1
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Gu Q, Wei J, Yoon CH, Yuan K, Jones N, Brent A, Llewelyn M, Peto TEA, Pouwels KB, Eyre DW, Walker AS. Distinct patterns of vital sign and inflammatory marker responses in adults with suspected bloodstream infection. J Infect 2024; 88:106156. [PMID: 38599549 DOI: 10.1016/j.jinf.2024.106156] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 04/01/2024] [Accepted: 04/04/2024] [Indexed: 04/12/2024]
Abstract
OBJECTIVES To identify patterns in inflammatory marker and vital sign responses in adult with suspected bloodstream infection (BSI) and define expected trends in normal recovery. METHODS We included patients ≥16 y from Oxford University Hospitals with a blood culture taken between 1-January-2016 and 28-June-2021. We used linear and latent class mixed models to estimate trajectories in C-reactive protein (CRP), white blood count, heart rate, respiratory rate and temperature and identify CRP response subgroups. Centile charts for expected CRP responses were constructed via the lambda-mu-sigma method. RESULTS In 88,348 suspected BSI episodes; 6908 (7.8%) were culture-positive with a probable pathogen, 4309 (4.9%) contained potential contaminants, and 77,131(87.3%) were culture-negative. CRP levels generally peaked 1-2 days after blood culture collection, with varying responses for different pathogens and infection sources (p < 0.0001). We identified five CRP trajectory subgroups: peak on day 1 (36,091; 46.3%) or 2 (4529; 5.8%), slow recovery (10,666; 13.7%), peak on day 6 (743; 1.0%), and low response (25,928; 33.3%). Centile reference charts tracking normal responses were constructed from those peaking on day 1/2. CONCLUSIONS CRP and other infection response markers rise and recover differently depending on clinical syndrome and pathogen involved. However, centile reference charts, that account for these differences, can be used to track if patients are recovering line as expected and to help personalise infection.
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Affiliation(s)
- Qingze Gu
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Jia Wei
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Chang Ho Yoon
- Big Data Institute, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Kevin Yuan
- Big Data Institute, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Nicola Jones
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Andrew Brent
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Tim E A Peto
- Nuffield Department of Medicine, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK; NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| | - Koen B Pouwels
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK; NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| | - David W Eyre
- Big Data Institute, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK; NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| | - A Sarah Walker
- Nuffield Department of Medicine, University of Oxford, Oxford, UK; NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK.
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2
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Young BC, Bush SJ, Lipworth S, George S, Dingle KE, Sanderson N, Brankin A, Walker T, Sharma S, Leong J, Plaha P, Hofer M, Chiodini P, Gottstein B, Furrer L, Crook D, Brent A. Modern Solutions for Ancient Pathogens: Direct Pathogen Sequencing for Diagnosis of Lepromatous Leprosy and Cerebral Coenurosis. Open Forum Infect Dis 2022; 9:ofac428. [PMID: 36119959 PMCID: PMC9472670 DOI: 10.1093/ofid/ofac428] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 08/21/2022] [Indexed: 11/26/2022] Open
Abstract
Microbes unculturable in vitro remain diagnostically challenging, dependent historically on clinical findings, histology, or targeted molecular detection. We applied whole-genome sequencing directly from tissue to diagnose infections with mycobacteria (leprosy) and parasites (coenurosis). Direct pathogen DNA sequencing provides flexible solutions to diagnosis of difficult pathogens in diverse contexts.
