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The antibody epitope was mapped to a site within a consensus tyrosine sulfation motif of CD162, previously shown to be essential for interaction with P selectin (and now shown to be essential for recognition of CD162 by L selectin).
ab78188 completely blocks recognition of CD162 by either P selectin or by L selectin, but does not affect leukocyte recognition of E selectin.
Abcam is committed to meeting high standards of ethical manufacturing and has decided to discontinue this product by June 2019 as it has been generated by the ascites method. We are sorry for any inconvenience this may cause.
Our Abpromise guarantee covers the use of ab78188 in the following tested applications.
The application notes include recommended starting dilutions; optimal dilutions/concentrations should be determined by the end user.
|Blocking||Use at an assay dependent concentration.|
|WB||Use at an assay dependent concentration. Predicted molecular weight: 43 kDa.|
|IP||Use at an assay dependent concentration.|
|IHC-P||Use at an assay dependent concentration.
Indirect biotin streptavidin method recommended. Formalin fixed, deparaffinized sections were stained without pretreatment or microwaved for 15 minutes in 0.01 mol/L citrate buffer pH 6.0 before staining.
|IHC-Fr||Use at an assay dependent concentration.
Frozen sections were fixed in acetone for 10 minutes at 4 °C before staining.
|Flow Cyt||Use 0.01µg for 106 cells.
ab170190 - Mouse monoclonal IgG1, is suitable for use as an isotype control with this antibody.
Human peripheral blood lymphocytes stained with ab78188 (red line). Human whole blood was processed using a modified protocol based on Chow et al, 2005 (PMID: 16080188). In brief, human whole blood was fixed in 4% formaldehyde (methanol-free) for 10 min at 22°C. Red blood cells were then lyzed by the addition of Triton X-100 (final concentration - 0.1%) for 15 min at 37°C. For experimentation, cells were treated with 50% methanol (-20°C) for 15 min at 4°C. Cells were then incubated with the antibody (ab78188, 0.01μg/1x106 cells) for 30 min at 4°C. The secondary antibody used was Alexa Fluor® 488 goat anti-mouse IgG (H&L) (ab150113) at 1/2000 dilution for 30 min at 4°C. Isotype control antibody (black line) was mouse IgG1 [ICIGG1] (ab91353, 0.1μg/1x106 cells) used under the same conditions. Unlabelled sample (blue line) was also used as a control. Acquisition of >30,000 total events were collected using a 20mW Argon ion laser (488nm) and 525/30 bandpass filter. Gating strategy - peripheral blood lymphocytes.
IHC image of CD162 staining in Human Normal aorta formalin fixed paraffin embedded tissue section, performed on a Leica BondTM system using the standard protocol F. The section was pre-treated using heat mediated antigen retrieval with sodium citrate buffer (pH6, epitope retrieval solution 1) for 20 mins. The section was then incubated with ab78188, 5µg/ml, for 15 mins at room temperature and detected using an HRP conjugated compact polymer system. DAB was used as the chromogen. The section was then counterstained with haematoxylin and mounted with DPX.
For other IHC staining systems (automated and non-automated) customers should optimize variable parameters such as antigen retrieval conditions, primary antibody concentration and antibody incubation times.
Please note: All products are "FOR RESEARCH USE ONLY AND ARE NOT INTENDED FOR DIAGNOSTIC OR THERAPEUTIC USE"


|Comparing quality of life between seniors living in families and institutionalized in nursing homes|
H Ghasemi, M Harirchi, A Masnavi, M Rahgozar, M Akbarian
Social Welfare Quarterly 10 (39), 177-200, 2011
|To identify the facilitator and barrier factors of physical activity among elderly people in tehran.|
L Salehi, MH Taghdisi, H Ghasemi, B Shokervash
Iranian Journal of Epidemiology 6 (2), 7-15, 2010
|Effects of silver nanoparticle (Ag NP) on oxidative stress biomarkers in rat|
A Ranjbar, Z Ataie, F Khajavi, H Ghasemi
Nanomedicine journal 1 (3), 205-210, 2014
|Hepatoprotective effect of Matricaria chamomilla. L in paraquat induced rat liver injury|
HS Tavakol, K Farzad, M Fariba, C Abdolkarim, G Hassan, ...
Drug research 65 (02), 61-4, 2015
|The prevalence and antibiotic resistance of Shigella sp. recovered from patients admitted to Bouali Hospital, Tehran, Iran during 1999-2001.|
MJ Hosseini, R Ranjbar, H Ghasemi, HR Jalalian
Pakistan journal of biological sciences: PJBS 10 (16), 2778-2780, 2007
|Association between rs4673 (C/T) and rs13306294 (A/G) haplotypes of NAD (P) H oxidase p22phox gene and severity of stenosis in coronary arteries|
M Najafi, B Alipoor, M Shabani, A Amirfarhangi, H Ghasemi
Gene 499 (1), 213-217, 2012
|Hepatoprotective effect of the root extract of green tea against malathion-induced oxidative stress in rats|
N Mehri, H Felehgari, A Harchegani, H Behrooj, N Kheiripour, ...
Journal of herbmed pharmacology 5, 2016
|Effects of silver nanoparticle (Ag NP) on oxidative stress, liver function in rat: hepatotoxic or hepatoprotective?|
T Heidary, FK Shayesteh, H Ghasemi, SMH Zijoud, A Ranjbar
Journal Issues ISSN 2350, 1588, 2014
|Circulating betatrophin levels are associated with the lipid profile in type 2 diabetes|
H Ghasemi, H Tavilani, I Khodadadi, M Saidijam, J Karimi
Chonnam medical journal 51 (3), 115, 2015
|The role of oxidative stress in metals toxicity/mitochondrial dysfunction as a key player|
H Ghasemi, F Rostampour, A Ranjbar
GALEN MEDICAL JOURNAL 3 (1), 2-13, 2014
|Ameliorative effect of Matricaria chamomilla. L on paraquat: Induced oxidative damage in lung rats|
A Ranjbar, F Mohsenzadeh, A Chehregani, F Khajavi, SMH Zijoud, ...
Pharmacognosy research 6 (3), 199, 2014
|Co-expression profiling of plasma miRNAs and long noncoding RNAs in gastric cancer patients|
H Ghaedi, MAN Mozaffari, Z Salehi, H Ghasemi, SS Zadian, S Alipoor, ...
Gene 687, 135-142, 2019
|Tempol effects on diabetic nephropathy in male rats|
A Ranjbar, H Ghasemi, M Hatami, F Dadras, TH Shayesteh, F Khoshjou
Journal of renal injury prevention 5 (2), 74, 2016
|Attenuation of cisplathin-induced toxic oxidative stress by propofol|
GT Moghadam, SM Hosseini-Zijoud, TH Shayesteh, H Ghasemi, ...
Anesthesiology and pain medicine 4 (4), 2014
|Investigation of hydrodynamics and transition regime in an internal loop airlift reactor using CFD|
H Ghasemi, SH Hosseini
Brazilian Journal of Chemical Engineering 29 (4), 821-833, 2012
|Medicinal properties of Persian shallot|
Y Moradi, H Moradi-Sardareh, H Ghasemi, N Mohamadi, MN Moradi, ...
European Journal of Experimental Biology 3 (1), 371-379, 2013
|Phenotype and genotype relationship of glutathione peroxidase1 (GPx1) and rs 1800668 variant: the homozygote effect on kinetic parameters|
M Najafi, H Ghasemi, A Roustazadeh, B Alipoor
Gene 505 (1), 19-22, 2012
|Protective effects of curcumin on diabetic nephropathy via attenuation of kidney injury molecule 1 (KIM-1) and neutrophil gelatinase-associated lipocalin (NGAL) expression and …|
H Ghasemi, B Einollahi, N Kheiripour, SR Hosseini-Zijoud, MF Nezhad
Iranian journal of basic medical sciences 22 (4), 376, 2019
|Seminal plasma zinc and magnesium levels and their relation to spermatozoa parameters in semen of diabetic men|
H Ghasemi, J Karimi, MT Goodarzi, I Khodadadi, H Tavilani, H Moridi, ...
International journal of diabetes in developing countries 36 (1), 34-39, 2016
|Antioxidative Effects of Tempol on Mitochondrial Dysfunction in Diabetic Nephropathy|
FK Akram Ranjbar, Nejat Kheiripour, Hassan Ghasemi, Mohamad Ali Seif Rabiei ...
Iran J Kidney Dis 12, 84-90, 2018


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Nanomedicina, Biomateriales, Biomedicina
Computational Intelligence and Data Sciences "Paradigms in Biomedical Engineering"
Viral and Antiviral Nanomaterials "Synthesis, Properties, Characterization, and Application"
Vascularization for Tissue Engineering and Regenerative Medicine
Nanotechnology Based Approaches for Tuberculosis Treatment
Design and Operation of Human Locomotion Systems
Social Web And Health Research "Benefits, Limitations, And Best Practices"
Models, Molecules and Mechanisms in Biogerontology "Physiological Abnormalities, Diseases and Interventions"
Nanooncology "Engineering nanomaterials for cancer therapy and diagnosis"
Encyclopedia Of Medical Robotics 4 Vols.
Impact of Nanoscience in the Food Industry Vol.12
Nanomedicine in Health and Disease
Mechanics of Cellular Bone Remodeling "Coupled Thermal, Electrical, and Mechanical Field Effects"
Nanomedicines and Nanoproducts "Applications, Disposition, and Toxicology in the Human Body"
Polyaniline Blends, Composites, and Nanocomposites
Dendrimers in Medical Science
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FOR some youngsters, a longing look at skinny models such as Kate Moss can
literally make them go weak at the knees.
A bad diet or eating disorders are already known to weaken girls’ bones. Now
it seems that simply worrying about weight can release hormones that lead to
Susan Barr and Jerilynn Prior of the University of British Columbia in
Vancouver, Canada, quizzed 51 healthy pre-teen girls, none of whom had eating
disorders, about weight worries. They also measured the mineral content of the
girls’ bones using a low dose of X-rays. To their surprise, they found that the
girls who were more concerned about their weight than average were significantly
more likely to have lower bone densities.
Most differences in bone content are determined by genetics, says Barr, and
the next biggest determinant is height. But the researchers found that worry
could account for about 8


