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Hau HM, Jahn N, Vlachos C, Eichler T, Lederer A, Geisler A, Scheuermann U, Seehofer D, Köppen S, Laudi S, Sucher R, Rademacher S. Does Timepoint of Surgical Procedure Affect the Outcome in Simultaneous Pancreas-Kidney Transplantation? A Retrospective Single-Center Analysis over 20 Years. J Clin Med 2024; 13:3688. [PMID: 38999254 PMCID: PMC11242423 DOI: 10.3390/jcm13133688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 06/13/2024] [Accepted: 06/20/2024] [Indexed: 07/14/2024] Open
Abstract
Background: Sleep deprivation and disturbances in circadian rhythms may hinder surgical performance and decision-making capabilities. Solid organ transplantations, which are technically demanding and often begin at uncertain times, frequently during nighttime hours, are particularly susceptible to these effects. This study aimed to assess how transplant operations conducted during daytime versus nighttime influence both patient and graft outcomes and function. Methods: simultaneous pancreas-kidney transplants (SPKTs) conducted at the University Hospital of Leipzig from 1998 to 2018 were reviewed retrospectively. The transplants were categorized based on whether they began during daytime hours (8 a.m. to 6 p.m.) or nighttime hours (6 p.m. to 8 a.m.). We analyzed the demographics of both donors and recipients, as well as primary outcomes, which included surgical complications, patient survival, and graft longevity. Results: In this research involving 105 patients, 43 SPKTs, accounting for 41%, took place in the daytime, while 62 transplants (59%) occurred at night. The characteristics of both donors and recipients were similar across the two groups. Further, the rate of (surgical) pancreas graft-related complications and reoperations (daytime 39.5% versus nighttime 33.9%; p = 0.552) were also not statistically significant between both groups. In this study, the five-year survival rate for patients was comparable for both daytime and nighttime surgeries, with 85.2% for daytime and 86% for nighttime procedures (p = 0.816). Similarly, the survival rates for pancreas grafts were 75% for daytime and 77% for nighttime operations (p = 0.912), and for kidney grafts, 76% during the day compared to 80% at night (p = 0.740), indicating no significant statistical difference between the two time periods. In a multivariable model, recipient BMI > 30 kg/m2, donor age, donor BMI, and cold ischemia time > 15 h were independent predictors for increased risk of (surgical) pancreas graft-related complications, whereas the timepoint of SPKT (daytime versus nighttime) did not have an impact. Conclusions: The findings from our retrospective analysis at a big single German transplant center indicate that SPKT is a reliable procedure, regardless of the start time. Additionally, our data revealed that patients undergoing nighttime transplants have no greater risk of surgical complications or inferior results concerning long-term survival of the patient and graft. However, due to the small number of cases evaluated, further studies are required to confirm these results.
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Affiliation(s)
- Hans Michael Hau
- Department of General-, Visceral- and Transplant Surgery, Medical University of Graz, 8010 Graz, Austria
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Nora Jahn
- Department for Anesthesiology and Intensive Care Medicine, Medical University of Graz, 8010 Graz, Austria
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Leipzig, 04103 Leipzig, Germany
| | - Christos Vlachos
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Tim Eichler
- Department of General-, Visceral- and Transplant Surgery, Medical University of Graz, 8010 Graz, Austria
| | - Andri Lederer
- Department of General-, Visceral- and Transplant Surgery, Medical University of Graz, 8010 Graz, Austria
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Antonia Geisler
- Department of General-, Visceral- and Transplant Surgery, Medical University of Graz, 8010 Graz, Austria
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Uwe Scheuermann
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Daniel Seehofer
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Sylvia Köppen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Leipzig, 04103 Leipzig, Germany
| | - Sven Laudi
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Leipzig, 04103 Leipzig, Germany
| | - Robert Sucher
- Department of General-, Visceral- and Transplant Surgery, Medical University of Graz, 8010 Graz, Austria
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Sebastian Rademacher
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
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Patlin BH, Mok H, Arra M, Haspel JA. Circadian rhythms in solid organ transplantation. J Heart Lung Transplant 2024; 43:849-857. [PMID: 38310995 PMCID: PMC11070314 DOI: 10.1016/j.healun.2024.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/17/2024] [Accepted: 01/29/2024] [Indexed: 02/06/2024] Open
Abstract
Circadian rhythms are daily cycles in physiology that can affect medical interventions. This review considers how these rhythms may relate to solid organ transplantation. It begins by summarizing the mechanism for circadian rhythm generation known as the molecular clock, and basic research connecting the clock to biological activities germane to organ acceptance. Next follows a review of clinical evidence relating time of day to adverse transplantation outcomes. The concluding section discusses knowledge gaps and practical areas where applying circadian biology might improve transplantation success.
