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Wilkinson MJ, Snow H, Downey K, Thomas K, Riddell A, Francis N, Strauss DC, Hayes AJ, Smith MJF, Messiou C. CT diagnosis of ilioinguinal lymph node metastases in melanoma using radiological characteristics beyond size and asymmetry. BJS Open 2021; 5:6104886. [PMID: 33609385 PMCID: PMC7893466 DOI: 10.1093/bjsopen/zraa005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 08/27/2020] [Indexed: 11/23/2022] Open
Abstract
Background Diagnosis of lymph node (LN) metastasis in melanoma with non-invasive methods is challenging. The aim of this study was to evaluate the diagnostic accuracy of six LN characteristics on CT in detecting melanoma-positive ilioinguinal LN metastases, and to determine whether inguinal LN characteristics can predict pelvic LN involvement. Methods This was a single-centre retrospective study of patients with melanoma LN metastases at a tertiary cancer centre between 2008 and 2016. Patients who had preoperative contrast-enhanced CT assessment and ilioinguinal LN dissection were included. CT scans containing significant artefacts obscuring the pelvis were excluded. CT scans were reanalysed for six LN characteristics (extracapsular spread (ECS), minimum axis (MA), absence of fatty hilum (FH), asymmetrical cortical nodule (CAN), abnormal contrast enhancement (ACE) and rounded morphology (RM)) and compared with postoperative histopathological findings. Results A total of 90 patients were included. Median age was 58 (range 23–85) years. Eighty-eight patients (98 per cent) had pathology-positive inguinal disease and, of these, 45 (51 per cent) had concurrent pelvic disease. The most common CT characteristics found in pathology-positive inguinal LNs were MA greater than 10 mm (97 per cent), ACE (80 per cent), ECS (38 per cent) and absence of RM (38 per cent). In multivariable analysis, inguinal LN characteristics on CT indicative of pelvic disease were RM (odds ratio (OR) 3.3, 95 per cent c.i. 1.2 to 8.7) and ECS (OR 4.2, 1.6 to 11.3). Cloquet’s node is known to be a poor predictor of pelvic spread. Pelvic LN disease was present in 50 per cent patients, but only 7 per cent had a pathology-positive Cloquet’s node. Conclusion Additional CT radiological characteristics, especially ECS and RM, may improve diagnostic accuracy and aid clinical decisions regarding the need for inguinal or ilioinguinal dissection.
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Affiliation(s)
- M J Wilkinson
- Department of Academic Surgery, Sarcoma and Melanoma Unit, The Royal Marsden Hospital, London, UK
| | - H Snow
- Department of Academic Surgery, Sarcoma and Melanoma Unit, The Royal Marsden Hospital, London, UK
| | - K Downey
- Department of Radiology, The Royal Marsden Hospital, London, UK
| | - K Thomas
- Statistics Department, The Royal Marsden Hospital, London, UK
| | - A Riddell
- Department of Radiology, The Royal Marsden Hospital, London, UK
| | - N Francis
- Department of Pathology, The Royal Marsden Hospital (Honorary) and Charing Cross Hospital, London, UK
| | - D C Strauss
- Department of Academic Surgery, Sarcoma and Melanoma Unit, The Royal Marsden Hospital, London, UK
| | - A J Hayes
- Department of Academic Surgery, Sarcoma and Melanoma Unit, The Royal Marsden Hospital, London, UK.,Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - M J F Smith
- Department of Academic Surgery, Sarcoma and Melanoma Unit, The Royal Marsden Hospital, London, UK
| | - C Messiou
- Department of Radiology, The Royal Marsden Hospital, London, UK.,Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
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Arnold S, Herschaf KE, Anthony PM, Hausheer JR, O'Brien R, Barban J, McDonald B, Whealton E, Bush NE, Batts C, Thomas K, McKenzie E, Burke R, Panagore PB, Pighini S, Woody T, Honkala I, Atwater PMH. Full Collection of Personal Narratives. Narrat Inq Bioeth 2021; 10:1-31. [PMID: 33416532 DOI: 10.1353/nib.2020.0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Fritsch C, Gout JF, Haroon S, Towheed A, Chung C, LaGosh J, McGann E, Zhang X, Song Y, Simpson S, Danthi PS, Benayoun BA, Wallace D, Thomas K, Lynch M, Vermulst M. Genome-wide surveillance of transcription errors in response to genotoxic stress. Proc Natl Acad Sci U S A 2021; 118:e2004077118. [PMID: 33443141 PMCID: PMC7817157 DOI: 10.1073/pnas.2004077118] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Mutagenic compounds are a potent source of human disease. By inducing genetic instability, they can accelerate the evolution of human cancers or lead to the development of genetically inherited diseases. Here, we show that in addition to genetic mutations, mutagens are also a powerful source of transcription errors. These errors arise in dividing and nondividing cells alike, affect every class of transcripts inside cells, and, in certain cases, greatly exceed the number of mutations that arise in the genome. In addition, we reveal the kinetics of transcription errors in response to mutagen exposure and find that DNA repair is required to mitigate transcriptional mutagenesis after exposure. Together, these observations have far-reaching consequences for our understanding of mutagenesis in human aging and disease, and suggest that the impact of DNA damage on human physiology has been greatly underestimated.
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Affiliation(s)
- C Fritsch
- Department of Cellular and Molecular Biology, University of Pennsylvania, Philadelphia, PA 19104
| | - J-F Gout
- School of Life Sciences, Biodesign Center for Mechanisms of Evolution, Arizona State University, Tempe, AZ 85287
- Department of Biological Sciences, Mississippi State University, Mississippi State, MS 39762
| | - S Haroon
- Department of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA 19104
| | - A Towheed
- Touro College of Osteopathic Medicine, Middletown, NY 10940
| | - C Chung
- School of Gerontology, University of Southern California, Los Angeles, CA 90089
| | - J LaGosh
- School of Gerontology, University of Southern California, Los Angeles, CA 90089
| | - E McGann
- School of Gerontology, University of Southern California, Los Angeles, CA 90089
| | - X Zhang
- Bioinforx, Inc., Madison, WI 53719
| | - Y Song
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, PA 19104
- Raymond G. Perelman Center for Cellular and Molecular Therapeutics, University of Pennsylvania, Philadelphia, PA 19104
| | - S Simpson
- Department of Molecular, Cellular and Biomedical Sciences, University of New Hampshire, Durham, NH 03824
| | - P S Danthi
- School of Gerontology, University of Southern California, Los Angeles, CA 90089
| | - B A Benayoun
- School of Gerontology, University of Southern California, Los Angeles, CA 90089
| | - D Wallace
- Raymond G. Perelman Center for Cellular and Molecular Therapeutics, University of Pennsylvania, Philadelphia, PA 19104
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA 19104
| | - K Thomas
- Department of Molecular, Cellular and Biomedical Sciences, University of New Hampshire, Durham, NH 03824
| | - M Lynch
- School of Life Sciences, Biodesign Center for Mechanisms of Evolution, Arizona State University, Tempe, AZ 85287;
| | - M Vermulst
- School of Gerontology, University of Southern California, Los Angeles, CA 90089;
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA 19104
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Davies K, Thomas K, Barton L, Williams C, Aujayeb A, Premchand N. Idiopathic systemic capillary leak syndrome (Clarkson's disease) presenting with recurrent hypovolemic shock. Acute Med 2021; 20:74-77. [PMID: 33749696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
A 49-year old male with a past medical history of myocardial infarction and compartment syndromes requiring fasciotomies presented on five occasions with hypovolemic shock. We describe his admissions and presumptive diagnoses which required large volumes of intravenous fluids, admission to intensive care for vasopressors and renal replacement therapy. The presentations were always precipitated by a prodrome of fatigue and pre-syncopal episodes. On his last admission, a diagnosis of Idiopathic systemic capillary leak syndrome (ISCLS), also known as Clarkson's Disease, was reached. He is currently receiving high dose intravenous immunoglobulins on a monthly basis.
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Affiliation(s)
- K Davies
- MBChB (Hons) MRes, Clinical Research Fellow in Rheumatology Northumbria Speciailist Emergency Care Hospital, Cramlington, NE23 6NZ
| | - K Thomas
- Advanced Critical Care Practitioner, Northumbria Speciailist Emergency Care Hospital, Cramlington, NE23 6NZ
| | - L Barton
- Acute Medicine and Critical Care Consultant, Northumbria Speciailist Emergency Care Hospital, Cramlington, NE23 6NZ
| | - C Williams
- Haematology Consultant, Northumbria Speciailist Emergency Care Hospital, Cramlington, NE23 6NZ
| | - A Aujayeb
- Respiratory and Acute Medicine Consultant, Northumbria Speciailist Emergency Care Hospital, Cramlington, NE23 6NZ
| | - N Premchand
- Acute Medicine and Infectious Diseases Consultant, Northumbria Speciailist Emergency Care Hospital, Cramlington, NE23 6NZ
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Ferrando-Vivas P, Doidge J, Thomas K, Gould DW, Mouncey P, Shankar-Hari M, Young JD, Rowan KM, Harrison DA. Prognostic Factors for 30-Day Mortality in Critically Ill Patients With Coronavirus Disease 2019: An Observational Cohort Study. Crit Care Med 2021; 49:102-111. [PMID: 33116052 PMCID: PMC7737692 DOI: 10.1097/ccm.0000000000004740] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To identify characteristics that predict 30-day mortality among patients critically ill with coronavirus disease 2019 in England, Wales, and Northern Ireland. DESIGN Observational cohort study. SETTING A total of 258 adult critical care units. PATIENTS A total of 10,362 patients with confirmed coronavirus disease 2019 with a start of critical care between March 1, 2020, and June 22, 2020, of whom 9,990 were eligible (excluding patients with a duration of critical care less than 24 hr or missing core variables). MEASUREMENTS AND MAIN RESULTS The main outcome measure was time to death within 30 days of the start of critical care. Of 9,990 eligible patients (median age 60 yr, 70% male), 3,933 died within 30 days of the start of critical care. As of July 22, 2020, 189 patients were still receiving critical care and a further 446 were still in acute hospital. Data were missing for between 0.1% and 7.2% of patients across prognostic factors. We imputed missing data ten-fold, using fully conditional specification and continuous variables were modeled using restricted cubic splines. Associations between the candidate prognostic factors and time to death within 30 days of the start of critical care were determined after adjustment for multiple variables with Cox proportional hazards modeling. Significant associations were identified for age, ethnicity, deprivation, body mass index, prior dependency, immunocompromise, lowest systolic blood pressure, highest heart rate, highest respiratory rate, Pao2/Fio2 ratio (and interaction with mechanical ventilation), highest blood lactate concentration, highest serum urea, and lowest platelet count over the first 24 hours of critical care. Nonsignificant associations were found for sex, sedation, highest temperature, and lowest hemoglobin concentration. CONCLUSIONS We identified patient characteristics that predict an increased likelihood of death within 30 days of the start of critical care for patients with coronavirus disease 2019. These findings may support development of a prediction model for benchmarking critical care providers.
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Affiliation(s)
| | - James Doidge
- Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Karen Thomas
- Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Doug W Gould
- Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Paul Mouncey
- Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Manu Shankar-Hari
- Intensive Care, Unit, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- School of Immunology & Microbial Sciences, Kings College London, London, United Kingdom
| | - J Duncan Young
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Kathryn M Rowan
- Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - David A Harrison
- Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
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Richards-Belle A, Orzechowska I, Gould DW, Thomas K, Doidge JC, Mouncey PR, Christian MD, Shankar-Hari M, Harrison DA, Rowan KM. COVID-19 in critical care: epidemiology of the first epidemic wave across England, Wales and Northern Ireland. Intensive Care Med 2020; 46:2035-2047. [PMID: 33034689 PMCID: PMC7545019 DOI: 10.1007/s00134-020-06267-0] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 09/26/2020] [Indexed: 01/06/2023]
Abstract
PURPOSE To describe critical care patients with COVID-19 across England, Wales and Northern Ireland and compare them with a historic cohort of patients with other viral pneumonias (non-COVID-19) and with international cohorts of COVID-19. METHODS Extracted data on patient characteristics, acute illness severity, organ support and outcomes from the Case Mix Programme, the national clinical audit for adult critical care, for a prospective cohort of patients with COVID-19 (February to August 2020) are compared with a recent retrospective cohort of patients with other viral pneumonias (non-COVID-19) (2017-2019) and with other international cohorts of critical care patients with COVID-19, the latter identified from published reports. RESULTS 10,834 patients with COVID-19 (70.1% male, median age 60 years, 32.6% non-white ethnicity, 39.4% obese, 8.2% at least one serious comorbidity) were admitted across 289 critical care units. Of these, 36.9% had a PaO2/FiO2 ratio of ≤ 13.3 kPa (≤ 100 mmHg) consistent with severe ARDS and 72% received invasive ventilation. Acute hospital mortality was 42%, higher than for 5782 critical care patients with other viral pneumonias (non-COVID-19) (24.7%), and most COVID-19 deaths (88.7%) occurred before 30 days. Meaningful international comparisons were limited due to lack of standardised reporting. CONCLUSION Critical care patients with COVID-19 were disproportionately non-white, from more deprived areas and more likely to be male and obese. Conventional severity scoring appeared not to adequately reflect their acute severity, with the distribution across PaO2/FiO2 ratio categories indicating acutely severe respiratory disease. Critical care patients with COVID-19 experience high mortality and place a great burden on critical care services.
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Affiliation(s)
- Alvin Richards-Belle
- Intensive Care National Audit and Research Centre (ICNARC), Napier House, 24 High Holborn, London, WC1V 6AZ, UK
| | - Izabella Orzechowska
- Intensive Care National Audit and Research Centre (ICNARC), Napier House, 24 High Holborn, London, WC1V 6AZ, UK
| | - Doug W Gould
- Intensive Care National Audit and Research Centre (ICNARC), Napier House, 24 High Holborn, London, WC1V 6AZ, UK
| | - Karen Thomas
- Intensive Care National Audit and Research Centre (ICNARC), Napier House, 24 High Holborn, London, WC1V 6AZ, UK
| | - James C Doidge
- Intensive Care National Audit and Research Centre (ICNARC), Napier House, 24 High Holborn, London, WC1V 6AZ, UK
| | - Paul R Mouncey
- Intensive Care National Audit and Research Centre (ICNARC), Napier House, 24 High Holborn, London, WC1V 6AZ, UK
| | - Michael D Christian
- The Royal London Hospital, London's Air Ambulance, Barts Health NHS Trust, Whitechapel Road, London, E1 1BB, UK
| | - Manu Shankar-Hari
- Intensive Care Unit, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - David A Harrison
- Intensive Care National Audit and Research Centre (ICNARC), Napier House, 24 High Holborn, London, WC1V 6AZ, UK
| | - Kathryn M Rowan
- Intensive Care National Audit and Research Centre (ICNARC), Napier House, 24 High Holborn, London, WC1V 6AZ, UK.
