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Richards T, Miles LF, Clevenger B, Keegan A, Abeysiri S, Rao Baikady R, Besser MW, Browne JP, Klein AA, Macdougall IC, Murphy GJ, Anker SD, Dahly D, Besser M, Browne J, Clevenger B, Kegan A, Klein A, Miles L, MacDougall I, Baikady RR, Dahly D, Bradbury A, Richards T, Burley T, Van Loen S, Anker S, Klein A, MacDougall I, Murphy G, Besser M, Unsworth I, Clayton T, Collier T, Potter K, Abeysiri S, Evans R, Knight R, Swinson R, Van Dyck L, Keidan J, Williamson L, Crook A, Pepper J, Dobson J, Newsome S, Godec T, Dodd M, Richards T, Van Dyck L, Evans R, Abeysiri S, Clevenger B, Butcher A, Swinson R, Collier T, Potter K, Anker S, Kelly J, Morris S, Browne J, Keidan J, Grocott M, Chau M, Knight R, Collier T, Baikady RR, Black E, Lawrence H, Kouthra M, Horner K, Jhanji S, Todman E, Keon‐Cohen Z, Rooms M, Tomlinson J, Bailes I, Walker S, Pirie K, Gerstman M, Kasivisvanathan R, Uren S, Magee D, Eeles A, Anker R, McCanny J, O'Mahony M, Reynolds T, Batley S, Hegarty A, Trundle S, Mazzola F, Tatham K, Balint A, Morrison B, Evans M, Pang CL, Smith L, Wilson C, Sjorin V, Khatri P, Wilson M, Parkinson D, Crosbie J, Dawas K, Smyth D, Bercades G, Ryu J, Reyes A, Martir G, Gallego L, Macklin A, Rocha M, Tam DK, Brealey DD, Dhesi J, Morrison C, Hardwick J, Partridge J, Braude P, Rogerson A, Jahangir N, Thomson C, Biswell L, Cross J, Pritchard F, Mohammed A, Wallace D, Galat MG, Okello J, Symes R, Leon J, Gibbs C, Sanghera S, Dennis A, Kibutu F, Fofie J, Bird S, Alli A, Jackson Y, Albuheissi S, Brain C, Shiridzinomwa C, Ralph C, Wroath B, Hammonds F, Adams B, Faulds J, Staddon S, Hughes T, Saha S, Finney C, Harris C, Mellis C, Johnson L, Riozzi P, Yarnold A, Buchanan F, Hopkins P, Greig L, Noble H, Edwards M, Grocott M, Plumb J, Harvie D, Dushianthan A, Wakatsuki M, Leggett S, Salmon K, Bolger C, Burnish R, Otto J, Rayat G, Golder K, Bartlett P, Bali S, Seaward L, Wadams B, Tyrell B, Collins H, Tantony N, Geale R, Wilson A, Ball D, Lindsey I, Barker D, Thyseen M, Chiam P, Hannaway C, Colling K, Messer C, Verma N, Nasseri M, Poonawala G, Sellars A, Mainali P, Hammond T, Hughes A, O'Hara D, McNeela F, Shillito L, Kotze A, Moriarty C, Wilson J, Davies S, Yates D, Carter J, Redman J, Ma S, Howard K, Redfearn H, Wilcock D, Lowe J, Alexander T, Jose J, Hornzee G, Akbar F, Rey S, Patel A, Coulson S, Saini R, Santipillai J, McCretton T, McCanny J, Chima K, Collins K, Pathmanathan B, Chattersingh A, McLeavy L, Al‐Saadi Z, Patel M, Skampardoni S, Chinnadurai R, Thomas V, Keen A, Pagett K, Keatley C, Howard J, Greenhalgh M, Jenkins S, Gidda R, Watts A, Breaton C, Parker J, Mallett S, James S, Penny L, Chan K, Reeves T, Catterall M, Williams S, Birch J, Hammerton K, Williamson N, Thomas A, Evans M, Mercer L, Horsfield G, Hughes C, Cupitt J, Stoddard E, McNamara H, Birt C, Hardy A, Dennis R, Butcher D, O'Sullivan S, Pope A, Elhanash S, Preston S, Officer H, Stoker A, Moss S, Walker A, Gipson A, Melville J, Bradley‐Potts J, McCormac R, Benson V, Melia K, Fielding J, Guest W, Ford S, Murdoch H, Beames S, Townshend P, Collins K, Glass J, Cartwright B, Altemimi B, Berresford L, Jones C, Kelliher L, de Silva S, Blightman K, Pendry K, Pinto L, Allard S, Taylor L, Chishti A, Scott J, O'Hare D, Lewis M, Hussain Z, Hallett K, Dermody S, Corbett C, Morby L, Hough M, Williams S, Williams P, Horton S, Ashcroft P, Homer A, Lang A, Dawson H, Harrison E, Thompson J, Hariharan V, Goss V, Ravi R, Butt G, Vertue M, Acheson A, Ng O, Bush D, Dickson E, Ward A, Morris S, Taylor A, Casey R, Wilson L, Vimalachandran D, Faulkner M, Jeffrey H, Gabrielle C, Martin S, Bracewell A, Ritzema J, Sproates D, Alexander‐Sefre F, Kubitzek C, Humphreys S, Curtis J, Oats P, Swann S, Holden A, Adam C, Flintoff L, Paoloni C, Bobruk K. The association between iron deficiency and outcomes: a secondary analysis of the intravenous iron therapy to treat iron deficiency anaemia in patients undergoing major abdominal surgery (PREVENTT) trial. Anaesthesia 2023; 78:320-329. [PMID: 36477695 PMCID: PMC10107684 DOI: 10.1111/anae.15926] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2022] [Indexed: 12/13/2022]
Abstract