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Affiliation(s)
- Bernadette C Young
- Correspondence: Bernadette Young, Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK ()
| | - Stephen J Bush
- Experimental Medicine Division, Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Sam Lipworth
- Experimental Medicine Division, Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Sophie George
- Experimental Medicine Division, Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Kate E Dingle
- Experimental Medicine Division, Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Nick Sanderson
- Experimental Medicine Division, Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Alice Brankin
- Experimental Medicine Division, Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Timothy Walker
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Srilakshmi Sharma
- Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, United Kingdom
| | - James Leong
- Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, United Kingdom
| | - Puneet Plaha
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Monika Hofer
- Department of Neuropathology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, United Kingdom
| | - Peter Chiodini
- Hospital of Tropical Diseases and the London School of Hygiene and Tropical Medicine London, London, United Kingdom
| | - B Gottstein
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Lavinia Furrer
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Derrick Crook
- Experimental Medicine Division, Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
- Microbiology and Infectious Diseases Department, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, United Kingdom
- National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
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3
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Ahern DJ, Ai Z, Ainsworth M, Allan C, Allcock A, Angus B, Ansari MA, Arancibia-Cárcamo CV, Aschenbrenner D, Attar M, Baillie JK, Barnes E, Bashford-Rogers R, Bashyal A, Beer S, Berridge G, Beveridge A, Bibi S, Bicanic T, Blackwell L, Bowness P, Brent A, Brown A, Broxholme J, Buck D, Burnham KL, Byrne H, Camara S, Candido Ferreira I, Charles P, Chen W, Chen YL, Chong A, Clutterbuck EA, Coles M, Conlon CP, Cornall R, Cribbs AP, Curion F, Davenport EE, Davidson N, Davis S, Dendrou CA, Dequaire J, Dib L, Docker J, Dold C, Dong T, Downes D, Drakesmith H, Dunachie SJ, Duncan DA, Eijsbouts C, Esnouf R, Espinosa A, Etherington R, Fairfax B, Fairhead R, Fang H, Fassih S, Felle S, Fernandez Mendoza M, Ferreira R, Fischer R, Foord T, Forrow A, Frater J, Fries A, Gallardo Sanchez V, Garner LC, Geeves C, Georgiou D, Godfrey L, Golubchik T, Gomez Vazquez M, Green A, Harper H, Harrington HA, Heilig R, Hester S, Hill J, Hinds C, Hird C, Ho LP, Hoekzema R, Hollis B, Hughes J, Hutton P, Jackson-Wood MA, Jainarayanan A, James-Bott A, Jansen K, Jeffery K, Jones E, Jostins L, Kerr G, Kim D, Klenerman P, Knight JC, Kumar V, Kumar Sharma P, Kurupati P, Kwok A, Lee A, Linder A, Lockett T, Lonie L, Lopopolo M, Lukoseviciute M, Luo J, Marinou S, Marsden B, Martinez J, Matthews PC, Mazurczyk M, McGowan S, McKechnie S, Mead A, Mentzer AJ, Mi Y, Monaco C, Montadon R, Napolitani G, Nassiri I, Novak A, O'Brien DP, O'Connor D, O'Donnell D, Ogg G, Overend L, Park I, Pavord I, Peng Y, Penkava F, Pereira Pinho M, Perez E, Pollard AJ, Powrie F, Psaila B, Quan TP, Repapi E, Revale S, Silva-Reyes L, Richard JB, Rich-Griffin C, Ritter T, Rollier CS, Rowland M, Ruehle F, Salio M, Sansom SN, Sanches Peres R, Santos Delgado A, Sauka-Spengler T, Schwessinger R, Scozzafava G, Screaton G, Seigal A, Semple MG, Sergeant M, Simoglou Karali C, Sims D, Skelly D, Slawinski H, Sobrinodiaz A, Sousos N, Stafford L, Stockdale L, Strickland M, Sumray O, Sun B, Taylor C, Taylor S, Taylor A, Thongjuea S, Thraves H, Todd JA, Tomic A, Tong O, Trebes A, Trzupek D, Tucci FA, Turtle L, Udalova I, Uhlig H, van Grinsven E, Vendrell I, Verheul M, Voda A, Wang G, Wang L, Wang D, Watkinson P, Watson R, Weinberger M, Whalley J, Witty L, Wray K, Xue L, Yeung HY, Yin Z, Young RK, Youngs J, Zhang P, Zurke YX. A blood atlas of COVID-19 defines hallmarks of disease severity and specificity. Cell 2022; 185:916-938.e58. [PMID: 35216673 PMCID: PMC8776501 DOI: 10.1016/j.cell.2022.01.012] [Citation(s) in RCA: 117] [Impact Index Per Article: 58.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 08/16/2021] [Accepted: 01/17/2022] [Indexed: 02/06/2023]
Abstract
Treatment of severe COVID-19 is currently limited by clinical heterogeneity and incomplete description of specific immune biomarkers. We present here a comprehensive multi-omic blood atlas for patients with varying COVID-19 severity in an integrated comparison with influenza and sepsis patients versus healthy volunteers. We identify immune signatures and correlates of host response. Hallmarks of disease severity involved cells, their inflammatory mediators and networks, including progenitor cells and specific myeloid and lymphocyte subsets, features of the immune repertoire, acute phase response, metabolism, and coagulation. Persisting immune activation involving AP-1/p38MAPK was a specific feature of COVID-19. The plasma proteome enabled sub-phenotyping into patient clusters, predictive of severity and outcome. Systems-based integrative analyses including tensor and matrix decomposition of all modalities revealed feature groupings linked with severity and specificity compared to influenza and sepsis. Our approach and blood atlas will support future drug development, clinical trial design, and personalized medicine approaches for COVID-19.