Authorities suspect he contracted the infection while attending to patients
D. Arun Kumar (47), Additional Chief Medical Superintendent at Railway Hospital, Mysuru, succumbed to complications related to COVID-19 on Saturday.
A release said he was in the intensive care unit at a private hospital sine more than a month and passed away on Saturday due to cardiac arrest. The railway authorities suspect he contracted the infection while attending to patients.
Mr. Kumar completed his MBBS from Vijaynagar Institute of Medical Science, Ballari, in 1996 and belonged to the 1996 batch of the Combined Medical Services Examination conducted by the UPSC. He joined the railways in 1998 and had served in different hospitals and health units of the South Western Railway.
He is survived by his wife Devatha Laxmi, Medical Officer, Department of Health and Family Welfare, and a son Srikar. Raghu Agarwal, Divisional Railway Manager, Mysuru, condoled the death of Mr. Kumar and said he worked relentlessly treating railway fraternity during COVID-19 times.
Source: Read Full Article


Trends: Nonprofit Hospital Challenges, Rules At Hospitals With Religious Affiliations
Nonprofit hospitals face a range of challenges related to increasing costs and diminishing resources, while hospitals with religious affiliations play by rules that can affect the care they deliver.
Reuters: Nonprofit U.S. Hospitals To Do More With Less -- Moody's
Nonprofit hospitals in the United States face a future of rising costs and dwindling funds as the healthcare reform is implemented and the Congress battles over the budget, according to a Moody's Investors Services report released on Wednesday. To survive what the rating agency is calling a "transition period," the hospitals, which frequently provide free or discounted care for lower-income patients, will have to drastically cut spending (5/9).
NPR: When Religious Rules And Women's Health Collide
When you go to the hospital these days, chances are good that it will be affiliated with a religious organization. And while that may might just mean the chaplain will be of a specific denomination or some foods will be off limits, there may also be rules about the kind of care allowed (Rovner, 5/8).


