Estimated glomerular filtration rate and the risk of stroke in individuals with diabetes mellitus and atrial fibrillation insight from a large contemporary population study.

BACKGROUND: Diabetes mellitus (DM) is associated with increased risk of embolic complications in non-valvular atrial fibrillation (NVAF). Impaired renal function (IRF) increases the risk of stroke as well, but this finding is not consistent among all studies. Our aim was to assess the incidence rates and risk of ischemic stroke and mortality by baseline Estimated Glomerular Filtration Rate (eGFR) levels Among individuals with AF and DM. METHODS: A prospective, historical cohort study using the Clalit Health Services electronic medical records database. Among patients with AF and DM, we compared three groups according to eGFR levels: eGFR ≥ 60, between 30 and 60, and ≤ 30 (mL/min/1.73m2). RESULTS: A total of 17,567 cases were included in the final analysis; of them, 11,013 (62.7%) had eGFR ≥ 60, 4930 (28%) had eGFR between 30 and 60, and 1624 (9.24%) with eGFR ≤ 30. The incidence of stroke per 100 person-years in the three study groups was: 1.88, 2.69, and 3.34, respectively (p < 0.001). IRF was associated with increased risk of stroke in univariate analysis, but not after multivariate adjustment (Adjusted Hazard Ratio (AHR) 0.96 {95%CI; 0.74-1.25} for eGFR 30-60 and 0.96 {95%CI; 0.60-1.55} for eGFR ≤ 30). Mortality per 100 person-years was 10.78, 21.49, and 41.55, respectively (p < 0.001). IRF was associated with increased mortality risk in univariate analysis, as well as in multivariate analysis (AHR 1.08 {95%CI; 0.98-1.18} for eGFR 30-60, and 1.59 {95%CI; 1.37-1.85} for eGFR ≤ 30. CONCLUSION: In patients with NVAF and DM, IRF was not associated with an increased risk of stroke, but severe IRF (eGFR ≤ 30) was associated with increased mortality risk.

Relation of Hemoglobin A1C Levels to Risk of Ischemic Stroke and Mortality in Patients With Diabetes Mellitus and Atrial Fibrillation.

Diabetes mellitus (DM) is associated with an increased risk of complications in atrial fibrillation (AF). This study aimed to assess the incidence and risks of ischemic stroke and mortality according to baseline HbA1c levels in patients with DM and AF. We conducted a cohort study using Clalit Health Services electronic medical records. The study population included all Clalit Health Services members aged ≥25 years, with the first diagnosis of AF between January 1, 2010, and December 31, 2016, who had a diagnosis of DM. The risk of stroke and all-cause death were compared according to HbA1c levels at the time of AF diagnosis: <7.0%, between 7% and 9%, and ≥9%. A total of 44,451 patients with DM and AF were identified. The median age was 75 years (interquartile 65 to 83), and 52.5% were women. During a mean follow-up of 38 months, higher levels of HbA1c were associated with an increased risk of stroke with a dose-dependent response when compared with patients with HbA1c <7% (Adjusted hazard ratio [aHR] =1.30 [95% confidence interval 1.10 to 2.05] for levels between 7% and 9% and 1.60 (95% confidence interval 1.25 to 2.03) for HbA1c >9%, even after adjusting for CHA2DS2-Vasc risk factors and use of oral anticoagulants. The risk for overall mortality was significantly higher in the HBA1C >9% group (aHR = 1.17 [1.07 to 1.28]). In conclusion, in this cohort of patients with AF and DM, HbA1c levels were associated with the risk of stroke in a dose-dependent manner even after accounting for other recognized risk factors for stroke.

Dance Improves Motor, Cognitive, and Social Skills in Children With Developmental Cerebellar Anomalies.

In this multiple single-cases study, we used dance to train sensorimotor synchronization (SMS), motor, and cognitive functions in children with developmental cerebellar anomalies (DCA). DCA are rare dysfunctions of the cerebellum that affect motor and cognitive skills. The cerebellum plays an important role in temporal cognition, including SMS, which is critical for motor and cognitive development. Dancing engages the SMS neuronal circuitry, composed of the cerebellum, the basal ganglia, and the motor cortices. Thus, we hypothesized that dance has a beneficial effect on SMS skills and associated motor and cognitive functions in children with DCA. Seven children (aged 7-11) with DCA participated in a 2-month dance training protocol (3 h/week). A test-retest design protocol with multiple baselines was used to assess children's SMS skills as well as motor, cognitive, and social abilities. SMS skills were impaired in DCA before the training. The training led to improvements in SMS (reduced variability in paced tapping), balance, and executive functioning (cognitive flexibility), as well as in social skills (social cognition). The beneficial effects of the dance training were visible in all participants. Notably, gains were maintained 2 months after the intervention. These effects are likely to be sustained by enhanced activity in SMS brain networks due to the dance training protocol.