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4
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Shapiro S, Fouad Alber K, Morton J, Wallis G, Britton M, Bunn A, Cheema H, Jalilzadeh Afshari S, Lin ECZ, Madge O, Naseer S, Ng E, Pora A, Sardar A, Brent A, Lasserson D. Incidence of symptomatic image-confirmed venous thromboembolism in outpatients managed in a hospital-led COVID-19 virtual ward. EJHaem 2021; 2:794-798. [PMID: 34909766 PMCID: PMC8657537 DOI: 10.1002/jha2.305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 09/07/2021] [Accepted: 09/09/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Susan Shapiro
- Oxford Haemophilia and Thrombosis CentreOxford University Hospitals NHS Foundation TrustOxfordUK
- Radcliffe Department of MedicineUniversity of OxfordOxfordUK
- NIHR Oxford Biomedical Research CentreOxfordUK
| | - Karim Fouad Alber
- Ambulatory Assessment UnitOxford University Hospitals NHS Foundation TrustOxfordUK
| | - Joshua Morton
- Ambulatory Assessment UnitOxford University Hospitals NHS Foundation TrustOxfordUK
| | - George Wallis
- Ambulatory Assessment UnitOxford University Hospitals NHS Foundation TrustOxfordUK
| | - Meriel Britton
- Ambulatory Assessment UnitOxford University Hospitals NHS Foundation TrustOxfordUK
| | - Alex Bunn
- Ambulatory Assessment UnitOxford University Hospitals NHS Foundation TrustOxfordUK
| | - Hashem Cheema
- Ambulatory Assessment UnitOxford University Hospitals NHS Foundation TrustOxfordUK
| | | | - Ei Chae Zun Lin
- Ambulatory Assessment UnitOxford University Hospitals NHS Foundation TrustOxfordUK
| | - Oliver Madge
- Ambulatory Assessment UnitOxford University Hospitals NHS Foundation TrustOxfordUK
| | - Saniya Naseer
- Ambulatory Assessment UnitOxford University Hospitals NHS Foundation TrustOxfordUK
| | - Esther Ng
- Ambulatory Assessment UnitOxford University Hospitals NHS Foundation TrustOxfordUK
| | - Alexander Pora
- Ambulatory Assessment UnitOxford University Hospitals NHS Foundation TrustOxfordUK
| | - Abbas Sardar
- Ambulatory Assessment UnitOxford University Hospitals NHS Foundation TrustOxfordUK
| | - Andrew Brent
- Infectious Diseases DepartmentOxford University Hospitals NHS Foundation TrustOxfordUK
- Nuffield Department of MedicineUniversity of OxfordOxfordUK
| | - Daniel Lasserson
- Ambulatory Assessment UnitOxford University Hospitals NHS Foundation TrustOxfordUK
- Warwick Medical SchoolUniversity of WarwickCoventryUK
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5
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Lu Q, Elakkad M, Daak A, Choh C, Durrani A, Brent A. 1030 Paediatric Appendicectomy - Appropriateness of Operative Intervention. Br J Surg 2021. [DOI: 10.1093/bjs/znab259.526] [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: 11/13/2022]
Abstract
Abstract
Aim
Acute appendicitis is one of the most common paediatric surgical emergencies. Prompt diagnosis and interventions reduce the risk of perforation and prevents complications. The aim of the audit was to determine the appropriateness of operative intervention and to improve patient care by implementing changes. We assessed several performance indicators including the percentage of appendicectomy performed within 12 hours of decision to operate, the percentage of negative appendicectomy and the 30 days re-admission rate.
Method
All consecutive paediatric patients who had appendicectomy in our district general hospital from Jan 2017 to 2019 were included in the initial audit. For re-audit, we collected data from July 2019 to March 2020. Patients were identified from the theatre system and ward notes, theatre charts and biochemistry and histology results were collected from the electronic patient records.
Results
A total of 193 patients were included in the initial audit. Results showed that 52.8% of patients were reviewed by a consultant prior to surgery, 92% of patients had surgery within 12 hours of the decision to operate. The rate of negative appendicectomy rate was 25%.