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Richards-Belle A, Orzechowska I, Doidge J, Thomas K, Harrison DA, Koelewyn A, Christian MD, Shankar-Hari M, Rowan KM, Gould DW. Critical care outcomes, for the first 200 patients with confirmed COVID-19, in England, Wales and Northern Ireland: A report from the ICNARC Case Mix Programme. J Intensive Care Soc 2020; 22:270-279. [PMID: 35145562 PMCID: PMC7548541 DOI: 10.1177/1751143720961672] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background Early in a pandemic, outcomes are biased towards patients with shorter durations of critical illness. We describe 60-day outcomes for patients critically ill with confirmed COVID-19 and explore the potential bias in the weekly reported data by ICNARC. Methods First 200 consecutive patients with confirmed COVID-19, admitted for critical care in England, Wales and Northern Ireland, followed-up for a minimum of 60 days from admission. Outcomes included survival and duration of critical care, receipt/duration of organ support in critical care and hospital survival. Results Mean age was 62.6 years, 70.5% were male, 52.0% were white, 39.2% obese and 9.0% had serious comorbidities. Median APACHE II score was 16 (IQR 12, 19). After 60 days, 83 (41.5%) patients had been discharged from hospital, 15 (7.5%) had been discharged from critical care but remained in hospital, 1 (0.5%) was still receiving critical care, 90 (45.0%) had died while receiving critical care and 11 (5.5%) had died in hospital after discharge from critical care. Median duration of critical care was 14.0 days (IQR 6.1, 23.0) for survivors and 10.0 days (IQR 5.0, 16.0) for non-survivors of critical care. Overall, 158 (79.0%) patients received advanced respiratory support for a median of 13 (IQR 8, 20) calendar days. Compared with weekly reports during the pandemic, critical care mortality started higher than but then decreased below that of the first 200 consecutive patients. Duration of critical care, for both survivors and non-survivors increased over time; however, both were still lower than those for the first 200 consecutive patients. Receipt and duration of organ support increased to values similar to those for the first 200 consecutive patients. Conclusion COVID-19 in critical care has high mortality and places a large burden on resources. Analysis of preliminary data with limited follow-up should be interpreted with caution, particularly for future planning in a pandemic.
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Affiliation(s)
| | | | - James Doidge
- Intensive Care National Audit and Research Centre (ICNARC), London, UK
| | - Karen Thomas
- Intensive Care National Audit and Research Centre (ICNARC), London, UK
| | - David A Harrison
- Intensive Care National Audit and Research Centre (ICNARC), London, UK
| | - Abby Koelewyn
- Intensive Care National Audit and Research Centre (ICNARC), London, UK
| | - Michael D Christian
- London’s Air Ambulance, Barts Health NHS Trust, The Royal London Hospital, London, UK
| | - Manu Shankar-Hari
- Intensive Care Unit, St Thomas’ Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Kathryn M Rowan
- Intensive Care National Audit and Research Centre (ICNARC), London, UK
| | - Doug W Gould
- Intensive Care National Audit and Research Centre (ICNARC), London, UK
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Thomas K, Friedman S, Jorgensen T, Smith A, Lavi M. Enhancing Community Health Workers’ Nutritional Expertise via The ECHO Model. J Acad Nutr Diet 2020. [DOI: 10.1016/j.jand.2020.06.217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Landewé R, van der Heijde D, Dougados M, Baraliakos X, Van den Bosch F, Gaffney K, Bauer L, Hoepken B, de Peyrecave N, Thomas K, Gensler LS. Induction of Sustained Clinical Remission in Early Axial Spondyloarthritis Following Certolizumab Pegol Treatment: 48-Week Outcomes from C-OPTIMISE. Rheumatol Ther 2020; 7:581-599. [PMID: 32529495 PMCID: PMC7410911 DOI: 10.1007/s40744-020-00214-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Achievement of remission is a key treatment goal for patients with axial spondyloarthritis (axSpA). C-OPTIMISE assessed achievement of sustained clinical remission in patients with axSpA, including radiographic (r) and non-radiographic (nr) axSpA, during certolizumab pegol (CZP) treatment, and subsequent maintenance of remission following CZP dose continuation, dose reduction or withdrawal. Here, we report outcomes from the first 48 weeks (induction period) of C-OPTIMISE, during which patients received open-label CZP. METHODS C-OPTIMISE (NCT02505542) was a two-part, multicenter, phase 3b study in adult patients with early axSpA (r-/nr-axSpA), including a 48-week open-label induction period followed by a 48-week maintenance period. Patients with active adult-onset axSpA, < 5 years' symptom duration, and fulfilling Assessment of SpondyloArthritis international Society classification criteria, were included. During the induction period, patients received a loading dose of CZP 400 mg at weeks 0, 2, and 4, followed by CZP 200 mg every 2 weeks (Q2W) up to week 48. The main outcome of the 48-week induction period was the achievement of sustained clinical remission (defined as an Ankylosing Spondylitis Disease Activity Score [ASDAS] < 1.3 at week 32 and < 2.1 at week 36 [or vice versa], and < 1.3 at week 48). RESULTS In total, 736 patients (407 with r-axSpA, 329 with nr-axSpA) were enrolled into the study. At week 48, 43.9% (323/736) of patients achieved sustained remission, including 42.8% (174/407) of patients with r-axSpA and 45.3% (149/329) with nr-axSpA. Patients also demonstrated substantial improvements in axSpA symptoms, MRI outcomes and quality of life measures. Adverse events occurred in 67.9% (500/736) of patients, of which 6.0% (44/736) were serious. CONCLUSIONS Over 40% of patients with early axSpA achieved sustained remission during 48 weeks of open-label CZP treatment. Additionally, patients across the axSpA spectrum demonstrated substantial improvements in imaging outcomes and quality of life following treatment. No new safety signals were identified. TRIAL REGISTRATION NCT02505542.
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Affiliation(s)
- Robert Landewé
- Amsterdam Rheumatology and Clinical Immunology Center, Amsterdam, The Netherlands.
- Zuyderland Medical Center, Heerlen, The Netherlands.
| | | | - Maxime Dougados
- Department of Rheumatology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
- INSERM (U1153): Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris-Cité, Paris, France
| | | | - Filip Van den Bosch
- Department of Internal Medicine and Pediatrics, VIB Center for Inflammation Research, Ghent University, Ghent, Belgium
| | - Karl Gaffney
- Rheumatology Department, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, UK
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Abstract
BACKGROUND AND PURPOSE Blood pressure measurement represents the pressure exerted during heart ejection and filling. There are several ways to measure blood pressure and a valid measure is essential. The purpose of this study was to evaluate the approach to noninvasive blood pressure measurement in children. METHODS Blood pressure measurements were taken using the automatic Phillips MP30 monitor and compared against Welch Allyn blood pressure cuffs with Medline manual sphygmomanometers. RESULTS A total of 492 measurements were taken on 82 subjects, and they demonstrated comparability between automatic and manual devices. CONCLUSIONS Although our study indicated acceptable agreement between automatic and manual blood pressure measurement, it also revealed measurement error remains a concern, with sample size, study protocol, training, and environment all playing a role.
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Skellett S, Orzechowska I, Thomas K, Fortune PM. The landscape of paediatric in-hospital cardiac arrest in the United Kingdom National Cardiac Arrest Audit. Resuscitation 2020; 155:165-171. [PMID: 32768496 DOI: 10.1016/j.resuscitation.2020.07.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 05/31/2020] [Accepted: 07/22/2020] [Indexed: 10/23/2022]
Abstract
AIM To report the patient characteristics and clinical outcome of paediatric in-hospital cardiac arrest in the United Kingdom (UK) National Cardiac Arrest Audit (NCAA) database. METHODS Analysis of all recorded paediatric cardiac arrests in the NCAA dataset over a seven-year period ending on 31 December 2018, within acute children's hospitals (including standalone paediatric hospitals and hospitals with tertiary paediatric services) and acute general hospitals participating in NCAA. In this period 1456 patients (with 1580 events), 1 month to 16 years of age, received chest compressions and/or defibrillation and were attended by a hospital-based resuscitation team in response to an emergency call. The main outcome measure was survival to discharge. RESULTS For this cohort of paediatric in-hospital cardiac arrest patients the overall rates of sustained return of spontaneous circulation (ROSC) were 69.1% with unadjusted survival to hospital discharge of 54.2%. The presenting rhythm was shockable in 4.3% of events and non-shockable in 82.1% (remainder undetermined); rates of survival to hospital discharge associated with these rhythms were 63.9% and 51.7%. A difference in outcomes was observed between Children's hospitals and acute general hospitals with ROSC rates of 79.1% and 55.5% respectively and survival to hospital discharge rates of 57.7% and 49.3% respectively. CONCLUSIONS These first results from the NCAA database describing the outcome of paediatric in-hospital cardiac arrest in UK hospitals will serve as a benchmark from which to assess the future impact of changes in service delivery, organisation and treatment for in-hospital cardiac arrest in young people. Outcomes for specialist paediatric centres should be studied further as higher rates of ROSC and survival to hospital discharge were observed.
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Affiliation(s)
- Sophie Skellett
- Paediatric Intensive Care, VCB, Great Ormond Street Hospital for Children NHS Foundation Trust, 4(th) Floor, London WC1N 3JH, UK.
| | | | | | - Peter-Marc Fortune
- Paediatric Critical Care Unit, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK.
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Thomas K, Cornell P, Zhang W, Carder P, Smith L, Hua C, Rahman M. The Relationship between State Regulations Related to Direct Care Staffing in Assisted Living and Residents’ Outcomes. Health Serv Res 2020. [DOI: 10.1111/1475-6773.13340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- K. Thomas
- Providence VA Medical Center Providence RI United States
| | - P. Cornell
- Providence VA Medical Center Providence RI United States
| | - W. Zhang
- Brown University Providence RI United States
| | - P. Carder
- Oregon Health & Science University ‐ Portland State University School of Public Health Portland OR United States
| | - L. Smith
- Portland State University Portland OR United States
| | - C. Hua
- Brown University Providence RI United States
| | - M. Rahman
- Brown University School of Public Health Providence RI United States
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Rahman M, White E, Thomas K, Jutkowitz E. Rural‐Urban Differences in Survival and Health care Utilization Among Medicare Beneficiaries Diagnosed with Alzheimer’s Disease and Related Dementias. Health Serv Res 2020. [DOI: 10.1111/1475-6773.13347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- M. Rahman
- Brown University School of Public Health Providence RI United States
| | - E. White
- Brown University School of Public Health Providence RI United States
| | - K. Thomas
- Brown University School of Public Health Providence RI United States
| | - E. Jutkowitz
- Brown University School of Public Health Providence RI United States
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65
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Salazar E, Perez KK, Ashraf M, Chen J, Castillo B, Christensen PA, Eubank T, Bernard DW, Eagar TN, Long SW, Subedi S, Olsen RJ, Leveque C, Schwartz MR, Dey M, Chavez-East C, Rogers J, Shehabeldin A, Joseph D, Williams G, Thomas K, Masud F, Talley C, Dlouhy KG, Lopez BV, Hampton C, Lavinder J, Gollihar JD, Maranhao AC, Ippolito GC, Saavedra MO, Cantu CC, Yerramilli P, Pruitt L, Musser JM. Treatment of Coronavirus Disease 2019 (COVID-19) Patients with Convalescent Plasma. Am J Pathol 2020; 190:1680-1690. [PMID: 32473109 PMCID: PMC7251400 DOI: 10.1016/j.ajpath.2020.05.014] [Citation(s) in RCA: 190] [Impact Index Per Article: 47.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 05/21/2020] [Accepted: 05/21/2020] [Indexed: 12/13/2022]
Abstract
Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2, has spread globally, and no proven treatments are available. Convalescent plasma therapy has been used with varying degrees of success to treat severe microbial infections for >100 years. Patients (n = 25) with severe and/or life-threatening COVID-19 disease were enrolled at the Houston Methodist hospitals from March 28, 2020, to April 14, 2020. Patients were transfused with convalescent plasma, obtained from donors with confirmed severe acute respiratory syndrome coronavirus 2 infection who had recovered. The primary study outcome was safety, and the secondary outcome was clinical status at day 14 after transfusion. Clinical improvement was assessed on the basis of a modified World Health Organization six-point ordinal scale and laboratory parameters. Viral genome sequencing was performed on donor and recipient strains. At day 7 after transfusion with convalescent plasma, nine patients had at least a one-point improvement in clinical scale, and seven of those were discharged. By day 14 after transfusion, 19 (76%) patients had at least a one-point improvement in clinical status, and 11 were discharged. No adverse events as a result of plasma transfusion were observed. Whole genome sequencing data did not identify a strain genotype-disease severity correlation. The data indicate that administration of convalescent plasma is a safe treatment option for those with severe COVID-19 disease.