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Affiliation(s)
- Brielle H Patlin
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Huram Mok
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Monaj Arra
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Jeffrey A Haspel
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri.
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Chu SN, Gardner JM. Circadian clocks drive rhythmic antitumor immune responses mediated by migratory dendritic cells. Am J Transplant 2024; 24:154-155. [PMID: 38159886 DOI: 10.1016/j.ajt.2023.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
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Yim WY, Xiong T, Geng B, Xu L, Feng Y, Chi J, Guo R, Li C, Chen Y, Shi J, Wang Y, Dong N. Donor circadian clock influences the long-term survival of heart transplantation by immunoregulation. Cardiovasc Res 2023; 119:2202-2212. [PMID: 37517007 DOI: 10.1093/cvr/cvad114] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 03/13/2023] [Accepted: 04/10/2023] [Indexed: 08/01/2023] Open
Abstract
AIMS Circadian clocks play important role in immunoregulation. We aimed to investigate cardiac circadian clock specific pathways and compare cardiac grafts procured at different timing on survival after transplantation to explore novel criteria for donor selection. METHODS AND RESULTS In primate heart, phase set enrichment analysis (PSEA) showed rhythmic transcripts were enriched in antigen processing and presentation during activation of circadian rhythm. Digital sorting of immune cell composition and single-sample gene set enrichment analysis (ssGSEA) in unused donor transcriptomes showed the pathway, positive regulation of circadian rhythm significantly correlates with allograft rejection and antigen presentation pathways as well as with increased compositions of matured dendritic cell, CD4+ T cell, and naive B cell. Single-centre retrospective cohort of 390 adult heart transplants between 1 January 2015 and 31 December 2020 was used to generate a propensity score matching (PSM) cohort. Survival curve differed significantly showing inferior long-term survival when donor hearts were procured at activation group (12 pm to 12 am) compared to repression group (12 am to 12 pm) (6-year survival: 64.2% vs. 75.8%, P = 0.0065). Activation group was also associated with significantly higher rates of in-hospital death, cardiopulmonary resuscitation, and usage of mechanical circulatory support after heart transplantation compared to repression group. Furthermore, tendency for post-transplant free of rejection rates was higher in repression group compared to activation group (acute rejection, Gehan-Breslow P = 0.11 and 0.04; chronic rejection, Log rank P = 0.077 and 0.15, in full and PSM cohorts, respectively). Adjusted Cox regression analysis showed that activation group was associated with 2.20 times increased hazard of death (hazard ratio: 2.20; 95% confidence interval: 1.23-3.95; P = 0.008) compared to repression group. CONCLUSIONS Circadian immunity may represent donor-related risk factors for cardiac allograft rejection through activating genes related to antigen presentation pathway and immune cells oscillation at specific time of day. Molecular circadian clock should be considered during retrieval of cardiac allografts in order to maximize graft durability.
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Affiliation(s)
- Wai Yen Yim
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277, Jiefang Avenue, Wuhan 430022, PRChina
| | - Tixiusi Xiong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277, Jiefang Avenue, Wuhan 430022, PRChina
| | - Bingchuan Geng
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277, Jiefang Avenue, Wuhan 430022, PRChina
| | - Li Xu
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277, Jiefang Avenue, Wuhan 430022, PRChina
| | - Yu Feng
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277, Jiefang Avenue, Wuhan 430022, PRChina
| | - Jiangyang Chi
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277, Jiefang Avenue, Wuhan 430022, PRChina
| | - Ruikang Guo
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277, Jiefang Avenue, Wuhan 430022, PRChina
| | - Chenghao Li
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277, Jiefang Avenue, Wuhan 430022, PRChina
| | - Yuqi Chen
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277, Jiefang Avenue, Wuhan 430022, PRChina
| | - Jiawei Shi
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277, Jiefang Avenue, Wuhan 430022, PRChina
| | - Yixuan Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277, Jiefang Avenue, Wuhan 430022, PRChina
- Key Laboratory of Organ Transplantation, Ministry of Education, Chinese Academy of Medical Sciences, Wuhan, China
- NHC Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
- Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Nianguo Dong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277, Jiefang Avenue, Wuhan 430022, PRChina