Conclusions
Following this audit, several changes have been implemented including improving consultant review of paediatric patients, increasing imaging done by radiologists for paediatric patient. Re-audit showed that 86.7% of patients were reviewed by a consultant preoperatively. Negative appendicectomy rate remained the same at 24.4%. Admissions within 30 days of discharge improved from 13.8% in the initial audit to 11.5% in re-audit.
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Affiliation(s)
- Q Lu
- Poole Hospital, Poole, United Kingdom
| | - M Elakkad
- Poole Hospital, Poole, United Kingdom
| | - A Daak
- Poole Hospital, Poole, United Kingdom
| | - C Choh
- Poole Hospital, Poole, United Kingdom
| | - A Durrani
- Poole Hospital, Poole, United Kingdom
| | - A Brent
- Poole Hospital, Poole, United Kingdom
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6
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Aiano F, Jones SEI, Amin-Chowdhury Z, Flood J, Okike I, Brent A, Brent B, Beckmann J, Garstang J, Ahmad S, Baawuah F, Ramsay ME, Ladhani SN. Feasibility and acceptability of SARS-CoV-2 testing and surveillance in primary school children in England: Prospective, cross-sectional study. PLoS One 2021; 16:e0255517. [PMID: 34449784 PMCID: PMC8396768 DOI: 10.1371/journal.pone.0255517] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/17/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The reopening of schools during the COVID-19 pandemic has raised concerns about widespread infection and transmission of SARS-CoV-2 in educational settings. In June 2020, Public Health England (PHE) initiated prospective national surveillance of SARS-CoV-2 in primary schools across England (sKIDs). We used this opportunity to assess the feasibility and agreeability of large-scale surveillance and testing for SARS-CoV-2 infections in school among staff, parents and students. METHODS Staff and students in 131 primary schools were asked to complete a questionnaire at recruitment and provide weekly nasal swabs for SARS-CoV-2 RT-PCR testing (n = 86) or swabs with blood samples for antibody testing (n = 45) at the beginning and end the summer half-term. In six blood sampling schools, students were asked to complete a pictorial questionnaire before and after their investigations. RESULTS In total, 135 children aged 4-7 years (n = 40) or 8-11 years (n = 95) completed the pictorial questionnaire fully or partially. Prior to sampling, oral fluid sampling was the most acceptable test (107/132, 81%) followed by throat swabs (80/134, 59%), nose swabs (77/132, 58%), and blood tests (48/130, 37%). Younger students were more nervous about all tests than older students but, after completing their tests, most children reported a "better than expected" experience with all the investigations. Students were more likely to agree to additional testing for nose swabs (93/113, 82%) and oral fluid (93/114, 82%), followed by throat swabs (85/113, 75%) and blood tests (72/108, 67%). Parents (n = 3,994) and staff (n = 2,580) selected a preference for weekly testing with nose swabs, throat swabs or oral fluid sampling, although staff were more flexible about testing frequency. CONCLUSIONS Primary school staff and parents were supportive of regular tests for SARS-CoV-2 and selected a preference for weekly testing. Children preferred nose swabs and oral fluids over throat swabs or blood sampling.
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Affiliation(s)
| | | | | | | | - Ifeanyichukwu Okike
- Public Health England, London, United Kingdom
- Derbyshire Healthcare NHS Foundation Trust, Derby, United Kingdom
| | - Andrew Brent
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- University of Oxford, Oxford, United Kingdom
| | - Bernadette Brent
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- University of Oxford, Oxford, United Kingdom
| | - Joanne Beckmann
- Public Health England, London, United Kingdom
- East London NHS Foundation Trust, London, United Kingdom
| | - Joanna Garstang
- Public Health England, London, United Kingdom
- Birmingham Community Healthcare NHS Trust, Aston, United Kingdom
| | - Shazaad Ahmad
- Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Public Health England, Manchester Royal Infirmary, Manchester, United Kingdom
| | | | | | - Shamez N. Ladhani
- Public Health England, London, United Kingdom
- Paediatric Infectious Diseases Research Group, St. George’s University of London, London, United Kingdom
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7
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Scarborough M, Li HK, Rombach I, Zambellas R, Walker AS, McNally M, Atkins B, Kümin M, Lipsky BA, Hughes H, Bose D, Warren S, Mack D, Folb J, Moore E, Jenkins N, Hopkins S, Seaton RA, Hemsley C, Sandoe J, Aggarwal I, Ellis S, Sutherland R, Geue C, McMeekin N, Scarborough C, Paul J, Cooke G, Bostock J, Khatamzas E, Wong N, Brent A, Lomas J, Matthews P, Wangrangsimakul T, Gundle R, Rogers M, Taylor A, Thwaites GE, Bejon P. Oral versus intravenous antibiotics for bone and joint infections: the OVIVA non-inferiority RCT. Health Technol Assess 2020; 23:1-92. [PMID: 31373271 DOI: 10.3310/hta23380] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [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: 02/08/2023] Open
