged as a crucial biological phenomenon underlying the sequestration of macromolecules (such as proteins and nucleic acids) into membraneless organelles in cells. Unstructured and intrinsically disordered domains are known to facilitate multivalent interactions driving protein LLPS. We hypothesized that LLPS could be an intrinsic property of proteins/polypeptides but with distinct phase regimes irrespective of their sequence and structure. To examine this, we studied many (a total of 23) proteins/polypeptides with different structures and sequences for LLPS study in the presence and absence of molecular crowder, polyethylene glycol (PEG-8000). We showed that all proteins and even highly charged polypeptides (under study) can undergo liquid condensate formation, however with different phase regimes and intermolecular interactions. We further demonstrated that electrostatic, hydrophobic, and H-bonding or a combination of such intermolecular interactions plays a crucial role in individual protein/peptide LLPS.

Gaps in standardized postoperative pain management quality measures: A systematic review.

BACKGROUND: The goal of this study was an assessment of availability postoperative pain management quality measures and National Quality Forum-endorsed measures. Postoperative pain is an important clinical timepoint because poor pain control can lead to patient suffering, chronic opiate use, and/or chronic pain. Quality measures can guide best practices, but it is unclear whether there are measures for managing pain after surgery. METHODS: The National Quality Forum Quality Positioning System, Agency for Healthcare Research and Quality Indicators, and Centers for Medicare and Medicaid Services Measures Inventory Tool databases were searched in November 2019. We conducted a systematic literature review to further identify quality measures in research publications, clinical practice guidelines, and gray literature for the period between March 11, 2015 and March 11, 2020. RESULTS: Our systematic review yielded 1,328 publications, of which 206 were pertinent. Nineteen pain management quality measures were identified from the quality measure databases, and 5 were endorsed by National Quality Forum. The National Quality Forum measures were not specific to postoperative pain management. Three of the non-endorsed measures were specific to postoperative pain. CONCLUSION: The dearth of published postoperative pain management quality measures, especially National Quality Forum-endorsed measures, highlights the need for more rigorous evidence and widely endorsed postoperative pain quality measures to guide best practices.

Social participation and healthy ageing: a neglected, significant protective factor for chronic non communicable conditions.

BACKGROUND: Low and middle income countries are ageing at a much faster rate than richer countries, especially in Asia. This is happening at a time of globalisation, migration, urbanisation, and smaller families. Older people make significant contributions to their families and communities, but this is often undermined by chronic disease and preventable disability. Social participation can help to protect against morbidity and mortality. We argue that social participation deserves much greater attention as a protective factor, and that older people can play a useful role in the prevention and management of chronic conditions. We present, as an example, a low-cost, sustainable strategy that has increased social participation among elders in Sri Lanka. DISCUSSION: Current international policy initiatives to address the increasing prevalence of non-communicable chronic diseases are focused on cardiovascular disease, diabetes, respiratory disease and cancers, responsible for much premature mortality. Interventions to modify their shared risk factors of high salt and fat diets, inactivity, smoking and alcohol use are advocated. But older people also suffer chronic conditions that primarily affect quality of life, and have a wider range of risk factors. There is strong epidemiological and physiological evidence that social isolation, in particular, is as important a risk factor for chronic diseases as the 'lifestyle' risk factors, yet it is currently neglected. There are useful experiences of inexpensive and sustainable strategies to improve social participation among older people in low and lower middle income countries. Our experience with forming Elders' Clubs with retired tea estate workers in Sri Lanka suggests many benefits, including social support and participation, inter-generational contact, a collective voice, and facilitated access to health promotion activities, and to health care and social welfare services. SUMMARY: Policies to address the increase in chronic non-communicable diseases should include consideration of healthy ageing, conditions that affect quality of life, and strategies to increase social participation. There are useful examples showing that it is feasible to catalyse the formation of Elders' Clubs or older people's associations which become self-sustaining, promote social participation, and improve health and well-being of elders and their families.

Assessment of the Diversity and Inclusion Culture in a Physician Assistant Program.

PURPOSE: Physician assistant (PA) programs aim to foster a collaborative culture that enables stakeholders to feel included, empowered, and valued. The purpose of this study was to explore the cultural climate of diversity and inclusion in one PA program to identify areas of strength and to serve as a baseline needs assessment for future program initiatives. METHODS: The study used a cross-sectional, descriptive approach for PA survey data (N = 85) to assess perceptions of diversity and inclusion of PA program students, faculty, and staff. RESULTS: The respondents largely agreed that the program created an inclusive learning environment (92%), the curriculum positively affected their understanding of diversity and cultural responsiveness (84.6%), and the program had an adequate amount of inclusivity for all program stakeholders (87%). Some faculty members (25%) and students (6.2%) disagreed that faculty were open to diverse political beliefs, and 35% of the respondents believed that more emphasis could be put on religious diversity. A few students (7.7%) perceived faculty as not supportive of non-native English language speakers; students of color (11.5%) were more likely than White students (5.1%) to have this perception. CONCLUSIONS: This study largely met the goal to create a professional environment of mutual respect and, ultimately, a climate of inclusiveness. It also identified opportunities for new initiatives to meet the needs of all program stakeholders. Follow-up research that distinguishes faculty from students and a multicenter study to explore perspectives based on demographic differences would be timely and useful.