In the intravenous iron therapy to treat iron deficiency anaemia in patients undergoing major abdominal surgery (PREVENTT) trial, the use of intravenous iron did not reduce the need for blood transfusion or reduce patient complications or length of hospital stay. As part of the trial protocol, serum was collected at randomisation and on the day of surgery. These samples were analysed in a central laboratory for markers of iron deficiency. We performed a secondary analysis to explore the potential interactions between pre-operative markers of iron deficiency and intervention status on the trial outcome measures. Absolute iron deficiency was defined as ferritin <30 μg.l-1 ; functional iron deficiency as ferritin 30-100 μg.l-1 or transferrin saturation < 20%; and the remainder as non-iron deficient. Interactions were estimated using generalised linear models that included different subgroup indicators of baseline iron status. Co-primary endpoints were blood transfusion or death and number of blood transfusions, from randomisation to 30 days postoperatively. Secondary endpoints included peri-operative change in haemoglobin, postoperative complications and length of hospital stay. Most patients had iron deficiency (369/452 [82%]) at randomisation; one-third had absolute iron deficiency (144/452 [32%]) and half had functional iron deficiency (225/452 [50%]). The change in pre-operative haemoglobin with intravenous iron compared with placebo was greatest in patients with absolute iron deficiency, mean difference 8.9 g.l-1 , 95%CI 5.3-12.5; moderate in functional iron deficiency, mean difference 2.8 g.l-1 , 95%CI -0.1 to 5.7; and with little change seen in those patients who were non-iron deficient. Subgroup analyses did not suggest that intravenous iron compared with placebo reduced the likelihood of death or blood transfusion at 30 days differentially across subgroups according to baseline ferritin (p = 0.33 for interaction), transferrin saturation (p = 0.13) or in combination (p = 0.45), or for the number of blood transfusions (p = 0.06, 0.29, and 0.39, respectively). There was no beneficial effect of the use of intravenous iron compared with placebo, regardless of the metrics to diagnose iron deficiency, on postoperative complications or length of hospital stay.
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Affiliation(s)
- T Richards
- Division of Surgery, University of Western Australia, Perkins South Building, Fiona Stanley Hospital, Murdoch, Perth, WA, Australia.,Institute of Clinical Trials and Methodology and Division of Surgery, University College London, UK
| | - L F Miles
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, VIC, Australia.,Department of Anaesthesia, Austin Health, Melbourne, VIC, Australia
| | - B Clevenger
- Department of Anaesthesia, Royal National Orthopaedic Hospital, Stanmore, UK
| | - A Keegan
- Department of Haematology, PathWest Laboratory Medicine, King Edward Memorial Hospital, Subiaco, WA, Australia
| | - S Abeysiri
- Division of Surgery, University of Western Australia, Perkins South Building, Fiona Stanley Hospital, Murdoch, Perth, WA, Australia
| | - R Rao Baikady
- Department of Anaesthesia, The Royal Marsden NHS Foundation Trust, London, UK
| | - M W Besser
- Department of Haematology, Addenbrooke's Hospital, Cambridge, UK
| | - J P Browne
- School of Public Health, University College Cork, Ireland
| | - A A Klein
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
| | - I C Macdougall
- Department of Renal Medicine, King's College Hospital, London, UK
| | - G J Murphy
- Department of Cardiovascular Sciences, University of Leicester, UK
| | - S D Anker
- Department of Cardiology, Berlin Institute of Health Centre for Regenerative Therapies; German Centre for Cardiovascular Research partner site Berlin; Charité Universitätsmedizin Berlin, Germany
| | - D Dahly
- School of Public Health, University College Cork, Ireland.,Health Research Board Clinical Research Facility, University College Cork, Ireland
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M, Leonard D, Mishra B, Ahmad S, Randall H, Hill J, Reid L, George M, McKinley S, Brockway L, Milligan W, Sobolewska J, Muir J, Tuckis L, Winstanley L, Jacob P, Kaye S, Morby L, Jan A, Sewell T, Boos C, Wadams B, Cope C, Jefferey P, Andrews N, Getty A, Suttling A, Turner C, Hudson K, Austin R, Howe S, Iqbal R, Gandhi N, Brophy K, Mirza P, Willard E, Collins S, Ndlovu N, Subkovas E, Karthikeyan V, Waggett L, Wood A, Bolger A, Stockport J, Evans L, Harman E, Starling J, Williams L, Saul V, Sinha M, Bell L, Tudgay S, Kemp S, Brown J, Frost L, Ingram T, Loughlin A, Adams C, Adams M, Hurford F, Owen C, Miller C, Donaldson D, Tivenan H, Button H, Nasser A, Jhagra O, Stidolph B, Brown C, Livingstone C, Duffy M, Madgwick P, Roberts P, Greenwood E, Fletcher L, Beveridge M, Earles S, McKenzie D, Beacock D, Dayer M, Seddon M, Greenwell D, Luxton F, Venn F, Mills H, Rewbury J, James K, Roberts K, Tonks L, Felmeden D, Taggu W, Summerhayes A, Hughes D, Sutton J, Felmeden L, Khan M, Walker E, Norris L, O’Donohoe L, Mozid A, Dymond H, Lloyd-Jones H, Saunders G, Simmons D, Coles D, Cotterill D, Beech S, Kidd S, Wrigley B, Petkar S, Smallwood