Abstract
BACKGROUND Management of bone and joint infection commonly includes 4-6 weeks of intravenous (IV) antibiotics, but there is little evidence to suggest that oral (PO) therapy results in worse outcomes. OBJECTIVE To determine whether or not PO antibiotics are non-inferior to IV antibiotics in treating bone and joint infection. DESIGN Parallel-group, randomised (1 : 1), open-label, non-inferiority trial. The non-inferiority margin was 7.5%. SETTING Twenty-six NHS hospitals. PARTICIPANTS Adults with a clinical diagnosis of bone, joint or orthopaedic metalware-associated infection who would ordinarily receive at least 6 weeks of antibiotics, and who had received ≤ 7 days of IV therapy from definitive surgery (or start of planned curative treatment in patients managed non-operatively). INTERVENTIONS Participants were centrally computer-randomised to PO or IV antibiotics to complete the first 6 weeks of therapy. Follow-on PO therapy was permitted in either arm. MAIN OUTCOME MEASURE The primary outcome was the proportion of participants experiencing treatment failure within 1 year. An associated cost-effectiveness evaluation assessed health resource use and quality-of-life data. RESULTS Out of 1054 participants (527 in each arm), end-point data were available for 1015 (96.30%) participants. Treatment failure was identified in 141 out of 1015 (13.89%) participants: 74 out of 506 (14.62%) and 67 out of 509 (13.16%) of those participants randomised to IV and PO therapy, respectively. In the intention-to-treat analysis, using multiple imputation to include all participants, the imputed risk difference between PO and IV therapy for definitive treatment failure was -1.38% (90% confidence interval -4.94% to 2.19%), thus meeting the non-inferiority criterion. A complete-case analysis, a per-protocol analysis and sensitivity analyses for missing data each confirmed this result. With the exception of IV catheter complications [49/523 (9.37%) in the IV arm vs. 5/523 (0.96%) in the PO arm)], there was no significant difference between the two arms in the incidence of serious adverse events. PO therapy was highly cost-effective, yielding a saving of £2740 per patient without any significant difference in quality-adjusted life-years between the two arms of the trial. LIMITATIONS The OVIVA (Oral Versus IntraVenous Antibiotics) trial was an open-label trial, but bias was limited by assessing all potential end points by a blinded adjudication committee. The population was heterogenous, which facilitated generalisability but limited the statistical power of subgroup analyses. Participants were only followed up for 1 year so differences in late recurrence cannot be excluded. CONCLUSIONS PO antibiotic therapy is non-inferior to IV therapy when used during the first 6 weeks in the treatment for bone and joint infection, as assessed by definitive treatment failure within 1 year of randomisation. These findings challenge the current standard of care and provide an opportunity to realise significant benefits for patients, antimicrobial stewardship and the health economy. FUTURE WORK Further work is required to define the optimal total duration of therapy for bone and joint infection in the context of specific surgical interventions. Currently, wide variation in clinical practice suggests significant redundancy that likely contributes to the excess and unnecessary use of antibiotics. TRIAL REGISTRATION Current Controlled Trials ISRCTN91566927. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 38. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Matthew Scarborough
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ho Kwong Li
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Division of Infectious Diseases, Imperial College London, London, UK
| | - Ines Rombach
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK
| | - Rhea Zambellas
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK
| | - A Sarah Walker
- MRC Clinical Trials Unit, University College London, London, UK.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Martin McNally
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Bridget Atkins
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Michelle Kümin
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Harriet Hughes
- Department of Microbiology and Public Health, University Hospital of Wales, Public Health Wales, Cardiff, Wales
| | - Deepa Bose
- Department of Orthopaedic Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Simon Warren
- Infectious Diseases and Microbiology, Royal National Orthopaedic Hospital NHS Trust, Stanmore, UK.,Infectious Diseases and Microbiology, Royal Free London NHS Foundation Trust, London, UK