Role of GacA in virulence of Vibrio vulnificus.

The GacS/GacA two-component signal transduction system regulates virulence, biofilm formation and symbiosis in Vibrio species. The present study investigated this regulatory pathway in Vibrio vulnificus, a human pathogen that causes life-threatening disease associated with the consumption of raw oysters and wound infections. Small non-coding RNAs (csrB1, csrB2, csrB3 and csrC) commonly regulated by the GacS/GacA pathway were decreased (P<0.0003) in a V. vulnificus CMCP6 ΔgacA : : aph mutant compared with the wild-type parent, and expression was restored by complementation of the gacA deletion mutation in trans. Of the 20 genes examined by RT-PCR, significant reductions in the transcript levels of the mutant in comparison with the wild-type strain were observed only for genes related to motility (flaA), stationary phase (rpoS) and protease (vvpE) (P=0.04, 0.01 and 0.002, respectively). Swimming motility, flagellation and opaque colony morphology indicative of capsular polysaccharide (CPS) were unchanged in the mutant, while cytotoxicity, protease activity, CPS phase variation and the ability to acquire iron were decreased compared with the wild-type (P<0.01). The role of gacA in virulence of V. vulnificus was also demonstrated by significant impairment in the ability of the mutant strain to cause either skin (P<0.0005) or systemic infections (P<0.02) in subcutaneously inoculated, non-iron-treated mice. However, the virulence of the mutant was equivalent to that of the wild-type in iron-treated mice, demonstrating that the GacA pathway in V. vulnificus regulates the virulence of this organism in an iron-dependent manner.

Computational Model for Studying Breakage-Dependent Amyloid Growth.

Amyloid fibrils are typically associated with neurodegenerative diseases. Recent studies have suggested that, similar to prions, many amyloid proteins are infectious in nature and may cause spreading and dissemination of diseases. Typical amyloid infection propagates by recruiting functional proteins into amyloidogenic form and multiplying by breaking the existing fibril. In this study, we model the kinetics of fibril growth through breakage and the subsequent elongation process, similar to the prion infection process. Using kinetic Monte Carlo simulations as well as mathematical counting methods, we show how the measurable quantities like the 50% aggregation time (T50) and the maximum growth rate (Vmax) scale with various parameters in the problem. This study has a direct application where it can be used to understand experiments that amplify the minute amount of amyloid seeds present in biological fluid for early detection of human disease. Using the knowledge from our simulations, we can predict the initial seed concentration, known as the filament kinetics.

Prevalence and correlates of depression among black and Latino stroke survivors with uncontrolled hypertension: a cross-sectional study.

OBJECTIVE: To examine the prevalence and correlates of depression in a cohort of black and Hispanic stroke survivors with uncontrolled hypertension. SETTING: Baseline survey data from 10 stroke centres across New York City. PARTICIPANTS: Black and Hispanic stroke survivors with uncontrolled hypertension (n=450). OUTCOME MEASURES: Depressive symptoms were assessed with the 8-item Patient Reported Outcomes Measurement Information System (PROMIS) measure. Depression was defined as a PROMIS score ≥55. Other data collected included clinical factors, health-related quality of life (EuroQoL five dimensions (EQ-5D)), functional independence (Barthel Index, BI), stroke-related disability (Modified Rankin Score), physical function (PROMIS Physical Function) and executive functioning (Frontal Assessment Battery). RESULTS: The mean age was 61.7±11.1 years, 44% of participants were women and 51% were black. Poststroke depression was noted in 32% of the cohort. Examining bivariate relationships, patients with depression were observed to have poorer function and quality of life as evidenced by significantly lower PROMIS physical function scores (36.9±8.32 vs 43.4±10.19, p<0.001); BI scores (79.9±19.2 vs 88.1±15.1, p<0.001); EQ-5D scores (0.66±0.24 vs 0.83±0.17, p<0.001) and higher Rankin scores (2.10±1.00 vs 1.46±1.01, p<0.001) compared with those without depression. Multivariate (model adjusted) significant correlates of depression included lower self-reported quality of life (OR=0.02 (CI 0.004 to 0.12) being younger (OR=0.94; 95% CI 0.91 to 0.97); not married (OR=0.46; CI 0.24 to 0.89)); and foreign-born (OR=3.34, 95% CI 1.4 to 7.97). There was a trend for higher comorbidity to be uniquely associated with depression (≥3 comorbid conditions, OR=1.49, 95% CI 1.00 to 2.23). CONCLUSIONS: Poststroke depression is common among black and Hispanic stroke survivors with higher rates noted among foreign-born patients and those with high comorbidity. These findings highlight the importance of screening for depression in minority stroke survivors. TRIAL REGISTRATION NUMBER: http://www.clinicaltrials.gov. Unique identifier: NCT01070056.