Original Research ARTICLE
Paroxysmal Atrial Fibrillation in Cryptogenic Stroke Patients With Major-Vessel Occlusion
- 1Department of Neurology, Iwate Prefectural Central Hospital, Morioka, Japan
- 2Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
- 3Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
- 4Department of Neurosurgery, Yokohama Shintoshi Hospital, Yokohama, Japan
- 5Department of Neurology, Tokai University, Isehara, Japan
- 6Department of Neurology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
- 7Department of Neurosurgery, Iwate Prefectural Central Hospital, Morioka, Japan
- 8Department of Neurology, Osaka University, Suita, Japan
Background and Purpose: To determine whether acute major-vessel occlusion (MVO) predicts atrial fibrillation (AF) in cryptogenic stroke (CS) patients, we analyzed the association between acute MVO and AF detected by insertable cardiac monitoring (ICM).
Methods: We conducted a retrospective, multicenter, observational study of patients with CS who underwent ICM implantation between October 2016 and March 2018. In this analysis, we included follow-up data until June 2018. We analyzed the association of MVO with AF detected by ICM.
Results: We included 84 consecutive patients with CS who underwent ICM implantation. The proportion of patients with newly detected AF by ICM was higher in patients with MVO than in those without (41% [12/29] vs. 13% [7/55], p < 0.01) within 90 days of ICM implantation. The MVO was associated with AF after adjustment for each clinically relevant factor.
Conclusions: MVO was independently associated with AF detection in patients with CS, which suggests that MVO may be a useful predictor of latent AF. It is therefore essential to actively assess latent AF in patients with CS presenting with MVO.
Patients with atrial fibrillation (AF) have a 4.8-fold higher risk of developing a stroke compared to those without (1) and is associated with increased stroke severity (2, 3). Moreover, ischemic stroke patients with AF have higher recurrence rates than those without (3); however, oral anticoagulants substantially reduce the risk of recurrent stroke compared to antiplatelet therapy (4, 5). AF detection in ischemic stroke patients is therefore crucial for determining appropriate antithrombotic therapy for secondary prevention. Even after sufficient diagnostic assessment, the cause of stroke remains undetermined and is diagnosed as cryptogenic stroke (CS) in 9 to 25% of ischemic stroke patients (6).
One-third to one-half of acute large-vessel occlusion is reported to have AF in a randomized control trial and a nation-wide registry (7, 8). Even among the CS patients with MVO, covert paroxysmal AF might be a major cause of stroke. Using a wearable 28-day Holter monitor starting 24–72 h after stroke, large-vessel occlusion in patients with CS was reported to be independently associated with atrial fibrillation detection (9). Recently, long-term recording with insertable cardiac monitoring (ICM) has been shown to be useful for AF detection in CS patients (10). In the current study, we analyzed the association between acute MVO and AF detection by ICM.
Materials and Methods
The current registry was a retrospective, observational registry that enrolled consecutive patients with ICM implantation for CS through five stroke centers in Japan between October 2016 and March 2018 (11). Inclusion criteria were as follows: (1) cryptogenic stroke, (2) ICM implantation, and (3) follow-up lasting 3 months or more. Written informed consent was waived because the study was retrospective. This study complied with the Ethical Guidelines for Medical and Health Research Involving Human Subjects in Japan and with the Declaration of Helsinki guidelines for investigations involving humans, and all methods were carried out in accordance with the relevant guidelines and regulations for observational studies. The Institutional Review Board of all five institutes approved the current study. The names of institutional review boards of all participating centers are as follows: Institutional Review Boards of Iwate Prefectural Central Hospital, National Cerebral and Cardiovascular Center, Yokohama Shintoshi Hospital, Saiseikai Fukuoka General Hospital, and Osaka university. CS was diagnosed based on the Stop Stroke Study-Trial of Org 10172 in Acute Stroke Treatment (SSS-TOAST) system (12). According to this system, after completing diagnostic tests, the local physicians classified a patient as having a cryptogenic embolism when catheter, computed tomography, or magnetic resonance angiography showed an abrupt vessel cutoff in an otherwise normal-appearing artery, which is a culprit of infarction, when imaging evidence showed complete recanalization of the previously occluded artery, or when multiple acute infarctions were present without abnormality in the relevant vessels. The physicians followed the Japanese proposal for clinical indications for ICM (13). Additionally, transesophageal echocardiography, ultrasonic examination for right-to-left shunt, venous duplex ultrasonography, and special blood tests for thrombosis-hemostasis and other parameters for stroke are recommended. In patients without a 24-h Holter electrocardiogram, the physicians confirmed the cardiac monitoring record for 24 h or more without automated rhythm detection.
We obtained the following clinical information from the hospital charts: age, sex, CHADS2 score (14) after index stroke, congestive heart failure, hypertension, diabetes mellitus, plasma B-type natriuretic peptide (BNP) or serum N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, premature atrial contraction (PAC) count in 24-h Holter electrocardiogram, left atrial diameter (LAD), MVO, and the number of days from stroke onset to ICM implantation and from ICM implantation to the first AF episode. MVO was defined as an occlusion of the internal carotid artery, middle cerebral artery occlusion (M1, M2, or M3), anterior cerebral artery, vertebral artery, posterior inferior cerebellar artery, basilar artery, or posterior cerebral artery. Given the small sample size, we stratified the continuous variables according to clinically relevant thresholds. Among 66 patients with PACs data, the median and IQR of PAC count were 69 and 20–222, respectively. Frequent PACs were therefore defined as more than 222 PACs per day in this study (15). High BNP or NT-proBNP was defined as >100 pg/mL or >300 pg/mL, respectively (16). Large LAD was defined as a diameter of 45 mm or more measured with transthoracic echocardiogram (17).
ICMs (Reveal LINQ; Medtronic, Minneapolis, MN, USA) were implanted under local anesthesia in the left parasternal position at 45 degrees relative to the sternum above the fourth intercostal space. Devices were programmed to detect AF using the company's unique AF detection algorithm. These algorithms recognize AF by assessing the irregularity of R-R peaks in 2 min intervals. The Medtronic CareLink Network was used to transmit device data remotely. The study physician received an alert if the device detected an AF episode. Detected AF episodes were adjudicated by the study physician. The ICM monitoring data up to June 2018 were used for current analysis.
The primary study outcome was the AF detection rate within 90 days from the ICM implantation, and the secondary outcome was found during total follow-up period. The difference in the AF detection rate and the number of days from ICM implantation to the first AF detection was compared between the MVO and non-MVO groups.
Clinical parameters were described using the median (interquartile range [IQR]), or number (%), as appropriate for the data type and distribution. Differences between the MVO and non-MVO groups were evaluated using Fisher's exact test for PAF detection and other categorical variables, and the Student t-test and Mann-Whitney U test were used for continuous variables. A significance level of 0.05 was used for confidence intervals and other statistical tests. Multivariate logistic regression models were developed to assess the independent association of MVO with AF detection in patients with complete data by adjusting for each of the following clinically relevant factors: age in model 1, CHADS2 score after index stroke in model 2, congestive heart failure in model 3, hypertension in model 4, diabetes mellitus in model 5, large LAD in model 6, high BNPor NT-proBNP in model 7, and frequent PAC in model 8. Age (18–21), CHADS2 score (14), congestive heart failure (19), hypertension (19), diabetes mellitus (19), large LAD (17, 18, 21), high BNP or NT-proBNP (16, 22), and frequent PAC (15) were shown to be associated with AF in CS. We compared the number of days from ICM implantation to AF detection between the MVO and non-MVO groups using the log-rank test and Cox proportional-hazards model, adjusting for the above-mentioned factors. All analyses were performed using JMP (version 12.0.1; SAS Institute, Cary, NC, USA).
During the study period, 3,348 patients with acute ischemic stroke were admitted to the participating stroke centers. Based on the TOAST criteria, 626 patients were diagnosed as CS. Among them, 84 consecutive patients underwent ICM implantation (Figure 1). The median onset-to-implantation period was 21 (IQR 14–39) days. All patients were followed for at least 90 days after the implantation, and the median follow-up period was 218 (IQR 158–345) days. We could not acquire the data of PACs with 24-h Holter electrocardiogram for 17 patients, natriuretic peptide (both BNP and NT-proBNP) for three patients, or LAD for three patients.
Figure 1. Flowchart of Study Population. Among 3,348 patients with acute ischemic stroke, 84 consecutive patients with insertable ICM implantation were enrolled in the current analysis. ICM, insertable cardiac monitoring; MVO, major vessel occlusion.
The AF detection rate was higher in MVO group than non-MVO group within 90 days and during total follow-up period (41% [12/29] vs. 13% [7/55], p < 0.01; 45% [13/29] vs. 18% [10/55], p < 0.01, Table 1). Multivariate logistic regression models demonstrated that the adjusted odds ratios [95% confidence interval (CI)] for AF detection significantly increased in MVO group than in non-MVO group, in each model adjusting for age, CHADS2 score after index stroke, congestive heart failure, hypertension, diabetes mellitus, large LAD, and high BNP or NT-proBNP (all P < 0.05, Table 2). However, the association between MVO and AF detection within total follow up period was dependent on frequent PACs. There was no multicollinearity between MVO and frequent PACs (variance inflation factor = 1.008). The days from ICM implantation to AF detection within 90 days were significantly lower in MVO group than non-MVO group, after adjustment for each clinically relevant factor, and AF detection during total follow-up periods was significantly lower in the MVO group than non-MVO group after adjustment for each clinically relevant factor except frequent PACs (Figure 2 and Table 3).
Figure 2. Kaplan–Meier Estimates from ICM Implantation to AF Detection. Days from implantation of insertable cardiac monitoring to AF detection was significantly shorter in patients with MVO than in those without (log-rank p < 0.01). (A) Detection of atrial fibrillation by 90 days. (B) Detection of atrial fibrillation by whole follow up period. AF, atrial fibrillation; ICM, insertable cardiac monitoring; MVO, major vessel occlusion.
Our results revealed that AF was more frequently detected through ICM in CS patients with MVO than those without MVO. To the best of our knowledge, this is the first report to demonstrate the association between MVO and higher rate of AF detection using ICM in patients with CS. This association was independent of age, CHADS2 score after index stroke, congestive heart failure, hypertension, diabetes mellitus, BNP or NT-proBNP levels, and LAD but dependent on frequent PACs. However, there was no multicollinearity between MVO and frequent PACs. An MVO may therefore be a useful independent predictor of latent AF in CS. Recently, MVO in patients with CS was reported to be independently associated with AF detection through wearable Holter monitoring within a month of stroke onset (9), which was consistent with our results. However, the patients in our cohort underwent ICM implantation 21 (IQR 14–39) days after stroke onset. It is important to combine wearable monitoring in acute phase and ICM in chronic phase after stroke.