| | - Damien Mack
- Infectious Diseases and Microbiology, Royal National Orthopaedic Hospital NHS Trust, Stanmore, UK.,Infectious Diseases and Microbiology, Royal Free London NHS Foundation Trust, London, UK
| | - Jonathan Folb
- Department of Microbiology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Elinor Moore
- Infectious Diseases and Microbiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Neil Jenkins
- Infectious Diseases, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Susan Hopkins
- Infectious Diseases and Microbiology, Royal Free London NHS Foundation Trust, London, UK
| | - R Andrew Seaton
- Infectious Diseases and Microbiology, Gartnaval General Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Carolyn Hemsley
- Department of Microbiology and Infectious Diseases, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jonathan Sandoe
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ila Aggarwal
- Department of Microbiology and Infectious Diseases, Ninewells Hospital, NHS Tayside, Dundee, UK
| | - Simon Ellis
- Infectious Diseases, Northumbria Healthcare NHS Foundation Trust, Cramlington, UK
| | - Rebecca Sutherland
- Infectious Diseases Unit, Regional Infectious Diseases Unit, Western General Hospital, NHS Lothian, Edinburgh, UK
| | - Claudia Geue
- Health Economics and Health Technology Assessment, University of Glasgow, Glasgow, UK
| | - Nicola McMeekin
- Health Economics and Health Technology Assessment, University of Glasgow, Glasgow, UK
| | | | - John Paul
- National Infection Service, Public Health England, Horsham, UK
| | - Graham Cooke
- Division of Infectious Diseases, Imperial College London, London, UK
| | - Jennifer Bostock
- Patient and Public Representative, Division of Health and Social Care Research, King's College London, , London, UK
| | - Elham Khatamzas
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nick Wong
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Andrew Brent
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jose Lomas
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Philippa Matthews
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Tri Wangrangsimakul
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Roger Gundle
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mark Rogers
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Adrian Taylor
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Guy E Thwaites
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Philip Bejon
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
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8
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Tsakok M, Shaw R, Murchison A, Ather S, Xie C, Watson R, Brent A, Andersson M, Benamore R, MacLeod F, Gleeson F. Diagnostic accuracy of initial chest radiograph compared to SARS-CoV-2 PCR in patients with suspected COVID-19. BJR Open 2020; 2:20200034. [PMID: 33178988 PMCID: PMC7594890 DOI: 10.1259/bjro.20200034] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 07/16/2020] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE The chest radiograph (CXR) is the predominant imaging investigation being used to triage patients prior to either performing a SARS-CoV-2 polymerase chain reaction (PCR) test or a diagnostic CT scan, but there are limited studies that assess the diagnostic accuracy of CXRs in COVID-19.To determine the accuracy of CXR diagnosis of COVID-19 compared with PCR in patients presenting with a clinical suspicion of COVID-19. METHODS AND MATERIALS The CXR reports of 569 consecutive patients with a clinical suspicion of COVID-19 were reviewed, blinded to the PCR result and classified into the following categories: normal, indeterminate for COVID-19, classic/probable COVID-19, non-COVID-19 pathology, and not specified. Severity reporting and reporter expertise were documented. The subset of this cohort that had CXR and PCR within 3 days of each other were included for further analysis for diagnostic accuracy. RESULTS Classic/probable COVID-19 was reported in 29% (166/569) of the initial cohort. 67% (382/569) had PCR tests. 344 patients had CXR and PCR within 3 days of each other. Compared to PCR as the reference test, initial CXR had a 61% sensitivity and 76% specificity in the diagnosis of COVID-19. CONCLUSION Initial CXR is useful as a triage tool with a sensitivity of 61% and specificity of 76% in the diagnosis of COVID-19 in a hospital setting. ADVANCES IN KNOWLEDGE .Diagnostic accuracy does not differ significantly between specialist thoracic radiologists and general radiologists including trainees following training.There was a 40% prevalence of PCR positive disease in the cohort of patients (n = 344) having CXR and PCR within 3 days of each other.Classic/probable COVID-19 was reported in 29% of total cohort of patients presenting with clinical suspicion of COVID-19 (n = 569).Initial CXR is useful as a triage tool with a sensitivity of 61% and specificity of 76% in the diagnosis of COVID-19 in a hospital setting.