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Affiliation(s)
- Eric Salazar
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas; Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, New York
| | - Katherine K Perez
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas; Department of Pharmacy, Houston Methodist Hospital, Houston, Texas
| | - Madiha Ashraf
- Division of Infectious Diseases, Department of Clinical Medicine, Houston Methodist Hospital, Houston, Texas
| | - Jian Chen
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas
| | - Brian Castillo
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas
| | - Paul A Christensen
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas
| | - Taryn Eubank
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas
| | - David W Bernard
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas; Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, New York
| | - Todd N Eagar
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas; Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, New York
| | - S Wesley Long
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas; Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, New York; Center for Molecular and Translational Human Infectious Diseases, Houston Methodist Research Institute, Houston, Texas
| | - Sishir Subedi
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas
| | - Randall J Olsen
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas; Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, New York; Center for Molecular and Translational Human Infectious Diseases, Houston Methodist Research Institute, Houston, Texas
| | - Christopher Leveque
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas
| | - Mary R Schwartz
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas
| | - Monisha Dey
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas
| | - Cheryl Chavez-East
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas
| | - John Rogers
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas
| | - Ahmed Shehabeldin
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas
| | - David Joseph
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas
| | - Guy Williams
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas
| | - Karen Thomas
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas
| | - Faisal Masud
- Division of Infectious Diseases, Department of Clinical Medicine, Houston Methodist Hospital, Houston, Texas; Department of Anesthesiology and Critical Care, Houston Methodist Hospital, Houston, Texas
| | - Christina Talley
- Academic Office of Clinical Trials, Houston Methodist Research Institute, Houston, Texas
| | - Katharine G Dlouhy
- Academic Office of Clinical Trials, Houston Methodist Research Institute, Houston, Texas
| | - Bevin V Lopez
- Academic Office of Clinical Trials, Houston Methodist Research Institute, Houston, Texas
| | - Curt Hampton
- Academic Office of Clinical Trials, Houston Methodist Research Institute, Houston, Texas
| | - Jason Lavinder
- Department of Molecular Biosciences, Dell Medical School, University of Texas at Austin, Austin, Texas
| | - Jimmy D Gollihar
- Combat Capabilities Development Command (CCDC) Army Research Laboratory-South, University of Texas at Austin, Austin, Texas
| | - Andre C Maranhao
- Department of Molecular Biosciences, Dell Medical School, University of Texas at Austin, Austin, Texas
| | - Gregory C Ippolito
- Department of Molecular Biosciences, Dell Medical School, University of Texas at Austin, Austin, Texas; Department of Oncology, Dell Medical School, University of Texas at Austin, Austin, Texas
| | - Matthew O Saavedra
- Center for Molecular and Translational Human Infectious Diseases, Houston Methodist Research Institute, Houston, Texas
| | - Concepcion C Cantu
- Center for Molecular and Translational Human Infectious Diseases, Houston Methodist Research Institute, Houston, Texas
| | - Prasanti Yerramilli
- Center for Molecular and Translational Human Infectious Diseases, Houston Methodist Research Institute, Houston, Texas
| | - Layne Pruitt
- Center for Molecular and Translational Human Infectious Diseases, Houston Methodist Research Institute, Houston, Texas
| | - James M Musser
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas; Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, New York; Center for Molecular and Translational Human Infectious Diseases, Houston Methodist Research Institute, Houston, Texas.
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66
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Fashaw S, McCreedy E, Thomas K, Shireman T. AGING, DISABILITY, AND END‐OF‐LIFE. Health Serv Res 2020. [DOI: 10.1111/1475-6773.13336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- S. Fashaw
- Brown University Providence RI United States
| | - E. McCreedy
- School of Public Health Brown University Providence RI United States
| | - K. Thomas
- Providence VA Medical Center Providence RI United States
| | - T. Shireman
- School of Public Health Brown University Providence RI United States
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67
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Woods M, Ruddell S, Sandsund C, Thomas K, Shaw C. A Service Development Evaluation of Retrospective Data Exploring Prophylactic Risk-Reducing Advice for Patients with Gynecological Cancers. J Gynecol Surg 2020; 36:198-204. [PMID: 32774074 DOI: 10.1089/gyn.2020.0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Objective: Patients at risk of lymphedema following pelvic lymph-node dissection for gynecologic cancers (PLND) often receive prophylactic risk-reducing advice and compression stockings to wear for 6 months, without clear supportive evidence or evaluation of the impact. This study explored if these measures affected lymphedema development 1 year after PLND. Materials and Methods: Relevant data of patients who had undergone PLND over a 10-year period were allocated into 2 groups: Group A had data on patients who received prophylactic lymphedema risk-reduction advice and compression stockings for to wear for 6 months. Group B had data on patients who did not receive prophylactic lymphedema risk-reduction advice or prophylactic compression stockings. Exclusion criteria were preexisting swelling, medication that increased edema, symptom management during end-of-life care. Data were analyzed for statistical significance between the groups. Results: Of 108 patients, 19/60 patients (35%) in Group A and 6/48 (12.5%) patients in Group B developed lymphedema. There was no statistical difference between the groups for the presence of lymphedema. Conclusions: This study did not show that prophylactic compression stockings reduced the development of lymphedema but suggested an increased awareness of the signs and symptoms of lymphedema among patients who received risk-reducing education and the compression garments. These results should be tested in a prospective, controlled trial, and suggest that a change in current clinical practice is appropriate. (J GYNECOL SURG 36:198).
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Affiliation(s)
- Mary Woods
- Lymphoedema Service, The Royal Marsden National Health Service Foundation Trust, Chelsea, London, United Kingdom
| | - Shannon Ruddell
- Lymphoedema Service, The Royal Marsden National Health Service Foundation Trust, Chelsea, London, United Kingdom
| | - Cathy Sandsund
- Lymphoedema Service, The Royal Marsden National Health Service Foundation Trust, Chelsea, London, United Kingdom
| | - Karen Thomas
- Lymphoedema Service, The Royal Marsden National Health Service Foundation Trust, Chelsea, London, United Kingdom
| | - Clare Shaw
- Lymphoedema Service, The Royal Marsden National Health Service Foundation Trust, Chelsea, London, United Kingdom
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68
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Fashaw S, Thomas K. Assessing Racial‐, Ethnic‐, and Socioeconomic‐Disparities in Access to High‐Quality Home Health Agencies. Health Serv Res 2020. [DOI: 10.1111/1475-6773.13401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- S. Fashaw
- Brown University Providence RI United States
| | - K. Thomas
- Providence VA Medical Center Providence RI United States
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69
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Smith L, Carder P, Bucy T, Winfree J, Brazier J, Zhang W, Kaskie B, Thomas K. Health Services Regulatory Analysis: A Novel Method to Connect Policy to Health Services. Health Serv Res 2020. [DOI: 10.1111/1475-6773.13490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- L. Smith
- Portland State University Portland OR United States
- Oregon Health & Science University ‐ Portland State University School of Public Health Portland OR United States
| | - P. Carder
- Portland State University Portland OR United States
- Oregon Health & Science University ‐ Portland State University School of Public Health Portland OR United States
| | - T. Bucy
- Portland State University Portland OR United States
- Oregon Health & Science University ‐ Portland State University School of Public Health Portland OR United States
| | - J. Winfree
- Portland State University Portland OR United States
| | - J. Brazier
- Brown University Providence RI United States
| | - W. Zhang
- Brown University Providence RI United States
| | - B. Kaskie
- University of Iowa Iowa City IA United States
| | - K. Thomas
- Brown University Providence RI United States
- Providence VA Medical Center Providence RI United States
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70
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Yuan Y, Price M, Thomas K, Van Houtven C, Garrido M. Veteran‐Directed Care Recipients Living in Rural Areas Have Fewer Incidents of Potentially Avoidable Health care Use Compared to Recipients of Other Purchased Care Services. Health Serv Res 2020. [DOI: 10.1111/1475-6773.13342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Y. Yuan
- PEPReC, Boston VA Healthcare System Boston MA United States
- Boston University School of Public Health Boston MA United States
| | - M. Price
- PEPReC, Boston VA Healthcare System Boston MA United States
| | - K. Thomas
- Brown University School of Public Health Providence RI United States
- Providence VA Medical Center Providence RI United States
| | - C. Van Houtven
- Durham Veterans Affairs Health Care System Durham NC United States
- Duke University Durham NC United States
| | - M. Garrido
- PEPReC, Boston VA Healthcare System Boston MA United States
- Boston University School of Public Health Boston MA United States
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71
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Thomas K, Patel A, Sadique MZ, Grieve RD, Mason AJ, Moler S, Gordon AC, Rowan KM, Mouncey PR, Lamontagne F, Harrison DA. Evaluating the clinical and cost-effectiveness of permissive hypotension in critically ill patients aged 65 years or over with vasodilatory hypotension: Statistical and health economic analysis plan for the 65 trial in article. J Intensive Care Soc 2020; 21:230-231. [PMID: 32782462 DOI: 10.1177/1751143720938894] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The 65 trial is a pragmatic, multicentre, parallel-group, open-label, randomised clinical trial of permissive hypotension (targeting a mean arterial pressure target of 60-65 mmHg during vasopressor therapy) versus usual care in critically ill patients aged 65 years or over with vasodilatory hypotension. The trial will recruit 2600 patients from 65 United Kingdom adult general critical care units. The primary outcome is all-cause mortality at 90 days. An economic evaluation is embedded. This paper describes the proposed statistical and health economic analysis for the 65 trial.
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Affiliation(s)
- Karen Thomas
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - Akshay Patel
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - M Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Richard D Grieve
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Alexina J Mason
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Silvia Moler
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Anthony C Gordon
- Section of Anaesthetics, Pain Medicine & Intensive Care, Imperial College London, London, UK.,Intensive Care Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - Francois Lamontagne
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke et Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Canada
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
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72
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Kawamura A, Harris I, Thomas K, Mema B, Mylopoulos M. Exploring How Pediatric Residents Develop Adaptive Expertise in Communication: The Importance of "Shifts" in Understanding Patient and Family Perspectives. Acad Med 2020; 95:1066-1072. [PMID: 31464732 DOI: 10.1097/acm.0000000000002963] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE Communication with patients and families can be complex, especially in challenging discussions. To communicate effectively, expert physicians must often use flexible approaches. This innovative use of knowledge to handle complexity is an essential capability of adaptive expertise. Despite its importance for effective communication and implications for medical education, little is known about how adaptive expertise develops in trainees. The purpose of this study was to explore how pediatric residents developed adaptive expertise in communication. METHOD A constructivist grounded theory study, using observations of physician-patient communication and semistructured interviews as data sources and purposeful sampling of 10 pediatric subspecialty residents at the University of Toronto, was conducted in 2016-2017. Data collection and analysis occurred iteratively, and themes were identified through the research team's constant comparative analysis. RESULTS Residents navigated challenging discussions with patients and families by enabling them to express their own narratives and integrating these with their medical knowledge to provide care. At times, a "shift" in the residents' understanding of the families' perspectives was needed to effectively navigate the discussion. Residents used this shift purposefully to create new communication strategies, resulting in an opportunity for learning. CONCLUSIONS "Shifts" are defined as adjustments in the resident's understanding of a family's perspective that affect clinical care. Analysis suggests that these "shifts" can be understood to support development of adaptive expertise. The workplace learning environment promoted this development by providing opportunities that prepared residents for future learning through active experimentation, offering multiple perspectives and enhancing deeper conceptual learning.
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Affiliation(s)
- Anne Kawamura
- A. Kawamura is associate professor, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada. I. Harris is professor, Department of Medical Education, University of Illinois at Chicago, Chicago, Illinois. K. Thomas is a resident, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada. B. Mema is associate professor, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada. M. Mylopoulos is associate professor, Department of Pediatrics, University of Toronto, Faculty of Medicine, and scientist, Wilson Centre for Research in Education, University of Toronto, Toronto, Ontario, Canada
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73
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Zhou G, Mein R, Game D, Rottenberg G, Bultitude M, Thomas K. Defining the inheritance of cystinuria: Is it always autosomal recessive? EUR UROL SUPPL 2020. [DOI: 10.1016/s2666-1683(20)33297-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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74
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Bultitude M, Thomas K. ‘Cystinuria Support’ – a new dedicated forum for patients with the rare disease cystinuria. EUR UROL SUPPL 2020. [DOI: 10.1016/s2666-1683(20)33058-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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75
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Azimi H, Klaassen AL, Thomas K, Harvey MA, Rainer G. Role of the Thalamus in Basal Forebrain Regulation of Neural Activity in the Primary Auditory Cortex. Cereb Cortex 2020; 30:4481-4495. [PMID: 32244254 DOI: 10.1093/cercor/bhaa045] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Many studies have implicated the basal forebrain (BF) as a potent regulator of sensory encoding even at the earliest stages of or cortical processing. The source of this regulation involves the well-documented corticopetal cholinergic projections from BF to primary cortical areas. However, the BF also projects to subcortical structures, including the thalamic reticular nucleus (TRN), which has abundant reciprocal connections with sensory thalamus. Here we present naturalistic auditory stimuli to the anesthetized rat while making simultaneous single-unit recordings from the ventral medial geniculate nucleus (MGN) and primary auditory cortex (A1) during electrical stimulation of the BF. Like primary visual cortex, we find that BF stimulation increases the trial-to-trial reliability of A1 neurons, and we relate these results to change in the response properties of MGN neurons. We discuss several lines of evidence that implicate the BF to thalamus pathway in the manifestation of BF-induced changes to cortical sensory processing and support our conclusions with supplementary TRN recordings, as well as studies in awake animals showing a strong relationship between endogenous BF activity and A1 reliability. Our findings suggest that the BF subcortical projections that modulate MGN play an important role in auditory processing.
