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Morton S, Sekhar M, Smethurst H, Mora A, Hodge RL, Hudson CL, Parsons J, Hopkins V, Stanworth SJ. Do liberal thresholds for red cell transfusion result in improved quality of life for patients undergoing intensive chemotherapy for acute myeloid leukemia? A randomized cross over feasibility study. Haematologica 2022; 107:1474-1478. [PMID: 35199504 PMCID: PMC9152957 DOI: 10.3324/haematol.2021.279867] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Indexed: 11/20/2022] Open
Affiliation(s)
- Suzy Morton
- Department of Clinical Haematology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom. B15 2WB; Medical Department, NHS Blood and Transplant, Birmingham, United Kingdom. B15 2SG.
| | - Mallika Sekhar
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, United Kingdom. NW1 2BU; Royal Free London NHS Foundation Trust, Department of Haematology, London, United Kingdom. NW3 2QG
| | - Heather Smethurst
- Clinical Trials Unit, NHS Blood and Transplant, Cambridge, United Kingdom. CB2 0PT
| | - Ana Mora
- Clinical Trials Unit, NHS Blood and Transplant, Cambridge, United Kingdom. CB2 0PT
| | - Renate L Hodge
- Clinical Trials Unit, NHS Blood and Transplant, Cambridge, United Kingdom. CB2 0PT
| | - Cara L Hudson
- Clinical Trials Unit, NHS Blood and Transplant, Bristol, United Kingdom. BS34 8RR
| | - Joseph Parsons
- Clinical Trials Unit, NHS Blood and Transplant, Bristol, United Kingdom. BS34 8RR
| | - Valerie Hopkins
- Clinical Trials Unit, NHS Blood and Transplant, Cambridge, United Kingdom. CB2 0PT
| | - Simon J Stanworth
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom. OX3 9BQ; Clinical Department, NHS Blood and Transplant, Oxford, United Kingdom. OX3 9BQ; Radcliffe Department of Medicine, University of Oxford, and NIHR Oxford Biomedical Research Centre
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2
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Estcourt LJ, Turgeon AF, McQuilten ZK, McVerry BJ, Al-Beidh F, Annane D, Arabi YM, Arnold DM, Beane A, Bégin P, van Bentum-Puijk W, Berry LR, Bhimani Z, Birchall JE, Bonten MJM, Bradbury CA, Brunkhorst FM, Buxton M, Callum JL, Chassé M, Cheng AC, Cove ME, Daly J, Derde L, Detry MA, De Jong M, Evans A, Fergusson DA, Fish M, Fitzgerald M, Foley C, Goossens H, Gordon AC, Gosbell IB, Green C, Haniffa R, Harvala H, Higgins AM, Hills TE, Hoad VC, Horvat C, Huang DT, Hudson CL, Ichihara N, Laing E, Lamikanra AA, Lamontagne F, Lawler PR, Linstrum K, Litton E, Lorenzi E, MacLennan S, Marshall J, McAuley DF, McDyer JF, McGlothlin A, McGuinness S, Miflin G, Montgomery S, Mouncey PR, Murthy S, Nichol A, Parke R, Parker JC, Priddee N, Purcell DFJ, Reyes LF, Richardson P, Robitaille N, Rowan KM, Rynne J, Saito H, Santos M, Saunders CT, Serpa Neto A, Seymour CW, Silversides JA, Tinmouth AA, Triulzi DJ, Turner AM, van de Veerdonk F, Walsh TS, Wood EM, Berry S, Lewis RJ, Menon DK, McArthur C, Zarychanski R, Angus DC, Webb SA, Roberts DJ, Shankar-Hari M. Effect of Convalescent Plasma on Organ Support-Free Days in Critically Ill Patients With COVID-19: A Randomized Clinical Trial. JAMA 2021. [PMID: 34606578 DOI: 10.1101/2021.06.11.21258760] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
IMPORTANCE The evidence for benefit of convalescent plasma for critically ill patients with COVID-19 is inconclusive. OBJECTIVE To determine whether convalescent plasma would improve outcomes for critically ill adults with COVID-19. DESIGN, SETTING, AND PARTICIPANTS The ongoing Randomized, Embedded, Multifactorial, Adaptive Platform Trial for Community-Acquired Pneumonia (REMAP-CAP) enrolled and randomized 4763 adults with suspected or confirmed COVID-19 between March 9, 2020, and January 18, 2021, within at least 1 domain; 2011 critically ill adults were randomized to open-label interventions in the immunoglobulin domain at 129 sites in 4 countries. Follow-up ended on April 19, 2021. INTERVENTIONS The immunoglobulin domain randomized participants to receive 2 units of high-titer, ABO-compatible convalescent plasma (total volume of 550 mL ± 150 mL) within 48 hours of randomization (n = 1084) or no convalescent plasma (n = 916). MAIN OUTCOMES AND MEASURES The primary ordinal end point was organ support-free days (days alive and free of intensive care unit-based organ support) up to day 21 (range, -1 to 21 days; patients who died were assigned -1 day). The primary analysis was an adjusted bayesian cumulative logistic model. Superiority was defined as the posterior probability of an odds ratio (OR) greater than 1 (threshold for trial conclusion of superiority >99%). Futility was defined as the posterior probability of an OR less than 1.2 (threshold for trial conclusion of futility >95%). An OR greater than 1 represented improved survival, more organ support-free days, or both. The prespecified secondary outcomes included in-hospital survival; 28-day survival; 90-day survival; respiratory