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Affiliation(s)
- Maria Tsakok
- Department of Radiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Robert Shaw
- Department of Clinical Infection, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Andrew Murchison
- Department of Radiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Sarim Ather
- Department of Radiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Cheng Xie
- Department of Radiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Robert Watson
- MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK, OX3 9DU, UK
| | - Andrew Brent
- Department of Clinical Infection, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Monique Andersson
- Microbiology Laboratory, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Rachel Benamore
- Department of Radiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Fiona MacLeod
- Department of Radiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Fergus Gleeson
- Department of Radiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
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Andersson M, Low N, French N, Greenhalgh T, Jeffery K, Brent A, Ball J, Pollock A, McCoy D, Iturriza-Gomara M, Buchan I, Salisbury H, Pillay D, Irving W. Rapid roll out of SARS-CoV-2 antibody testing-a concern. BMJ 2020; 369:m2420. [PMID: 32580928 DOI: 10.1136/bmj.m2420] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Monique Andersson
- Department of Microbiology, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Nicola Low
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Neil French
- University of Liverpool and Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, UK
| | - Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Katie Jeffery
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Andrew Brent
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Allyson Pollock
- Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | | | - Miren Iturriza-Gomara
- NIHR Health Protection Unit in Gastrointestinal Infections, University of Liverpool, Liverpool, UK
| | - Iain Buchan
- Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Helen Salisbury
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Will Irving
- University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, UK
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Affiliation(s)
- Jason Yuen
- Southwest Neurosurgical Centre, Derriford Hospital, Plymouth, UK
| | - Biyi Chen
- Department of Neurosurgery, John Radcliffe Hospital, Oxford, UK
| | - Andrew Brent
- Department of Microbiology, John Radcliffe Hospital, Oxford, UK
| | - Puneet Plaha
- Department of Neurosurgery, John Radcliffe Hospital, Oxford, UK -
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Affiliation(s)
- Jo Murray
- Oxford Academic Health Science Network, Patient Safety Collaborative, Oxford, UK
| | - Andrew Brent
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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12
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Sendi P, Brent A. Mycobacterium tuberculosis and prosthetic joint infection. Lancet Infect Dis 2018; 16:893-4. [PMID: 27477980 DOI: 10.1016/s1473-3099(16)30142-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 05/24/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Parham Sendi
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Switzerland; Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals Foundation NHS Trust, Oxford, UK.
| | - Andrew Brent
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals Foundation NHS Trust, Oxford, UK
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Mellion S, Wathen J, Brent A, Adelgais K. Safety of Intranasal Midazolam: An Analysis of Adverse Events in a Multicenter Cohort. Ann Emerg Med 2013. [DOI: 10.1016/j.annemergmed.2013.07.309] [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: 10/26/2022]
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14
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Matthews E, Brent A, Williams S. An alternative use of Foley catheters in Ilizarov external fixation. Ann R Coll Surg Engl 2010; 91:522-23. [PMID: 20301804 DOI: 10.1308/rcsann.2009.91.6.522b] [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: 11/22/2022] Open
Affiliation(s)
- E Matthews
- Department of Orthopaedics and Trauma, University Hospitals Leicester, Leicester, UK
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Underwood T, Brent A, Clarke AD, Talbot RW, Nash GF. Inflated 'non-leak' mortality compared to 1995 Wessex CRC Audit. Colorectal Dis 2008; 10:304; author reply 304-5. [PMID: 18215200 DOI: 10.1111/j.1463-1318.2007.01447.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Abstract
OBJECTIVE The aim of this study was to determine the significance of indeterminate lung lesions reported from staging CT scans on patients with colorectal cancer. METHOD CT-scan reports of 439 patients were reviewed to identify patients in which indeterminate lung lesion had been reported. The tumour, node, metastasis (TNM) stage of these patients was recorded together with any follow-up scan reports or multidisciplinary team (MDT) discussions regarding these lesions. RESULTS Twenty-three patients had definite lung metastases. Forty-five patients had indeterminate lung lesions. Of these, 22 patients had N1 or N2 disease, 20 had N0 disease and three patients were not operated on due to comorbidity. Of these 45 patients, 30 had further follow-up scans. In 19, the indeterminate lesions were unchanged and were therefore downgraded to benign lesions. The lesions had progressed or new lesions had developed in five. These patients were therefore shown to have metastatic lung disease. All five of these patients had N1 or N2 disease. One patient had a primary rather than metastatic lung lesion. Follow-up scans showed the lesion to be no longer present in five. Of the remainder, One patient declined further follow up. Three patients did not have a follow up scan for reasons not mentioned in their records. Two patients were not scanned because further MDT review of the original scans showed that the lesions were not metastases. Four patients died before follow up scans were done. (one postoperative myocardial infarction (MI), one postoperative sepsis, one postoperative cerebrovascular accident (CVA) and one inferior vena cava (IVC) obstruction). Five patients have not yet had follow-up scan at the time of writing. CONCLUSION Since the introduction of spiral CT scanners, smaller lesions are being seen at the time of preoperative staging. Our study concludes that only a small proportion of indeterminate lung lesions did develop into definite metastases and those that did had node positive disease. Indeterminate lung lesions are not a reason to delay surgery for colorectal cancer.