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Affiliation(s)
- H Azimi
- Department of Medicine, University of Fribourg, Fribourg CH-1700, Switzerland
| | - A-L Klaassen
- Department of Medicine, University of Fribourg, Fribourg CH-1700, Switzerland.,Department of Psychology, University of Fribourg, Fribourg CH-1700, Switzerland
| | - K Thomas
- Department of Medicine, University of Fribourg, Fribourg CH-1700, Switzerland
| | - M A Harvey
- Department of Medicine, University of Fribourg, Fribourg CH-1700, Switzerland
| | - G Rainer
- Department of Medicine, University of Fribourg, Fribourg CH-1700, Switzerland
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76
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Havatza K, Togia K, Flouda S, Pieta A, Gioti O, Nikolopoulos D, Kapsala N, Ntourou A, Rapsomaniki P, Gerogianni T, Tseronis D, Aggelakos M, Karageorgas T, Katsimpri P, Bertsias G, Thomas K, Boumpas D, Fanouriakis A. FRI0170 THERAPEUTIC ΤARGETS AND QUALITY INDICATORS IN SYSTEMIC LUPUS ERYTHEMATOSUS (SLE), DEFINED ACCORDING TO THE 2019 UPDATE OF THE EULAR RECOMMENDATIONS: DATA FROM THE “ATTIKON“ LUPUS COHORT. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.6255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:Targets of therapy and quality of care are receiving increased attention in the management of SLE, as outlined in the 2019 update of the EULAR recommendations for SLE treatment.Objectives:To assess compliance with quality indicators and attainment of treatment targets, according to recent EULAR recommendations, in the SLE cohort of “Attikon” Rheumatology Unit.Methods:100 consecutive SLE patients followed for at least one year were. A 30 item Quality Indicator Set (QIS) was developed, according to the 2019 EULAR recommendations for SLE, to include laboratory tests for diagnosis and monitoring, evaluation of disease activity and damage using validated indices, use of patient-reported outcomes, counselling for women’s health and reproduction issues, attainment of targets of therapy [remission or low disease activity state (LLDAS) with low-dose glucocorticoids (GC, ≤7.5mg/day prednizone) and hydroxychloroquine (HCQ dose≤5mg/kg/day)], prevention of disease flares and prevention and management of co-morbidities. Chart review and patient interview was performed to assess the degree of compliance with each item of the QIS and achievement of treatment targets.Results:Disease activity was monitored by means of validated indices in 31% and antiphospholipid antibody testing during the first 6 months from diagnosis was performed in 58.8% of patients. Sustained remission (defined as remission of a sustained period of 12 months) or LLDAS was achieved by only 3% and 22% respectively; in contrast, other targets of therapy, such as ≤1 minor flares during last year, were achieved by 85% (43% had complete absence of flares), with 90.2% of patients receiving low-dose GC and 81.8% corrected HCQ dose. Fertility and pregnancy counselling were offered in 40% (12/30 eligible women) and 63.3% (19/30) of patients, respectively, while 65.4% had a Pap Test and only 3 of 32 eligible patients had received the HPV vaccine. Annual lipid status was assessed in 43% and counselling for smoking cessation in 44.6%. Flu vaccination was performed in 77%, while pneumococcal (including both of the pneumococcal vaccines) and herpes-zoster vaccination, were given in 32.7% and 2% (1/44 eligible patients) respectively.Conclusion:Our real-life data suggest low vaccination rates (excluding flu) and suboptimal management of cardiovascular risk factors in lupus patients. While the majority of patients received the suggested doses of GC and HCQ, only one quarter of patients achieved remission or LLDAS. There is an unmet need for new therapies in SLE to improve therapy targets.References:[1]Arora S, Sequeira W, Yazdany J, Jolly M, “Does Systemic Lupus Erythematosus Care Provided in a Lupus Clinic Result in Higher Quality of Care Than That Provided in a General Rheumatology Clinic?”, Arthritis Care Res. 2018 Dec;70(12):1771-1777. doi: 10.1002/acr.23569. Epub 2018 Nov 10.Disclosure of Interests:KATERINA HAVATZA: None declared, KONSTANTINA TOGIA: None declared, Sofia Flouda: None declared, Antigoni Pieta: None declared, Ourania Gioti: None declared, Dionysis Nikolopoulos: None declared, Noemin Kapsala: None declared, Aliki Ntourou: None declared, Panagiota Rapsomaniki: None declared, Thaleia Gerogianni: None declared, Dimitrios Tseronis: None declared, Michail Aggelakos: None declared, Theofanis Karageorgas: None declared, PELAGIA KATSIMPRI: None declared, George Bertsias Grant/research support from: GSK, Consultant of: Novartis, Konstantinos Thomas: None declared, DIMITRIOS BOUMPAS Grant/research support from: Unrestricted grant support from various pharmaceutical companies, Antonis Fanouriakis Paid instructor for: Paid instructor for Enorasis, Amgen, Speakers bureau: Paid speaker for Roche, Genesis Pharma, Mylan
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Thomas K, Lazarini A, Kaltsonoudis E, Drosos A, Repa A, Sidiropoulos P, Fragkiadaki K, Tektonidou M, Sfikakis P, Tsatsani P, Gazi S, Katsimbri P, Boumpas D, Argyriou E, Boki K, Evangelatos G, Iliopoulos A, Karagianni K, Sakkas L, Melissaropoulos K, Georgiou P, Grika E, Vlachoyiannopoulos P, Dimitroulas T, Garyfallos A, Georganas C, Vounotrypidis P, Ntelis K, Areti M, Kitas GD, Vassilopoulos D. AB1201 INCREASING RATES OF INFLUENZA VACCINATION COVERAGE IN RHEUMATOID ARTHRITIS PATIENTS: DATA FROM A MULTICENTER, LONGITUDINAL COHORT STUDY OF 1,406 PATIENTS. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.4812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:Despite the increased incidence of influenza infection in rheumatoid arthritis (RA) patients, vaccination coverage has been shown to be suboptimal. Prospective data regarding the current rate and predictors of influenza vaccination adherence in RA patients are limited.Objectives:To calculate the current rate and predictors of influenza vaccination in a real-life, prospective, longitudinal RA cohort.Methods:Data regarding demographics, disease characteristics, treatments and co-morbidities from a multi-center, longitudinal cohort of Greek RA patients were collected at baseline and ~ 3 years later. Disease and patient characteristics were compared between patients with at least one influenza vaccine administration and non-vaccinated ones, during the 3 year follow-up period.Results:From a cohort of 1,569 RA patients, 1,406 with available vaccination data at baseline and 3 years later (mean interval: 2.9 years) were included; (women: 80.4%, mean age: 61.8 years, mean disease duration: 9.7 years, RF and/or anti-CCP positive: 50.4%, mean DAS-28 = 3.33, mean HAQ: 0.44, bDMARD use: 44.8%). At baseline, 54.2% of patients reported influenza vaccination in the past (31.8% during the previous season), while during the 3 year follow-up period, 81% had ≥1 influenza vaccinations (p=<0.001). Patients who received ≥1 influenza vaccine were older (63.5 vs. 54.7 years, p<0.001), were more likely to be seropositive (59.2% vs. 45.2%, p<0.001), had higher HAQ (0.46 vs. 0.36, p=0.02) and BMI (27.7 vs. 26.9, p=0.02) at baseline, more likely to be treated with bDMARDs (46.8% vs. 36.4%, p<0.001) and more likely to have chronic lung disease (9.7% vs. 5.3%, p=0.02), dyslipidemia (36.4% vs. 24.2%, p<0.001), hypertension (46.1% vs. 29.2%, p<0.001) and to report vaccination against influenza the previous season before baseline evaluation (34.9% vs. 18.2%, p<0.001). By multivariate analysis, history of influenza vaccination during the last season before baseline (OR=1.87, CI: 1.27-2.74, p=0.001), bDMARD treatment (OR=1.51, CI: 1.07-2.13, p=0.018) and age (OR=1.05, CI: 1.04-1.06, p<0.001) were independent predictors of influenza vaccination.Conclusion:In this ongoing, longitudinal, prospective, real-life RA cohort study, a significant increase in the influenza vaccination coverage was noted (from 53% to 81%). Influenza vaccination was independently associated with recent history of influenza vaccination, older age, and bDMARD treatment.Acknowledgments:Supported by grants from the Greek Rheumatology Society and Professional Association of Rheumatologists.Disclosure of Interests:Konstantinos Thomas: None declared, Argyro Lazarini: None declared, Evripidis Kaltsonoudis: None declared, Alexandros Drosos: None declared, ARGYRO REPA: None declared, Prodromos Sidiropoulos: None declared, Kalliopi Fragkiadaki: None declared, Maria Tektonidou Grant/research support from: AbbVie, MSD, Novartis and Pfizer, Consultant of: AbbVie, MSD, Novartis and Pfizer, Petros Sfikakis Grant/research support from: Grant/research support from Abvie, Novartis, MSD, Actelion, Amgen, Pfizer, Janssen Pharmaceutical, UCB, Panagiota Tsatsani: None declared, Sousana Gazi: None declared, Pelagia Katsimbri: None declared, Dimitrios Boumpas: None declared, Evangelia Argyriou: None declared, Kyriaki Boki: None declared, Gerasimos Evangelatos: None declared, Alexios Iliopoulos: None declared, Konstantina Karagianni: None declared, Lazaros Sakkas: None declared, Konstantinos Melissaropoulos: None declared, Panagiotis Georgiou: None declared, Eleftheria Grika: None declared, PANAYIOTIS VLACHOYIANNOPOULOS: None declared, Theodoros Dimitroulas: None declared, Alexandros Garyfallos Grant/research support from: MSD, Aenorasis SA, Speakers bureau: MSD, Novartis, gsk, Constantinos Georganas: None declared, Periklis Vounotrypidis: None declared, Konstantinos Ntelis: None declared, Maria Areti: None declared, George D Kitas: None declared, Dimitrios Vassilopoulos: None declared
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Landewé RBM, Van der Heijde D, Dougados M, Baraliakos X, Van den Bosch F, Gaffney K, Bauer L, Hoepken B, De Peyrecave N, Thomas K, Gensler LS. OP0103 DOES GENDER, AGE OR SUBPOPULATION INFLUENCE THE MAINTENANCE OF CLINICAL REMISSION IN AXIAL SPONDYLOARTHRITIS FOLLOWING CERTOLIZUMAB PEGOL DOSE REDUCTION? Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.2361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:Previous studies have shown that withdrawing tumour necrosis factor inhibitors (TNFi) in patients (pts) with axial spondyloarthritis (axSpA) who have achieved sustained remission often leads to relapse.1However, none have formally tested TNFi dose reduction strategies in a broad axSpA population or evaluated whether relapse following TNFi dose reduction and withdrawal is associated with a specific demographic subgroup.Objectives:C-OPTIMISE evaluated the percentage of pts without flare after TNFi dose continuation, reduction or withdrawal in adults with early axSpA treated with the Fc-free, PEGylated TNFi certolizumab pegol (CZP). Here, we analyse whether responses to reduced maintenance dose were comparable in pts stratified by axSpA subpopulation, gender and age.Methods:C-OPTIMISE (NCT02505542) was a multicentre, two-part phase 3b study in adults with early (<5 years’ symptom duration) active axSpA (stratified for radiographic [r]- and non-radiographic [nr]- axSpA). Pts received CZP 200 mg every 2 weeks (wks) (Q2W; 400 mg loading dose at Wks 0, 2 and 4) during the open-label induction period. At Wk 48, pts in sustained remission (Ankylosing Spondylitis Disease Activity Score [ASDAS] <1.3 at Wk 32 or 36 [if ASDAS <1.3 at Wk 32, it must be <2.1 at Wk 36, or vice versa] and at Wk 48) were randomised to double-blind full maintenance dose (CZP 200 mg Q2W); reduced maintenance dose (CZP 200 mg every 4 wks [Q4W]) or placebo (PBO) for a further 48 wks (maintenance period). The primary endpoint was the percentage of pts not experiencing a flare (ASDAS ≥2.1 at two consecutive visits or ASDAS >3.5 at any timepoint) during Wks 48–96. Analyses were conducted on subgroups according to axSpA subpopulation, gender and age ≤/> the median age of the randomised set (32 years).Results:During the 48-wk induction period, 43.9% of patients (323/736) achieved sustained remission and 313 pts entered the 48-wk maintenance period (r/nr-axSpA: 168/145 pts; males/females: 247/66 pts; age ≤32/>32: 165/148 pts). During the maintenance period, responses in r- and nr-axSpA pts were comparable across all three randomised arms. 83.9% r-axSpA and 83.3% nr-axSpA pts receiving the full CZP maintenance dose did not experience a flare, and in the reduced maintenance dose arm 82.1% r-axSpA and 75.5% nr-axSpA pts did not experience a flare. In the PBO group this was reduced to 17.9% and 22.9%, respectively. Similar responses were seen in pts stratified by gender or age, with substantially higher percentages of pts randomised to CZP full or reduced maintenance dose remaining free of flares compared to PBO in all subgroups (Figure).Conclusion:The results of C-OPTIMISE indicate that a reduced maintenance dose is suitable for pts with axSpA who achieve sustained remission following 1 year of CZP treatment, regardless of axSpA subpopulation, gender or age. Complete treatment withdrawal is not recommended due to the high risk of flare.References:[1]Landewe R. Lancet 2018;392:134–44.Acknowledgments:This study was funded by UCB Pharma. Editorial services were provided by Costello MedicalDisclosure of Interests:Robert B.M. Landewé Consultant of: AbbVie; AstraZeneca; Bristol-Myers Squibb; Eli Lilly & Co.; Galapagos NV; Novartis; Pfizer; UCB Pharma, Désirée van der Heijde Consultant of: AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli-Lilly, Galapagos, Gilead Sciences, Inc., Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma; Director of Imaging Rheumatology BV, Maxime Dougados Grant/research support from: AbbVie, Eli Lilly, Merck, Novartis, Pfizer and UCB Pharma, Consultant of: AbbVie, Eli Lilly, Merck, Novartis, Pfizer and UCB Pharma, Speakers bureau: AbbVie, Eli Lilly, Merck, Novartis, Pfizer and UCB Pharma, Xenofon Baraliakos Grant/research support from: Grant/research support from: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Consultant of: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Speakers bureau: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Filip van den Bosch Consultant of: AbbVie, Celgene Corporation, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB, Speakers bureau: AbbVie, Celgene Corporation, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB, Karl Gaffney Grant/research support from: AbbVie, Celgene, MSD, Novartis, Pfizer, and UCB Pharma, Consultant of: AbbVie, Celgene, MSD, Novartis, Pfizer, and UCB Pharma, Speakers bureau: AbbVie, Celgene, MSD, Novartis, Pfizer, and UCB Pharma, Lars Bauer Employee of: UCB Pharma, Bengt Hoepken Employee of: UCB Pharma, Natasha de Peyrecave Employee of: UCB Pharma, Karen Thomas Employee of: UCB Pharma, Lianne S. Gensler Grant/research support from: Pfizer, Novartis, UCB, Consultant of: AbbVie, Eli Lilly, GSK, Novartis, UCB