support-free days; cardiovascular support-free days; progression to invasive mechanical ventilation, extracorporeal mechanical oxygenation, or death; intensive care unit length of stay; hospital length of stay; World Health Organization ordinal scale score at day 14; venous thromboembolic events at 90 days; and serious adverse events. RESULTS Among the 2011 participants who were randomized (median age, 61 [IQR, 52 to 70] years and 645/1998 [32.3%] women), 1990 (99%) completed the trial. The convalescent plasma intervention was stopped after the prespecified criterion for futility was met. The median number of organ support-free days was 0 (IQR, -1 to 16) in the convalescent plasma group and 3 (IQR, -1 to 16) in the no convalescent plasma group. The in-hospital mortality rate was 37.3% (401/1075) for the convalescent plasma group and 38.4% (347/904) for the no convalescent plasma group and the median number of days alive and free of organ support was 14 (IQR, 3 to 18) and 14 (IQR, 7 to 18), respectively. The median-adjusted OR was 0.97 (95% credible interval, 0.83 to 1.15) and the posterior probability of futility (OR <1.2) was 99.4% for the convalescent plasma group compared with the no convalescent plasma group. The treatment effects were consistent across the primary outcome and the 11 secondary outcomes. Serious adverse events were reported in 3.0% (32/1075) of participants in the convalescent plasma group and in 1.3% (12/905) of participants in the no convalescent plasma group. CONCLUSIONS AND RELEVANCE Among critically ill adults with confirmed COVID-19, treatment with 2 units of high-titer, ABO-compatible convalescent plasma had a low likelihood of providing improvement in the number of organ support-free days. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02735707.
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Affiliation(s)
- Lise J Estcourt
- NHS Blood and Transplant, Oxford, England
- Radcliffe Department of Medicine and BRC Hematology Theme, University of Oxford, Oxford, England
| | - Alexis F Turgeon
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, Quebec, Canada
- CHU de Québec-Université Laval Research Center, Population Health and Optimal Health Practices Unit, Trauma-Emergency-Critical Care Medicine, CHU de Québec-Université Laval, Quebec City, Quebec, Canada
| | - Zoe K McQuilten
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Clinical Hematology, Monash Health, Melbourne, Australia
| | - Bryan J McVerry
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Farah Al-Beidh
- Division of Anesthetics, Pain Medicine, and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, England
| | - Djillali Annane
- Intensive Care Unit, Raymond Poincaré Hospital, Paris, France
- Simone Veil School of Medicine, University of Versailles, Versailles, France
- University Paris Saclay, Garches, France
| | - Yaseen M Arabi
- Intensive Care Department, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | | | - Abigail Beane
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, England
| | | | - Wilma van Bentum-Puijk
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | - Zahra Bhimani
- Li Ka Shing Knowledge Institute, Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Marc J M Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Charlotte A Bradbury
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, England
- Faculty of Health Sciences, University of Bristol, Bristol, England
| | - Frank M Brunkhorst
- Center for Clinical Studies and Center for Sepsis Control and Care, Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Meredith Buxton
- Global Coalition for Adaptive Research, San Francisco, California
| | - Jeannie L Callum
- Canadian Blood Services, Ottawa, Ontario, Canada
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queens University, Kingston, Ontario, Canada
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Allen C Cheng
- Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Matthew E Cove
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - James Daly
- Australian Red Cross Lifeblood, Sydney and Perth, Australia
| | - Lennie Derde
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Intensive Care Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | - Menno De Jong
- Department of Medical Microbiology, University of Amsterdam Medical Center, University of Amsterdam, the Netherlands
| | - Amy Evans
- NHSBT Clinical Trials Unit, NHS Blood and Transplant, Cambridge, England
| | - Dean A Fergusson
- Ottawa Hospital Research Institute, Clinical Epidemiology Unit, Ottawa, Ontario, Canada
| | - Matthew Fish
- School of Immunology and Microbial Sciences, Kings College London, London, England
| | | | - Claire Foley
- NHSBT Clinical Trials Unit, NHS Blood and Transplant, Cambridge, England
| | - Herman Goossens
- Department of Microbiology, Antwerp University Hospital, Antwerp, Belgium
| | - Anthony C Gordon