A study assessing the thrombus histology in CS with endovascular thrombectomy revealed that CS and cardioembolic stroke showed a strong overlap in histopathologic characteristics, and both were different from arterio-embolic stroke (23). These findings suggest that a cardioembolic cause of stroke may be predominant among CS patients with acute MVO. Although the histological findings were obtained only from patients with thrombectomy, this may be the same in patients with and without thrombectomy because a large registry of data showed that the distribution of risk factors and stroke subtypes were almost the same between patients with and without endovascular thrombectomy (8). Sufficient examination and assessment for latent AF, including long-term monitoring with ICM, should thus be performed in CS patients with MVO.
Several factors are thought to be predictors of latent AF in CS: increased age (18–21), hypertension (19), diabetes mellitus (19), heart failure (19), higher CHADS2 score (14), higher National Institute of Health Stroke Scale score (24), cortical or cerebellar infarcts (25), higher BNP or NT-proBNP levels (16, 22), frequent PACs (15) and atrial run on Holter electrocardiogram (26), and larger LAD on echocardiography (17, 21). Some classes of drugs, including angiotensin II receptor blockers, are suitable candidates for AF prevention (27). From these predictors, we selected age, CHADS2 score, BNP or NT-proBNP levels, and LAD as adjusting variables. Even though we did not explore all the potential risk factors for AF, MVO was independently associated with AF. Due to small sample size, we did not develop multivariate analyses by adjusting for all clinically relevant factors simultaneously but developed multivariate analyses separately by adjusting for each factor.
In the Cryptogenic stroke and Underlying AF (CRYSTAL AF) trial, the median time from randomization to detection of AF was 41 (IQR 14-84) days during the 6-month follow-up period and 84 (IQR 18-265) during the 12-month follow-up period (10). Based on these results, our study defined primary outcome as within 90 days from the ICM implantation. In the present study, the detection of AF within 90 days was observed in 12 among 13 cases during the total follow-up period. It suggests that MVO related AF could be detected relatively early after the index CS.
In our stroke centers, although 626 patients were diagnosed as CS according to SSS-TOAST system, only 84 patients underwent ICM implantation. One of the reasons was that the study period was just after the Japanese authority approval in September 2016. In our cohort, the numbers of the patients who underwent ICM implantation in every quarter of the year were 2, 7, 9, 9, 28, and 29, from the fourth quarter of 2016 to the first quarter of 2018. Additionally, Japanese proposals for clinical indications for ICM implantation are stricter compared to international proposals (12). After sufficient workup examination, we thus did not implant ICM in patients with possible symptoms of stroke, including moderate to severe atherosclerosis on aortic arch, right-to-left shunt, abnormal blood tests on thrombosis-hemostasis, cervico-cerebral artery dissection, active cancer, and two or more simultaneous causes. No ICM was implanted in patients without sufficient workup evaluation. Third, given the cost and invasiveness, we avoided implanting ICM in patients with older age or severe disability. These are also the reasons why the detection rate of AF was high compared with previous reports.
This study has several limitations. First, the sample size was relatively small. The small sample size did not allow us to develop multivariate analyses by adjusting for all clinically relevant factors simultaneously. However, despite a small sample size, we identified clearly a strong association between MVO and AF. Second, we did not explore all the potential risk factors for AF and MVO. There may consequently be potential confounding factors. Third, this study was a retrospective and observational study. Prospective studies are required to validate the relationship between MVO and AF. Fourth, among 626 CS patients, only 84 patients underwent ICM implantation and included in the current analysis, leading to potential selection bias. Lastly, there may be some differences in diagnostic workup between patients with and without MVO, which may also cause potential selection bias.
AF was more frequently detected through ICM in CS patients with MVO than those without MVO. This association was independent of previously known factors associated with AF, which suggests that MVO may be a useful predictor of latent AF. Our data indicated that it is essential to investigate latent AF using long-term recording with ICM in patients with CS presenting with MVO.
Data Availability Statement
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.
The studies involving human participants were reviewed and approved by the Institutional Review Board of all 5 institutes. The name of institutional review boards of all participating centers are as follows: Institutional Review Boards of Iwate Prefectural Central Hospital, National Cerebral and Cardiovascular Center, Yokohama Shintoshi Hospital, Saiseikai Fukuoka General Hospital, and Osaka University. Written informed consent from the (patients/ participants OR patients/participants legal guardian/next of kin) was not required to participate in this study in accordance with the national legislation and the institutional requirements.
RD and HY were responsible for the organization and coordination of the study. KT was the principal investigator and responsible for the data analysis. MM, TI, TH, and NK developed the study design. All authors contributed to the writing of the manuscript and approved the final version. All members contributed to the management or administration of the study.
Conflict of Interest
RD, HY, MM, TI, KS, HY, and KT disclose lecture fees from Medtronic.
The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
We thank all the investigators in the five participating stroke centers: Osaka University Graduate School of Medicine, National Cardiovascular and Cerebral Center, Yokohama Shintoshi Neurosurgical Hospital, Saiseikai Fukuoka General Hospital, and Iwate Prefectural Central Hospital.
3. Kimura K, Minematsu K, Yamaguchi T. Atrial fibrillation as a predictive factor for severe stroke and early death in 15,831 patients with acute ischaemic stroke. J. Neurol. Neurosurg. Psychiatry. (2005) 76:679–83. doi: 10.1136/jnnp.2004.048827
4. EAFT (European Atrial Fibrillation Trial) Study Group. Secondary prevention in non-rheumatic atrial fibrillation after transient ischaemic attack or minor stroke. Lancet. (1993) 342:1255–62. doi: 10.1016/0140-6736(93)92358-Z
7. Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. (2016) 387:1723–31. doi: 10.1016/S0140-6736(16)00163-X
8. Yoshimura S, Sakai N, Uchida K, Yamagami H, Ezura M, Okada Y, et al. Endovascular therapy in ischemic stroke with acute large-vessel occlusion: recovery by endovascular salvage for cerebral ultra-acute embolism Japan registry 2. J. Am. Heart Assoc. (2018) 7:e008796. doi: 10.1136/neurintsurg-2018-SNIS.224
9. Pala J, Juega J, Francisco-Pascual J, Bustamante A, Penalba A, Pala E, et al. Large vessel occlusion is independently associated with atrial fibrillation detection. Eur. J. Neurol. (2020) 27:1618–24. doi: 10.1111/ene.14281
10. Sanna T, Diener HC, Passman RS, Di Lazzaro V, Bernstein RA, Morillo CA, et al. Cryptogenic stroke and underlying atrial fibrillation. N. Engl. J. Med. (2014) 370:2478–86. doi: 10.1056/NEJMoa1313600
11. Iwata T, Todo K, Yamagami H, Morimoto M, Hashimoto T, Doijiri R, et al. High detection rate of atrial fibrillation with insertable cardiac monitor implantation in patients with cryptogenic stroke diagnosed by magnetic resonance imaging. J. Stroke Cerebrovasc. Dis. (2019) 28:2569–73. doi: 10.1016/j.jstrokecerebrovasdis.2019.05.023
12. Hakan Ay, Karen LF, Singhal A, Wade S, Smith, Gregory Sorensen A, et al. An evidence-based causative classification system for acute ischemic stroke. Ann. Neurol. (2005) 58:688–97. doi: 10.1002/ana.20617
13. Toyoda K, Okumura K, Hashimoto Y, Ikeda T, Komatsu T, Hirano T, et al. Identification of covert atrial fibrillation in cryptogenic ischemic stroke: current clinical practice in Japan. J. Stroke Cerebrovasc. Dis. (2016) 25:1829–37. doi: 10.1016/j.jstrokecerebrovasdis.2016.05.012
14. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. (2001) 285:2864–70. doi: 10.1001/jama.285.22.2864
15. Todo K, Iwata T, Doijiri R, Yamagami H, Morimoto M, Hashimoto T, et al. Frequent premature atrial contractions in cryptogenic stroke predict atrial fibrillation detection with insertable cardiac monitoring. Cerebrovasc. Dis. (2020) 49:144–50. [Published correction appears in Cerebrovasc Dis. (2020) 49:1–7]. doi: 10.1159/000505958
16. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur. Heart J. (2016) 18:2129–2200. doi: 10.1093/eurheartj/ehw128
17. Hamatani Y, Ogawa H, Takabayashi K, Yamashita Y, Takagi D, Esato M, et al. Left atrial enlargement is an independent predictor of stroke and systemic embolism in patients with non-valvular atrial fibrillation. Sci. Rep. (2016) 6:31042. doi: 10.1038/srep31042
18. Cotter PE, Martin PJ, Ring L, Warburton EA, Belham M, Pugh PJ. Incidence of atrial fibrillation detected by implantable loop recorders in unexplained stroke. Neurology. (2013) 80:1546–50. doi: 10.1212/WNL.0b013e31828f1828
19. Benjamin EJ, Levy D, Sonya M, Vaziri SM, D'Agostino RB, Belanger AJ, et al. Independent risk factors for atrial fibrillation in a population-based cohort. The Framingham Heart Study. JAMA. (1994) 271:840–44. doi: 10.1001/jama.271.11.840
20. Thijs VN, Brachmann J, Morillo CA, Passman RS, Sanna T, Bernstein RA, et al. Predictors for atrial fibrillation detection after cryptogenic stroke: results from CRYSTAL AF. Neurology. (2016) 86:261–9. doi: 10.1212/WNL.0000000000002282
21. Poli S, Diedler J, Härtig F, Götz N, Bauer A, Sachse T, et al. Insertable cardiac monitors after cryptogenic stroke–a risk factor based approach to enhance the detection rate for paroxysmal atrial fibrillation. Eur. J. Neurol. (2016) 23:375–81. doi: 10.1111/ene.12843
22. Okada Y, Shibazaki K, Kimura K, Iguchi Y, Miki T. Brain natriuretic peptide as a predictor of delayed atrial fibrillation after ischaemic stroke and transient ischaemic attack. Eur. J. Neurol. (2010) 17:326–31. doi: 10.1111/j.1468-1331.2009.02813.x
23. Boeckh-Behrens T, Kleine JF, Zimmer C, Scheipl F, Pelisek J, Schirmer L, et al. Thrombus histology suggests cardioembolic cause in cryptogenic stroke. Stroke. (2016) 47:1864–71. doi: 10.1161/STROKEAHA.116.013105
24. Fujii S, Shibazaki K, Kimura K, Sakai K, Aoki J. A simple score for predicting paroxysmal atrial fibrillation in acute ischemic stroke. J. Neurol. Sci. (2013) 328:83–6. doi: 10.1016/j.jns.2013.02.025
25. Favilla CG, Ingala E, Jara J, Fessler E, Cucchiara B, Messe SR, et al. Predictors of finding occult atrial fibrillation after cryptogenic stroke. Stroke. (2015) 46:1210–15. doi: 10.1161/STROKEAHA.114.007763
26. Gürdogan M, Kehaya S, Korkmaz S, Altay S, Ökan U, Kaya C. The relationship between diffusion-weighted magnetic resonance imaging lesions and 24-hour rhythm holter findings in patients with cryptogenic stroke. Medicina. (2019) 55:38. doi: 10.3390/medicina55020038
27. Maggioni AP, Latini R, Carson PE, Singh SN, Barlera S, Glazer R, et al. Val-HeFT investigators. Valsartan reduces the incidence of atrial fibrillation in patients with heart failure: results from the Valsartan Heart Failure Trial (Val-HeFT). Am. Heart J. (2005) 149:548–57. doi: 10.1016/j.ahj.2004.09.033
Keywords: cryptogenic stroke, insertable cardiac monitors, major-vessel occlusion, paroxysmal atrial fibrillation, stroke recurrence
Citation: Doijiri R, Yamagami H, Morimoto M, Iwata T, Hashimoto T, Sonoda K, Yamazaki H, Koge J, Kimura N and Todo K (2020) Paroxysmal Atrial Fibrillation in Cryptogenic Stroke Patients With Major-Vessel Occlusion. Front. Neurol. 11:580572. doi: 10.3389/fneur.2020.580572
Received: 06 July 2020; Accepted: 29 September 2020;
Published: 12 November 2020.
Edited by:Antonio Arauz, Manuel Velasco Suárez Instituto Nacional de Neurología y Neurocirugía, Mexico
Reviewed by:Miguel A. Barboza, University of Costa Rica, Costa Rica
Juan Manuel Marquez-Romero, Mexican Social Security Institute (IMSS), Mexico
Copyright © 2020 Doijiri, Yamagami, Morimoto, Iwata, Hashimoto, Sonoda, Yamazaki, Koge, Kimura and Todo. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Ryosuke Doijiri, firstname.lastname@example.org