- Key Laboratory of Organ Transplantation, Ministry of Education, Chinese Academy of Medical Sciences, Wuhan, China
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Dong C, Li J, Tang Q, Wang Y, Zeng C, Du L, Sun Q. Denervation aggravates renal ischemia reperfusion injury via BMAL1-mediated Nrf2/ARE pathway. Arch Biochem Biophys 2023; 746:109736. [PMID: 37657745 DOI: 10.1016/j.abb.2023.109736] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 08/04/2023] [Accepted: 08/27/2023] [Indexed: 09/03/2023]
Abstract
AIM To explore the change of clock gene rhythm under renal denervation (RDN) and its effect on renal function and oxidative stress during renal ischemia-reperfusion (IR) injury. METHOD C57/BL6 mice were randomly divided into 4 groups at daytime 7 A M (zeitgeber time [ZT] 0) or at nighttime 7 P M (ZT12) in respectively: Sham (S) group, RDN group, IR group and RDN + IR (DIR) group. Renal pathological and functional changes were assessed by H&E staining, and serum creatinine, urea nitrogen and neutrophil gelatinase-associated lipocalin levels. Renal oxidative stress was detected by SOD and MDA levels, and renal inflammation was measured by IL-6, IL-17 A F and TNF-ɑ levels. BMAL1, CLOCK, Nrf2 and HO-1 mRNA and protein expressions were tested by qPCR and Western Blot. RESULT Compared with S groups, the rhythm of BMAL1, CLOCK and Nrf2 genes in the kidney were disordered in RDN groups, while renal pathological and functional indexes did not change significantly. Compared with IR groups, renal pathological and functional indexes were significantly higher in the DIR groups, as well as oxidative stress and inflammation in renal tissues. The nocturnal IR injury in the RDN kidney was the worst while the BMAL1, Nrf2 and HO-1 expressions were the highest. In DIR groups, renal injury was aggravated after the Brusatol treatment, but there was no significant improvement after the t-BHQ treatment at night, which might be consistent with the changes of Nrf2 and HO-1 protein expressions. CONCLUSION RDN lead to the disruption of BMAL1-mediated Nrf2 rhythm accumulation in the kidney, which reduced the renal ability to resist oxidative stress and inflammation, due to the impaired effect of activating Nrf2/ARE pathway in renal IR injury at nighttime.
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Affiliation(s)
- Chong Dong
- Organ Transplantation Center, Tianjin First Central Hospital, Tianjin, China; Tianjin Key Laboratory for Organ Transplantation, Tianjin, China
| | - Jing Li
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee, 1193053, Regensburg, Germany
| | - Qiao Tang
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yifei Wang
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Cheng Zeng
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Li Du
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Qian Sun
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, China.
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Geldmaker LE, Baird BA, Hasse CH, Haehn DA, Anyane-Yeboah AN, Knutson JE, Wieczorek MA, Ball CT, Lyon TD, Thiel DD. Analysis of Transurethral Resection of Bladder Tumor Efficiency Utilizing Nonprocedural Operating Room Times. Urology 2023; 177:6-11. [PMID: 37160169 DOI: 10.1016/j.urology.2023.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 05/11/2023]
Abstract
OBJECTIVE To analyze the contribution of nonprocedural operating room (OR) times to transurethral resection of bladder tumor (TURBT) operative efficiency. METHODS Over a 24-month period, all nonprocedural OR times from TURBT surgeries performed at a single institution were prospectively collected. Nonprocedural times included: in-room to anesthesia release time, anesthesia release to cut time, and close to wheels out time. Procedural OR time was cut to close time. We also analyzed the impact of time of day on TURBT efficiency (morning vs afternoon). Comparisons between groups were made using the Wilcoxon rank sum test for continuous variables. RESULTS We identified 777 consecutive TURBT procedures from 2019 to 2020. The median total OR time was 63 minutes (interquartile range: 50-81 minutes). The nonprocedural time occupied a median of 49.4% of the total operating time (interquartile range: 38.9%-60.4%). Median anesthesia release to cut time was slower when 1 TURBT was performed a day compared to 2 or more (13 minutes vs 12 minutes, P = .04). Median close to wheels out time was faster when there was 1 TURBT in a day (7 minutes vs 8 minutes, P = .02). Median in-room to anesthesia release time was faster in the morning than it was in the afternoon (10 minutes vs 11 minutes, P = .02). CONCLUSION Nonprocedural times made up roughly half of the total TURBT operating time and should be considered in OR efficiency analyses. TURBT OR efficiency may be related to the number of TURBTs performed in a day as well as the time of day of TURBT start.