- Division of Anesthetics, Pain Medicine, and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, England
| | - Iain B Gosbell
- Australian Red Cross Lifeblood, Sydney and Perth, Australia
- Western Sydney University, Sydney, Australia
| | - Cameron Green
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Rashan Haniffa
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | | | - Alisa M Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | | | | | - David T Huang
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Nao Ichihara
- Department of Healthcare Quality Assessment, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Emma Laing
- NHSBT Clinical Trials Unit, NHS Blood and Transplant, Cambridge, England
| | | | | | - Patrick R Lawler
- Cardiac Intensive Care Unit, Peter Munk Cardiac Centre, University Health Network, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kelsey Linstrum
- Clinical Research Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Edward Litton
- School of Medicine and Pharmacology, University of Western Australia, Crawley
| | | | | | - John Marshall
- Li Ka Shing Knowledge Institute, Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Daniel F McAuley
- Centre for Experimental Medicine, School of Medicine, Dentistry, and Biomedical Sciences, Queen's University Belfast, Belfast, Ireland
| | - John F McDyer
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Shay McGuinness
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- Medical Research Institute of New Zealand, Wellington
| | | | - Stephanie Montgomery
- Clinical Research Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - Srinivas Murthy
- School of Medicine, University of British Columbia, Vancouver, Canada
| | - Alistair Nichol
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Anesthesia and Intensive Care, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
- Department of Intensive Care, Alfred Health, Melbourne, Australia
| | - Rachael Parke
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- Medical Research Institute of New Zealand, Wellington
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Jane C Parker
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Nicole Priddee
- Scottish National Blood Transfusion Service, Edinburgh, Scotland
| | - Damian F J Purcell
- Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Australia
| | - Luis F Reyes
- Universidad de La Sabana, Chia, Colombia
- Clinica Universidad de La Sabana, Chia, Colombia
| | | | - Nancy Robitaille
- Héma-Québec, Montreal, Quebec, Canada
- Division of Hematology and Oncology, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
- Department of Pediatrics, Université de Montréal, Montreal, Quebec, Canada
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - Jennifer Rynne
- School of Immunology and Microbial Sciences, Kings College London, London, England
| | - Hiroki Saito
- Department of Emergency and Critical Care Medicine, St Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohama, Japan
| | - Marlene Santos
- Li Ka Shing Knowledge Institute, Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Christopher W Seymour
- Clinical Research Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Jon A Silversides
- Centre for Experimental Medicine, School of Medicine, Dentistry, and Biomedical Sciences, Queen's University Belfast, Belfast, Ireland
| | - Alan A Tinmouth
- Ottawa Hospital Research Institute, Clinical Epidemiology Unit, Ottawa, Ontario, Canada
| | - Darrell J Triulzi
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anne M Turner
- Medical Research Institute of New Zealand, Wellington
| | - Frank van de Veerdonk
- Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Erica M Wood
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Clinical Hematology, Monash Health, Melbourne, Australia
| | | | - Roger J Lewis
- Berry Consultants LLC, Austin, Texas
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - David K Menon
- University Division of Anesthesia, Addenbrooke's Hospital Cambridge, Cambridge, England
| | - Colin McArthur
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Ryan Zarychanski
- Department of Medicine, Critical Care and Hematology/Medical Oncology, University of Manitoba, Winnipeg, Canada
| | - Derek C Angus
- Clinical Research Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Steve A Webb
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- St John of God Hospital, Subiaco, Australia
| | - David J Roberts
- NHS Blood and Transplant, Oxford, England
- Radcliffe Department of Medicine and BRC Hematology Theme, University of Oxford, Oxford, England
| | - Manu Shankar-Hari
- School of Immunology and Microbial Sciences, Kings College London, London, England
- Guy's and St Thomas' NHS Foundation Trust, ICU Support Offices, St Thomas' Hospital, London, England
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3