Matrix assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) allows the identification of microorganisms directly from positive blood culture broths. Use of the MALDI-TOF MS for rapid identification of microorganisms from blood culture broths can reduce the turnaround time to identification and may lead to earlier appropriate treatment of bacteremia. During February and April 2010, direct MALDI-TOF MS was routinely performed on all positive blood cultures. During December 2009 and March 2010 no direct MALDI-TOF MS was used. Information on antibiotic therapy was collected from the hospital and intensive care units' information systems from all positive blood cultures during the study period. In total, 253 episodes of bacteremia were included of which 89 during the intervention period and 164 during the control period. Direct performance of MALDI-TOF MS on positive blood culture broths reduced the time till species identification by 28.8-h and was associated with an 11.3% increase in the proportion of patients receiving appropriate antibiotic treatment 24 hours after blood culture positivity (64.0% in the control period versus 75.3% in the intervention period (p0.01)). Routine implementation of this technique increased the proportion of patients on adequate antimicrobial treatment within 24 hours.
Citation: Vlek ALM, Bonten MJM, Boel CHE (2012) Direct Matrix-Assisted Laser Desorption Ionization Time-of-Flight Mass Spectrometry Improves Appropriateness of Antibiotic Treatment of Bacteremia. PLoS ONE 7(3): e32589. https://doi.org/10.1371/journal.pone.0032589
Editor: T. Mark Doherty, Statens Serum Institute, Denmark
Received: September 28, 2011; Accepted: January 30, 2012; Published: March 16, 2012
Copyright: © 2012 Vlek et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: No external funding was received for this study.
Competing interests: The authors have declared that no competing interests exist.
Bloodstream infections are associated with high rates of morbidity and mortality and microbiological identification of causative pathogens is crucial for optimal management. However, conventional identification is based on time-consuming procedures, and species identification and susceptibility testing usually requires at least 48 hours after blood cultures become positive.
Developed in the 1980s , , the MALDI technique is an ionization technique that allows the analysis of biomolecules. Ionized biomolecules are accelerated in an electric field, and different molecules are separated according to their mass to charge ratio. The method is used for detection and characterization of biomolecules with molecular masses between 400 and 350,000 Da. The feasibility of MALDI-TOF MS identification of bacterial colonies from solid media has been assessed on a wide array of clinically relevant bacterial strains as well as yeast isolates. Correct identification at the species level is obtained in 80–95% of bacterial isolates , and in 66–87% when applied directly on positive blood culture broths –.
Faster identification of microorganisms causing bacteremia could allow appropriate species-specific therapy to be started sooner, thereby improving patient outcome and reducing potential development of resistance and possible side effects . Direct application of MALDI-TOF MS on blood culture broth samples after growth identification of automated culture methods (such as the Bactec 9240 system (Becton-Dickinson, Sparks, USA)) might allow earlier implementation of appropriate antimicrobial treatment, but has not been investigated in real-life settings. The aim of this prospective clinical trial was to assess the impact of performing direct MALDI-TOF MS on positive blood cultures on turnaround time and antimicrobial management in patients with bloodstream infections.
The study was conducted between December 2009 and April 2010 in the University Medical Center Utrecht. Direct MALDI-TOF MS was routinely performed on all consecutively positive blood cultures during February and April 2010, and standard care procedures were used in December 2009 and March 2010. In January 2010, technicians were trained in performing direct MALDI-TOF MS analysis. Direct MALDI-TOF MS was performed twice daily on weekdays and once daily during weekends. All episodes of positive blood cultures, based on alerts of the Bactec 9240 system, were included. One episode included all positive blood cultures with the same pathogen(s) within one week in one patient. Cultures were defined as contaminated if Coagulase-negative staphylococci or other cutaneous flora was cultured and not considered clinically relevant by the treating physician. Susceptibility testing was performed using the Phoenix system (Becton-Dickinson, Sparks, USA) during the total study period. Results of susceptibility testing required on average 48 hours after blood cultures became positive. In the standard care group, antibiotic treatment could be adjusted based on the information that was available from Gram staining, culturing results and results of susceptibility testing. In the intervention group, antibiotic treatment could be adjusted based on the results of direct MALDI-TOF MS analysis in addition to the information that was available from Gram staining, culturing results and results of susceptibility testing.
Informed consent was not obtained as included patients were not subjected to extra procedures or questions. No personal information was stored in the study database. As the intervention of this study was purely laboratory based without involvement of patients formal IRB review was not necessary. Samples were collected as part of standard care and samples employed in the analyses were de-identified before access.
Preparation of samples
Five ml of a positive blood culture broth was centrifuged at 170 g for 5 minutes. Subsequently, 3 ml of the supernatant was centrifuged at 1500 g for 5 minutes. The pellet was resuspended in 5 ml of distilled water and centrifuged again at 1500 g for 5 minutes. 3 µl of the pellet was resuspended in 25 µl of 70% formic acid and mixed with 25 µl of acetonitrile. After final centrifugation at 18600 g for 2 minutes, 1 µl of the supernatant was spotted in duplicate onto a MALDI-TOF MS MSP 96 ground steel target plate (#224990, Bruker Daltonics, Bremen, Germany). The spots were overlaid with 1 µl of matrix solution (α-cyano-4-hydroxycinnamic acid, #255344, Bruker Daltonics) and air dried.
Analyses were performed on a microflex LT mass spectrometer (Bruker Daltonics). To identify microorganisms, raw spectra obtained for each isolate were imported into BioTyper software, version 2.0 (Bruker Daltonics), and analysed using default parameter settings. Based on the results of previous studies that showed high percentages of correct identification in isolates with score values above 1.7 , , isolates with spectral score≥1.7 were considered correctly identified.
Data collection and statistical analysis
Times of blood culture positivity were recorded by the Bactec 9240 system and identification times were extracted from the laboratory information system. Antibiotic therapy data (including all changes made) were collected from the hospital and intensive care units' information systems. Antimicrobial therapy was considered inappropriate when isolated pathogens were resistant to prescribed antimicrobial agents or when antibiotic therapy was not according to the hospital guidelines. Species identification based on the Phoenix system (Becton-Dickinson) was considered reference standard.
All episodes were analyzed according to intention-to-treat analysis. Primary outcome measure was the proportion of episodes on adequate antimicrobial treatment within 24 hours. Secondary outcome parameters included identification time, time until the first switch in antibiotic treatment and number of switches in therapy.
Results for continuous variables are expressed as means with standard deviation (SD) or as median with interquartile range (IQR) when not normally distributed, and for categorical variables as percentages with the absolute number between parentheses. Summary data were calculated using a Student's t test (normal distribution) or Mann-Whitney U test (skewed distribution) for continuous variables and by chi-square analysis for categorical variables. Statistical analyses were performed with SPSS version 15.0 (Windows, Chicago, USA).
There were 253 episodes (218 patients) of bacteremia during the 4-month study period; 89 during the direct MALDI-TOF MS period and 164 during the standard care period. This difference in included episodes between both periods results from differences in the total number of blood cultures submitted to the laboratory (1580 during the intervention period vs 1831 during the control period) and the number of blood cultures that became positive (136 during the intervention period vs 244 during the control period). In addition, no direct MALDI-TOF MS was performed on public holidays (figure 1).
Patients included in both periods were comparable with respect to age (53.0 vs 55.0 for direct MALDI-TOF MS versus standard care respectively, p0.37), proportion of ICU patients (20.2% vs 21.3%, p0.84), proportion of paediatric patients (22.5% vs 19.5%, p0.77) and proportion of contaminated blood cultures (13.5% vs 11.0%, p0.56). Most blood cultures grew Gram-positive cocci (59.7%) or Gram-negative bacilli (25.3%) (table S1). Differences in isolated pathogens between the intervention and standard care were not significant (p0.74).
Direct MALDI-TOF MS analysis yielded correct identification in 56.2% of episodes (n = 50) with spectral score≥1.7. No reliable identification was obtained in 39.3% (n = 35) of episodes (no MALDI-TOF identification (n = 25), identification with score value<1.7 (n = 4) or identification of one species while the blood culture yielded 2 or 3 species (n = 6)). In the remaining 4.5% of episodes, no direct MALDI-TOF MS was performed (n = 4).
Of monomicrobial episodes, 63.6% was correctly identified and of episodes caused by Gram-negative bacilli, 87.0% of all identifications were correct (table 1 and table S2). For most polymicrobial episodes, no reliable identification was obtained (table 2).
Direct MALDI-TOF MS analysis resulted in a 28.8-h reduction in the median time to species identification, from 45.2 hours (IQR 35.5–55.9) during standard care to 16.4 hours (IQR 10.3–42.9) in the intervention period (p<0.001) (table 3). In the direct MALDI-TOF MS group, species identification was available within 10 hours in 23.6% of episodes. Without direct MALDI-TOF MS, in 76.2% of episodes identification was only available after more than 35 hours after growth detection.
At the time of blood culture positivity, antimicrobial therapy covered the pathogen(s) isolated from the blood culture in 53.0% (n = 134) of patients (MALDI-TOF MS 55.1%, conventional 51.8%) (p 0.20). In 20.9% (n = 53) of patients antimicrobial therapy was considered inappropriate and in 26.1% (n = 66) of patients blood cultures were considered contaminated or no antimicrobial treatment had been initiated. Inappropriate therapy most frequently occurred for Coagulase-negative staphylococci (n = 12), S. aureus (n = 10), enterococci (n = 8) and for Enterobacteriaceae considered as potential AmpC producers (n = 5) (table S3).
Twenty-four hours after blood culture positivity, proportions of appropriate treatment were 64.0% and 75.3% in the standard care and intervention period, respectively (p0.01) (table 4). If a reliable MALDI-TOF MS result was obtained the proportion of appropriate treatment after 24 hours rose to 82.0%.
Median times until the first switch in antibiotic therapy were 17.5 hours (IQR 9.8–38.8) and 24.0 hours (IQR 9.5–47.0) in the intervention and standard care periods, respectively (p0.30) (table 3). In 57.3% of bacteremia episodes antibiotic therapy was not changed (intervention 55.0%, standard care 58.8%). The number of antibiotic changes and the time till change were not statistically significant between both study groups (data not shown).
In this trial of 253 episodes of bloodstream infections, MALDI-TOF MS directly performed on positive blood culture broths reduced the time until definitive identification of bacterial species by 28.8 hours and increased the proportion of patients on appropriate antimicrobial therapy within 24 hours by 11.3%.
In previous studies, the clinical impact of rapid microbiology results has been investigated by means of different interventions, including the immediate incubation of blood cultures outside the laboratory operation time , reducing turnaround time by the use of the Microscan system (Baxter-Microscan, Sacramento, USA) , more rapid reporting of culture results  and direct analysis of positive blood cultures with the Vitek System (bioMerieux, Marcy-l'Etoile, France) in combination with more rapid reporting of culture results . As a consequence of these interventions, shorter time until the first switch in antibiotic treatment , shorter hospital stay , lower mortality , lower antibiotic use  and lower costs ,  were reported.
Most of these studies examined the clinical effect of more rapid identification in combination with rapid susceptibility testing –, and only one of these studies was restricted to blood culture isolates . Moreover, the exact time of antibiotic switching was not recorded in all studies and different definitions of switching were used , . In this study only the identification time was shortened while the duration of susceptibility testing was left unchanged. Therefore, any change in the proportion of patients on adequate treatment can be attributed to the use of direct MALDI-TOF MS analysis.
Contribution of microbiology results to antimicrobial management depends on local antimicrobial policies and bacterial ecology. This study was performed in a setting where antibiotic resistance is infrequent, which allows species identification to be a more powerful tool than in settings with more complex resistance patterns. Inadequate empirical therapy occurs infrequently in our population because of low resistance levels. For instance, there were no bacteremia episodes with MRSA and vancomycin resistant enterococci and empirical therapy was adequate in the majority of patients already receiving antimicrobial treatment.
In this study antimicrobial therapy was judged inappropriate when isolated pathogens were resistant to prescribed agents or when antibiotic therapy was not according to the hospital guidelines. Consequently, a few antimicrobial regimens judged inappropriate may, although suboptimal, be effective against the causative pathogens. In this study, direct MALDI-TOF MS yielded correct identification in a lower proportion of episodes compared to the results of previous studies. This might be explained by a relatively large proportion of Gram positive and polymicrobial infections in this study, while in other studies polymicrobial samples have been excluded. It is known that Gram positive and polymicrobial infections are often not accurately identified by direct MALDI-TOF MS . However, adaptations in sample processing may increase rates of correctly identified microorganisms , – and thereby increase clinical impact of direct MALDI-TOF MS even further.
Limitations of this study include the fact that the study size was too small to evaluate differences in morbidity or mortality between the intervention group and the standard care group. In addition, MALDI-TOF MS only provides identification without information on antimicrobial susceptibility. This information can guide antibiotic management better in a setting with low levels of antibiotic resistance compared to areas with higher levels of resistance. This may decrease generalizability of our data to countries with higher levels of antibiotic resistance.
In conclusion, the use of direct MALDI-TOF MS on positive blood cultures resulted in a faster identification of microorganisms causing bloodstream infection. Routine implementation of this technique increased the proportion of episodes on adequate antimicrobial treatment within 24 hours. The cost effectiveness of this procedure remains to be determined.
Number of microorganisms identified from episodes of positive blood cultures throughout the study period.
Conventional and direct MALDI-TOF MS identification of isolated pathogens from 77 monobacterial samples.
Conceived and designed the experiments: AV EB MB. Performed the experiments: AV EB. Analyzed the data: AV EB MB. Contributed reagents/materials/analysis tools: AV EB MB. Wrote the paper: AV EB MB.
- 1. Seifert H (2009) The clinical importance of microbiological findings in the diagnosis and management of bloodstream infections. Clin Infect Dis 48: S238–S245.
- 2. Karas M, Bachmann D, Hillenkamp F (1985) Influence of the Wavelength in High-Irradiance Ultraviolet Laser Desorption Mass Spectrometry of Organic Molecules. Anal Chem 57: 2935–9.
- 3. Tanaka K, Waki H, Ido Y, Akita S, Yoshida Y, et al. (1988) Protein and Polymer Analyses up to m/z 100 000 by Laser Ionization Time-of flight Mass Spectrometry. Rapid Commun Mass Spectrom 2: 151–3.
- 4. Bizzini A, Greub G (2010) Matrix-assisted laser desorption ionization time-of-flight mass spectrometry, a revolution in clinical microbial identification. Clin Microbiol Infect 16: 1614–9.
- 5. La Scola B, Raoult D (2009) Direct identification of bacteria in positive blood culture bottles by matrix-assisted laser desorption ionisation time-of-flight mass spectrometry. PLoS One 4: e8041.
- 6. Christner M, Rohde H, Wolters M, Sobottka I, Wegscheider K, et al. (2010) Rapid identification of bacteria from positive blood culture bottles by use of matrix-assisted laser desorption-ionization time of flight mass spectrometry fingerprinting. J Clin Microbiol 48: 1584–91.
- 7. Prod'hom G, Bizzini A, Durussel C, Bille J, Greub G (2010) Matrix-assisted laser desorption ionization-time of flight mass spectrometry for direct bacterial identification from positive blood culture pellets. J Clin Microbiol 48: 1481–3.
- 8. Schmidt V, Jarosch A, Marz P, Sander C, Vacata V, et al. (2011) Rapid identification of bacteria in positive blood culture by matrix-assisted laser desorption ionization time-of-flight mass spectrometry. Eur J Clin Microbiol Infect Dis. In press.
- 9. Deresinski S (2007) Principles of antibiotic therapy in severe infections: optimizing the therapeutic approach by use of laboratory and clinical data. Clin Infect Dis 45: S177–S183.
- 10. Kerremans JJ, van der Bij AK, Goessens W, Verbrugh HA, Vos MC (2009) Immediate incubation of blood cultures outside routine laboratory hours of operation accelerates antibiotic switching. J Clin Microbiol 47: 3520–3.
- 11. Doern GV, Vautour R, Gaudet M, Levy B (1994) Clinical impact of rapid in vitro susceptibility testing and bacterial identification. J Clin Microbiol 32: 1757–62.
- 12. Barenfanger J, Drake C, Kacich G (1999) Clinical and financial benefits of rapid bacterial identification and antimicrobial susceptibility testing. J Clin Microbiol 37: 1415–8.
- 13. Kerremans JJ, Verboom P, Stijnen T, van Hakkaart RL, Goessens W, et al. (2008) Rapid identification and antimicrobial susceptibility testing reduce antibiotic use and accelerate pathogen-directed antibiotic use. J Antimicrob Chemother 61: 428–35.
- 14. Drancourt M (2010) Detection of microorganisms in blood specimens using matrix-assisted laser desorption ionization time-of-flight mass spectrometry: a review. Clin Microbiol Infect 16: 1620–5.
- 15. Ferroni A, Suarez S, Beretti JL, Dauphin B, Bille E, et al. (2010) Real-time identification of bacteria and Candida species in positive blood culture broths by matrix-assisted laser desorption ionization-time of flight mass spectrometry. J Clin Microbiol 48: 1542–8.
- 16. Moussaoui W, Jaulhac B, Hoffmann AM, Ludes B, Kostrzewa M, et al. (2010) Matrix-assisted laser desorption ionization time-of-flight mass spectrometry identifies 90% of bacteria directly from blood culture vials. Clin Microbiol Infect 16: 1631–8.
- 17. Juiz PM, Almela M, Melcion C, Campo I, Esteban C, et al. (2011) A comparative study of two different methods of sample preparation for positive blood cultures for the rapid identification of bacteria using MALDI-TOF MS. Eur J Clin Microbiol Infect Dis. In press.