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Affiliation(s)
| | - Bryce A Baird
- Department of Urology, Mayo Clinic, Jacksonville, FL
| | | | | | | | - Jill E Knutson
- Department of Anesthesiology, Mayo Clinic, Jacksonville, FL
| | - Mikolaj A Wieczorek
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Jacksonville, FL
| | - Colleen T Ball
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Jacksonville, FL
| | - Timothy D Lyon
- Department of Urology, Mayo Clinic, Jacksonville, FL; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, FL
| | - David D Thiel
- Department of Urology, Mayo Clinic, Jacksonville, FL.
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Cunningham PS, Kitchen GB, Jackson C, Papachristos S, Springthorpe T, van Dellen D, Gibbs J, Felton TW, Wilson AJ, Bannard-Smith J, Rutter MK, House T, Dark P, Augustine T, Akman OE, Hazel AL, Blaikley JF. ClinCirc identifies alterations of the circadian peripheral oscillator in critical care patients. J Clin Invest 2023; 133:e162775. [PMID: 36538377 PMCID: PMC9927929 DOI: 10.1172/jci162775] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022] Open
Abstract
BackgroundAssessing circadian rhythmicity from infrequently sampled data is challenging; however, these types of data are often encountered when measuring circadian transcripts in hospitalized patients.MethodsWe present ClinCirc. This method combines 2 existing mathematical methods (Lomb-Scargle periodogram and cosinor) sequentially and is designed to measure circadian oscillations from infrequently sampled clinical data. The accuracy of this method was compared against 9 other methods using simulated and frequently sampled biological data. ClinCirc was then evaluated in 13 intensive care unit (ICU) patients as well as in a separate cohort of 29 kidney-transplant recipients. Finally, the consequences of circadian alterations were investigated in a retrospective cohort of 726 kidney-transplant recipients.ResultsClinCirc had comparable performance to existing methods for analyzing simulated data or clock transcript expression of healthy volunteers. It had improved accuracy compared with the cosinor method in evaluating circadian parameters in PER2:luc cell lines. In ICU patients, it was the only method investigated to suggest that loss of circadian oscillations in the peripheral oscillator was associated with inflammation, a feature widely reported in animal models. Additionally, ClinCirc was able to detect other circadian alterations, including a phase shift following kidney transplantation that was associated with the administration of glucocorticoids. This phase shift could explain why a significant complication of kidney transplantation (delayed graft dysfunction) oscillates according to the time of day kidney transplantation is performed.ConclusionClinCirc analysis of the peripheral oscillator reveals important clinical associations in hospitalized patients.FundingUK Research and Innovation (UKRI), National Institute of Health Research (NIHR), Engineering and Physical Sciences Research Council (EPSRC), National Institute on Academic Anaesthesia (NIAA), Asthma+Lung UK, Kidneys for Life.
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Affiliation(s)
- Peter S. Cunningham
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Gareth B. Kitchen
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- Manchester Royal Infirmary, Manchester University NHS Foundation Trust (MFT), Manchester, United Kingdom
| | - Callum Jackson
- Department of Mathematics, University of Manchester, Manchester, United Kingdom
| | - Stavros Papachristos
- Manchester Royal Infirmary, Manchester University NHS Foundation Trust (MFT), Manchester, United Kingdom
| | - Thomas Springthorpe
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - David van Dellen
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- Manchester Royal Infirmary, Manchester University NHS Foundation Trust (MFT), Manchester, United Kingdom
| | - Julie Gibbs
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Timothy W. Felton
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- Wythenshawe Hospital, MFT, Manchester, United Kingdom
| | - Anthony J. Wilson
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- Manchester Royal Infirmary, Manchester University NHS Foundation Trust (MFT), Manchester, United Kingdom
| | - Jonathan Bannard-Smith
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- Manchester Royal Infirmary, Manchester University NHS Foundation Trust (MFT), Manchester, United Kingdom
| | - Martin K. Rutter
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- Manchester Royal Infirmary, Manchester University NHS Foundation Trust (MFT), Manchester, United Kingdom
| | - Thomas House
- Department of Mathematics, University of Manchester, Manchester, United Kingdom
| | - Paul Dark
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- Northern Care Alliance NHS Foundation Trust (Salford Care Organisation), Salford, United Kingdom
| | - Titus Augustine
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- Manchester Royal Infirmary, Manchester University NHS Foundation Trust (MFT), Manchester, United Kingdom
| | - Ozgur E. Akman
- School of Mathematics, University of Exeter, Exeter, United Kingdom
| | - Andrew L. Hazel
- Department of Mathematics, University of Manchester, Manchester, United Kingdom
| | - John F. Blaikley
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- Wythenshawe Hospital, MFT, Manchester, United Kingdom
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