[Re]moving Bodies - A Shared Diminished Reality Installation for Exploring Relational Movement.

In this article we explore an epistemic approach we name dis/embodiment and introduce "Articulations," an interdisciplinary project bringing together Virtual Reality (VR) designers, cognitive scientists, dancers, anthropologists, and human-machine interaction specialists. According to Erin Manning, our sense of self and other emerges from processes of bodying and relational movement (becoming oneself by moving in relation with the world). The aim of the project is to exploit the potential of multi-person VR in order to explore the intersubjective dynamics of relational movement and bodying, and to do so with scientific, artistic and therapeutic purposes in mind. To achieve this bridge, we bring up a novel paradigm we name "Shared Diminished Reality". It consists in using minimalist representation to instantiate users' bodies in the virtual space. Instead of using humanoid avatars or full body skeletons, we reduce the representation of the moving bodies to three spheres whose trajectories reflect the tracking of the head and the two wrists. This "diminished"virtual rendition of the body-in-movement, we call dis/embodiment. It provides a simple but clear experience of one's own responsive movement in relation to the world and other bodies. It also allows for subtle manipulations of bodies' perceptual and cross-perceptual feedback and simplifies the tracking and the analysis of movements. After having introduced the epistemic framework, the basic architecture, and the empirical method informing the installation, we present and discuss, as a proof-of-concept, some data collected in a situated experiment at a science-art event. We investigate motion patterns observed in different experimental conditions (in which participants either could or could not see the representation of their own hands in the virtual space) and their relation with subjective reports collected. We conclude with reflection on further possibilities of our installation in exploring bodying and relational movement.

Diagnoses and Health Care Utilization for After-Hours Telemedicine Versus Primary Care Visits.

OBJECTIVE: The use of a nation-wide, pediatricians online (PO) after-hours telemedicine service has been offered in Israel for more than a decade. We sought to compare PO visits with those to the primary care pediatrician (PCP). METHODS: This is a retrospective cross-sectional study using Israel's largest health care provider database. We included children aged 0 to 18 years using either PO or PCP between 2015 and 2018. We compared the baseline characteristics, matching by socioeconomic status, chronic illness, and diagnosis, and compared their admission rates, laboratory testing, and medication prescription. RESULTS: During this study period there were 262,541 PO visits and a random 10% sample of PCP visits which yielded 1,813,103 visits. Users of PO were more likely to have a higher socioeconomic status (43% vs 28.9%), fever (13.3% vs 4.4%) and less likely to have acute respiratory conditions (8.8% vs 16.7%). Users of PO had higher rates of emergency department admissions (2.9% vs 0.4%), hospital admissions (0.9% vs 0.2%), and lower rates of laboratory testing (3.7% vs 7.4%) and medication prescription (42.0% vs 52.0%) within 24 hours. All differences were statistically significant (P < .005). CONCLUSIONS: Our pediatric telemedicine service operating after-hours has been found to be feasible, and widely used, for a myriad of clinical conditions. Significant differences exist between PO and PCP visit characteristics and outcomes. However, it remained unclear whether these differences reflect the difference in the patient population or whether they are the result of the different clinical services. Further research is warranted to clarify this matter.

Pre-Diabetes Increases Stroke Risk in Patients With Nonvalvular Atrial Fibrillation.

BACKGROUND: Diabetes mellitus (DM) increases the risk of embolism in nonvalvular atrial fibrillation (NVAF). The association between pre-diabetes and risk of ischemic stroke has not been studied separately in this population. OBJECTIVES: The purpose of this study was to evaluate whether pre-diabetes is associated with increased risk of stroke and death in patients with NVAF. METHODS: We conducted a historical cohort study using the Clalit Health Services electronic medical records. The study population included all members aged ≥25 years, with a first diagnosis of NVAF between January 1, 2010, and December 31, 2016. We compared 3 groups of individuals: those with pre-diabetes, those with diabetes, and normoglycemic patients. RESULTS: A total of 44,451 cases were identified. The median age was 75 years, and 52.5% were women. During a mean follow-up of 38 months, the incidence rates of stroke (per 100 person-years) were: 1.14 in normoglycemic individuals, 1.40 in those with pre-diabetes, and 2.15 in those with diabetes. In both univariate and multivariate analyses, pre-diabetes was associated with an increased risk of stroke compared with normoglycemic persons (adjusted hazard ratio [adjHR]: 1.19; 95% confidence interval [CI]: 1.01 to 1.4) even after adjustment for CHA2DS2-Vasc risk factors and use of anticoagulants, while diabetes conferred an even higher risk (vs. normoglycemia (adjHR: 1.56; 95% CI: 1.37 to 1.79). The risk for mortality was higher for individuals with diabetes (adjHR: 1.47; 95% CI: 1.41 to 1.54) but not for those with pre-diabetes (adjHR: 0.98; 95% CI: 0.92 to 1.03). CONCLUSIONS: In this cohort of patients with incident NVAF, pre-diabetes was associated with an increased risk of stroke even after accounting for other recognized risk factors.