This review article has for major objective to summarize the old and latest developments on the hormonal controls of pancreatic growth. The article deals with hormonal controls during the fetal, neonatal and adult periods of pancreas development, growth and regeneration. During the fetal period, comparisons were made between studies performed with pancreatic explants and those designed in vivo. After birth, the effects of glucocorticoids, thyroxine, gastrin, bombesin, secretin, cholecystokinin alone or with secretin are reported. In the adults, similar studies were reported on hormones with addition of the effects of neuropeptides, the cell types targeted by hormones and the hormonal control after pancreatectomy and pancreatitis.


Join me in the fight to create a world without type 1 diabetes!
Hello Friends and Family,
On June 18, 2014 we got life changing news when we found out Isaac, our funny, handsome 4 year-old was diagnosed with Type 1 diabetes. Our Journey is just beginning in his lifetime battle with diabetes. As a family we want to do our role in not only making Isaac as "normal" of a kid as he can be, but also supporting the cause, in hopes that one day a cure can be found.
I'll be taking part in this year's walk to raise funds for the millions of people living with and affected by type 1 diabetes (T1D). The money I raise will help JDRF fund critical research to progressively remove the impact of T1D from people's lives until no one has to fear developing the disease.
Type 1 diabetes is a life-threatening autoimmune disease in which a person's pancreas stops producing insulin - a hormone essential to the ability to get energy from food. It strikes both children and adults suddenly and changes life as they know it forever. It cannot be prevented and there is no cure.
Please support me and donate to my Walk fundraising campaign. Your gift will make a difference for millions of people affected by this devastating, life-threatening disease. Won't you please give to JDRF as generously as possible today?
Your donation will count towards the team's fundraising total. In addition, please give credit to the person that asked for your support to recognize them for their efforts in creating a world without type 1 diabetes (T1D).


Introduction: Dysphagia is very common in children with neurological disabilities. These patients usually suffer from respiratory and nutritional problems. The videofluoroscopic swallowing study (VFSS) is the most recommended test to evaluate dysphagia, as it shows the real situation during swallowing. Objectives: To analyse the results obtained in our centre after one year of the implementation of VFSS, the clinical improvement after confirmation, and the prescription of an individualised treatment for the patients affected. Material and methods: VFSS performed in the previous were collected. The following variables were analysed: age, pathology, degree of neurological damage, oral and pharyngeal and/or oesophageal dysphagia and its severity, aspirations, prescribed treatment, and nutritional and respiratory improvement after diagnosis. A statistical analysis was performed using SPSS v21. Results: A total of 61 VFSS were performed. Dysphagia was detected in more than 70%, being moderate-severe in 58%. Aspirations and/or penetrations were recorded in 59%, of which 50% were silent. Adapted diet was prescribed to 56%, and gastrostomy was performed on 13 (21%) patients. A statistical association was found between neurological disease and severity of dysphagia. The degree of motor impairment is related to the presence of aspirations. After VFSS evaluation and treatment adjustment, nutritional improvement was found in Z-score of weight (+ 0.3 SD) and BMI (+ 0.4 SD). There was respiratory improvement in 71% of patients with dysphagia being controlled in the Chest Diseases Department. Conclusions: After implementation of VFSS, a high percentage of patients were diagnosed and benefited from a correct diagnosis and treatment. VFSS is a fundamental diagnostic test that should be included in paediatric centres as a diagnostic method for children with suspected dysphagia.
García Romero, R., Ros Arnal, I., Romea Montañés, M. J., López Calahorra, J. A., Gutiérrez Alonso, C., Izquierdo Hernández, B., & Martín de Vicente, C. (2018). Evaluation of dysphagia. Results after one year of incorporating videofluoroscopy into its study. Anales de Pediatria, 89(2), 92–97. https://doi.org/10.1016/j.anpedi.2017.07.009


Five new coronavirus vaccination centres are opening in Essex today.
The life-saving Covid-19 vaccinations will be delivered to thousands more residents across the county where the new sites are opening.
Chelmsford City Racecourse and Colchester United Football Club are two of the new centres, as well as Cliffs Pavillion and another two venues in Clacton and Thurrock.
Each centre will have the ability to vaccinate hundreds of people a day and thousands a week.
The new centres are among several opening nationally this week as the NHS rapidly accelerates the number of sites it can give the crucial first dose of the vaccine.
They include the Cliffs Pavilion in Southend-on-Sea, the largest purpose-built arts venue in Essex.
Councillor Trevor Harp, Cabinet Member for Health at Southend-on-Sea Borough Council, said: “We are really pleased that the Cliffs Pavilion, an iconic Southend venue, is being used to help support our NHS in the largest vaccination drive in history.
"I’m sure our local community are going to be relieved to have an additional vaccination centre on our doorstep, but I would remind people to only attend if they have an appointment.”
Fraser Garrity, Manager of Chelmsford City Racecourse, said: "We're so pleased to be able to play a small part in helping the NHS carry out this vital function for the local community.
"Our facilities have hosted a wide range of big conferences and events since we opened in 2015, but this is the most important task they will ever be used for.”
Tim Waddington, Colchester United General Manager, added: “At the very start of the pandemic we offered the stadium as a venue for whatever it could be used for by the NHS.
"We have supported the NHS by hosting training programmes and COVID-19 testing - we’re delighted to now see vaccinations starting here.”
People in the top four priority groups including people aged 70 years old and over, and those who are clinically extremely vulnerable, are being invited to book an appointment at the vaccination centres through the national booking service.
The centres will also be vaccinating health and care staff who are being urged to get their first dose as soon as possible to protect themselves and others.
There are six new large-scale vaccination centres in total going live over the coming week:
- Chelmsford City Racecourse
- Colchester United Jobserve Community Stadium
- The Cliffs Pavilion, Southend-on-Sea
- Former Riverwalk School, Bury St Edmunds
- Clacton Hospital
- Alastair Farquharson Centre, Thurrock Community Hospital
It brings the total number of large vaccination centres in Essex and Suffolk to nine after vaccination services opened in The Lodge in Runwell in Wickford, Gainsborough Sports Centre and Harlow Leisurezone.
They are now more than 1,400 vaccination sites nationally in addition to the hospital hubs, GP and pharmacy-led vaccination services already offering coronavirus vaccinations across the region.
Nigel Leonard, Executive Director of Strategy and Transformation at Essex Partnership University NHS Foundation Trust (EPUT), which is coordinating the large vaccination centres across Mid and South Essex and Suffolk and North East Essex, said: “The opening of these centres will have a huge impact on our ability to accelerate vaccinations to the people of Essex and Suffolk and protect those most at risk as quickly as possible.
“I would like to thank my NHS colleagues, partners and everyone involved for their incredible work and dedication to enable these centres to open as quickly as possible.”
The NHS is urging people only to come to a vaccination centre when invited to do so, to help ensure that priority groups are served first and to maintain safe social distancing at every venue.
They also stress that you should not arrive any more than five minutes before your appointment.
NHS staff are also visiting those who are housebound and unable to travel to their local service or vaccination centre.