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Panopoulos S, Thomas K, Georgiopoulos G, Boumpas D, Katsiari C, Bertsias G, Drosos A, Boki K, Dimitroulas T, Garyfallos A, Papagoras C, Katsimpri P, Tziortziotis A, Adamichou C, Kaltsonoudis E, Argyriou E, Vosvotekas G, Sfikakis P, Vassilopoulos D, Tektonidou M. FRI0147 PREVALENCE OF COMORBIDITIES IN ANTIPHOSPHOLIPID SYNDROME VERSUS RHEUMATOID ARTHRITIS: A MULTICENTRE, AGE- AND SEX-MATCHED STUDY. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.1883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:Comorbidities in rheumatic diseases (RDs) have been associated with increased morbidity and mortality. Evidence on prevalence of comorbidities in antiphospholipid syndrome (APS) and its difference from high comorbidity burden RDs is limited.Objectives:To compare the prevalence of common comorbidities between APS [primary (PAPS) and Systemic lupus erythematosus (SLE)-APS] and Rheumatoid arthritis (RA) patients.Methods:326 APS patients from the Greek registry (237 women, mean age 48.7±13.4 years, 161 PAPS) were matched 1:2 for age and sex with 652 RA patients from Greek RA Registry. Prevalence of cardiovascular (CV) risk factors, stroke, coronary artery disease (CAD), osteoporosis, diabetes mellitus (DM), Chronic obstructive pulmonary disease (COPD), depression and neoplasms were compared between APS and RA using logistic regression analysis.Results:Regarding CV burden, hyperlipidemia and obesity (ΒMI≥30) were comparable while hypertension, smoking, CAD and stroke were more prevalent in APS compared to RA patients (Table 1). Osteoporosis and depression were more frequent in APS while DM, COPD and neoplasms were comparable between two groups. Comparison of APS subgroups to 1:2 matched RA patients revealed that smoking and stroke were more prevalent in PAPS and SLE-APS vs RA. Hypertension, CAD and osteoporosis were more prevalent only in SLE-APS vs. RA while DM was less prevalent in PAPS vs. RA patients.Table 1.Comparison of comorbidities between Antiphospholipid syndrome (APS) vs. matched Rheumatoid Arthritis (RA) patients and between primary APS (PAPS) or Systemic Lupus Erythematosus-APS (SLE-APS) vs matched RA patientsAPSRAOR*PAPSRAORSLE-APSRAORn (%)326652161322165330Hypertension97 (29.8)136 (21)1.61 (1.19-2.18)40 (25)75 (23.3)1.09 (0.70-1.69)57 (34.6)61 (18.5)2.33 (1.52-3.56)Smoking175 (53.7)264 (40.5)1.70 (1.30-2.22)87 (54)142 (44)1.49 (1.02-2.18)88 (53.3)122 (37)1.95 (1.33-2.85)Hyperlipidemia79 (24.2)135 (20.7)1.23 (0.89-1.68)40 (24.8)62 (19.3)1.39 (0.88-2.18)39 (23.6)73 (22)1.09 (0.70-1.70)Obesity48 (20.5)105 (19.5)1.06 (0.73-1.56)20 (17)51 (19)0.86 (0.49-1.52)28 (24)54 (19.7)1.28 (0.76-2.15)Stroke±66 (20.3)9 (1.4)13.8 (6.5-29.1)36 (22.4)4 (1.2)19.9 (6.6-59.9)30 (18.2)5 (1.5)7.8 (2.7-22.6)Coronary disease±16 (4.9)13 (2)3.14 (1.17-8.45)2 (1.2)7 (2.2)0.46 (0.04-4.77)14 (8.5)6 (1.8)10.9 (2.7-44.3)Osteoporosis×66 (20.3)92 (14)1.45 (1.01-2.06)19 (11.8)42 (13)0.96 (0.54-1.73)47 (28.5)50 (15)1.91 (1.20-3.05)Diabetes×18 (5.5)58 (9)0.58 (0.33-1.01)5 (3)29 (9)0.34 (0.13-0.89)13 (8)29 (9)0.88 (0.44-1.79)COPD≠11 (3.4)14 (2.2)1.26 (0.56-2.84)3 (1.9)6 (2)0.96 (0.23-4.0)8 (5)8 (2.4)1.28 (0.44-3.72)Depression#53 (16.3)66 (10)1.70 (1.15-2.53)23 (14)30 (9.3)1.69 (0.93-3.05)30 (18.2)36 (10.9)1.65 (0.96-2.84)Neoplasms˅14 (4.3)27 (4.1)1.05 (0.54-2.06)5 (3)12 (3.7)0.84 (0.28-2.52)9 (5.5)15 (4.6)1.31 (0.55-3.1)*OR: Odds ratio, crude or adjusted for: ± age, sex, smoking, hypertension, hyperlipidemia, BMI, corticosteroid (Cs) duration × Cs duration ≠ smoking, Cs duration #sex, disease duration, Cs duration ˅ age, disease durationConclusion:Comorbidity burden in APS (PAPS and SLE-APS) is comparable or even higher to that in RA, entailing a high level of diligence for CV risk prevention, awareness for depression and corticosteroid exposure minimization.Disclosure of Interests:Stylianos Panopoulos: None declared, Konstantinos Thomas: None declared, Georgios Georgiopoulos: None declared, Dimitrios Boumpas Grant/research support from: Unrestricted grant support from various pharmaceutical companies, Christina Katsiari: None declared, George Bertsias Grant/research support from: GSK, Consultant of: Novartis, Alexandros Drosos: None declared, Kyriaki Boki: None declared, Theodoros Dimitroulas: None declared, Alexandros Garyfallos Grant/research support from: MSD, Aenorasis SA, Speakers bureau: MSD, Novartis, gsk, Charalambos Papagoras: None declared, PELAGIA KATSIMPRI: None declared, Apostolos Tziortziotis: None declared, Christina Adamichou: None declared, Evripidis Kaltsonoudis: None declared, Evangelia Argyriou: None declared, GEORGIOS VOSVOTEKAS Grant/research support from: MSD, Janssen, Consultant of: MSD, Novartis, Roche, UCB pharma, Bristol-Myers Squibb, AbbVie, Speakers bureau: UCB pharma, Menarini, Bristol-Myers Squibb, MSD, Petros Sfikakis Grant/research support from: Grant/research support from Abvie, Novartis, MSD, Actelion, Amgen, Pfizer, Janssen Pharmaceutical, UCB, Dimitrios Vassilopoulos: None declared, Maria Tektonidou Grant/research support from: AbbVie, MSD, Novartis and Pfizer, Consultant of: AbbVie, MSD, Novartis and Pfizer
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Karampeli M, Thomas K, Tseronis D, Aggelakos M, Kassara D, Havatza K, Flouda S, Nikolopoulos D, Pieta A, Tzavara V, Katsimbri P, Boumpas D, Karageorgas T. AB1216 INTERSTITIAL PNEUMONIA WITH AUTOIMMUNE FEATURES (IPAF): A SINGLE CENTER, PROSPECTIVE STUDY. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.2753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Background:Interstitial pneumonia with autoimmune features (IPAF)1describes a group of patients with interstitial lung disease and autoimmune features who do not meet the classification criteria for a specific connective tissue disease. Limited data regarding IPAF are available so far.Objectives:To identify the epidemiological and clinical characteristics of patients with IPAF and to observe disease progression, response to treatment and frequency of infections in 1-year follow-up period.Methods:Thirty-nine patients from ‘Attikon’ University Hospital of Athens fulfilling the IPAF criteria were enrolled. Clinical and laboratory findings, comorbidities, medications, pulmonary outcomes assessed with repeated pulmonary function tests (PFTs) and chest HRCT and complications in a 1-year follow-up period were documented for each patient. Univariate models were performed in order to identify determinants of infection and clinically significant difference in PFTs (defined as change of ≥ 10% in FVC and/or ≥ 15% in DLCO).Results:The mean age at the time of IPAF diagnosis was 63.2 (±11) years and 62% of the patients were female. The most common clinical features included in the IPAF criteria were arthritis (82%) and Raynaud’s phenomenon (26%). A morbilliform and/or polymorphic rash of the face, neck and extremities (not included in the IPAF criteria) was noted in 54% of patients. ANA (59%) and anti–Ro (21%) were the most common auto-antibodies. Non-specific Interstitial Pneumonia (NSIP) was the most prevalent radiological pattern (61.5%) as shown in table 1. Treatment comprised corticosteroids and immunosuppressants including hydroxychloroquine, methotrexate, azathioprine, mycophenolate and cyclophosphamide. PFTs following treatment at 6 and 12 months from baseline showed a trend of improvement (Table 2, p> 0.05). At 1 year from baseline, 20.5% of patients showed a clinically significant deterioration while 25% had a clinically significant improvement. Infections were observed in 23.1% of patients during the first semester and in 12.8% during the second semester of the follow-up period. All were respiratory tract infections and two patients (5.1%) required hospitalization. All infections occurred in patients with non-UIP pattern (p=0.02) which might be attributed to higher doses of corticosteroids used in these patients (mean initial prednisolone dose = 27 (±18) mg/d in patients with non-UIP pattern versus 17 (±16) mg/d in patients with UIP pattern, p=0.4).Table 1.Prevalence of HRCT patterns in 39 patients.Radiological patternNo (%)NSIP24 (61,5%)OP2 (5,1%)NSIP with OP overlap2 (5,1%)LIP1 (2,6%)UIP7 (18%)NSIP and UIP3 (7,7%)NSIP: Non-specific Interstitial Pneumonia, OP: Organizing Pneumonia, LIP: Lymphocytic Interstitial Pneumonia, UIP: Usual Interstitial Pneumonia.Table 2.PFTs at baseline, 6 and 12 months.PFTs (% of predicted value ± SD)Baseline6 months12 monthsP valueFVC79% (±19%)82% (±18%)84% (±17%)nsDLCO49% (±16%)52% (±17%)53% (±17%)nsConclusion:Rash is a common feature in IPAF and may be considered for inclusion into IPAF criteria. A trend of improvement in PFTs and a significant risk of respiratory tract infections mainly in the first semester of treatment and in patients with non-UIP radiological pattern were observed. Larger prospective studies are warranted in order to elucidate IPAF’s prognosis and to identify effective management approaches.References:[1]Fischer A, et al. An official European Respiratory Society/American Thoracic Society research statement: interstitial pneumonia with autoimmune features. Eur Respir J 2015; 46: 976-987.Disclosure of Interests:Maria Karampeli: None declared, Konstantinos Thomas: None declared, Dimitrios Tseronis: None declared, Michail Aggelakos: None declared, Dimitra Kassara: None declared, Katerina Havatza: None declared, Sofia Flouda: None declared, Dionysis Nikolopoulos: None declared, Antigoni Pieta: None declared, Vasiliki Tzavara: None declared, Pelagia Katsimbri: None declared, Dimitrios Boumpas Grant/research support from: Unrestricted grant support from various pharmaceutical companies, Theofanis Karageorgas: None declared
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Salazar E, Perez KK, Ashraf M, Chen J, Castillo B, Christensen PA, Eubank T, Bernard DW, Eagar TN, Long SW, Subedi S, Olsen RJ, Leveque C, Schwartz MR, Dey M, Chavez-East C, Rogers J, Shehabeldin A, Joseph D, Williams G, Thomas K, Masud F, Talley C, Dlouhy KG, Lopez BV, Hampton C, Lavinder J, Gollihar JD, Maranhao AC, Ippolito GC, Saavedra MO, Cantu CC, Yerramilli P, Pruitt L, Musser JM. Treatment of COVID-19 Patients with Convalescent Plasma in Houston, Texas. medRxiv 2020:2020.05.08.20095471. [PMID: 32511574 PMCID: PMC7274255 DOI: 10.1101/2020.05.08.20095471] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND COVID-19 disease, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has spread globally, and no proven treatments are available. Convalescent plasma therapy has been used with varying degrees of success to treat severe microbial infections for more than 100 years. METHODS Patients (n=25) with severe and/or life-threatening COVID-19 disease were enrolled at the Houston Methodist hospitals from March 28 to April 14, 2020. Patients were transfused with convalescent plasma obtained from donors with confirmed SARS-CoV-2 infection and had been symptom free for 14 days. The primary study outcome was safety, and the secondary outcome was clinical status at day 14 post-transfusion. Clinical improvement was assessed based on a modified World Health Organization 6-point ordinal scale and laboratory parameters. Viral genome sequencing was performed on donor and recipient strains. RESULTS At baseline, all patients were receiving supportive care, including anti-inflammatory and anti-viral treatments, and all patients were on oxygen support. At day 7 post-transfusion with convalescent plasma, nine patients had at least a 1-point improvement in clinical scale, and seven of those were discharged. By day 14 post-transfusion, 19 (76%) patients had at least a 1-point improvement in clinical status and 11 were discharged. No adverse events as a result of plasma transfusion were observed. The whole genome sequencing data did not identify a strain genotype-disease severity correlation. CONCLUSIONS The data indicate that administration of convalescent plasma is a safe treatment option for those with severe COVID-19 disease. Randomized, controlled trials are needed to determine its efficacy.
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Landewé RB, van der Heijde D, Dougados M, Baraliakos X, Van den Bosch FE, Gaffney K, Bauer L, Hoepken B, Davies OR, de Peyrecave N, Thomas K, Gensler L. Maintenance of clinical remission in early axial spondyloarthritis following certolizumab pegol dose reduction. Ann Rheum Dis 2020; 79:920-928. [PMID: 32381562 PMCID: PMC7307216 DOI: 10.1136/annrheumdis-2019-216839] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 04/09/2020] [Accepted: 04/13/2020] [Indexed: 12/11/2022]
Abstract
Background The best strategy for maintaining clinical remission in patients with axial spondyloarthritis (axSpA) has not been defined. C-OPTIMISE compared dose continuation, reduction and withdrawal of the tumour necrosis factor inhibitor certolizumab pegol (CZP) following achievement of sustained remission in patients with early axSpA. Methods C-OPTIMISE was a two-part, multicentre phase 3b study in adults with early active axSpA (radiographic or non-radiographic). During the 48-week open-label induction period, patients received CZP 200 mg every 2 weeks (Q2W). At Week 48, patients in sustained remission (Ankylosing Spondylitis Disease Activity Score (ASDAS) <1.3 at Weeks 32/36 and 48) were randomised to double-blind CZP 200 mg Q2W (full maintenance dose), CZP 200 mg every 4 weeks (Q4W; reduced maintenance dose) or placebo (withdrawal) for a further 48 weeks. The primary endpoint was remaining flare-free (flare: ASDAS ≥2.1 at two consecutive visits or ASDAS >3.5 at any time point) during the double-blind period. Results At Week 48, 43.9% (323/736) patients achieved sustained remission, of whom 313 were randomised to CZP full maintenance dose, CZP reduced maintenance dose or placebo. During Weeks 48 to 96, 83.7% (87/104), 79.0% (83/105) and 20.2% (21/104) of patients receiving the full maintenance dose, reduced maintenance dose or placebo, respectively, were flare-free (p<0.001 vs placebo in both CZP groups). Responses in radiographic and non-radiographic axSpA patients were comparable. Conclusions Patients with early axSpA who achieve sustained remission at 48 weeks can reduce their CZP maintenance dose; however, treatment should not be completely discontinued due to the high risk of flare following CZP withdrawal. Trial registration number NCT02505542, ClinicalTrials.gov.