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Estcourt LJ, Turgeon AF, McQuilten ZK, McVerry BJ, Al-Beidh F, Annane D, Arabi YM, Arnold DM, Beane A, Bégin P, van Bentum-Puijk W, Berry LR, Bhimani Z, Birchall JE, Bonten MJM, Bradbury CA, Brunkhorst FM, Buxton M, Callum JL, Chassé M, Cheng AC, Cove ME, Daly J, Derde L, Detry MA, De Jong M, Evans A, Fergusson DA, Fish M, Fitzgerald M, Foley C, Goossens H, Gordon AC, Gosbell IB, Green C, Haniffa R, Harvala H, Higgins AM, Hills TE, Hoad VC, Horvat C, Huang DT, Hudson CL, Ichihara N, Laing E, Lamikanra AA, Lamontagne F, Lawler PR, Linstrum K, Litton E, Lorenzi E, MacLennan S, Marshall J, McAuley DF, McDyer JF, McGlothlin A, McGuinness S, Miflin G, Montgomery S, Mouncey PR, Murthy S, Nichol A, Parke R, Parker JC, Priddee N, Purcell DFJ, Reyes LF, Richardson P, Robitaille N, Rowan KM, Rynne J, Saito H, Santos M, Saunders CT, Serpa Neto A, Seymour CW, Silversides JA, Tinmouth AA, Triulzi DJ, Turner AM, van de Veerdonk F, Walsh TS, Wood EM, Berry S, Lewis RJ, Menon DK, McArthur C, Zarychanski R, Angus DC, Webb SA, Roberts DJ, Shankar-Hari M. Effect of Convalescent Plasma on Organ Support-Free Days in Critically Ill Patients With COVID-19: A Randomized Clinical Trial. JAMA 2021; 326:1690-1702. [PMID: 34606578 PMCID: PMC8491132 DOI: 10.1001/jama.2021.18178] [Citation(s) in RCA: 132] [Impact Index Per Article: 44.0] [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: 07/12/2021] [Accepted: 09/24/2021] [Indexed: 02/06/2023]
Abstract
IMPORTANCE The evidence for benefit of convalescent plasma for critically ill patients with COVID-19 is inconclusive. OBJECTIVE To determine whether convalescent plasma would improve outcomes for critically ill adults with COVID-19. DESIGN, SETTING, AND PARTICIPANTS The ongoing Randomized, Embedded, Multifactorial, Adaptive Platform Trial for Community-Acquired Pneumonia (REMAP-CAP) enrolled and randomized 4763 adults with suspected or confirmed COVID-19 between March 9, 2020, and January 18, 2021, within at least 1 domain; 2011 critically ill adults were randomized to open-label interventions in the immunoglobulin domain at 129 sites in 4 countries. Follow-up ended on April 19, 2021. INTERVENTIONS The immunoglobulin domain randomized participants to receive 2 units of high-titer, ABO-compatible convalescent plasma (total volume of 550 mL ± 150 mL) within 48 hours of randomization (n = 1084) or no convalescent plasma (n = 916). MAIN OUTCOMES AND MEASURES The primary ordinal end point was organ support-free days (days alive and free of intensive care unit-based organ support) up to day 21 (range, -1 to 21 days; patients who died were assigned -1 day). The primary analysis was an adjusted bayesian cumulative logistic model. Superiority was defined as the posterior probability of an odds ratio (OR) greater than 1 (threshold for trial conclusion of superiority >99%). Futility was defined as the posterior probability of an OR less than 1.2 (threshold for trial conclusion of futility >95%). An OR greater than 1 represented improved survival, more organ support-free days, or both. The prespecified secondary outcomes included in-hospital survival; 28-day survival; 90-day survival; respiratory support-free days; cardiovascular support-free days; progression to invasive mechanical ventilation, extracorporeal mechanical oxygenation, or death; intensive care unit length of stay; hospital length of stay; World Health Organization ordinal scale score at day 14; venous thromboembolic events at 90 days; and serious adverse events. RESULTS Among the 2011 participants who were randomized (median age, 61 [IQR, 52 to 70] years and 645/1998 [32.3%] women), 1990 (99%) completed the trial. The convalescent plasma intervention was stopped after the prespecified criterion for futility was met. The median number of organ support-free days was 0 (IQR, -1 to 16) in the convalescent plasma group and 3 (IQR, -1 to 16) in the no convalescent plasma group. The in-hospital mortality rate was 37.3% (401/1075) for the convalescent plasma group and 38.4% (347/904) for the no convalescent plasma group and the median number of days alive and free of organ support was 14 (IQR, 3 to 18) and 14 (IQR, 7 to 18), respectively. The median-adjusted OR was 0.97 (95% credible interval, 0.83 to 1.15) and the posterior probability of futility (OR <1.2) was 99.4% for the convalescent plasma group compared with the no convalescent plasma group. The treatment effects were consistent across the primary outcome and the 11 secondary outcomes. Serious adverse events were reported in 3.0% (32/1075) of participants in the convalescent plasma group and in 1.3% (12/905) of participants in the no convalescent plasma group. CONCLUSIONS AND RELEVANCE Among critically ill adults with confirmed COVID-19, treatment with 2 units of high-titer, ABO-compatible convalescent plasma had a low likelihood of providing improvement in the number of organ support-free days. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02735707.
