Prefatory Remark

I am honored to have been invited to offer some brief remarks on the problems and challenges confronting American legal education. As a lawyer and legislator, I have seen both the strengths and weaknesses of our legal system, and I believe that some changes may well be in order if we are to address successfully the challenges that lie ahead

Are older people putting themselves at risk when using their walking frames?

Background Walking aids are issued to older adults to prevent falls, however, paradoxically their use has been identified as a risk factor for falling. To prevent falls, walking aids must be used in a stable manner, but it remains unknown to what extent associated clinical guidance is adhered to at home, and whether following guidance facilitates a stable walking pattern. It was the aim of this study to investigate adherence to guidance on walking frame use, and to quantify user stability whilst using walking frames. Additionally, we explored the views of users and healthcare professionals on walking aid use, and regarding the instrumented walking frames (‘Smart Walkers’) utilized in this study. Methods This observational study used Smart Walkers and pressure-sensing insoles to investigate usage patterns of 17 older people in their home environment; corresponding video captured contextual information. Additionally, stability when following, or not, clinical guidance was quantified for a subset of users during walking in an Activities of Daily Living Flat and in a gait laboratory. Two focus groups (users, healthcare professionals) shared their experiences with walking aids and provided feedback on the Smart Walkers. Results Incorrect use was observed for 16% of single support periods and for 29% of dual support periods, and was associated with environmental constraints and a specific frame design feature. Incorrect use was associated with reduced stability. Participants and healthcare professionals perceived the Smart Walker technology positively. Conclusions Clinical guidance cannot easily be adhered to and self-selected strategies reduce stability, hence are placing the user at risk. Current guidance needs to be improved to address environmental constraints whilst facilitating stable walking. The research is highly relevant considering the rising number of walking aid users, their increased falls-risk, and the costs of falls. Trial Registration Not applicable

Reducing Greenhouse Gas Emissions From U.S. Transportation

Outlines the need to cut transportation emissions to limit climate change effects, mitigation options and technologies, policies to promote mitigation, and various scenarios for public attitudes, public policy, technological progress, and energy prices

Biomechanics for inclusive urban design : effects of tactile paving on older adults’ gait when crossing the street

In light of our ageing population it is important that the urban environment is easily accessible and hence supports older adults’ independence. Tactile ‘blister’ paving was originally designed to provide guidance for visually impaired people at pedestrian crossings. However, as research links irregular surfaces to falls in older adults, such paving may have an adverse effect on older people. We investigated the effects of tactile paving on older adults’ gait in a scenario closely resembling “crossing the street”. Gait analysis of 32 healthy older adults showed that tactile, as compared to smooth, paving increases the variability in timing of foot placement by 20%, thereby indicating a disturbance of the rhythmic gait pattern. Moreover, toe-clearance during the swing phase increased by 7% on tactile paving, and the ability to stop upon cue from the traffic light was compromised. These results need to be viewed under consideration of the limitations associated with laboratory studies and real world analysis is needed to fully understand their implications for urban design

Trajectories of dementia-related cognitive decline in a large mental health records derived patient cohort

BACKGROUND: Modeling trajectories of decline can help describe the variability in progression of cognitive impairment in dementia. Better characterisation of these trajectories has significant implications for understanding disease progression, trial design and care planning. METHODS: Patients with at least three Mini-mental State Examination (MMSE) scores recorded in the South London and Maudsley NHS Foundation Trust Electronic Health Records, UK were selected (N = 3441) to form a retrospective cohort. Trajectories of cognitive decline were identified through latent class growth analysis of longitudinal MMSE scores. Demographics, Health of Nation Outcome Scales and medications were compared across trajectories identified. RESULTS: Four of the six trajectories showed increased rate of decline with lower baseline MMSE. Two trajectories had similar initial MMSE scores but different rates of decline. In the faster declining trajectory of the two, a higher incidence of both behavioral problems and sertraline prescription were present. CONCLUSIONS: We find suggestive evidence for association of behavioral problems and sertraline prescription with rate of decline. Further work is needed to determine whether trajectories replicate in other datasets

Surgical results: A justification of the surgeon selection process for the ACAS trial

AbstractPurpose: The selection of surgeons to participate in a prospective randomized trial comparing the efficacy of a surgical method with medical management is critically important because it will have a direct impact on the outcome of the study and the future use of the operation. We report the success of the method used for selecting surgeons who participated in the Asymptomatic Carotid Atherosclerosis Study (ACAS) by examining the surgical morbidity and mortality rates and the outcome of the study.Methods: A Surgical Management Committee established criteria for auditing surgeons who wished to participate in the study. The parameters included a minimum performance of at least 12 carotid endarterectomies (CEA) per year and an audit of each surgeon's last 50 consecutive CEAs with required documentation of a combined neurologic morbidity and mortality rate of <3.0% for asymptomatic patients and <5.0% for all indications including symptomatic patients.Results: As of February 1991, 164 surgeons from 48 medical centers applied for ACAS participation. One hundred seventeen were approved, and their aggregate experience of 5641 operations yielded a combined neurologic morbidity and mortality rate of 2.3% for asymptomatic and symptomatic patients combined. The morbidity and mortality rate for CEA on asymptomatic patients was 1.7%. These surgeons, plus those recruited after February 1991, became investigators in the ACAS trial and were responsible for the surgical care of 825 patients who were randomized to the surgical arm. Seven hundred twenty-four patients actually underwent CEA. One patient (0.14%) died and ten patients (1.38%) had strokes within the 30-day perioperative interval, for a combined stroke or death incidence of 1.52%. The 5-year stroke event rate in the surgical group (including perioperative morbidity and mortality rates) was 5.1%, compared with 11% of patients treated medically, yielding a relative risk reduction of 53% in favor of surgery ( p =0.004).Conclusions: A method for selecting surgeons for participation in the ACAS trial was successful in providing low perioperative morbidity and mortality rates. This materially influenced the outcome of the study in favor of CEA. (J VASC SURG 1996;23:323-8.