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Affiliation(s)
- Robert Bm Landewé
- Amsterdam Rheumatology & Clinical Immunology Center, Amsterdam, The Netherlands .,Zuyderland Medical Center, Heerlen, The Netherlands
| | | | - Maxime Dougados
- Hopital Cochin, Rheumatology, Université Paris Descartes, Paris, France
| | - Xenofon Baraliakos
- Rheumazentrum Ruhrgebiet, Ruhr University Bochum, Bochum, Herne, Germany
| | - Filip E Van den Bosch
- Department of Internal Medicine and Pediatrics, VIB Center for Inflammation Research, Ghent University, Ghent, Belgium
| | - Karl Gaffney
- Rheumatology Department, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, UK
| | | | | | | | | | | | - Lianne Gensler
- University of California San Francisco, San Francisco, California, USA
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Canizares M, Glennie RA, Perruccio AV, Abraham E, Ahn H, Attabib N, Christie S, Johnson MG, Nataraj A, Nicholls F, Paquet J, Phan P, Rasoulinejad P, Manson N, Hall H, Thomas K, Fisher CG, Rampersaud YR. Erratum to 'Patients' expectations of spine surgery for degenerative conditions: results from the Canadian Spine Outcomes and Research Network (CSORN)'. [Spine J. 2020;20(3):399-408]. Spine J 2020; 20:674. [PMID: 32081566 DOI: 10.1016/j.spinee.2020.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- M Canizares
- The Arthritis Program, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada.
| | - R A Glennie
- Canadian Spine Outcomes and Research Network, Canada; Dalhousie University, Halifax, Nova Scotia, Canada
| | - A V Perruccio
- The Arthritis Program, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - E Abraham
- Canadian Spine Outcomes and Research Network, Canada; Dalhousie University, Saint John, New Brunswick, Canada
| | - H Ahn
- Canadian Spine Outcomes and Research Network, Canada; University of Toronto, Toronto, Ontario, Canada
| | - N Attabib
- Canadian Spine Outcomes and Research Network, Canada; Dalhousie University, Saint John, New Brunswick, Canada
| | - S Christie
- Canadian Spine Outcomes and Research Network, Canada; Dalhousie University, Halifax, Nova Scotia, Canada
| | - M G Johnson
- Canadian Spine Outcomes and Research Network, Canada; University of Manitoba, Winnipeg, Manitoba, Canada
| | - A Nataraj
- Canadian Spine Outcomes and Research Network, Canada; University of Alberta, Edmonton, Alberta, Canada
| | - F Nicholls
- Canadian Spine Outcomes and Research Network, Canada; University of Calgary, Calgary, Alberta, Canada
| | - J Paquet
- Canadian Spine Outcomes and Research Network, Canada; Universite Laval, Quebec City, Quebec, Canada
| | - P Phan
- Canadian Spine Outcomes and Research Network, Canada; The Ottawa Hospital - Civic Campus, Ottawa, Ontario, Canada
| | - P Rasoulinejad
- Canadian Spine Outcomes and Research Network, Canada; Western University, London Health Sciences, London, Ontario, Canada
| | - N Manson
- Canadian Spine Outcomes and Research Network, Canada; Dalhousie University, Saint John, New Brunswick, Canada
| | - H Hall
- Canadian Spine Outcomes and Research Network, Canada; University of Toronto, Toronto, Ontario, Canada
| | - K Thomas
- Canadian Spine Outcomes and Research Network, Canada; University of Calgary, Calgary, Alberta, Canada
| | - C G Fisher
- Canadian Spine Outcomes and Research Network, Canada; University of British Columbia, Vancouver, British Columbia, Canada
| | - Y R Rampersaud
- The Arthritis Program, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada; Canadian Spine Outcomes and Research Network, Canada; University of Toronto, Toronto, Ontario, Canada
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Panopoulos S, Chatzidionysiou Κ, Tektonidou MG, Bournia VK, Drosos AA, Liossis SNC, Dimitroulas T, Sakkas L, Boumpas D, Voulgari PV, Daoussis D, Thomas K, Georgiopoulos G, Vosvotekas G, Garyfallos Α, Sidiropoulos P, Bertsias G, Vassilopoulos D, Sfikakis PP. Treatment modalities and drug survival in a systemic sclerosis real-life patient cohort. Arthritis Res Ther 2020; 22:56. [PMID: 32293545 PMCID: PMC7092571 DOI: 10.1186/s13075-020-2140-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 03/05/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND European data indicate that systemic sclerosis (SSc)-related death rates are increasing, thus raising concerns about SSc's optimal management. Herein, we describe current treatment modalities and drug survival in a real-life SSc cohort. METHODS Details on immunosuppressive/antiproliferative (methotrexate, mycophenolate, cyclophosphamide, azathioprine, rituximab, tocilizumab) and vasoactive agent [(endothelin receptor antagonists (ERAs), sildenafil, iloprost, and calcium channel blockers (CCB)] administration during the disease course (11.8 ± 8.4 years, mean + SD) of 497 consecutive patients examined between 2016 and 2018 were retrospectively recorded. Drug survival was assessed by Kaplan-Meier analysis. RESULTS Methotrexate was the most frequently administered immunosuppressive/antiproliferative agent (53% of patients), followed by cyclophosphamide (26%), mycophenolate (12%), and azathioprine (11%). Regarding vasoactive agents, CCB had been ever administered in 68%, ERAs in 38%, iloprost in 7%, and sildenafil in 7% of patients; 23% of patients with pulmonary fibrosis had never received immunosuppressive/antiproliferative agents, 33% of those with digital ulcers had never received ERAs, iloprost, or sildenafil, whereas 19% of all patients had never received either immunosuppressive/antiproliferative or other than CCB vasoactive agents. Survival rates of methotrexate, cyclophosphamide, and mycophenolate differed significantly, being 84/75%, 59/43%, and 74/63% at 12/24 months, respectively, with inefficacy being the most frequent discontinuation cause. Conversely, CCB, ERAs, and sildenafil had high and comparable retention rates of 97/91%, 88/86%, and 80/80%, respectively. CONCLUSIONS Existing therapeutic limitations indicate that more evidence-based treatment is warranted for successful management of SSc. Vasculopathy seems to be managed more rigorously, but the low retention rates of immunosuppressive/antiproliferative drugs suggest that effective and targeted disease-modifying agents are warranted.
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Affiliation(s)
- S Panopoulos
- Joint Rheumatology Program, 1st Department of Propedeutic Internal Medicine-Rheumatology Unit, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Agiou Thoma str., 115 27, Athens, Greece.
| | - Κ Chatzidionysiou
- Joint Rheumatology Program, 1st Department of Propedeutic Internal Medicine-Rheumatology Unit, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Agiou Thoma str., 115 27, Athens, Greece
| | - M G Tektonidou
- Joint Rheumatology Program, 1st Department of Propedeutic Internal Medicine-Rheumatology Unit, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Agiou Thoma str., 115 27, Athens, Greece
| | - V K Bournia
- Joint Rheumatology Program, 1st Department of Propedeutic Internal Medicine-Rheumatology Unit, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Agiou Thoma str., 115 27, Athens, Greece
| | - A A Drosos
- Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, Ioannina, Greece
| | - Stamatis-Nick C Liossis
- Division of Rheumatology, Department of Internal Medicine, Patras University Hospital, Medical School, University of Patras, Patras, Greece
| | - T Dimitroulas
- 4th Department of Internal Medicine, Hippokration General Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - L Sakkas
- Department of Rheumatology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - D Boumpas
- Joint Rheumatology Program, 4th Department of Internal Medicine, National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Athens, Greece
| | - P V Voulgari
- Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, Ioannina, Greece
| | - D Daoussis
- Division of Rheumatology, Department of Internal Medicine, Patras University Hospital, Medical School, University of Patras, Patras, Greece
| | - K Thomas
- Joint Rheumatology Program, Clinical Immunology -Rheumatology Unit, 2nd Department of Medicine and Laboratory, National and Kapodistrian University of Athens, School of Medicine, Hippokration General Hospital, Athens, Greece
| | - G Georgiopoulos
- Joint Rheumatology Program, Clinical Immunology -Rheumatology Unit, 2nd Department of Medicine and Laboratory, National and Kapodistrian University of Athens, School of Medicine, Hippokration General Hospital, Athens, Greece
| | - G Vosvotekas
- 1st Department of Medicine, Aristotle University of Thessaloniki, School of Medicine, University General Hospital of Thessaloniki AHEPA, Thessaloniki, Greece
| | - Α Garyfallos
- 4th Department of Internal Medicine, Hippokration General Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - P Sidiropoulos
- Department of Clinical Rheumatology, Clinical Immunology and Allergy, Faculty of Medicine-University of Crete, Heraklion, Greece
| | - G Bertsias
- Department of Clinical Rheumatology, Clinical Immunology and Allergy, Faculty of Medicine-University of Crete, Heraklion, Greece
| | - D Vassilopoulos
- Joint Rheumatology Program, Clinical Immunology -Rheumatology Unit, 2nd Department of Medicine and Laboratory, National and Kapodistrian University of Athens, School of Medicine, Hippokration General Hospital, Athens, Greece
| | - P P Sfikakis
- Joint Rheumatology Program, 1st Department of Propedeutic Internal Medicine-Rheumatology Unit, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Agiou Thoma str., 115 27, Athens, Greece
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Murray JR, Tree AC, Alexander EJ, Sohaib A, Hazell S, Thomas K, Gunapala R, Parker CC, Huddart RA, Gao A, Truelove L, McNair HA, Blasiak-Wal I, deSouza NM, Dearnaley D. Standard and Hypofractionated Dose Escalation to Intraprostatic Tumor Nodules in Localized Prostate Cancer: Efficacy and Toxicity in the DELINEATE Trial. Int J Radiat Oncol Biol Phys 2020; 106:715-724. [PMID: 31812718 DOI: 10.1016/j.ijrobp.2019.11.402] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 11/11/2019] [Accepted: 11/25/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE To report a planned analysis of the efficacy and toxicity of dose escalation to the intraprostatic dominant nodule identified on multiparametric magnetic resonance imaging using standard and hypofractionated external beam radiation therapy. METHODS AND MATERIALS DELINEATE is a single centre prospective phase 2 multicohort study including standard (cohort A: 74 Gy in 37 fractions) and moderately hypofractionated (cohort B: 60 Gy in 20 fractions) prostate image guided intensity modulated radiation therapy in patients with National Comprehensive Cancer Network intermediate- and high-risk disease. Patients received an integrated boost of 82 Gy (cohort A) and 67 Gy (cohort B) to lesions visible on multiparametric magnetic resonance imaging. Fifty-five patients were treated in cohort A, and 158 patients were treated in cohort B; the first 50 sequentially treated patients in cohort B were included in this planned analysis. The primary endpoint was late Radiation Therapy Oncology Group rectal toxicity at 1 year. Secondary endpoints included acute and late toxicity measured with clinician- and patient-reported outcomes at other time points and biochemical relapse-free survival for cohort A. Median follow-up was 74.5 months for cohort A and 52.0 months for cohort B. RESULTS In cohorts A and B, 27% and 40% of patients, respectively, were classified as having National Comprehensive Cancer Network high-risk disease. The cumulative 1-year incidence of Radiation Therapy Oncology Group grade 2 or worse rectal and urinary toxicity was 3.6% and 0% in cohort A and 8% and 10% in cohort B, respectively. There was no reported late grade 3 rectal toxicity in either cohort. Within cohort A, 4 of 55 (7%) patients had biochemical relapse. CONCLUSIONS Delivery of a simultaneous integrated boost to intraprostatic dominant nodules is feasible in prostate radiation therapy using standard and moderately hypofractionated regimens, with rectal and genitourinary toxicity comparable to contemporary series without an intraprostatic boost.
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Affiliation(s)
- Julia R Murray
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom.
| | - Alison C Tree
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | | | - Aslam Sohaib
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Steve Hazell
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Karen Thomas
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Ranga Gunapala
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Chris C Parker
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - Robert A Huddart
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - Annie Gao
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - Lesley Truelove
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - Helen A McNair
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - Irena Blasiak-Wal
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - Nandita M deSouza
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - David Dearnaley
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
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Lamontagne F, Richards-Belle A, Thomas K, Harrison DA, Sadique MZ, Grieve RD, Camsooksai J, Darnell R, Gordon AC, Henry D, Hudson N, Mason AJ, Saull M, Whitman C, Young JD, Rowan KM, Mouncey PR. Effect of Reduced Exposure to Vasopressors on 90-Day Mortality in Older Critically Ill Patients With Vasodilatory Hypotension: A Randomized Clinical Trial. JAMA 2020; 323:938-949. [PMID: 32049269 PMCID: PMC7064880 DOI: 10.1001/jama.2020.0930] [Citation(s) in RCA: 145] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 01/23/2020] [Indexed: 12/19/2022]
Abstract
Importance Vasopressors are commonly administered to intensive care unit (ICU) patients to raise blood pressure. Balancing risks and benefits of vasopressors is a challenge, particularly in older patients. Objective To determine whether reducing exposure to vasopressors through permissive hypotension (mean arterial pressure [MAP] target, 60-65 mm Hg) reduces mortality at 90 days in ICU patients aged 65 years or older with vasodilatory hypotension. Design, Setting, and Participants A multicenter, pragmatic, randomized clinical trial was conducted in 65 ICUs in the United Kingdom and included 2600 randomized patients aged 65 years or older with vasodilatory hypotension (assessed by treating clinician). The study was conducted from July 2017 to March 2019, and follow-up was completed in August 2019. Interventions Patients were randomized 1:1 to vasopressors guided either by MAP target (60-65 mm Hg, permissive hypotension) (n = 1291) or according to usual care (at the discretion of treating clinicians) (n = 1307). Main Outcome and Measures The primary clinical outcome was all-cause mortality at 90 days. Results Of 2600 randomized patients, after removal of those who declined or had withdrawn consent, 2463 (95%) were included in the analysis of the primary outcome (mean [SD] age 75 years [7 years]; 1387 [57%] men). Patients randomized to the permissive hypotension group had lower exposure to vasopressors compared with those in the usual care group (median duration 33 hours vs 38 hours; difference in medians, -5.0; 95% CI, -7.8 to -2.2 hours; total dose in norepinephrine equivalents median, 17.7 mg vs 26.4 mg; difference in medians, -8.7 mg; 95% CI, -12.8 to -4.6 mg). At 90 days, 500 of 1221 (41.0%) in the permissive hypotension compared with 544 of 1242 (43.8%) in the usual care group had died (absolute risk difference, -2.85%; 95% CI, -6.75 to 1.05; P = .15) (unadjusted relative risk, 0.93; 95% CI, 0.85-1.03). When adjusted for prespecified baseline variables, the odds ratio for 90-day mortality was 0.82 (95% CI, 0.68 to 0.98). Serious adverse events were reported for 79 patients (6.2%) in the permissive care group and 75 patients (5.8%) in the usual care group. The most common serious adverse events were acute renal failure (41 [3.2%] vs 33 [2.5%]) and supraventricular cardiac arrhythmia (12 [0.9%] vs 13 [1.0%]). Conclusions and Relevance Among patients 65 years or older receiving vasopressors for vasodilatory hypotension, permissive hypotension compared with usual care did not result in a statistically significant reduction in mortality at 90 days. However, the confidence interval around the point estimate for the primary outcome should be considered when interpreting the clinical importance of the study. Trial Registration isrctn.org Identifier: ISRCTN10580502.