Combining Inpatient and Outpatient Data for Diagnosis of Non-Valvular Atrial Fibrillation Using Electronic Health Records: A Validation Study.

PURPOSE: Previous studies have demonstrated differences in atrial fibrillation (AF) detection based on data from hospital sources without data from outpatient sources. We investigated the detection of documented diagnoses of non-valvular AF in a large Israeli health-care organization using electronic health record data from multiple sources. PATIENTS AND METHODS: This was an open-chart validation study. Three distinct algorithms for identifying AF in electronic health records, differing in the source of their International Classification of Diseases, Ninth Revision code and use of the associated free text, were defined. Algorithm 1 incorporated inpatient data with outpatient data and the associated free text. Algorithm 2 incorporated inpatient and outpatient data regardless of the free text associated with AF diagnosis. Algorithm 3 used only inpatient data source. These algorithms were compared to a gold standard and their sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. To establish the gold standard (documentation of arrhythmia based on electrocardiography interpretation or a cardiologist's written diagnosis), 200 patients at highest risk for having non-valvular AF were randomly selected for open-chart validation by two physicians. RESULTS: The algorithm that included hospital settings, outpatient settings, and incorporated associated free text in the outpatient records had the optimal balance between all validation measures, with a high level of sensitivity (85.4%), specificity (95.0%), PPV (81.4%), and NPV (96.2%). The alternative algorithm that combined inpatient and outpatient data without free text also performed better than the algorithm that included only hospital data (82.9%, 95.0%, 81.0%, and 95.6%, compared to 70.7%, 96.9%, 85.3%, and 92.8%, sensitivity, specificity, PPV, and NPV, respectively). CONCLUSION: In this study, involving a comprehensive data collection from inpatient and outpatient sources, incorporating outpatient data with inpatient data improved the diagnosis of non-valvular AF compared to inpatient data alone.

Effectiveness of Managing Diabetes During Ramadan Conversation Map intervention: A difference-in-differences (self-comparison) design.

BACKGROUND: Some individuals with diabetes fast during Ramadan despite medical concerns for risk of adverse outcomes. The Managing Diabetes During Ramadan Conversation Map is a self-management education group-based intervention for Muslim individuals with type 2 diabetes, specifically addressing diabetes management during Ramadan. OBJECTIVE: The aim of this study was to evaluate the effectiveness of the Managing Diabetes During Ramadan Conversation Map intervention in improving short-term clinical outcomes and reducing healthcare utilization following Ramadan. DESIGN: This was a retrospective rolling cohort study. SETTINGS: Participants were Clalit Health Services members with type 2 diabetes who participated in the intervention between 2014 and 2017 across Israel. PARTICIPANTS: This study included 1732 participants who enrolled in the intervention over the five-year study period. The cohort was mainly between the ages of 45 and 74 years (83.3%), female (71.9%), of lower socioeconomic status (92.1%), with a diabetes duration of 10 years or more (51.7%), obese (64.0%), and had never smoked (73.8%). METHODS: The data used in this study came from Clalit Health Services' electronic health records, which are integrated in a central data warehouse. We used a difference-in-differences (self-comparison) design to examine the effect of the intervention on changes in laboratory results and healthcare utilization over a six month baseline and follow-up. Mixed model linear regressions and Poisson regressions were used to estimate continuous and count outcomes, respectively. RESULTS: Post intervention, participants experienced a reduction of 8.61 mg/dL in their glucose levels (p = 0.005) and 0.34% in their HbA1c levels (p < 0.001). In a sub-group analysis of participants with HbA1c > 7%, larger reductions in glucose (17.02 mg/dL [p < 0.001]) and HbA1c (0.63% [p < 0.001]) levels were recorded. This sub-group also experienced a reduction of 4.83 mg/dL in LDL level (p = 0.007) and had 0.2 fewer primary care visits (p < 0.001). CONCLUSIONS: Participation in the Managing Diabetes During Ramadan Conversation Map improved patient glucose and HbA1c levels. A greater benefit was reported in those individuals with HbA1c > 7%. These findings hold important global health implications for the millions of individuals with type 2 diabetes for whom Ramadan can pose a challenge in disease control.