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Some of the principal treatments carried out by Mr Ngi Wieh Yii at Spire include:
Mr Yii also undertakes surgery for skin cancer.
I have been a Consultant Plastic and Cosmetic Surgeon since 2002.
Non-surgical cosmetic treatment
MBBS / University of Malaya / 1986
Bachelor of Medicine, Bachelor of Surgery
FRCS Ed / Edinburgh / 1990
Fellow Royal College of Surgeons (Edinburgh) Scotland
FRCS (Plast) / London / 1998
Specialist training in plastic surgery
FRCS (Eng) / London / 2012
Fellow of the Royal College of Surgeons
Fellow of the Royal College of Surgeon of England
Fellow of the Royal College of Surgeons of Edinburgh
Fellow of the Royal Society of Medicine
British Association of Plastic, Reconstructive and Aesthetic Surgeons
American Society of Plastic Surgeons
International Society of Aesthetic Plastic Surgery
British Society for Surgery of the Hand
British Medical Association
Consultant Plastic Surgeon, University Hospitals of Leicester NHS TrustBack to top
My personal interests include music, history and travel.Back to top
|Telephone||For appointments at Spire Leicester Hospital 0116 265 3685|
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22 February 2018
Nine Spire Healthcare hospitals have received a top patient safety award from health watchdogs the National Joint Regist…
08 June 2017
Spire Southampton Hospital has cemented its place as one of the top Cardiac hospitals in the country following the resul…


In terms of Women’s health and diet, there are some specific well being issues and dietary wants just for women. Ladies who have had a hysterectomy who have had abnormal pap smears up to now should get themselves checked every year by a health practitioner; there’s nonetheless a danger of abnormal cell progress at the high of the vaginal canal. Women’s Well being now reaches more than 49 million readers worldwide, with 29 editions in 53 nations, and continues to be the quickest-growing ladies’s journal on the planet.
This course is aimed at motivated normal practitioners, gynecologists, cardiologists, internists, oncologists, neurologists, psychologists, nurses, epidemiologists, and public health scientists wishing to develop their data and develop into leaders in women’s NIHES Master students, this can be a three-day elective course.
Soy and Women Well being: Publishing their work within the January 15, 2006 concern of Most cancers Analysis, a group of researchers from West Forest College, Winston-Salem, North Carolina, USA concluded that soy phytoestrogens could shield towards breast cancer danger in post menopausal ladies.
A few of the commonest ladies-particular well being issues are PMS, menopause, and fertility. The American Most cancers Society recommends that women bear a self-examination of their …


Delhi records sharp decline, reports 238 new Covid-19 cases, 24 deaths
The new additions took the Covid-19 case tally of Delhi to 1,430,671 and toll to 24,772, as per the bulletin.
Delhi on Friday witnessed a sharp decline in the number of new infections as it reported 238 new coronavirus disease (Covid-19) cases and 24 fatalities in the last 24 hours, according to the state health bulletin. The new additions took the case tally to 1,430,671 and toll to 24,772, as per the bulletin.
The daily cases in the national capital declined by 67 as 305 new infections were reported on Thursday, the state dashboard for the viral disease showed. Daily fatalities too fell in the past 24 hours as 44 people succumbed to the virus the previous day.
The reduction in the number of new cases and deaths in the Capital comes even after increased testing in the last 24 hours. Around 77,112 samples were tested for Covid-19 on Friday in comparison to over 75,000 tests done on Thursday, as per the state data.
The Covid positivity rate, which was a great concern for Delhi, especially in the month of May, fell to 0.31 per cent on Friday. The positivity rate reduced by 0.10 percentage points, as it stood at 0.41 per cent on Thursday, the state health bulletin showed. The active caseload in Delhi has reached 3,922.
According to the health dashboard of Delhi, the case fatality rate from Covid-19 did not change in the last 24 hours. On Thursday, it stood at 1.73 per cent and is same on Friday as well.
The number of patients that recovered in the last one day amounts to 504, in contrast to 560 on Thursday. The total recoveries in Delhi so far stand at 1,401,977, as per the data.
The total number of containment zones as of Friday is 8,032, while on Thursday it was 9,547, the data showed.
As the coronavirus case trajectory in Delhi is following a downward trend, the number of vaccinated beneficiaries has reached 5,910,350. In the past 24 hours, Delhi vaccinated over 81,000 beneficiaries, according to the data.


posted on Jan, 29 2009 @ 11:13 PM
reply to post by plumranch
Also a vet... I do A LOT of spay/neuter surgeries working for a lot cost spay neuter clinic on the weekends. I routinely use it for a final last
closure for the skin. I typically for example- close the abdominal wall, then the subQ tissue, then the skin using a stitch pattern that goes right
beneath the skin and should and usually does make the skin come together. For cats particularly the feral ones, I use this as well to just cover the
incision. I believe they do not lick it as much after surgery if it is completely closed with the glue allowing the incision site a few days to get
some initial healing in before the cat can really start licking it! I have seen less incision reactions this way, especially in feral spays.
I occasionally do rat surgeries and ALWAYS USE IT!!!! Rats will remove sutures, I do not care if they are subQ or metal or staples they get them out
often compromising the incision site. In vet school my friend’s pet rat removed her spay incision suture to the abdominal wall and was found in her
cage with her intestines just waving in the breeze! (the story had a happy ending, the rat was brought to the emergency clinic at the vet school and
was able to be saved with re-closure and a course of antibiotics). So I ALWAYS use a small suture size to close then use the glue, that is the only
way I have found to reliably stop these guys from removing their sutures!
I can also say I used it on my self once, cause in the middle of the day I F$&^*$d up and did not take my blade off my scalpel when I was done with
one surgery, went to go put the pack in the sink and the blade came through and into my hand. I could have used several stitches but there was no
other vet there and we had a bunch more animals to do, so I glued it! It stung REALLY bad and even though I washed out the cut before hand it got
infected and then all swollen and I had to get the glue off by soaking ect for the wound to drain. It was fine after that.
Lastly, while it is great for just the skin, I NEVER use it on any other wounds or deep in tissue! If too much gets in-between the opposing layers of
skin/tissue it will stop it from healing and can cause a foreign body reaction. People and animals can also have allergic reactions to it! It should
also never be used as replacement for good suturing technique!
If you were out in the wilderness or on the battle field, then I think this is a great option for an initial primary closure of wounds but otherwise
if in need of stitches go to your local ER!


Background: Small round cell tumors (SRCTs) are a broad category of diverse malignant tumors composed of monotonous undifferentiated cells. Involvement of serous fluids by SRCT is rare; however, the identification of exfoliated malignant cells is a crucial component of management and has significant implications for treatment and prognosis. The most common effusion tumors with SRCT morphology include Ewing sarcoma, synovial sarcoma, rhabdomyosarcoma (RMS), small-cell neuroendocrine carcinoma (SCNC), and desmoplastic SRCT, and the cytomorphologic distinction between these tumors is challenging. The purpose of this article is to describe the morphologic features of the most common SRCT in fluids and propose helpful ancillary testing. Summary: Effusion SRCTs display similar primitive and undifferentiated morphologic features although each has subtle variations. Ewing sarcoma is a mesenchymal neoplasm and harbors characteristic translocations t(11;22) (EWSR1-FLI1) or t(21;22) (EWSR1-ERG). In fluids, Ewing sarcoma shows poorly differentiated cells of variable size with round to oval nuclei, prominent nucleoli, and scant cytoplasm. In contrast, synovial sarcoma typically involves extremities and expresses a fusion transcript in t(X;18) (SS18-SSX). This soft tissue neoplasm demonstrates uniform cells with irregular nuclear contours, characteristic nuclear folding, and scant cytoplasm. RMS is a neoplasm arising from skeletal muscle, and the alveolar subtype demonstrates a translocation in t(2;13) (PAX3-FOXO1). The malignant cells show a spectrum of small round cells and pleomorphic large cells with rhabdoid morphology. RMS cells characteristically express myogenin and MyoD1, markers of skeletal muscle differentiation. Although SCNC is not a classic SRCT, the morphology is similar. SCNC demonstrates tight clusters of malignant cells with nuclear molding and salt-and-pepper chromatin. This tumor classically has neuroendocrine differentiation and is positive for synaptophysin and chromogranin on immunohistochemistry. And last, desmoplastic SRCT typically presents as an intra-abdominal mass in young men and characteristically harbors the translocation t(11;22) (p13;q12) (EWSR1-WT1). Cytomorphologically, the tumor shows small monomorphic cells occasionally arranged as rosette-like structures. Key Message: The diagnosis of SRCT can be made in effusion samples and is best achieved with a combination of morphologic features, clinical history, and ancillary testing.