A, Jones R, Radford E, Milgate S, Metherell S, Cottam V, Buckley C, Broadley A, Wood D, Allison J, Rennie K, Balian L, Howard L, Pippard L, Board S, Pitt-Kerby T. Epidemiology and impact of frailty in patients with atrial fibrillation in Europe. Age Ageing 2022; 51:6670566. [PMID: 35997262 DOI: 10.1093/ageing/afac192] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [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: 03/17/2022] [Revised: 06/08/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent. OBJECTIVES We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients. METHODS A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined. RESULTS Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty. CONCLUSIONS In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.
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Affiliation(s)
- Marco Proietti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Giulio Francesco Romiti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Translational and Precision Medicine, Sapienza - University of Rome, Italy
| | - Marco Vitolo
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Stephanie L Harrison
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau, Tours, France
| | - Francisco Marin
- Department of Cardiology, Hospital Universitario Virgen de la Arrixaca, IMIB-Arrixaca, University of Murcia, CIBER-CV, Murcia, Spain
| | - Michael Näbauer
- Department of Cardiology, Ludwig-Maximilians-University, Munich, Germany
| | - Tatjana S Potpara
- School of Medicine, University of Belgrade, Belgrade, Serbia.,Clinical Center of Serbia, Belgrade, Serbia
| | - Gheorghe-Andrei Dan
- University of Medicine, 'Carol Davila', Colentina University Hospital, Bucharest, Romania
| | - Aldo P Maggioni
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
| | - Matteo Cesari
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Effects of fluoxetine on functional outcomes after acute stroke (FOCUS): a pragmatic, double-blind, randomised, controlled trial. Lancet 2019; 393:265-274. [PMID: 30528472 PMCID: PMC6336936 DOI: 10.1016/s0140-6736(18)32823-x] [Citation(s) in RCA: 174] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 10/24/2018] [Accepted: 10/29/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Results of small trials indicate that fluoxetine might improve functional outcomes after stroke. The FOCUS trial aimed to provide a precise estimate of these effects. METHODS FOCUS was a pragmatic, multicentre, parallel group, double-blind, randomised, placebo-controlled trial done at 103 hospitals in the UK. Patients were eligible if they were aged 18 years or older, had a clinical stroke diagnosis, were enrolled and randomly assigned between 2 days and 15 days after onset, and had focal neurological deficits. Patients were randomly allocated fluoxetine 20 mg or matching placebo orally once daily for 6 months via a web-based system by use of a minimisation algorithm. The primary outcome was functional status, measured with the modified Rankin Scale (mRS), at 6 months. Patients, carers, health-care staff, and the trial team were masked to treatment allocation. Functional status was assessed at 6 months and 12 months after randomisation. Patients were analysed according to their treatment allocation. This trial is registered with the ISRCTN registry, number ISRCTN83290762. FINDINGS Between Sept 10, 2012, and March 31, 2017, 3127 patients were recruited. 1564 patients were allocated fluoxetine and 1563 allocated placebo. mRS data at 6 months were available for 1553 (99·3%) patients in each treatment group. The distribution across mRS categories at 6 months was similar in the fluoxetine and placebo groups (common odds ratio adjusted for minimisation variables 0·951 [95% CI 0·839-1·079]; p=0·439). Patients allocated fluoxetine were less likely than those allocated placebo to develop new depression by 6 months (210 [13·43%] patients vs 269 [17·21%]; difference 3·78% [95% CI 1·26-6·30]; p=0·0033), but they had more bone fractures (45 [2·88%] vs 23 [1·47%]; difference 1·41% [95% CI 0·38-2·43]; p=0·0070). There were no significant differences in any other event at 6 or 12 months. INTERPRETATION Fluoxetine 20 mg given daily for 6 months after acute stroke does not seem to improve functional outcomes. Although the treatment reduced the occurrence of depression, it increased the frequency of bone fractures. These results do not support the routine use of fluoxetine either for the prevention of post-stroke depression or to promote recovery of function. FUNDING UK Stroke Association and NIHR Health Technology Assessment Programme.
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