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Affiliation(s)
- Lise J Estcourt
- NHS Blood and Transplant, Oxford, England
- Radcliffe Department of Medicine and BRC Hematology Theme, University of Oxford, Oxford, England
| | - Alexis F Turgeon
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, Quebec, Canada
- CHU de Québec-Université Laval Research Center, Population Health and Optimal Health Practices Unit, Trauma-Emergency-Critical Care Medicine, CHU de Québec-Université Laval, Quebec City, Quebec, Canada
| | - Zoe K McQuilten
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Clinical Hematology, Monash Health, Melbourne, Australia
| | - Bryan J McVerry
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Farah Al-Beidh
- Division of Anesthetics, Pain Medicine, and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, England
| | - Djillali Annane
- Intensive Care Unit, Raymond Poincaré Hospital, Paris, France
- Simone Veil School of Medicine, University of Versailles, Versailles, France
- University Paris Saclay, Garches, France
| | - Yaseen M Arabi
- Intensive Care Department, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | | | - Abigail Beane
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, England
| | | | - Wilma van Bentum-Puijk
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | - Zahra Bhimani
- Li Ka Shing Knowledge Institute, Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Marc J M Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Charlotte A Bradbury
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, England
- Faculty of Health Sciences, University of Bristol, Bristol, England
| | - Frank M Brunkhorst
- Center for Clinical Studies and Center for Sepsis Control and Care, Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Meredith Buxton
- Global Coalition for Adaptive Research, San Francisco, California
| | - Jeannie L Callum
- Canadian Blood Services, Ottawa, Ontario, Canada
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queens University, Kingston, Ontario, Canada
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Allen C Cheng
- Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Matthew E Cove
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - James Daly
- Australian Red Cross Lifeblood, Sydney and Perth, Australia
| | - Lennie Derde
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Intensive Care Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | - Menno De Jong
- Department of Medical Microbiology, University of Amsterdam Medical Center, University of Amsterdam, the Netherlands
| | - Amy Evans
- NHSBT Clinical Trials Unit, NHS Blood and Transplant, Cambridge, England
| | - Dean A Fergusson
- Ottawa Hospital Research Institute, Clinical Epidemiology Unit, Ottawa, Ontario, Canada
| | - Matthew Fish
- School of Immunology and Microbial Sciences, Kings College London, London, England
| | | | - Claire Foley
- NHSBT Clinical Trials Unit, NHS Blood and Transplant, Cambridge, England
| | - Herman Goossens
- Department of Microbiology, Antwerp University Hospital, Antwerp, Belgium
| | - Anthony C Gordon
- Division of Anesthetics, Pain Medicine, and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, England
| | - Iain B Gosbell
- Australian Red Cross Lifeblood, Sydney and Perth, Australia
- Western Sydney University, Sydney, Australia
| | - Cameron Green
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Rashan Haniffa
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | | | - Alisa M Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | | | | | - David T Huang
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Nao Ichihara
- Department of Healthcare Quality Assessment, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Emma Laing
- NHSBT Clinical Trials Unit, NHS Blood and Transplant, Cambridge, England
| | | | | | - Patrick R Lawler
- Cardiac Intensive Care Unit, Peter Munk Cardiac Centre, University Health Network, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kelsey Linstrum
- Clinical Research Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Edward Litton
- School of Medicine and Pharmacology, University of Western Australia, Crawley
| | | | | | - John Marshall
- Li Ka Shing Knowledge Institute, Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Daniel F McAuley
- Centre for Experimental Medicine, School of Medicine, Dentistry, and Biomedical Sciences, Queen's University Belfast, Belfast, Ireland
| | - John F McDyer
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Shay McGuinness
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- Medical Research Institute of New Zealand, Wellington
| | | | - Stephanie Montgomery
- Clinical Research Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - Srinivas Murthy
- School of Medicine, University of British Columbia, Vancouver, Canada
| | - Alistair Nichol
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Anesthesia and Intensive Care, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
- Department of Intensive Care, Alfred Health, Melbourne, Australia