Population-based cohort of 500 patients with Gaucher disease in Israel.

OBJECTIVE: To characterise a population-based cohort of patients with Gaucher disease (GD) in Israel relative to the general population and describe sociodemographic and clinical differences by disease severity (ie, enzyme replacement therapy [ERT] use). DESIGN: A cross-sectional study was conducted. SETTING: Data from the Clalit Health Services electronic health record (EHR) database were used. PARTICIPANTS: The study population included all patients in the Clalit EHR database identified as having GD as of 30 June 2014. RESULTS: A total of 500 patients with GD were identified and assessed. The majority were ≥18 years of age (90.6%), female (54.0%), Jewish (93.6%) and 34.8% had high socioeconomic status, compared with 19.0% in the general Clalit population. Over half of patients with GD with available data (51.0%) were overweight/obese and 63.5% had a Charlson Comorbidity Index ≥1, compared with 46.6% and 30.4%, respectively, in the general Clalit population. The majority of patients with GD had a history of anaemia (69.6%) or thrombocytopaenia (62.0%), 40.4% had a history of bone events and 22.2% had a history of cancer. Overall, 41.2% had received ERT. CONCLUSIONS: Establishing a population-based cohort of patients with GD is essential to understanding disease progression and management. In this study, we highlight the need for physicians to monitor patients with GD regardless of their ERT status.

Synchronization, Attention and Transformation: Multidimensional Exploration of the Aesthetic Experience of Contemporary Dance Spectators.

The co-presence of bodies in intersubjective situations can give rise to processes of kinesthetic empathy and physiological synchronization, especially in the context of dance: the body and attention of the spectators are oriented towards the dancers. In this study, we investigate the processes of "body-mind" resonance between a choreography and its spectators, and more specifically the lasting impact of this resonance post-performance. We then explore the relation between the observed effects and subjective measures of attention. The study focuses on the work of the French choreographer Myriam Gourfink, who develops a unique movement, based on the slower breathing of dancers: the breathing generates an extremely slow movement without rhythmic ruptures. Phenomenological studies of her work report changes in temporal perception and changes in bodily attentional states. We made use of two cognitive tasks in order to quantify this change in temporal perception: Spontaneous Motor Tempo (SMT) and Apparent Motion effect (AM) before and after a 40-min live performance. Subjective reports were collected at the end of the performance. Physiological data were recorded before and after the performance. We performed a control experiment with a choreography of a distinctly different quality of movement. Post-Gourfink performance, we observed a significant deceleration of SMT and a decrease in its variability, while AM was reported with longer temporal intervals. Neither of these effects was observed in the control condition. Furthermore, an increase in perception of AM was correlated with a slower breathing rate after the performance. Correlations with subjective reports suggest a link between changes in cognitive and physiological dynamics and the degree of absorption of the spectators in the performance. In addition, these changes were related to specific reported attentional dispositions that we interpret as a form of attentional resonance. The ensemble of the results suggests an expansion of the "specious present" that is related to the slowing of physiological rhythms, and an attentional resonance between spectators and the choreography. The intricate relation we observed between inter-personal resonance and temporal cognition, foregrounds the notion of shared present as a neurophenomenological construct.

Coordinated Interpersonal Behaviour in Collective Dance Improvisation: The Aesthetics of Kinaesthetic Togetherness.

Collective dance improvisation (e.g., traditional and social dancing, contact improvisation) is a participatory, relational and embodied art form which eschews standard concepts in aesthetics. We present our ongoing research into the mechanisms underlying the lived experience of "togetherness" associated with such practices. Togetherness in collective dance improvisation is kinaesthetic (based on movement and its perception), and so can be simultaneously addressed from the perspective of the performers and the spectators, and be measured. We utilise these multiple levels of description: the first-person, phenomenological level of personal experiences, the third-person description of brain and body activity, and the level of interpersonal dynamics. Here, we describe two of our protocols: a four-person mirror game and a 'rhythm battle' dance improvisation score. Using an interpersonal closeness measure after the practice, we correlate subjective sense of individual/group connectedness and observed levels of in-group temporal synchronization. We propose that kinaesthetic togetherness, or interpersonal resonance, is integral to the aesthetic pleasure of the participants and spectators, and that embodied feeling of togetherness might play a role more generally in aesthetic experience in the performing arts.