The assigned book (IT IS MUST TO BE UTILIZED FOR THIS WRITTEN ASSIGNMENT) for our course is the following book below and include the PDF file attached titled “Evidence-Based Nursing Practice the Time Is Right” as part of your references as well. Please make sure to utilize APA In-Text citation correctly/appropriately and APA Reference correctly/appropriately:
• Dearholt, S. L., & Dang, D. (2012). Johns Hopkins nursing evidence-based practice: Model and guidelines (2nd ed.). Indianapolis, IN: Sigma Theta Tau International.
QUESTIONS BY THE PROFESSOR THAT NEED TO BE ANSWERED:
Nurses can contribute to the policies and procedures that are created based on the nursing tasks we do. Being that nurses are at the bedside 24/7/365 days a year, nurses are at the forefront of clinical care.
Nurses see what works, what doesn’t and what can be done better. Using this information, implementing practices, in addition to quality Evidence Based Practice (EBP) research nurses can make a safer environment and level of care for our patients.
Organizations need to allow time for nurses to implement EBP! (Keep in mind that I work as a Correctional Nurse that is employed by the largest Jail System in the United States of America, which is the Los Angeles County Sheriff’s Department Medical Services Bureau.)


Asif Khan, Allergy ImmunologyAllergy and Immunology
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Asif Khan, MD
Describe the most rewarding experience that you have had working with a patient?
Hearing families describe how our care at the office provided them a better quality of life. We have had so many rewarding experiences, we couldn't just pick one.
What is your charity organization of choice and why?
Passion and Profession, it's an excellent path for individuals wishing to pursue both a passion and a professional career..
What does living in the Youngstown community mean to you?
Hard working, community focused residents who understand the meaning of family.
What is your favorite quote or saying?
Wisdom is knowing how little you know.
What makes your specialties the right fields of medicine for you?
I enjoy the investigative nature of allergy, and immunology, that is, helping a patient discover the cause of their illness.
Finish this sentence: If I weren't a doctor I would be___.
working on trying to become a doctor.
What Sets Us Apart
We have health plans for everyone, even those uninsured, please visit our site at myallergycenter.com See you soon! Dr. Khan
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As cited throughout this website, there is an abundance of published research on the role and value of CHWs in healthcare settings. Here are just a few that may be of interest to you and your colleagues.
- Patient-Centered Community Health Worker Intervention to Improve Posthospital Outcomes: A Randomized Clinical Trial
- A Randomized Controlled Trial of Asthma Self-management Support Comparing Clinic-Based Nurses and In-Home Community Health Workers
- Community Health Workers and Environmental Interventions for Children with Asthma: A Systematic Review
- Effect of Weatherization Combined with Community Health Worker In-home Education on Asthma Control
- The Impact of Integrating Community Health Workers into the Patient-centered Medical Home
- Improving Asthma Management among African-American Children via a Community Health Worker Model: Findings from a Chicago-Based Pilot Intervention (PDF)
- A Community-Based Asthma Management Program: Effects on Resource Utilization and Quality of Life (PDF)
- Social Return on Investment: CHWs in Cancer Research (PDF)
- Return on Investment from Employment of CHWs
- The Effectiveness of a Community Health Worker Outreach Program on Healthcare Utilization of West Baltimore City Medicaid Patients with Diabetes, with or without Hypertension (PDF)
- Measuring Return on Investment of Outreach by Community Health Workers (PDF)
- The Seattle Times: Program Uses Home Visits to Help Asthmatic Kids Breathe Easier
- The Guide to Community Preventive Services recommends home-based education and interventions to reduce home environmental triggers of asthma, as well as asthma education and social supports to improve outcomes for children with asthma, based on its 2011 scientific review of the research literature and also finds the CHW role to be beneficial and cost-effective in the implementation of these interventions.
- Gutierrez-Kapheim M et al. Utilizing CHW Model for to Communicate Strategies for Asthma Self – Management and Self-Advocacy Strategies Among Public Housing Residents, Journal of Communication in Health Care, Vol 8, Issue 2, May 20, 2015
- Margellos H et al. Improving Asthma Management among African American Children Via a CHW Model: Findings from a Chicago-based Pilot Intervention, Journal of Asthma, Vol 49, Issue 4, February 21, 2012
The intervention was shown to be cost-effective, resulting in an estimated ROI of $5.58 saved per dollar spent. Findings suggest that individualized asthma education provided by a trained, culturally competent CHW is effective in improving asthma management among poorly controlled, inner-city children.
- Peretz, P et al. Community Health Workers as Drivers of a Successful Community-Based Disease Management Initiative, American Journal of Public Health 2012 August 102(8): 1443-1446.
Families participating in the yearlong NYC CHW care coordination program received comprehensive asthma education, home environmental assessments, trigger reduction strategies, and clinical and social referrals. After 12 months, hospitalizations and emergency department visits decreased by more than 50%, and caregiver confidence in controlling the child’s asthma increased to nearly 100%.
- Woods ER, Bhaumik U, Sommer SJ et al. Community Asthma Initiative to Improve Health Outcomes and Reduce Disparities Among Children with Asthma, CDC Morbidity and Mortality Weekly Report, Supplement for Feb 12, 2014, 65(1): 11-20.
This CDC report describes Boston Children’s Hospital’s Community Asthma Initiative, in which nurses and community health workers have assisted in the reduction of asthma-related hospitalizations.


You can become a patient at Danner Dental whether or not you have insurance! Many people believe they can only visit an in-network dentist. Individuals who lack dental insurance coverage may think they are not entitled to quality care without it. For both situations, this is incorrect, except for very restricted HMO or DPO contracts. Everyone deserves quality care and we will do our best to help you receive it.
At Danner Dental, we are an unrestricted dental care provider. That means that Dr. Danner will always discuss and provide all the treatment options available to you. He will do so free of insurance contracts and bias, because he works for you and not your insurance company. Our team is dedicated to helping our patients get the most out of their network benefits, Which is why we work closely with medical insurance experts. Also, as a courtesy to our patients, we are happy to submit all claims for direct reimbursement. Count on us for high-quality dental treatments and procedures you can afford.
For the convenience of our Canton area patients, we accept all major credit cards including Visa, MasterCard, American Express and Discover, as well as HSA/FSA plans and Bitcoin cryptocurrency as payment for treatment.
Accepted Lending Partners and Payment Plans
To further assist patients in finding affordable options for quality care, Danner Dental has established partnerships with trusted lending companies to find monthly payments that will fit most budgets. These include CareCredit™, Alphaeon Credit®, Dental Finance, Lending Club, Proceed Finance, Sunbit, ScratchPay Dental and United Medical Credit. In every case, our treatment coordinator can assist with the application process to make it as easy as possible for you. Click on any of the links below to prequalify or apply for financing, and feel free to contact Danner Dental with any questions or to discuss how to better afford your dental care.


Health and Wellness Schuyler County Office for the Aging aims to get you motivated (or stay motivated) to keep healthy. Living healthy involves eating the right foods, engaging in physical activity, taking medications as prescribed, getting enough sleep, and scheduling routine preventive screenings. Living healthy means living a more vital life.
If you have not done any physical activity in years or you have a disability or chronic illness that inhibits you from participating in physical activity, it is important to note that exercise has been proven to enhance the physical, mental, and emotional well-being for people of any age range or ability level. Even a little bit helps - and it is never too late start. Studies have shown that NOT exercising is far riskier to your health than exercising!
Office for the Aging has contracted with the Arc of Schuyler to provide Tai Chi for Arthritis classes. The Arc of Schuyler offers class series two times per year- once in the Spring and once in the Fall. The Tai Chi classes are evidence-based, meaning this series of classes has been widely tested and evaluated and found to be effective in helping to improve health and reduce the risk of injuries and diseases among older adults. In addition, class instructors have been trained to modify exercises for those with special needs. Classes have a small suggested contribution. Please call the Arc of Schuyler at (607)535-6934 for a schedule of classes.
Office for the Aging offers presentations from area providers on health-related issues. Additionally, some medication management supplies, such as pill organizers and ID bracelets, are available at no cost.
Other Programs offered in Schuyler County~
Bone Builders: These exercise classes are designed to help reduce the incidence of osteoporosis in men and women age 50 and older. Trained RSVP volunteers lead weekly classes, utilizing progressive weight-bearing exercises developed at Tufts University. These FREE classes are offered at sites across Schuyler County. For more information, please contact the Schuyler-Yates RSVP Program at (607)535-7105.
Open Swim: Watkins Glen Central School District offers a lifeguard-supervised family swim program. This is a self-directed program: you may swim laps or do your own aqua-exercises. The hours are 6:00- 7:30pm Monday and Wednesday when school is in session. Please note: There is a $3.00 fee per day for adults. For more information, please visit the Watkins Glen Central School District website at http://wgcsd.org/pool.cfm.
Aqua Aerobics is also available at the school pool through the BOCES Adult Education program. For more information on this, call 1-877-ADULTED.
Seneca Fitness Center: Watkins Glen Central School District offers access to the school’s fitness center daily. There is a cost which can be paid as a daily drop-in rate or through a membership fee which includes a reduced rate for individuals age 65 and older. For more information, please visit the Watkins Glen Central School District website at http://wgcsd.org/fitnesscenter.cfm.
Indoor Track: The Watkins Glen Central School District offers access to the school’s indoor track from 6:30- 7:30am and 5:00- 9:00pm Mon- Fri and 8:30am- 12:30pm both Sat and Sun. There is NO cost to utilize the track. For more information, please visit the Watkins Glen Central School District website at http://wgcsd.org/fitnesscenter.cfm.