| | - Rachael Parke
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- Medical Research Institute of New Zealand, Wellington
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Jane C Parker
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Nicole Priddee
- Scottish National Blood Transfusion Service, Edinburgh, Scotland
| | - Damian F J Purcell
- Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Australia
| | - Luis F Reyes
- Universidad de La Sabana, Chia, Colombia
- Clinica Universidad de La Sabana, Chia, Colombia
| | | | - Nancy Robitaille
- Héma-Québec, Montreal, Quebec, Canada
- Division of Hematology and Oncology, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
- Department of Pediatrics, Université de Montréal, Montreal, Quebec, Canada
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - Jennifer Rynne
- School of Immunology and Microbial Sciences, Kings College London, London, England
| | - Hiroki Saito
- Department of Emergency and Critical Care Medicine, St Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohama, Japan
| | - Marlene Santos
- Li Ka Shing Knowledge Institute, Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Christopher W Seymour
- Clinical Research Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Jon A Silversides
- Centre for Experimental Medicine, School of Medicine, Dentistry, and Biomedical Sciences, Queen's University Belfast, Belfast, Ireland
| | - Alan A Tinmouth
- Ottawa Hospital Research Institute, Clinical Epidemiology Unit, Ottawa, Ontario, Canada
| | - Darrell J Triulzi
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anne M Turner
- Medical Research Institute of New Zealand, Wellington
| | - Frank van de Veerdonk
- Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Erica M Wood
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Clinical Hematology, Monash Health, Melbourne, Australia
| | | | - Roger J Lewis
- Berry Consultants LLC, Austin, Texas
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - David K Menon
- University Division of Anesthesia, Addenbrooke's Hospital Cambridge, Cambridge, England
| | - Colin McArthur
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Ryan Zarychanski
- Department of Medicine, Critical Care and Hematology/Medical Oncology, University of Manitoba, Winnipeg, Canada
| | - Derek C Angus
- Clinical Research Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Steve A Webb
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- St John of God Hospital, Subiaco, Australia
| | - David J Roberts
- NHS Blood and Transplant, Oxford, England
- Radcliffe Department of Medicine and BRC Hematology Theme, University of Oxford, Oxford, England
| | - Manu Shankar-Hari
- School of Immunology and Microbial Sciences, Kings College London, London, England
- Guy's and St Thomas' NHS Foundation Trust, ICU Support Offices, St Thomas' Hospital, London, England
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Stanworth SJ, Hudson CL, Estcourt LJ, Johnson RJ, Wood EM. Risk of bleeding and use of platelet transfusions in patients with hematologic malignancies: recurrent event analysis. Haematologica 2015; 100:740-7. [PMID: 25795717 DOI: 10.3324/haematol.2014.118075] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 03/11/2015] [Indexed: 12/22/2022] Open
Abstract
A recent randomized trial (TOPPS) compared prophylactic platelet transfusions (for counts <10×10(9)/L) with a strategy of no-prophylaxis in adults with hematologic malignancies. Seventy percent of enrolled patients received an autologous hematopoietic stem cell transplant. Statistical models were developed to explore which patient factors or clinical characteristics are important prognostic factors for bleeding. These models were presented for baseline characteristics and for recurrent analysis of bleeding to assess the risks of World Health Organization grade 2-4 bleeding on any given day. Additional analyses explored the importance of fever. Treatment plan (chemotherapy/allogeneic hematopoietic stem cell transplant), female sex, and treatment arm (no-prophylaxis) were significantly associated with an increased number of days of bleeding. The number of days with a platelet count <10×109/L was significantly associated with a grade 2-4 bleed (P<0.0001). Patients with a temperature of at least 38°C had the highest hazard of a grade 2-4 bleed (hazard ratio: 1.7, 95% confidence interval: 1.3 to 2.4, compared with the risk in patients with a temperature <37.5°C). There was no evidence that minor bleeding predicted a grade 2-4 bleed. The results highlighted the limited role of correction of thrombocytopenia by platelet transfusion in reducing the risk of bleeding. Clinically stable patients undergoing autologous hematopoietic stem cell transplantation had the lowest risk of bleeding and benefited least from prophylactic platelet transfusions. Prospective studies are required to address the usefulness of risk factors to support better targeted platelet transfusions. TOPPS Controlled-Trials.com number ISRCTN08758735.