Profiling of transcriptional and epigenetic changes during directed endothelial differentiation of human embryonic stem cells identifies FOXA2 as a marker of early mesoderm commitment

Introduction: Differentiation of vascular endothelial cells (ECs) in clinically relevant numbers for injection into ischaemic areas could offer therapeutic potential in the treatment of cardiovascular conditions, including myocardial infarction, peripheral vascular disease and stroke. While we and others have demonstrated successful generation of functional endothelial-like cells from human embryonic stem cells (hESCs), little is understood regarding the complex transcriptional and epigenetic changes that occur during differentiation, in particular during early commitment to a mesodermal lineage. Methods: We performed the first gene expression microarray study of hESCs undergoing directed differentiation to ECs using a monolayer-based, feeder-free and serum-free protocol. Microarray results were confirmed by quantitative RT-PCR and immunocytochemistry, and chromatin immunoprecipitation (ChIP)-PCR analysis was utilised to determine the bivalent status of differentially expressed genes. Results: We identified 22 transcription factors specific to early mesoderm commitment. Among these factors, FOXA2 was observed to be the most significantly differentially expressed at the hESC–EC day 2 timepoint. ChIP-PCR analysis revealed that the FOXA2 transcription start site is bivalently marked with histone modifications for both gene activation (H3K4me3) and repression (H3K27me3) in hESCs, suggesting the transcription factor may be a key regulator of hESC differentiation. Conclusion: This enhanced knowledge of the lineage commitment process will help improve the design of directed differentiation protocols, increasing the yield of endothelial-like cells for regenerative medicine therapies in cardiovascular disease

Baker Center Journal of Applied Public Policy, Vol. III No. I

Welcome to the third issue of the Baker Center Journal for Applied PublicPolicy. I am pleased that this issue, as its predecessors, evidences the vibrancy of the Baker Center’s governance and public policy programs and makes a contribution to our collective understanding about a variety of policy issues currently being discussed in America. Relating to our system of governance, Jess Hale Jr. examines a proposal for a uniform state approach to reining in renegade presidential electors and Professor Glenn Reynolds reviews Jack Goldsmith’s book The Terror Presidency: Law and Judgment Inside the Bush Administration. Relating to media and foreign affairs and the role of the media in political life, Dr. Mike Fitzgerald and two of his students provide us with “A Comparative Study of Images Created by Press Coverage of the United States and the Republic of Belarus.” Relating to health policy, Dr. David Mirvis, recently appointed as a Senior Fellow for Health Policy at the Center, explores the public policy implications of viewing health as an engine of economic growth. Relating to energy and environmental policy, Drs. Bruce Tonn and Amy Gibson and Baker Scholars Stephanie Smith and Rachel Tuck explore U.S. Attitudes and Perspectives on National Energy Policy. I am also very pleased that this issue includes a report of an excellent conference – “Formulation of a Bipartisan Energy and Climate Policy: Toward and Open and Transparent Process “- that was co-sponsored by the Baker Center and the Woodrow Wilson International Center for Scholars. This issue also includes the result ofanother successful collaboration between the Baker and Wilson Centers that focused on “Five Public Policy Ideas for Building Obama’s New Economy.” I look forward to further productive collaborations between the Baker and Wilson Centers. Relating to global security policy, this issue includes a Student Symposium onNational Security. Although the Baker Center Journal has provided an outlet for publication of student scholarship since its inception, I am particularly pleased that the student co-editors - Baker Scholars Elizabeth Wilson Vaughan and Bradford A. Vaughan - took the initiative to expand upon the efforts of their predecessors and to provide us with an expanded set of excellent students essays each of which addresses an important national security policy issue. It is an important part of the Baker Center’s mission to engage UTK students in the political and public policy process, and I applaud our student authors fortheir contributions to this symposium. I hope you find this issue of the Baker Center Journal for Applied Public Policy to be both interesting and thought-provoking and that it will encourage you to participate in America’s unique and wonderful political and policy processes

Experimental Evidence for the Effects of Calcium and Vitamin D on Bone: A Review

Animal models fed low calcium diets demonstrate a negative calcium balance and gross bone loss while the combination of calcium deficiency and oophorectomy enhances overall bone loss. Following oophorectomy the dietary calcium intake required to remain in balance increases some 5 fold, estimated to be approximately 1.3% dietary calcium. In the context of vitamin D and dietary calcium depletion, osteomalacia occurs only when low dietary calcium levels are combined with low vitamin D levels and osteoporosis occurs with either a low level of dietary calcium with adequate vitamin D status or when vitamin D status is low in the presence of adequate dietary calcium intake. Maximum bone architecture and strength is only achieved when an adequate vitamin D status is combined with sufficient dietary calcium to achieve a positive calcium balance. This anabolic effect occurs without a change to intestinal calcium absorption, suggesting dietary calcium and vitamin D have activities in addition to promoting a positive calcium balance. Each of the major bone cell types, osteoblasts, osteoclasts and osteocytes are capable of metabolizing 25 hydroxyvitamin D (25D) to 1,25 dihydroxyvitamin D (1,25D) to elicit biological activities including reduction of bone resorption by osteoclasts and to enhance maturation and mineralization by osteoblasts and osteocytes. Each of these activities is consistent with the actions of adequate circulating levels of 25D observed in vivo