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Affiliation(s)
- François Lamontagne
- Université de Sherbrooke, Sherbrooke, Quebec, Canada
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Alvin Richards-Belle
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Karen Thomas
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - David A. Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - M. Zia Sadique
- London School of Hygiene and Tropical Medicine, Department of Health Services Research and Policy, London, United Kingdom
| | - Richard D. Grieve
- London School of Hygiene and Tropical Medicine, Department of Health Services Research and Policy, London, United Kingdom
| | - Julie Camsooksai
- Critical Care, Poole Hospital NHS Foundation Trust, Poole, Dorset, United Kingdom
| | - Robert Darnell
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Anthony C. Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, United Kingdom
- Intensive Care Unit, Imperial College Healthcare NHS Trust, St Mary’s Hospital, Paddington, London, United Kingdom
| | | | - Nicholas Hudson
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Alexina J. Mason
- London School of Hygiene and Tropical Medicine, Department of Health Services Research and Policy, London, United Kingdom
| | - Michelle Saull
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | | | - J. Duncan Young
- Kadoorie Centre for Critical Care Research and Education, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Kathryn M. Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Paul R. Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
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Parikh N, Sikaria D, Wallach W, Thomas K. Abstract No. 516 Reproducibility of in vivo ablation zone using a single microwave ablation system. J Vasc Interv Radiol 2020. [DOI: 10.1016/j.jvir.2019.12.577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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88
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Agrawal T, Tea I, El Tallawi KC, Thomas K, Guha A, Trachtenberg B, Hussain I. THE GREAT MIMICKER: AN UNUSUAL CASE OF CARDIAC AMYLOIDOSIS PRESENTING AS HYPERTROPHIC CARDIOMYOPATHY WITH DYNAMIC OBSTRUCTION. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)33563-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Sweetman S, Sharkey A, Thomas K, Dhesi J. Reduction of last-minute cancellations in elective urology surgery: A quality improvement study. Int J Surg 2020; 74:29-33. [DOI: 10.1016/j.ijsu.2019.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 11/18/2019] [Accepted: 12/10/2019] [Indexed: 10/25/2022]
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Tan MP, Harris V, Warren-Oseni K, McDonald F, McNair H, Taylor H, Hansen V, Sharabiani M, Thomas K, Jones K, Dearnaley D, Hafeez S, Huddart RA. The Intensity-Modulated Pelvic Node and Bladder Radiotherapy (IMPART) Trial: A Phase II Single-Centre Prospective Study. Clin Oncol (R Coll Radiol) 2020; 32:93-100. [PMID: 31400946 PMCID: PMC6966321 DOI: 10.1016/j.clon.2019.07.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 06/24/2019] [Accepted: 06/25/2019] [Indexed: 11/20/2022]
Abstract
AIMS Node-positive bladder cancer (NPBC) carries a poor prognosis and has traditionally been treated palliatively. However, surgical series suggest that a subset of NPBC patients can achieve long-term control after cystectomy and lymph node dissection. There is little published data regarding the use of radiotherapy to treat NPBC patients. This is in part due to concerns regarding the toxicity of whole-pelvis radiotherapy using conventional techniques. We hypothesised that, using intensity-modulated radiotherapy (IMRT), the pelvic nodes and bladder could be treated within a radical treatment volume with acceptable toxicity profiles. MATERIALS AND METHODS The Intensity-modulated Pelvic Node and Bladder Radiotherapy (IMPART) trial was a phase II single-centre prospective study designed to assess the feasibility of delivering IMRT to treat the bladder and pelvic nodes in patients with node-positive or high-risk node-negative bladder cancer (NNBC). The primary end point was meeting predetermined dose constraints. Secondary end points included acute and late toxicity, pelvic relapse-free survival and overall survival. RESULTS In total, 38 patients were recruited and treated between June 2009 and November 2012; 22/38 (58%) had NPBC; 31/38 (81.6%) received neoadjuvant chemotherapy; 18/38 (47%) received concurrent chemotherapy; 37/38 (97%) patients had radiotherapy planned as per protocol. Grade 3 gastrointestinal and genitourinary acute toxicity rates were 5.4 and 20.6%, respectively. At 1 year, the grade 3 late toxicity rate was 5%; 1-, 2- and 5-year pelvic relapse-free survival rates were 55, 37 and 26%, respectively. The median overall survival was 1.9 years (95% confidence interval 1.1-3.8) with 1-, 2- and 5-year overall survival rates of 68, 50 and 34%, respectively. CONCLUSION Delivering IMRT to the bladder and pelvic nodes in NPBC and high-risk NNBC is feasible, with low toxicity and low pelvic nodal recurrence rates. Long-term control seems to be achievable in a subset of patients. However, relapse patterns suggest that strategies targeting both local recurrence and the development of distant metastases are required to improve patient outcomes.
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Affiliation(s)
- M P Tan
- Academic Radiotherapy Unit, Institute of Cancer Research, Sutton, Surrey, UK; The Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
| | - V Harris
- Academic Radiotherapy Unit, Institute of Cancer Research, Sutton, Surrey, UK; The Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK; Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - K Warren-Oseni
- The Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
| | - F McDonald
- The Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
| | - H McNair
- The Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
| | - H Taylor
- The Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
| | - V Hansen
- The Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK; Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
| | - M Sharabiani
- The Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK; The School of Public Health, Imperial College London, London, UK
| | - K Thomas
- The Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK; ICBARC, London, UK
| | - K Jones
- The Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
| | - D Dearnaley
- Academic Radiotherapy Unit, Institute of Cancer Research, Sutton, Surrey, UK; The Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
| | - S Hafeez
- Academic Radiotherapy Unit, Institute of Cancer Research, Sutton, Surrey, UK; The Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
| | - R A Huddart
- Academic Radiotherapy Unit, Institute of Cancer Research, Sutton, Surrey, UK; The Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK.
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Abstract
UNLABELLED With survival after stroke improving, more people are discharged into the community with multiple and persistent deficits. Fatigue is a common unmet need for stroke survivors, but there are no evidence-based guidelines for its assessment and management. This study explored how UK-based therapists conceptualise post-stroke fatigue (PSF) in current practice. OBJECTIVE To describe current understanding of PSF among physiotherapists (PT) and occupational therapists (OT). DESIGN A cross-sectional online survey using Qualtrics software (a survey creation and analysis programme) was sent to therapists working with stroke survivors in 2019. Responses to the open ended question, 'How would you describe PSF if approached by another healthcare professional?' were analysed thematically by two independent researchers. PARTICIPANTS 137 survey respondents (71 PT and 66 OT) from a range of clinical settings (25 acute care, 24 sub-acute rehabilitation care, 3 primary care and 85 community care) with 7 months-36 years of experience working with stroke survivors completed the survey. RESULTS Respondents stated that PSF should be regarded as an important medical condition because it is common and can be associated with severe symptoms. Symptoms were perceived to be highly variable and the syndrome was difficult to define objectively. It was felt to have both physical and cognitive components. A variety of different opinions were expressed with regard to causation, conceptualisation and best management. CONCLUSION Therapists working with stroke survivors conceptualise and manage PSF in different ways. Clinical practice is hampered by a lack of a widely adopted definition, and a small evidence base. Research into causes and management of PSF is a priority.
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Affiliation(s)
- Karen Thomas
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Clarissa Hjalmarsson
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Ricky Mullis
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jonathan Mant
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Alexander EJ, Murray JR, Morgan VA, Giles SL, Riches SF, Hazell S, Thomas K, Sohaib SA, Thompson A, Gao A, Dearnaley DP, DeSouza NM. Validation of T2- and diffusion-weighted magnetic resonance imaging for mapping intra-prostatic tumour prior to focal boost dose-escalation using intensity-modulated radiotherapy (IMRT). Radiother Oncol 2019; 141:181-187. [PMID: 31493904 PMCID: PMC6908966 DOI: 10.1016/j.radonc.2019.07.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 07/22/2019] [Accepted: 07/25/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND PURPOSE To assess the diagnostic accuracy and inter-observer agreement of T2-weighted (T2W) and diffusion-weighted (DW) magnetic resonance imaging (MRI) for mapping intra-prostatic tumour lesions (IPLs) for the purpose of focal dose-escalation in prostate cancer radiotherapy. MATERIALS AND METHODS Twenty-six men selected for radical treatment with radiotherapy were recruited prospectively and underwent pre-treatment T2W+DW-MRI and 5 mm spaced transperineal template-guided mapping prostate biopsies (TTMPB). A 'traffic-light' system was used to score both data sets. Radiologically suspicious lesions measuring ≥0.5 cm3 were classified as red; suspicious lesions 0.2-0.5 cm3 or larger lesions equivocal for tumour were classified as amber. The histopathology assessment combined pathological grade and tumour length on biopsy (red = ≥4 mm primary Gleason grade 4/5 or ≥6 mm primary Gleason grade 3). Two radiologists assessed the MRI data and inter-observer agreement was measured with Cohens' Kappa co-efficient. RESULTS Twenty-five of 26 men had red image-defined IPLs by both readers, 24 had red pathology-defined lesions. There was a good correlation between lesions ≥0.5 cm3 classified "red" on imaging and "red" histopathology in biopsies (Reader 1: r = 0.61, p < 0.0001, Reader 2: r = 0.44, p = 0.03). Diagnostic accuracy for both readers for red image-defined lesions was sensitivity 85-86%, specificity 93-98%, positive predictive value (PPV) 79-92% and negative predictive value (NPV) 96%. Inter-observer agreement was good (Cohen's Kappa 0.61). CONCLUSIONS MRI is accurate for mapping clinically significant prostate cancer; diffusion-restricted lesions ≥0.5 cm3 can be confidently identified for radiation dose boosting.
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Affiliation(s)
- E J Alexander
- The Royal Marsden NHS Foundation Trust, Sutton, UK; The Institute of Cancer Research, Sutton, UK.
| | - J R Murray
- The Royal Marsden NHS Foundation Trust, Sutton, UK; The Institute of Cancer Research, Sutton, UK.
| | - V A Morgan
- The Institute of Cancer Research, Sutton, UK.
| | - S L Giles
- The Institute of Cancer Research, Sutton, UK.
| | - S F Riches
- The Institute of Cancer Research, Sutton, UK.
| | - S Hazell
- The Royal Marsden NHS Foundation Trust, Sutton, UK.
| | - K Thomas
- The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - S A Sohaib
- The Royal Marsden NHS Foundation Trust, Sutton, UK.
| | - A Thompson
- The Royal Marsden NHS Foundation Trust, Sutton, UK.
| | - A Gao
- The Royal Marsden NHS Foundation Trust, Sutton, UK; The Institute of Cancer Research, Sutton, UK.
| | - D P Dearnaley
- The Royal Marsden NHS Foundation Trust, Sutton, UK; The Institute of Cancer Research, Sutton, UK.
| | - N M DeSouza
- The Royal Marsden NHS Foundation Trust, Sutton, UK; The Institute of Cancer Research, Sutton, UK.
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Schmidt JW, Vikram A, Thomas K, Arthur TM, Weinroth M, Parker J, Hanes A, Geornaras I, Morley PS, Wheeler TL, Belk KE. Antimicrobial Resistance in Retail Ground Beef with and Without a “Raised Without Antibiotics” Claim. Meat and Muscle Biology 2019. [DOI: 10.22175/mmb.10781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
ObjectivesThe occurrences of human bacterial infections complicated by antimicrobial resistance (AMR) have increased in recent decades. Concerns have been raised that food-animal production practices that incorporate antimicrobials contribute significantly to human AMR exposures since food-animal production accounts for approximately 81% of U.S. antimicrobial consumption by mass. Although empirical studies comparing AMR levels in meat products, including ground beef, are scant ground beef products with Raised without Antibiotics (RWA) label claims are perceived to harbor less AMR than “conventional” (CONV) products with no label claims regarding antimicrobial use. The objective of this research was to determine AMR levels in retail ground beef with and without an RWA label claims.Materials and MethodsRetail ground beef samples were obtained from 6 U.S. cities. Samples were obtained on the following dates: 9/18/2017, 10/30/2017, 11/27/2017. 1/29/2018. 3/5/2018, and 6/11/2018. A total of 599 samples were obtained. Samples with a “Raised without Antibiotics” or USDA Organic claim (N = 299) were assigned to the RWA production system. Samples lacking a “Raised without Antibiotics” claim (N = 300) were assigned to the CONV production system. Each sample was cultured for the detection of five antimicrobial resistant bacteria (ARB). Genomic DNA was isolated from each sample and qPCR was used to determine the abundance of ten antimicrobial resistance genes (ARGs). The impacts of production system and city on ARB detection were assessed by the Likelihood-ratio chi-squared test. The impacts of production system and city on ARG abundance was assessed by two-way ANOVA.ResultsTetracycline-resistant Escherichia coli (CONV = 46.3%; RWA = 34.4%) and erythromycin-resistant Enterococcus (CONV = 48.0%; RWA = 37.5%) were more frequently (P < 0.01) detected in CONV. Detection of third generation cephalosporin-resistant E. coli (CONV = 5.7%; RWA = 1.0%), vancomycin-resistant Enterococcus (CONV = 0.0%; RWA = 0.0%) and methicillin-resistant Staphylococcus aureus (CONV = 1.3%; RWA = 0.7%) did not differ (P = 1.00). The blaCTX-M ARG was more abundant in CONV (2.4 vs. 2.1 log copies/gram, P = 0.01) but the tet(A) (2.4 vs. 2.5 log copies/gram, P = 0.02) and tet(M) (3.6 vs. 3.9 log copies/gram, P < 0.01) ARGs were more abundant in RWA. aadA1, blaCMY-2, mecA, erm(B), and tet(B) abundances did not differ significantly (Fig. 5) (P > 0.05). Abundances of aac (6’)-Ie-aph (2”)-Ia and blaKPC-2 were not analyzed since they were quantified in less than 5% of the samples.ConclusionU.S. retail CONV and RWA ground beef harbor generally similar levels of AMR since only 5 of 15 AMR measurements were statistically different between production systems. Three AMR measurements were higher in CONV, while 2 AMR measurements were higher in RWA. These results are in general agreement with a recently published study authored by our group that examined antimicrobial resistance in CONV and RWA ground beef obtained from U.S. foodservice suppliers (Vikram et al., J. Food Prot. 81:2007–2018. 2018.). Together these studies suggest that antimicrobial use during U.S. cattle production has minimal to no impact on human exposure to AMR via ground beef.Figure 5.