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Affiliation(s)
- Simon J Stanworth
- NHS Blood and Transplant/Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Oxford, UK; Radcliffe Department of Medicine, University of Oxford, UK
| | - Cara L Hudson
- Statistics and Clinical Studies, NHS Blood and Transplant, Bristol, UK
| | - Lise J Estcourt
- NHS Blood and Transplant/Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Oxford, UK; Radcliffe Department of Medicine, University of Oxford, UK
| | - Rachel J Johnson
- Statistics and Clinical Studies, NHS Blood and Transplant, Bristol, UK
| | - Erica M Wood
- Transfusion Research Unit, Monash University, Melbourne, Australia
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Abstract
The examination of four hearts, with partial or complete obliteration of the pericardial sac by fibrous adhesions, after injection of the coronary arteries with a colloidal suspension of lamp black showed that the extracardiac anastomoses of the coronary arteries were increased owing to the presence of adhesions. In all four instances a particularly rich injection of the parietal pericardium was obtained and microscopic examination of the adhesions showed them to contain injected vessels, extending from epicardium to parietal pericardium. A microscopic study of cleared blocks (3 mm. in thickness) of myocardium and attached pericardial adhesions, showed the arborization and anastomosis of branches of the arteries of the parietal pericardium with those of the heart. This vascularization was not limited to the usual areas of subepicardial fat, but was seen in regions not ordinarily containing arterial branches. In no one of the four cases were the coronary arteries significantly diseased. In one of the four cases, the normal sites of anastomoses between the cardiac and extracardiac vessels were destroyed by cutting away the great vessels entering and leaving the heart, as well as the peri- and intervascular reflections of parietal pericardium. Injection mass was found however, in the arteries of the parietal pericardium and the diaphragm, showing that it has passed directly through the adhesions from coronary to extracardiac vessels. If the extracardiac anastomoses of the coronary arteries constitute a significant reserve for cardiac circulation, it would appear that this reserve would be augmented by the presence of pericardial adhesions. Direct communication between branches of the coronary arteries and the pericardial branches of the internal mammary arteries with free anastomosis with the anterior branches of the thoracic aorta is established over areas corresponding to the extent of the adhesions. Work is now in progress in this laboratory to study the functional significance of such an experimentally induced collateral circulation in experimental coronary occlusion.
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Affiliation(s)
- A R Moritz
- Institute of Pathology and the Department of Medicine of Western Reserve University and the Department of Medicine of Lakeside Hospital, Cleveland
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Abstract
Widespread anastomoses of the auricular branches and the coronary branches to the pericardial fat with the pericardiacophrenic branches of the internal mammary arteries and the anterior mediastinal, pericardial, bronchial, superior and inferior phrenic, intercostal and esophageal branches of the aorta have been described. The most extensive anastomoses between the cardiac and extracardiac vessels are around the ostia of the pulmonary veins. It was possible not only to demonstrate the passage of injection mass from the coronary arteries into the vessels of surrounding structures, but also to show vessels in the heart injected through the thoracic branches of the aorta. This rich potential extracardiac coronary collateral circulation is probably of significance in compensating for sclerosis of the large trunks of the coronary arteries.
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Affiliation(s)
- C L Hudson
- Department of Medicine and the Institute of Pathology of Western Reserve University, and the Department of Medicine of Lakeside Hospital, Cleveland
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Walters HL, Lobdell KW, Tantengco V, Lyons JM, Hudson CL, Struble SL, Hakimi M. The Ross procedure in children and young adults with congenital aortic valve disease. J Heart Valve Dis 1997; 6:335-42. [PMID: 9263860] [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] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
METHODS Thirty-three children and young adults with congenital aortic valve disease underwent pulmonary autograft replacement of the aortic valve between October 1993 and March 1997. There wer six females and 27 males; at operation, median age was 16 years (range: 3 to 41 years) and median body weight 60 kg (range: 14 to 121 kg). Fifteen patients (46%) had undergone one or more previous cardiac surgical procedures. A bicuspid aortic valve was present in 31 patients (94%); moderate to severe aortic stenosis and regurgitation was present in 10 (30%) and 26 (79%), respectively. RESULTS All patients underwent the Ross procedure while in NYHA class I (64%) or class II (36%). A preoperative shortening fraction of 41 +/- 1.4% suggested well-preserved systolic function, but the mean left ventricular end-diastolic pressure of 16.6 +/- 1.3 mmHg was consistent with preoperative left ventricular pressure and volume overload. The aortic root was replaced using an interrupted suture technique in two patients and with three separate running sutures in 31. The right ventricular outflow tract was reconstructed in all classes with a cryopreserved pulmonary homograft valved conduit (median diameter 23 mm; range 19 to 30 mm). Intraoperative complications included transient atrioventricular dissociation (one), permanent atrioventricular dissociation (one), and left coronary artery distortion relieved by shortening the distal ascending aorta (one). Postoperatively, postpericardiotomy syndrome developed in six patients (18%), supraventricular tachycardia