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Affiliation(s)
- A Brent
- Poole General Hospital, General Surgery, Poole, UK.
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19
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Armstrong T, Brent A. Re: Antao B and MacKinnon AE. Axial fixation of testes for prevention of recurrent testicular torsion. 2006 Surgeon 4:1; 20-21. Surgeon 2007; 5:255; author reply 255-6. [PMID: 17855846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
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Affiliation(s)
- A Brent
- North Hampshire Hospital, Basingstoke, Hampshire RG24 9NA, UK
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21
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Brent A. Information Websites for Patients with Stomas. Ann R Coll Surg Engl 2006. [DOI: 10.1308/rcsann.2006.88.1.82] [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: 11/22/2022] Open
Affiliation(s)
- A Brent
- SHO in General Surgery, Poole General Hospital Poole, UK
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Berkley JA, Brent A, Mwangi I, English M, Maitland K, Marsh K, Peshu N, Newton CR. Mortality among Kenyan children admitted to a rural district hospital on weekends as compared with weekdays. Pediatrics 2004; 114:1737-8; author reply 1738. [PMID: 15574646 DOI: 10.1542/peds.2004-1263] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Abstract
Shock is often under-reported in children attending hospitals in developing countries. Readily obtainable features of shock (capillary refill time, temperature gradient, pulse volume, and signs of dehydration) are widely used to help prioritise management in the emergency assessment of critically ill or injured children. However, data are lacking on their validity, including, importantly, reproducibility between observers. Agreement of these signs was examined in 100 consecutive children admitted to a paediatric ward on the coast of Kenya. After an initial training of clinical sign recognition, there was moderate agreement for most features of cardiovascular compromise (delayed capillary refill > or =4 s, kappa = 0.49; and weak pulse volume, kappa = 0.4) and only substantial agreement for temperature gradient (kappa = 0.62). For hydration status, only in the assessment of skin turgor was there a moderate level of agreement (kappa = 0.55). Capillary refill times and assessment of pulse volume recommended by the recent American consensus guidelines achieved only a "low" moderate to poor interrater agreement, questioning the reliability of such parameters.
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Affiliation(s)
- H Otieno
- The Centre for Geographic Medicine Research, Coast, KEMRI, Kenya, PO Box 230, Kilifi, Kenya
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Dickson SJ, Brent A, Davidson RN, Wall R. Comparison of Bronchoscopy and Gastric Washings in the Investigation of Smear-Negative Pulmonary Tuberculosis. Clin Infect Dis 2003; 37:1649-53. [PMID: 14689347 DOI: 10.1086/379716] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2003] [Accepted: 08/14/2003] [Indexed: 11/03/2022] Open
Abstract
This study compares the utility of gastric washings (GWs) and bronchoscopy in the diagnosis of smear-negative pulmonary tuberculosis (TB). The aim of the study was to identify which investigation or combination of investigations provided the greatest yield of positive Mycobacterium tuberculosis cultures of samples from patients with smear-negative pulmonary TB. We retrospectively analyzed the medical records of 180 patients with smear-negative pulmonary TB. The positive culture yield for bronchoalveolar lavage fluid (62 [34%] of 180 patients) was significantly greater than that for specimens from 3 GWs (32 [21%] of 149 patients) (P=.02). Combining GW and bronchoscopy increased the positive culture yield: bronchoscopy combined with 2 GWs resulted in a positive culture rate of 38%. Bronchoscopy is superior to GW in the diagnosis of smear-negative pulmonary TB; however, the combination of bronchoscopy and 2 GWs should be regarded as optimal for the diagnosis of smear-negative pulmonary TB.
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Affiliation(s)
- Stuart J Dickson
- Department of Infection and Tropical Medicine, Lister Unit, Northwick Park Hospital, Harrow, Middlesex, United Kingdom
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Brent A. Glimpses of life found in the midst of tragedy. Assoc Med J 2000. [DOI: 10.1136/sbmj.0008284] [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: 11/03/2022]
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26
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Brent A. Planning your elective - South Africa. Assoc Med J 2000. [DOI: 10.1136/sbmj.0008283] [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: 11/04/2022]
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