Neuronal bases of structural coherence in contemporary dance observation.

The neuronal processes underlying dance observation have been the focus of an increasing number of brain imaging studies over the past decade. However, the existing literature mainly dealt with effects of motor and visual expertise, whereas the neural and cognitive mechanisms that underlie the interpretation of dance choreographies remained unexplored. Hence, much attention has been given to the action observation network (AON) whereas the role of other potentially relevant neuro-cognitive mechanisms such as mentalizing (theory of mind) or language (narrative comprehension) in dance understanding is yet to be elucidated. We report the results of an fMRI study where the structural coherence of short contemporary dance choreographies was manipulated parametrically using the same taped movement material. Our participants were all trained dancers. The whole-brain analysis argues that the interpretation of structurally coherent dance phrases involves a subpart (superior parietal) of the AON as well as mentalizing regions in the dorsomedial prefrontal cortex. An ROI analysis based on a similar study using linguistic materials (Pallier et al., 2011) suggests that structural processing in language and dance might share certain neural mechanisms.

Audience entrainment during live contemporary dance performance: physiological and cognitive measures.

Perceiving and synchronizing to a piece of dance is a remarkable skill in humans. Research in this area is very recent and has been focused mainly on entrainment produced by regular rhythms. Here, we investigated entrainment effects on spectators perceiving a non-rhythmic and extremely slow performance issued from contemporary dance. More specifically, we studied the relationship between subjective experience and entrainment produced by perceiving this type of performance. We defined two types of entrainment. Physiological entrainment corresponded to cardiovascular and respiratory coordinated activities. Cognitive entrainment was evaluated through cognitive tasks that quantified time distortion. These effects were thought to reflect attunement of a participant' internal temporal clock to the particularly slow pace of the danced movement. Each participant' subjective experience-in the form of responses to questionnaires-were collected and correlated with cognitive and physiological entrainment. We observe: (a) a positive relationship between psychological entrainment and attention to breathing (their own one or that of dancers); and (b) a positive relationship between cognitive entrainment (reflected as an under-estimation of time following the performance) and attention to their own breathing, and attention to the muscles' dancers. Overall, our results suggest a close relationship between attention to breathing and entrainment. This proof-of-concept pilot study was intended to prove the feasibility of a quantitative situated paradigm. This research is inscribed in a large-scale interdisciplinary project of dance spectating (labodanse.org).

Inference and exact numerical representation in early language development.

How do children as young as 2 years of age know that numerals, like one, have exact interpretations, while quantifiers and words like a do not? Previous studies have argued that only numerals have exact lexical meanings. Children could not use scalar implicature to strengthen numeral meanings, it is argued, since they fail to do so for quantifiers [Papafragou, A., & Musolino, J. (2003). Scalar implicatures: Experiments at the semantics-pragmatics interface. Cognition, 86, 253-282]. Against this view, we present evidence that children's early interpretation of numerals does rely on scalar implicature, and argue that differences between numerals and quantifiers are due to differences in the availability of the respective scales of which they are members. Evidence from previous studies establishes that (1) children can make scalar inferences when interpreting numerals, (2) children initially assign weak, non-exact interpretations to numerals when first acquiring their meanings, and (3) children can strengthen quantifier interpretations when scalar alternatives are made explicitly available.

A role for the second subglottal resonance in lexical access.

Acoustic coupling between the vocal tract and the lower (subglottal) airway results in the introduction of pole-zero pairs corresponding to resonances of the uncoupled lower airway. If the second formant (F2) passes through the second subglottal resonance a discontinuity in amplitude occurs. This work explores the hypothesis that this F2 discontinuity affects how listeners perceive the distinctive feature [back] in transitions from a front vowel (high F2) to a labial stop (low F2). Two versions of the utterances "apter" and "up there" were synthesized with an F2 discontinuity at different locations in the initial VC transition. Subjects heard portions of the utterances with and without the discontinuity, and were asked to identify whether the utterances were real words or not. Results show that the frequency of the F2 discontinuity in an utterance influences the perception of backness in the vowel. Discontinuities of this sort are proposed to play a role in shaping vowel inventories in the world's languages [K. N. Stevens, J. Phonetics 17, 3-46 (1989)]. The results support a model of lexical access in which articulatory-acoustic discontinuities subserve phonological feature identification.