in three (9%), and ventricular tachycardia in one (3%). At three days after surgery, one patient developed ischemic left ventricular dysfunction requiring repositioning of the distorted left coronary artery higher on the neo-aortic root. Hospital survival rate was 100%. During a median follow-up of 17 months (range: 1 to 41 months) one patient suffered a non-cardiac death due to blunt trauma. there has been a significant postoperative improvement in NYHA class among surviving patients (class I, 94%; class II, 6%; p = 0.004 versus preoperative). Postoperative aortic regurgitation was absent or trivial in 17 (60%) and mild in the remaining 11 (40%) patients for whom follow-up echocardiographic data are available. One patient required reoperation 16.5 months after the Ross procedure to replace a rapidly degenerating pulmonary homograft, and one with moderately severe homograft stenosis and five with mild homograft stenosis are being monitored. Postoperatively, a gradual early expansion in the diameter of the neo-aortic root and reduction in echocardiographic indices of left ventricular hypertrophy and dilatation occurred. CONCLUSIONS Pulmonary autograft replacement of the aortic valve in young patients with congenital aortic valve disease has produced excellent short-term anatomic/physiologic results and symptomatic relief with no mortality. Indices of left ventricular dilatation and hypertrophy regress after repair when the Ross operation precedes important deterioration in preoperative ventricular function. Important technical considerations include: (i) the native distal ascending aorta should be sufficiently shortened before performing the distal aortic anastomosis; and (ii) the left coronary anastomosis should be positioned relatively high on the neo-aortic root with a slight amount of tension. Both of these maneuvers reduce the likelihood of coronary artery distortion. Rapid degeneration of the pulmonary homograft and the propensity towards progressive dilatation of the neo-aorta are important postoperative considerations. Until more is known about the etiology and natural history of these two potential complications, postoperative anti-inflammatory and/or immunosuppressive therapy and strict control of hypertension should be strongly considered.
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Affiliation(s)
- H L Walters
- Department of Cardiovascular Surgery, Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit 48201, USA
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Affiliation(s)
- K W Weingand
- Procter & Gamble Co., Human & Environmental Safety Div., Cincinnati, OH 45239
| | - C L Hudson
- Procter & Gamble Co., Human & Environmental Safety Div., Cincinnati, OH 45239
| | - L W Odioso
- Procter & Gamble Co., Human & Environmental Safety Div., Cincinnati, OH 45239
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Weingand KW, Hudson CL, Odioso LW. Enzymatic reagents for quantifying total plasma cholesterol from dogs, rats, and hamsters. Clin Chem 1990; 36:1995. [PMID: 2242591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- K W Weingand
- Procter & Gamble Co., Human & Environmental Safety Div., Cincinnati, OH 45239
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Weingand KW, Hudson CL. Accurate measurement of total plasma triglyceride concentrations in laboratory animals. Lab Anim Sci 1989; 39:453-4. [PMID: 2811291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- K W Weingand
- Procter & Gamble Company, Miami Valley Laboratories, Cincinnati, OH 45239
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Hudson CL. The form and financing of medical care in the United States of America. Cleve Clin Q 1970; 37:5-12. [PMID: 5418071 DOI: 10.3949/ccjm.37.1.5] [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] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Hudson CL. The responsibility of the University in the continuing education of physicians. J Med Educ 1968; 43:526-531. [PMID: 5647095 DOI: 10.1097/00001888-196805000-00002] [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] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
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Hudson CL. Whatever became of that old-fashioned patient? JAMA 1968; 203:585-7. [PMID: 5694192] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Hudson CL. The changing medical climate of America. Mo Med 1967; 64:965-9. [PMID: 6081125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Hudson CL. The changing climate of America. Nebr State Med J 1967; 52:312-7. [PMID: 4227424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Hudson CL. The case of the receipted bill. JAMA 1967; 200:767-9. [PMID: 5337106] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Hudson CL. (P.L. 89-239) remarks on Regional Medical Programs. J Med Assoc Ga 1967; 56:154-5. [PMID: 6040144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Hudson CL. Rehabilitation and the American Medical Association. Arch Phys Med Rehabil 1967; 48:161-3. [PMID: 6022538] [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: 01/18/2023]
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Hudson CL. Mental health--a responsibility of the entire medical profession. J Tenn Med Assoc 1967; 60:261-3. [PMID: 6042202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Hudson CL. The AMA and the Federal Government. A study in changing relationships. JAMA 1966; 198:1193-5. [PMID: 5953500] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Hudson CL. Freedom--the wave of the future. J Med Assoc Ga 1966; 55:500-3. [PMID: 5341408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Hudson CL. Blue shield--a physician's viewpoint. J Med Assoc State Ala 1966; 36:575 passim. [PMID: 5979347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Hudson CL. Are we creating our own "big brother"? W V Med J 1966; 62:385-9. [PMID: 5331505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Hudson CL. Finding our way on a path to the future. JAMA 1966; 197:97-9. [PMID: 5952507] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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