USER friendly cloning coupled with chitin-based natural transformation enables rapid mutagenesis of Vibrio vulnificus.

Vibrio vulnificus is a bacterial contaminant of shellfish and causes highly lethal sepsis and destructive wound infections. A definitive identification of virulence factors using the molecular version of Koch's postulates has been hindered because of difficulties in performing molecular genetic analysis of this opportunistic pathogen. For example, conjugation is required to introduce plasmid DNA, and allelic exchange suicide vectors that rely on sucrose sensitivity for counterselection are not efficient. We therefore incorporated USER friendly cloning techniques into pCVD442-based allelic exchange suicide vectors and other expression vectors to enable the rapid and efficient capture of PCR amplicons. Upstream and downstream DNA sequences flanking genes targeted for deletion were cloned together in a single step. Based on results from Vibrio cholerae, we determined that V. vulnificus becomes naturally transformable with linear DNA during growth on chitin in the form of crab shells. By combining USER friendly cloning and chitin-based transformation, we rapidly and efficiently produced targeted deletions in V. vulnificus, bypassing the need for two-step, suicide vector-mediated allelic exchange. These methods were used to examine the roles of two flagellin loci (flaCDE and flaFBA), the motAB genes, and the cheY-3 gene in motility and to create deletions of rtxC, rtxA1, and fadR. Additionally, chitin-based transformation was useful in moving antibiotic resistance-labeled mutations between V. vulnificus strains by simply coculturing the strains on crab shells. The methods and genetic tools that we developed should be of general use to those performing molecular genetic analysis and manipulation of other gram-negative bacteria.

Gingival Crevicular Fluid: An Overview.

Gingival crevicular fluid is an inflammatory exudate derived from the periodontal tissues. It is composed of serum and locally generated materials such as tissue breakdown products, inflammatory mediators, and antibodies directed against dental plaque bacteria. It plays a special part in maintaining the structure of junctional epithelium and the antimicrobial defense of periodontium. Some of the suspected periodontal pathogens such as Porphyromonas gingivalis and Treponema denticola produce broad-spectrum neutral proteinases as part of their virulence arsenal. These proteinases may be detected in plaque and gingival crevicular fluid samples of patients with periodontitis. The potential diagnostic importance of gingival fluid was recognized more than six decades ago. The fluid component of gingival crevicular fluid is derived primarily from microvascular (postcapillary venule) leakage. There are number of distinct advantages and challenges of using gingival crevicular fluid as a diagnostic test for periodontal disease.

Introducing Primary Care Telephone Visits: An Urban Safety-Net Community Clinic Experience.

BACKGROUND: Telephone consultation is widely used in primary care and can provide an effective and efficient alternative for the in-person visit. Gouverneur Health, a safety-net primary care practice in New York City serving a predominately immigrant population, evaluated the feasibility and physician and patient acceptability of a telephone visit initiative in 2015. MEASURES: Patient and physician surveys, and physician focus groups. RESULTS: Though only 85 of 270 scheduled telephone visits (31%) were completed, 84% of patients reported being highly satisfied with their telephone visit. Half of physicians opted to participate in the pilot. Among participating physicians, all reported they were able to communicate adequately and safely care for patients over the telephone. CONCLUSIONS: Participating patients and physicians in a linguistically and culturally diverse urban safety-net primary care clinic were highly satisfied with the use of telephone visits, though completion of the visits was low. Lessons learned from this implementation can be used to expand access and provision of high-quality primary care to other vulnerable populations.

Assessing Diabetes Care Disparities with Ambulatory Care Quality Measures.

OBJECTIVE: To identify and describe racial/ethnic disparities in overall diabetes management. DATA SOURCE/STUDY SETTING: Electronic health record data from calendar year 2010 were obtained from all primary care clinics at one large health system in Minnesota (n = 22,633). STUDY DESIGN: We used multivariate logistic regression to estimate the odds of achieving the following diabetes management goals: A1C <8 percent, LDL cholesterol <100 mg/dl, blood pressure <140/90 mmHg, tobacco-free, and daily aspirin. PRINCIPAL FINDINGS: Blacks and American Indians have higher odds of not achieving all goals compared to whites. Disparities in specific goals were also found. CONCLUSIONS: Although this health system has above-average diabetes care quality, significant disparities by race/ethnicity were identified. This underscores the importance of stratifying quality measures to improve care and outcomes for all.