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Affiliation(s)
- J. W. Schmidt
- USDA, Agricultural Research Service U.S. Meat Animal Research Center
| | - A. Vikram
- USDA, Agricultural Research Service U.S. Meat Animal Research Center
| | - K. Thomas
- Colorado State University Animal Sciences
| | - T. M. Arthur
- USDA, Agricultural Research Service U.S. Meat Animal Research Center
| | | | - J. Parker
- Colorado State University Clinical Sciences
| | - A. Hanes
- Colorado State University Clinical Sciences
| | | | - P. S. Morley
- Texas A&M University College of Veterinary Medicine
| | - T. L. Wheeler
- USDA, Agricultural Research Service U.S. Meat Animal Research Center
| | - K. E. Belk
- Colorado State University Animal Sciences
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94
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DuBuske I, Thomas K, Schmidlin K. M289 SUCCESSFUL LONG TERM MANAGEMENT OF CHRONIC GRANULOMATOUS DISEASE WELL-CONTROLLED AT AGE 42. Ann Allergy Asthma Immunol 2019. [DOI: 10.1016/j.anai.2019.08.394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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95
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Martinez A, Parilla D, Green M, Murphy A, Suarez-Ponce S, Rasmussen T, Thomas K, Patel SB, Smith KR, Gomez BT, Parada JP. 1157. GET IT OUT! Nurses and Clinical Quality Improvement Specialists Drive Initiative to Reduce Standardized Utilization Ratios for Indwelling Urinary Catheters in Hospitalized Patients. Open Forum Infect Dis 2019. [PMCID: PMC6808786 DOI: 10.1093/ofid/ofz360.1020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background Urinary tract infections (UTIs) account for 34% of all healthcare-associated infections (HAI). Urinary catheters (UC) are placed in 15–25% of hospitalized patients and >75% of HAI UTIs are UC-related. Bacteria introduced via UC can colonize the bladder within 3 days. So, the greatest risk factor for acquiring a catheter-associated urinary tract infection (CAUTI) is prolonged use of indwelling UC. Nursing (RN) staff noted inconsistency with appropriate use of UC and commonly UC remained in place well after their original indication had expired. Methods As part of a multi-faceted approach for quality improvement and patient safety, we rolled out an Agency for Healthcare Research and Quality (AHRQ)-based initiative to reduce UC days/Standardized Utilization Ratio (SUR). Daily critical reviews of the indication for UC were conducted by two groups. First, frontline night shift RN staff identified patients who no longer had a valid justification for continued UC. They handed-off the information to day-shift RNs, who recommend removal of UC during daily rounds with the physician teams. A second review was performed by Clinical Quality Improvement Specialists (CQIS) based on defined criteria from our nursing decatheterization protocol. Their discontinue UC recommendations were also sent to the care teams. The critical reviews of UC for CAUTI reduction started with 4 ICUs in August 2018, with additional ICUs added in December, January and March. Monthly UC SURs were tracked Results Figure 1 shows the number of UCs recommended for removal by RNs vs. CQIS (bars), as well as the percent discordance between RNs and CQIS (line). CQIS identified many more removable UCs than the RNs (888 vs. 256). 211 UC were removed after RN recommendations, and an additional 386 UCs were removed as a result of the CQIS audits. Figure 2 shows the marked corresponding decline in our SUR over this intervention. Conclusion As more units participated in the initiative, we saw increasing numbers of “discontinue UC” recommendations. Over time there was also a moderate decrease in the discordance between RN and CQIS recommendations for UC removal. CQIS routinely identified many more UCs to be removed compared with RNs, and more than doubled the number of discontinued UC. Notably, the UC SUR markedly improved, decreasing from 0.98 to 0.78. ![]()
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Disclosures All authors: No reported disclosures.
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Affiliation(s)
| | | | | | - Anne Murphy
- Loyola University Medical Center, MAYWOOD, Illinois
| | | | | | - Karen Thomas
- Loyola University Medical Center, MAYWOOD, Illinois
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Inkelis S, Thomas K, Bangen K, Weigand A, Thayer R, Delano-Wood L, Bondi M. A-42 Case of Persistent Amnestic Syndrome due to Small Right-Sided Retrosplenial Lacunes. Arch Clin Neuropsychol 2019. [DOI: 10.1093/arclin/acz034.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objective
Lesions to the retrosplenial cortex secondary to acute stroke or tumor have been shown to disrupt Papez’s circuit due to disconnection between the anterior thalamus and hippocampus, via the posterior cingulate, producing an amnestic syndrome. This case demonstrates how small but strategic lacunes in this region may produce memory deficits.
Method
The patient is a 52-year-old, right-handed, African-American woman with 18 years of education who reported memory changes over the last 8 years (e.g., misplacing items, forgetting details of conversations). Her medical history was notable for BMI of 31 and borderline diabetes. She completed structural magnetic resonance imaging 6 years prior to, and concordant with, her neuropsychological evaluation. Both scans showed two small (2-3 mm) right-sided retrosplenial lacunes, without evidence of hippocampal or global volume loss over the 6-year span.
Results
Her neurocognitive profile was characterized by impairments in both verbal (stories, word-list) and figural memory, with relative strengths in attention, processing speed, and executive functioning. Across memory measures, she performed in the low average-to-mildly impaired range on immediate recall, mildly-to-severely impaired range on delayed recall, and did not benefit from yes-no recognition format. She demonstrated additional features of an amnestic profile, including flat learning slope, recency effect, elevated cued recall intrusion errors, and very elevated false positive errors on recognition.
Conclusions
Findings expand upon the existing literature to show that chronic, small retrosplenial lacunes can disrupt the connection between the anterior thalamus and hippocampus, resulting in a clinical presentation of circumscribed memory impairment that persists years beyond acute vascular changes.
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Dsilva AA, Basheer A, Thomas K. Snake envenomation: is the 20 min whole blood clotting test (WBCT20) the optimum test for management? QJM 2019; 112:575-579. [PMID: 30918965 DOI: 10.1093/qjmed/hcz077] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 02/14/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The 20 min whole blood clotting test (WBCT20) is a simple bedside test recommended by World Health Organization (WHO) to assess hemotoxic envenomation and guide administration of polyvalent anti-snake venom (ASV). However, reliability and validity of this test has not been well documented in literature. METHODS Sixty consecutive patients with history of snake bite were prospectively evaluated at a teaching hospital in India over 2 years. Envenomation was established by clinical and laboratory criteria. WBCT20 was done at 0, 4 and 12 h using standardized protocol. Prothrombin time (PT) with international normalized ratio (INR) was estimated at similar intervals to detect venom-induced consumption coagulopathy. Sensitivity, specificity and likelihood ratios (LR) were determined for WBCT20 using envenomation criteria as gold standard. WBCT20 was compared with PT/INR at cutoff values of ≥1.4 and ≥1.2. Two observers performed test-retest correlation to determine inter-observer variability of WBCT20. RESULTS . UNLABELLED Seventeen of 60 patients had evidence of hemotoxic envenomation. Four patients had combined neurotoxicity and hemotoxicity. Sensitivity and specificity of WBCT20 were 94 and 76%; positive and negative LR were 3.9 and 0.08, respectively. No inter-observer variability was noted. CONCLUSIONS WBCT20 is a highly sensitive test with excellent reliability for detecting envenomation. However, the false positive rate in this study was 24%. Asymptomatic snake bite patients with a positive WBCT20 but no corresponding clinical signs of envenomation should be tested using PT/INR before receiving ASV to prevent unnecessary waste of anti-venom.
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Affiliation(s)
- A A Dsilva
- From the Department of General Medicine, PIMS Hospital, Pondicherry
| | - A Basheer
- From the Department of General Medicine, PIMS Hospital, Pondicherry
| | - K Thomas
- From the Department of General Medicine, PIMS Hospital, Pondicherry
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98
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Osuna J, Thomas K, Edmonds E, Bangen K, Weigand A, Wong C, Cooper S, Bondi M. Subtle Cognitive Decline predicts progression to Mild Cognitive Impairment Above and Beyond Alzheimer’s Disease Risk Factors. Arch Clin Neuropsychol 2019. [DOI: 10.1093/arclin/acz035.14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objective
Early identification of those at risk for mild cognitive impairment (MCI) and Alzheimer’s disease (AD) is critical for early intervention. Recent work shows that subtle cognitive decline (SCD), operationally-defined using sensitive neuropsychological scores, predicts progression to MCI/AD and is associated with AD biomarkers. We aimed to determine whether SCD adds unique value in predicting progression to MCI/AD above and beyond other AD risk factors.
Method
547 cognitively unimpaired participants from the Alzheimer’s Disease Neuroimaging Initiative (359 without SCD; 188 with SCD) underwent neuropsychological testing and lumbar puncture. Participants were classified as SCD if they performed >1 SD below the demographically-adjusted mean on 1) two neuropsychological total scores in different cognitive domains, or 2) two memory test process scores (e.g., intrusion errors), or 3) one total score and one process score. Cox regressions examined whether SCD status predicted progression to MCI and AD within 5 years after adjusting for age, education, sex, MMSE, depressive symptoms, ischemia risk, apolipoprotein E genotype, and AD biomarker “positivity” based on the cerebrospinal fluid phosphorylated tau-to-β-amyloid ratio.
Results
SCD status predicted progression to MCI (HR = 2.74, 95% CI = 2.07-3.63, p < .001) and AD (HR = 2.20, 95% CI = 1.04-4.65, p = .04) within 5 years, even after including known AD risk factors in the model.
Conclusion
SCD conveys a 2-3 fold increased risk of progression to MCI/AD and is a unique predictor above and beyond risk factors that are commonly used in preclinical AD research. These findings support our novel SCD criteria as a cost-effective and non-invasive method for identifying those at risk for future cognitive decline.
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Abstract
OBJECTIVE To understand poststroke fatigue from the perspective of stroke survivors and caregivers expressed in an online discussion forum. DESIGN The search terms 'tiredness', 'fatigue', 'tired', 'weary' and 'weariness' were used to identify relevant posts. Thematic analysis performed by two independent researchers who coded all forum posts and identified pertinent themes. Posts were coded in relation to two research questions: (1) how is poststroke fatigue described? and (2) what coping strategies are suggested to target poststroke fatigue? Each theme was then summarised by a lead quotation in forum users' own words. SETTING UK-based web forum hosted by Stroke Association, TalkStroke. Archives from 2004 to 2011 were accessed. PARTICIPANTS 65 stroke survivors and caregivers (mean age 54 years, 61% female) contributed to 89 relevant posts that included a relevant search term. This included 38 stroke survivors, 23 individuals with family or carer role and 4 others unidentified. RESULTS Six themes were generated: (1) medicalisation of poststroke fatigue: 'a classic poststroke symptom', (2) a tiredness unique to stroke: 'a legacy of stroke', (3) normalisation and acceptance of poststroke fatigue: 'part and parcel of stroke', (4) fighting the fatigue: 'an unwelcome guest', (5) survivors' and caregivers' biological explanations: 'the brain healing' and (6) coping mechanisms: 'pace yourself'. Forum users also repeatedly commented that poststroke fatigue was 'not understood by the profession'. CONCLUSION This is the first study to employ data from an online forum to characterise poststroke fatigue. Our data are considered naturalistic owing to the absence of a researcher guiding the discussion and thus generates useful insights for healthcare professionals. Findings suggest a requirement for consistent understanding and explanation to be provided by healthcare professionals. The beliefs outlined here highlight the gap between clinical and community knowledge. Further research to translate understanding of patient and carer perspective into improved management of poststroke fatigue is required.
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Affiliation(s)
- Karen Thomas
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Chloe Gamlin
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Anna De Simoni
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Ricky Mullis
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jonathan Mant
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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100
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Thomas K, Patel A, Sadique MZ, Grieve RD, Mason AJ, Moler S, Gordon AC, Rowan KM, Mouncey PR, Lamontagne F, Harrison DA. Evaluating the clinical and cost-effectiveness of permissive hypotension in critically ill patients aged 65 years or over with vasodilatory hypotension: Statistical and Health Economic Analysis Plan for the 65 trial. J Intensive Care Soc 2019. [DOI: 10.1177/1751143719860387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
The 65 trial is a pragmatic, multicentre, parallel-group, open-label, randomised clinical trial of permissive hypotension (targeting a mean arterial pressure target of 60–65 mmHg during vasopressor therapy) versus usual care in critically ill patients aged 65 years or over with vasodilatory hypotension. The trial will recruit 2600 patients from 65 United Kingdom adult general critical care units. The primary outcome is all-cause mortality at 90 days. An economic evaluation is embedded. This paper describes the proposed statistical and health economic analysis for the 65 trial.
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Affiliation(s)
- Karen Thomas
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - Akshay Patel
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - M Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Richard D Grieve
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Alexina J Mason
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Silvia Moler
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Anthony C Gordon
- Section of Anaesthetics, Pain Medicine & Intensive Care, Imperial College, London, UK
- Intensive Care Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - Francois Lamontagne
- Centre de Recherche du Centre Hospitalier, Universitaire de Sherbrooke, Sherbrooke, QC, Canada
- Faculté de Médecine, des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
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